Need your opinion on these echo results... not trusting my doc.

[KarenK]

My latest echo states severe aortic stenosis however it shows the valve area as 1.37, gradient 32.5, EF 65%. These numbers seem like it's moderate, not severe. What else could push it into the severe level?

The other items that were a bit off:
Aortic max vel 3.90 m/s
Tricuspid Valve max vel 2.84 m/s
It also shows LV Hypertrophy & impaired early LV relaxation w/ normal filling pressure, both are mild.
RVSP 37.3 mmHg/mildly elevated pulmonary pressure
MV Peak A: .92 m/s (normal 1.0-1.5)
The also did my Agatston aortic valve calcium score 1983

Any input would be most appreciated.

 

[Gkeraney]

My own take would be that is firmly moderate though I know nothing about that calcium score. It's probably the aortic max velo close to 4 that caused the cardio to say that, wag.

 

[dornole]

Did your cardiologist read the echo, or somebody else? I ask because mine are read and signed by someone else and then I discuss with my cardiologist to clarify.

 

[BicuspidBuddy]

Agree with Gkeraney. Aortic max velocity. Plus LV hypertrophy.

But yeah that looks more like moderate AS. I'm guessing you have no symptoms. More importantly, what does your cardio say to you in terms of wait and watch, and timing for follow-up echo?

 

[BicuspidBuddy]

The also did my Agatston aortic valve calcium score 1983

I'm no cardiologist, but in looking up things, here is some information where your calcium score indicates "severe": https://www.jacc.org/doi/abs/10.1016/j.jcmg.2019.01.045

I do not believe this is the standard way of diagnosing the severity of AS, at least not in Canada. Hubby has never had a calcium score done, and we are preparing for surgery based on very abnormal measurements of transthoracic echocardiography, primarily AVA and pressure gradients.

 

[KarenK]

Did your cardiologist read the echo, or somebody else? I ask because mine are read and signed by someone else and then I discuss with my cardiologist to clarify.

Someone else read the echo however all the doctors, etc., are all a part of the same medical system... I have questioned whether there is an understanding of support among them. When I ask for a test result from any of them, they all say no, "It's our policy". Their policy is a violation of State and Federal HIPPA laws. Also, this cardiologist has never discussed anything with me! I'm treated like I'm incidental in this. I had to have a heated argument with his NP to get the echo results. I had a heart cath scheduled a couple days ago. After they got me all hooked up and a couple lines in my arm they informed me that I would be staying overnight in the hospital for this out patient procedure, "That's the law." I got up and left. Now I have an appointment with a new cardiologist in 4 months. Hopefully they can get me in sooner.

 

[KarenK]

I'm no cardiologist, but in looking up things, here is some information where your calcium score indicates "severe": https://www.jacc.org/doi/abs/10.1016/j.jcmg.2019.01.045

I do not believe this is the standard way of diagnosing the severity of AS, at least not in Canada. Hubby has never had a calcium score done, and we are preparing for surgery based on very abnormal measurements of transthoracic echocardiography, primarily AVA and pressure gradients.

Thank you! Definitely an interesting read. A calcium score of 1300 is severe... yikes, that makes my 1983 score sound very severe!
I don't think they normally do a calcium score on bicuspid valves as the know that is a problem. I'm not bicuspid, so the issue is highly likely to be a calcium issue.

 

[KarenK]

Agree with Gkeraney. Aortic max velocity. Plus LV hypertrophy.

But yeah that looks more like moderate AS. I'm guessing you have no symptoms. More importantly, what does your cardio say to you in terms of wait and watch, and timing for follow-up echo?

I did a little more research today and I saw where one talked about surgery if it's progressing quickly. It's definition of quick progression was +0.3 m/s velocity, +7 mmHg pressure gradient, and -0.1 cm2 decrease in valve area in a years time. It's been 10 months since my last echo and I meet the criteria in the first two measurements and I don't have that info for the valve area.

Possibly mildly symptomatic? I've had some palpations but very few, had a flutter for the first time a couple days ago. Breathlessness, age or symptom? I don't know and I do have some swelling in feet and ankles on occasion but that may be related to problems with my feet.

How will I know for sure?

 

[KarenK]

My own take would be that is firmly moderate though I know nothing about that calcium score. It's probably the aortic max velo close to 4 that caused the cardio to say that, wag.

You are probably right on the max vel. After comparing echos, I noted the rate that its progressed. I'm likely to be 4 or more in 2-3 months.

