ISO Understanding My Heart Problem & Cardiologist

[blazer93]

Hi All:

I was diagnosed with abnormal EKGs for last few years with enlarge left ventricle and had my 1st ECHOcardiogram done on 12/2008. ECHO revealed dialated aorta problem and moderate to severely leaking bicuspid aortic valve. I spoke with my cardiologist after 1st echo and he basically said: take ACE Inhibitor lisinopril to mitigate need for immediate heart surgery; your symptoms are few and quite managable, no more tests are needed right now, find answers to your heart questions on the internet. I did not know what to ask at first meeting. Now I just got copy of 2nd echo report and am seeing cardiologist in 3 days. In last few months I am having significant chest pains when sleeping and when bending over. I am having trouble using the ECHO rpt info to develop questions for cardiologist. The jargon is not self-explanatory. I have some questions, but I am unsure if I am asking rights question nor complete set of questions. Maybe some members willing to review my ECHO rpts and provide suggestions. Here are my ECHO rpts:

FROM 12/2008:
============
2-D \ M Mode Measurements
Right Ventricular Diastolic Dimension: 3.2 cm (betwn 0.7 & 3.0)
IVSD: 1.5 cm (betwn 0.7 & 1.1)
LVPWD: 1.2cm (betwn 0.7 & 1.1)
LVEd: 5.6cm (betwn 4.0 & 5.6)
LVEs: 3.2cm (betwn 2.0 and 3.8)
Fractional Shortening: 43% (betwn 25 & 42)
Ejection Fraction: 75% (betw 55 & 75)
Aortic Root Diameter: 4.2 cm (betwn 2.2 & 3.7)
Left Atrial Size: 3.6 cm (betwn 2.5 & 4.0)

DOPPLER Measuremnts:
LVOT Peak Velocity: 0.7 m/sec
Aortic Valve Peak Velocity: 1.4m/sec (betw 1.0 & 1.7)
Tricuspid Valve Regurgitation Velocity: 2.3 m/sec
Right Atrial Pressure Estimated: 5 mmHg
RVSP: 25 mmHg
Pulmonic Valve Peak Velocity: 1.0 m/sec (betwn 0.6 & 1.3)
Pulmonic Valve Peak Gradient: 0.6 mmHg
Peak E: 0.6
E:A Ratio: 1.1 (betwn 1.1 & 1.5)

Description M-Mode 2-D
Left Ventricle
Diastolic Function: Normal
Left Ventricular hypertrophy: Mild(1.1 to 1.4cm), Moderate (1.5 to 1.9cm)
LVOT: no outflow obstruction present
Left Ventricular Dimensions: Normal
Function: normal
Global Wall Notion: Normal

Aortic Valve:
Findings: Bicuspid
Regurgitation: Moderate, Severe
Stenosis: None
Aortic Root: Dilated Aortic Root, Mild

Mitral Valve
Findings: normal
Stenosis: none
Regurgitation: Trace
Left Atrial Dimension: Normal (1.9 to 4.0 cm)

Tricuspid Valve
Findings: Normal
Regurgitation: Mild
Stenosis: None

Pulmonic Valve:
Finding: Normal
Regurgitation: Trace
Stenosis: None

Right Heart
Right Atrial Dimensions: Normal
Right Ventricular Dimensions: Normal
Right Ventricular Function: Normal
Pulmonary Hypertension: Normal
Intraatrial or intraventricular shunting: Not Present

Effusion: Pericardial None

Summary:
Comments: (Normal LV systolic & diastolic function, LV chamber size at upper limit of normal, mild to moderate LVH, Bicuspid aortic valve with moderate to severe aortic regurgitation, mildly dilated aortic root, trace mitral regurgitation, mild tricuspid regurgitation, Mild RV enlargement with normal systolic function, mornal estimated pulmonary pressures)


FROM 6/2009:
===========
2-D \ M Mode Measurements
Right Ventricular Diastolic Dimension: 3.1 cm (betwn 0.7 & 3.0)
IVSD: 1.0 cm (betwn 0.7 & 1.1)
LVPWD: 1.0cm (betwn 0.7 & 1.1)
LVEd: 6.1cm (betwn 4.0 & 5.6)
LVEs: 3.9cm (betwn 2.0 and 3.8)
Fractional Shortening: 36% (betwn 25 & 42)
Ejection Fraction: 70% (betw 55 & 75)
Aortic Root Diameter: 4.0 cm (betwn 2.2 & 3.7)
Left Atrial Size: 3.1 cm (betwn 2.5 & 4.0)

