New Echocardiogram Results.

[Christina]

I recently changed cardiologists after more than 7 years and believe I did the right thing. The previous cardio office had gotten so big that they didn't take enough time for each patient and there simply wasn't enough time given for patients to ask questions. The new cardio sat and talked with me for 20 minutes or more. Asked ME all kinds of questions. Never made me feel rushed. Plus he does echo's every year. When there are problems they do them as needed.
Well, there was something wrong and the cardio said that the Mean gradient is too high again. He said, we might be able to control that with meds, but no guarantee. It might be caused by my 19mm St. Jude's valve. I just read in my records at time of surgery in 8/2000 that the Mean gradient was 44 then. Today it was 45. He wants me back in 3 months and see how I am doing. If problems arrise to call him. I think I am doing okay though. Just came back from the reunion and Pam and I easily walked between 5-10 miles one day when we were at Epcot Center. Felt tired at the end of that day but it was a long day and being tired then is understandable. We'll see how this will pan out. I certainly don't look forward to another surgery. That would be my 3rd.

I need some help in reading the results and hope that some of you can help and decipher all this. Is the Mean gradient really that high that a 3rd surgery is warrented in the next few years?

2D
IVSd 1.4cm
LVIDd 3.6cm
LVPWd 1.2cm
LVIDs 2.5cm
LVOT Diam 1.7cm


Doppler

TR Vmax 2.69m/s
TR MaxPG 28.91mmHg
MV E Vel 1.21 m/s
MV A Vel 1.36 m/s
LVOT MaxPG 14.99mmHg
LVOT MeanPG 7.33mmHG
AV Vmax 3.98m/s
AV maxPG 64.44mmHg
AV meanPG 45.06mmHG
AVAVmax 1.2cm2
AVA (VTI) 1.2cm2

Findings:
Study quality: Technically adequate
ECG rhythm: Sinus
Chmber size: Atrial and ventricular chamber sizes are within normal limits .

Left Ventrical: Moderate concentric left ventricular hypertrophy. left ventricular systolic function is normal with an EF of 60%
Tricuspid Valve: Structurally normal. Tricuspid regurgitations is mild. Pulmonary artery systolic pressure is 29 mmHg plus the central venous pressure.
Pulmonic Valve: Not well visualized. Pulmonic regurgitation is mild.
Mitral Valve: Mildly Calcified. Leaflet excursions remain clearly visible. Mitral regurgitation is mild.
Aortic Valve: Mechanical prosthetic valve with mean transvalvular gradient of 45mmHg.
Pericardium: Normal
Aorta: Ascending aorta arch are of normal caliber with no significant atherosclerotic disease.

Date 03/04/2008

 

[Mary]

Christina, my mean gradient was 56 when I had replacement. Is the cardio going to run another echo when you go back in three months? Any chance that this one was wrong?
I know this is worrisome, but try not to worry.

 

[queenie]

Christina, you and I are in the same boat. He is telling you that the force going through your mechanical aortic valve is too hard. The heart is having to work too hard. I have found in my research that it is caused by two things--thrombus or pannus. It could also be a combination of both but, something is obstructing the flow. How long have you had your mechanical valve? Mine is 5 years old and has been increasingly restricted for the last 3 years. My peak gradient is 82 and my mean is 45.6. I am seeing a surgeon at Duke in two weeks. This will be my second surgery, Did you have a tissue valve before? I am sorry you are going through this but, it's nice to know I'm not alone. Take care,

 

[Susan BAV]

I probably ought to dig out my papers but I recall that several months preop my family doctor looked at my echo and said that my gradient at 55 was not good--but I don't recall if that was the mean or the peak. But it was that phrase, gradient 55, that I began researching; and I found a lot of information with just that simple search. Perhaps I used the word heart or something also in my web search. (A few weeks ago I confused an EF measurement with a gradient measurement in a post and had to delete it but sent a PM so I hadn't confused the member with my erroneous information--can I blame that on pumphead ?)

Anyway, Christina and Queenie, I hope you find some answers. Hoping all goes well for you both,

 

[Mary]

I probably ought to dig out my papers but I recall that several months preop my family doctor looked at my echo and said that my gradient at 55 was not good--but I don't recall if that was the mean or the peak. But it was that phrase, gradient 55, that I began researching; and I found a lot of information with just that simple search. Perhaps I used the word heart or something also in my web search. (A few weeks ago I confused an EF measurement with a gradient measurement in a post and had to delete it but sent a PM so I hadn't confused the member with my erroneous information--can I blame that on pumphead ?)