 

[dornole]

You don’t have an electronic health record? I can see all my test results going back years, with trend graphs. It is profoundly weird if you can’t access your test results.

 

[pellicle]

with trend graphs.

that's a nice touch ... ours is more basic (just the reports)

 

[KarenK]

You don’t have an electronic health record? I can see all my test results going back years, with trend graphs. It is profoundly weird if you can’t access your test results.

They have gone rouge over here. They don't want you to have your records, I've been denied repeatedly. Today I made a formal request for my records. I send a certified letter to aid in documenting my written request which included copy from HIPAA's website regarding an individuals rights to their medical records and how they are to provide them. Seems like the legal department of this medical system has gone overboard. They are making up laws and ignoring existing State and Federal laws.

 

[tom in MO]

I had stenosis and no symptoms. Based upon an echo, I was told I needed surgery to replace the valve soon (<2 months) because the symptoms of aortic stenosis are not seen in many patients before they suffer "the syndrome known as sudden death." (That's a quote from my cardio.) I had one spell of dizziness before my valve was replaced. Focus on your health.

 

[Chuck C]

The also did my Agatston aortic valve calcium score 1983

I'm not bicuspid,

Hi Karen.

Sorry to hear about all these issues.

Have you had your Lp(a) tested? Having elevated Lp(a) is known to cause early cardio vascular disease, which would be reflected in a high calcium score. Also, elevated Lp(a) is known to be strongly associated with valvular calcification. In fact, it is estimated that for about 1 out of 7 patients with aortic stenosis the cause is elevated Lp(a). In that you are not bicuspid, yet you have aortic stenosis, and in that you have a very high calcium score, I would strongly suggest getting your Lp(a) checked.

Although cardiologists are gradually becoming more educated about Lp(a), for most of them this is still a blind spot. If it turns out that you have high Lp(a), nothing can be done to change the fact that you need surgery for your aortic stenosis, but it would be an important thing to be aware of long term, as there are some theraputics in the pipeline, with expected FDA approval in about 2025.

Your insurance should pay for Lp(a) testing. If you go to Quest Diagnostics, Lp(a) is included in their advanced lipid panel. LabCorp still does not include Lp(a) in their advanced panel, but you can still order an individual test from either lab for about $ 40 to $55. Even if insurance won't cover it, I would suggest it is worth paying for this test.

Please see links below:

Lp(a) and aortic stenosis:

"What is the evidence we have for Lp(a) as a risk factor for aortic valve stenosis? The epidemiological and genetic evidence is quite strong that high Lp(a) is associated with the development of aortic valve stenosis. Lp(a) is an important carrier of oxidized phospholipids which are considered as an key culprit for the development of aortic valve stenosis."

https://academic.oup.com/eurheartj/article/43/39/3968/6670979
Lp(a) and heart disease and strokes:"

• Like LDL-cholesterol, Lp(a)-cholesterol can build up in the walls of your blood vessels. The higher your Lp(a) level is, the more likely this is to happen. These cholesterol deposits, called plaques, can decrease blood flow to your heart, brain, kidneys, lungs, legs, and other parts of your body. Plaques can grow over time or suddenly rupture, blocking blood vessels and leading to heart attacks or strokes.2
• Lp(a) can cause increased clotting, which can lead to rapidly formed blockages in blood vessels.2
• Lp(a) promotes inflammation which increases the likelihood that plaques will rupture.2

https://www.cdc.gov/genomics/diseas...) structure,,signs of coronary heart disease.

 

[KarenK]

Hi Karen.

Sorry to hear about all these issues.

Have you had your Lp(a) tested? Having elevated Lp(a) is known to cause early cardio vascular disease, which would be reflected in a high calcium score. Also, elevated Lp(a) is known to be strongly associated with valvular calcification. In fact, it is estimated that for about 1 out of 7 patients with aortic stenosis the cause is elevated Lp(a). In that you are not bicuspid, yet you have aortic stenosis, and in that you have a very high calcium score, I would strongly suggest getting your Lp(a) checked.

Although cardiologists are gradually becoming more educated about Lp(a), for most of them this is still a blind spot. If it turns out that you have high Lp(a), nothing can be done to change the fact that you need surgery for your aortic stenosis, but it would be an important thing to be aware of long term, as there are some theraputics in the pipeline, with expected FDA approval in about 2025.