DOPPLER Measuremnts:
LVOT Peak Velocity: 1.3 m/sec
Aortic Valve Peak Velocity: 1.6m/sec (betw 1.0 & 1.7)
Pulmonic Valve Peak Velocity: 1.1 m/sec (betwn 0.6 & 1.3)
Peak E: 0.6
Peak A: 0.5
E:A Ratio: 1.5 (betwn 1.1 & 1.5)

Description M-Mode 2-D
Left Ventricle
Diastolic Function: Normal
Left Ventricular hypertrophy: Normal (0.7 to 1.1 cm)
LVOT: no outflow obstruction present
Left Ventricular Dimensions: Normal
Function: normal
Global Wall Notion: Normal

Aortic Valve:
Findings: Bicuspid
Regurgitation: Moderate, Severe
Stenosis: None
Aortic Root: Dilated Aortic Root, Mild

Mitral Valve
Findings: normal
Stenosis: none
Regurgitation: Trace
Left Atrial Dimension: Normal (1.9 to 4.0 cm)

Tricuspid Valve
Findings: Normal
Regurgitation: Trace
Stenosis: None

Pulmonic Valve:
Finding: Normal
Regurgitation: Trace
Stenosis: None

Right Heart
Right Atrial Dimensions: Normal
Right Ventricular Dimensions: Normal
Right Ventricular Function: Normal
Pulmonary Hypertension: Normal
Intraatrial or intraventricular shunting: Not Present

Effusion: Pericardial None

Summary:
Comments: (Dilated LV, LVEDd 6.1cm, LVEDs 3.9cm, Normal LV systolic & diastolic function, Bicuspid aortic valve with moderate to severe aortic regurgitation, mildly dilated aortic root, trace mitral regurgitation, mild tricuspid regurgitation, PHT 304 ms, Dialated aortic root 4.0 cm, LV size has grown larger compared to last echo study 12/2008)

Here are some of my questions for upcoming mtg with cardiologist:
1. What is my ejection fraction at rest?
2. How large does my left ventricle get in millimeters at rest?
3. Do I have abnormal heart rhythms? If yes do I need arrhythmic medicines?
4. Have heart tests done satisfactorially determine the nature and extent of my heart problems, or are other tests needed now? If other, which ones and why?
5. Given new symptoms I am experiencing in last few months and the ECHO rpt on dialated aortic root, do I need stronger or different ACE inhibitor? Nitro medicines?
6. GP doctor recommends I take 1 aspirin a day. Does that make sense given its effect on lisinopril medication? Ditto if I take 1 glass of wine / day?
7. If I am damaging my heart by delaying surgery, how long do you recommend that I continue delaying valve replacement surgery?
8. Do I have an aortic aneurysm? If yes, what do you recommend and why? If yes, what is my prognosis?
9. Should I be seeing a cardiologist more frequently and if yes, why?
10. In comparing the two ECHO rpts, why are some of the Doppler measurements done different for each report?
11. What does it mean when aortic root diameter decreases over six months from 4.2 to 4.0 cm? Statistical noise?
12. When is LV size enlargement too much?

I get the feeling that my heart problems need monitoring but are not urgent from listening to cardiologist. Thanks for your time and help.

 

[Ross]

Outside of your symptoms, the report doesn't look all that bad. Quite good actually, but echos are only as good as the tech doing them. I think if I were in your shoes, I'd ask about further testing such as, stress testing and possibly catheterization. I don't give a whole lot of credit to echos. They're ok for basic diagnostic purposes, but when someone is having symptoms such as you are, it needs to be escalated into some better testing.

Your heart is definitely overcompensating for the regurg which is why your ejection fraction is so high. Left go too long can lead to permanent heart damage.

I know this doesn't answer your questions per say, but let me go get you some links to look at for your own information.

http://www.echobyweb.com/htm_level1_eng/introduction.htm

http://www.echobyweb.com/htm_level1_eng/echo_examination.htm

http://www.echobyweb.com/htm_level1_eng/atlases_index.htm

 

[MissMelis]

I just wanted to say welcome...I am not good with these numbers...but given that you are having symptoms, sometimes that says more than numbers do.

Welcome to VR, don't be afraid to ask questions!

Melissa

 

[ALCapshaw2]

I second Ross' comments.

When you have a condition that can ONLY be Fixed by Surgery, get the opinion of a SURGEON. In your case, be sure to find a surgeon who has LOTS of experience with BAV and Connective Tissue Disorders. Also ask how much experience he has repairing / replacing the AORTA and about his Success Rate.

Bottom Line: It's probably time to go Surgeon Shopping.

'AL Capshaw'

 

[briansmom]

Welcome to the group! I'm sorry you need to be here, but this is a fantastic group of supportive and knowledgeable people.

IMHO, when you have moderate to severe regurgitation and an already dilated left ventricle, it is time for surgery. You don't mention if there are any specific reasons for your cardiologist to recommend delaying.

Did you have a stress echo or just a regular echo? If it was a regular echo, then those are your numbers at rest. I don't think the size of your left ventricle will change under stress but your EF probably will. My son's EF gets better with exercise but I don't know if that's common or not. Make sure that if you discuss surgery, they plan to do something with your aorta. You don't want to have surgery now and then down the road need another for your aorta.

 

[Maryka]

Since I am expounding on Johns Hopkins (see latest thread started by cdheartman), I recommend you get an evaluation at Hopkins. Still the best, in my book.

 

[Jkm7]

Hi and Welcome. Happy you found us but sorry for the reason.

I can't comment too much about your numbers etc but just want to comment that I take 325 mg ecotrin (coated aspirin) along with lisinopril. Not an unusual combination though I see you have done some reading. I also have a glass of red wine when I wish with full approval of my surgeon, Cardiologist and Primary Care Doc.

Hope your cardio answers your questions at your appointment. Please let us know how it goes.

 

[tobagotwo]

Just some thoughts on your questions (I am not a medical professional)…

1. What is my ejection fraction at rest?
- Your ejection fraction (EF) is the percentage of blood that gets pushed out of your left ventricle when the ventricle contracts, out of a not-really-possible 100%. So, there is no “at rest” fraction. If you’re not a very highly conditioned athlete, such as a bicycle racer, anything over 65% is likely caused by left ventricular hypertrophy (heart enlargement on the side that pushes blood to your body). That’s not really a good thing, although it sounds like a higher percentage should be better. It indicates the stress your heart is under, and the fact that it’s responding to that stress by becoming stronger and larger. However, that cycle would eventually go too far, if you did not get surgery.

2. How large does my left ventricle get in millimeters at rest?
- Your Diastolic pressure is your “at-rest” pressure, and your Systolic pressure is when your heartbeat is at its fullest force. Therefore, your LVEd: 5.6cm (betwn 4.0 & 5.6) is your left ventricle at rest (the ”d” is for diastolic), and your LVEs: 3.2cm (betwn 2.0 and 3.8) is your left ventricle under pressure (the “s” is for systolic).
- The limits given are norms for a large range of people (all of us), so how badly your particular left ventricle is enlarged really depends partly on what the original size of it was in your chest before all this started. They are useful markers for the doctor, but may inadequately define your personal situation.

3. Do I have abnormal heart rhythms? If yes do I need arrhythmic medicines?
- While this report doesn’t address arrhythmias, it’s very common to have PVCs and PACs (A.K.A. palpitations) when your heart is under this much strain. They likely did an electrocardiogram as well as the echo (or will when you get to the office this time), which would address any arrhythmias. Usually, they are harmless (although uncomfortable), and medication is not called for.

4. Have heart tests done satisfactorially determine the nature and extent of my heart problems, or are other tests needed now? If other, which ones and why?
- If they feel you are close to surgery, they will likely request a TEE (transesophogeal echo) or a cardiac catheterization soon. At the point where they bring that up, you might want to consider talking to a surgeon first. Otherwise, you may wind up going through these tests multiple times, which is usually just not necessary. After all, they do know you’re headed for surgery, they’re just trying to determine when it should be. The cardiac cath will be required just before surgery, so it’s best to time it with the surgery. The TEE is usually only helpful if you have unusual circumstances or are a difficult thoracic read.
- There is also an MRA, which is a Magnetic Resonance Angiogram (MRI for the heart) with injected dye, which can help them to visualize the heart and cardiac arteries. That one is non-intrusive, so may be a better alternative, if they are unsure. You should not be undergoing a stress echo or nuclear stress echo at this stage of the game. They are unpleasant and the results are unreliable at this stage.