Your insurance should pay for Lp(a) testing. If you go to Quest Diagnostics, Lp(a) is included in their advanced lipid panel. LabCorp still does not include Lp(a) in their advanced panel, but you can still order an individual test from either lab for about $ 40 to $55. Even if insurance won't cover it, I would suggest it is worth paying for this test.

Please see links below:

Lp(a) and aortic stenosis:

"What is the evidence we have for Lp(a) as a risk factor for aortic valve stenosis? The epidemiological and genetic evidence is quite strong that high Lp(a) is associated with the development of aortic valve stenosis. Lp(a) is an important carrier of oxidized phospholipids which are considered as an key culprit for the development of aortic valve stenosis."

https://academic.oup.com/eurheartj/article/43/39/3968/6670979
Lp(a) and heart disease and strokes:"

• Like LDL-cholesterol, Lp(a)-cholesterol can build up in the walls of your blood vessels. The higher your Lp(a) level is, the more likely this is to happen. These cholesterol deposits, called plaques, can decrease blood flow to your heart, brain, kidneys, lungs, legs, and other parts of your body. Plaques can grow over time or suddenly rupture, blocking blood vessels and leading to heart attacks or strokes.2
• Lp(a) can cause increased clotting, which can lead to rapidly formed blockages in blood vessels.2
• Lp(a) promotes inflammation which increases the likelihood that plaques will rupture.2

https://www.cdc.gov/genomics/diseas...) structure,,signs of coronary heart disease.

Wow, thanks Chuck!
I think you are absolutely spot on. I had never even heard of Lp(a) until now. There is a familial severe hypercholesterolemia at play here. I had my first cholesterol test at age 30. They couldn't tell me how high my cholesterol was because their equipment didn't go that high. My HDL still runs very high so my doctor thinks that has kept me from much plaque build up.

My father was diagnosed with AVS and an aneurysm but late in life and never had surgery. My sister was diagnosed with both also. She had a poor surgical outcome. The hospital released her to rehab where she passed a short time later.

I have read about people who have had heavy calcium build up again in just 4 - 5 years after AVR. It's puzzled me as to how it could accumulate so fast again. I'll definitely be following this topic and will get checked. That was so terrific of you to provide such information. Thanks again!

 

[Chuck C]

I have read about people who have had heavy calcium build up again in just 4 - 5 years after AVR. It's puzzled me as to how it could accumulate so fast again

Hi Karen.
That is an interesting comment. There are many studies about Lp(a) and aortic stenosis and valve calcification on native valves. However, there is not much published on whether high Lp(a) causes accelerated calcification for bioprosthetic tissue valves. However, the top Lp(a) researcher in the US, who is also a cardiologist, believes that Lp(a) accelerates calcification of bioprosthetic valves (SVD). There is anecdote to support this and a post hoc analysis to suggest this, but there is no randomized trial specifically investigating this, so it might be some time whether it can be said conclusively.

If the evidence grows for Lp(a) elevation leading to rapid SVD for tissue valves, this could very well come into play for valve choice. Between 20 to 30% of the population has elevated Lp(a), and it is 90%+ genetic. There is no lifestyle change which has been shown to lower Lp(a). Also, statins do not lower Lp(a)- they actually raise Lp(a) somewhat, which is odd because Lp(a) is a form of LDL. When heart disease and/or valve disease run in families, often genetic elevated Lp(a) is found to be the culprit. This would especially be the case when the valve disease is not found to be due to BAV.

 

[KarenK]

Hey Chuck,
90%+ genetic, that's surprisingly high. As of this point I don't know if the rest of my siblings have been tested or even made the connection that this might be an issue for them. I separated myself from that unhealthy situation a few years ago but I do need to give them a heads up. I will be forwarding this information long to them.

 

[slipkid]

I realize I am late to the party and this probably has no bearing but based on my own personal past experience I would try to get another echo to confirm the original one (using a different cardiologist & different hospital.outpatient center that reads it).

I had an echo with completely wrong results which I questioned that my cardiolgist at the time did not even know was wrong. Even when I told him about the errors which made zero sense (eg: saying I had aortic stenosis with a calcified tricuspid valve, and also pressure gradients out of line with what my only 5 year old MECHANICAL aortic valve supports) he said he didn't see anything wrong in the report (not to mention the fact that they incorrectly entered the test in my chart as a stress echo when it was a straightforward echo in the first place). I had to basically hold his hand and have him scroll up on his laptop to the appropriate wrong sections in the report. His office/practice was a madhouse btw, seemed like a train station when I was in there. I'll never use that practice again. Long story....