5. Given new symptoms I am experiencing in last few months and the ECHO rpt on dialated aortic root, do I need stronger or different ACE inhibitor? Nitro medicines?
- The chest pain symptoms are angina, and you should make the cardiologist aware of them and their severity. Active symptoms are very important in determining the right time for surgery.
- You should take care to exhale as you bend over, and not to hold your breath. Avoid strenuous lifting and heavy exercise. The dilated root is not particularly dangerous right now, and likely wouldn’t be a cause for more medication at this time. Nitro might help some with the angina, but has issues of its own, and it largely duplicates the effects of the lisinopril (vasodilator – relaxes the arteries). I don’t often hear about nitroglycerin being prescribed to valve patients preoperatively, although afterwards, it may be used to help ease pressure for those who continue to show some pulmonary hypertension.

6. GP doctor recommends I take 1 aspirin a day. Does that make sense given its effect on lisinopril medication? Ditto if I take 1 glass of wine / day?
- The aspirin causes the platelets to be less “sticky” in the bloodstream. This helps keep them from forming clots that could become strokes. That’s not the main effect of the lisinopril, which is to lower blood pressure, and the wine is more for psychological benefit than anything else. One aspirin will not undo all of the lisinopril’s effects.
- By the way, with lisinopril, you should stick to only the one glass of wine, and time it for when you are ready to settle down, as it may affect your ability to drive or react. Also, avoid diuretics (‘water pills”) or potassium supplements, unless your cardiologist is aware and approving them.

7. If I am damaging my heart by delaying surgery, how long do you recommend that I continue delaying valve replacement surgery?
- That is between you, your cardiologist, your general practitioner, and a second opinion from a surgeon or at least a cardiologist from a different group, if you are concerned about timing. Your somewhat enlarged right ventricle may be indicating some secondary pulmonary hypertension, and your left ventricle is enlarged. If that 75% EF is accurate, I’d be looking for a second opinion, even if it’s just a cardiologist from a different group (the 70% may be a variation in readings or a beneficial effect of the lisinopril). My leaning is that you are close to surgery, likely within a year.

8. Do I have an aortic aneurysm? If yes, what do you recommend and why? If yes, what is my prognosis?
- The aortic root is just a handy name for the section of the aorta closest to the heart. It will need to be replaced or resectioned at the time the valve is replaced. Dilation means an enlarged blood vessel, and usage seems to be for a minimal aneurysm. An aneurysm usually indicates some weakening of the layers of the vessel walls as well as expansion. These "expanded roots" are quite common and usually cause little added risk for surgery or afterwards, if repaired or replaced during the surgery.

9. Should I be seeing a cardiologist more frequently and if yes, why?
- You are already seeing the cardiologist at six-month intervals. He may recommend three months. Like stenosis, the worse a heart with regurgitation (insufficiency, leakage) gets, the faster it gets worse. The cardiologist would want to be on the cautious side of any accelerating symptoms or heart measurements. Be very certain that your cardiologist is aware of any symptoms you may be having, including palpitations, Shortness of Breath, angina, extra fatigue (“feeling old”), etc.
- If your cardiologist still seems unconcerned, ask him why. He may be trying not to convey too much worry to you as a patient. However, he’s seeing you often enough that he should have some concern.

10. In comparing the two ECHO rpts, why are some of the Doppler measurements done different for each report?
- The cardiologist may request different measurements for a particular echo. Different techs may do different measurements on their own, or compile their results in slightly different ways. Actual results vary some, even if you had an echo done two days in a row. The angle of your heart as you lie on your left side may cause trace leakages that don’t really exist, and might not be there from echo to echo.

11. What does it mean when aortic root diameter decreases over six months from 4.2 to 4.0 cm? Statistical noise?
- It very likely didn’t, even with the lisinopril (which may have helped your RV and EF a bit). One of the measures is less accurate. Dilation doesn’t ebb and flow a lot: it is or it isn’t.

12. When is LV size enlargement too much?
- Good question, and one that actually varies form person to person. You’re already a bit past normal. The real answer probably is when it starts to work less effectively. How much do your symptoms interfere with your daily life?


A lot of the terms in echoes are covered in the Glossary, which is in MS Word: http://www.valvereplacement.com/forums/attachment.php?attachmentid=6998&d=1243346246. If you don’t have MS Word or MS Office, there is a viewer for it here: http://www.microsoft.com/downloads/...87-8732-48D5-8689-AB826E7B8FDF&displaylang=en.

Best wishes,

 

[blazer93]

Response to Feedback: My Current Heart Symptoms

Response to Feedback: My Current Heart Symptoms

Hi All:

Thanks for feedback. I appreciate the advice and education. My chest pain symptoms were probably understated to readers upon reflection. These symptoms will be one of first things I mention to cardiologist tomorrow. The first time I met the cardiologist in Dec. 2008 I told him that my symptoms were trivial. When I told my advice nurse to my GP doctor these symptoms today, she told me to go to emergency room now. I told her I would rather get GP and cardiologist doctor orders for further tests and services. Here is a better elaboration of my chest pain symptoms:

a. In the last 5 or more months I have been experiencing Chronic Heart-related chest pressure and tightening. I feel this pressure and stiffness almost all day now and the degree of pressure and stiffness has increased slightly since Feb. 2009. It does not restricting most of my activities. However, I am reluctant to do much bending over and I have effectively stopped doing aerobic outdoor recreation and aerobic home improvement work. I still pick my 50 lb. kids up from time to time without problem.

b.. In the last 2 months I have been experiencing Sharper, Acute Heart-related chest pains. My chest pain happens unexpectedly and rarely during 30 min aerobic gym workout or during 20 mins of lite weightlifting following 30 min. gym workout , and regularly after going to bed rest waking me up prematurely in early AM and regularly when I bend over when knelling and standing, and regularly when sitting in a car for more than 3 hours without break. The pain is restricted to the area on the front of the chest under the ribs near the heart to left of breastbone. I have had this type of pain for over 20 years. Only in the last 5 months has it been occuring outside of long car rides.

c. Heart-related palpitations. I have felt rarely a fluttering of my heart when involuntarily waking up during nite sleep and sometimes during gym exercise.

I will stop the weightlifting until I talk to the cardiologist.

 

[Ross]

Could be Angina, but I think there is more going on then that and really needs to be addressed.

 

[blazer93]

Post-Cardiologist Visit Plus Is Chest Pain Due to Coronary or Acid Reflux

Post-Cardiologist Visit Plus Is Chest Pain Due to Coronary or Acid Reflux

Hi:

Cardiologist spent over 1/2 hour with me on 6/12. He basically stated it was premature for me to consider surgery at this time, and is keeping me on a 6-month revisit schedule. He thinks my chest pain symptoms are due to acid reflux, told me to see my internist and take Prilosec, and he wants me to have a nuclear stress test (probably to exclude coronary problems as reason for chest pain waking me up when asleep). He thinks my rare palpitations are due to heart missing a beat.

I see the internist late this week to see what he thinks about the cardiologist's views. I probably will take some Nexum or Prilosec this week to see what happens when I go to sleep. I am not confident that I have an acid reflux problem, but can't hurt to try self-medicating. I need to chase down what is causing my chest pains, especially when I sleep.

 

[scuba_898]

blazer

welcome to the site. I myself was diagnosed with BAV and mod to severe regurgitation back in March. I was told that at the time i do not show any signs of stenosis or aneurysms. the cardiologist i saw put me on a six month check up schedule and gave me restrictions on physical activity. Since that visit i was diagnosed with Acid Reflux, which i have learned is a connective tissue disorder and goes hand in hand with BAV. I am only 29 years old. how old are you, i saw that you mentioned you still pick up your 50 lbs kids.

I just wanted to say welcome, good luck and I hope some of the members here can provide some insight for you. I am still new, I have my second check up in August.

 

[blazer93]

Spirit is Willing

Spirit is Willing

Hi:

I am 56 yo, lift some nautilus weights 3x / week (fly, legs, detoids, quads, lats) for about 20 mins. and do 30 mins of elliptical trainer stuff on a hilly program 3x / week. My cardiologist gave me no exercise restrictions.

My 7 and 8 yo kids like to use me lift a raft when we go swimming too! I am not that strong.