Anyway, Christina and Queenie, I hope you find some answers. Hoping all goes well for you both,

Susan, if it was pre-op, I'm sure it was the mean.
55 as the peak would probably indicate moderate stenosis.
A peak of 82, with a mean of 45, would be worrisome and probably indicate an appointment with a surgeon was in your future.

 

[ALCapshaw2]

Christina, you and I are in the same boat. He is telling you that the force going through your mechanical aortic valve is too hard. The heart is having to work too hard. I have found in my research that it is caused by two things--thrombus or pannus. It could also be a combination of both but, something is obstructing the flow. How long have you had your mechanical valve? Mine is 5 years old and has been increasingly restricted for the last 3 years. My peak gradient is 82 and my mean is 45.6. I am seeing a surgeon at Duke in two weeks. This will be my second surgery, Did you have a tissue valve before? I am sorry you are going through this but, it's nice to know I'm not alone. Take care, (Queenie)

Interesting summation Queenie.

Christina - It would be informative to learn the Root Cause of your elevated gradient. ASK your new Cardio to elaborate on this point.

If either of the causes cited by Queenie are the cause, I believe the On-X Valve may offer some improvement with it's harder and smoother surfaces and barrier to prevent or at least retard pannus growth.

Unfortunately, pannus growth is a reaction of Your Body and seems to be independent of valve type (i.e. it can happen with mechanical or tissue valves).

'AL Capshaw'

 

[Christina]

Christina, you and I are in the same boat. He is telling you that the force going through your mechanical aortic valve is too hard. The heart is having to work too hard. I have found in my research that it is caused by two things--thrombus or pannus. It could also be a combination of both but, something is obstructing the flow. How long have you had your mechanical valve? Mine is 5 years old and has been increasingly restricted for the last 3 years. My peak gradient is 82 and my mean is 45.6. I am seeing a surgeon at Duke in two weeks. This will be my second surgery, Did you have a tissue valve before? I am sorry you are going through this but, it's nice to know I'm not alone. Take care,

Queenie,

Thanks for taking the time to post and for caring.
I have had this St. Jude's mechanical valve for going on 8 years this August. My previous cardio allowed echo's every two years. I don't know what to compare the numbers to though. Their handwriting leaves a lot to be desired. What is a good mean/peak gradient and what is bad?
Below are the numbers that I posted previously. I believe the numbers above the Mean Gradient are the Peak gradient. Just guessing.
I had forgotten to ask him the question about heavy lifting so I put in a call to the cardio's office on Wednesday to ask if I had any restrictions. They returned my call and told me not to do any heavy lifting.
I have to see him every three months from now on and if anything comes up in the mean time to call for an immediate appointment.
He seems to think that the too small Aortic valve (19mm) is the cause.
I hope to avoid a 3rd surgery at all cost.

Christina

2D
IVSd 1.4cm
LVIDd 3.6cm
LVPWd 1.2cm
LVIDs 2.5cm
LVOT Diam 1.7cm


Doppler

TR Vmax 2.69m/s
TR MaxPG 28.91mmHg
MV E Vel 1.21 m/s
MV A Vel 1.36 m/s
LVOT MaxPG 14.99mmHg
LVOT MeanPG 7.33mmHG
AV Vmax 3.98m/s
AV maxPG 64.44mmHg
AV meanPG 45.06mmHG
AVAVmax 1.2cm2
AVA (VTI) 1.2cm2

 

[Christina]

Interesting summation Queenie.

Christina - It would be informative to learn the Root Cause of your elevated gradient. ASK your new Cardio to elaborate on this point.

If either of the causes cited by Queenie are the cause, I believe the On-X Valve may offer some improvement with it's harder and smoother surfaces and barrier to prevent or at least retard pannus growth.

Unfortunately, pannus growth is a reaction of Your Body and seems to be independent of valve type (i.e. it can happen with mechanical or tissue valves).

'AL Capshaw'

Al,

I'll have to write this down and ask the cardio the root cause of my elevated gradient when I see him in June or put in another call and ask him to elaborate on this point.
Do I understand it correctly that Pannus growth is the same as scar tissue?
Does the On-X valve need to be anticoagulated?
If another surgery is unavoidable I am thinking of going the tissue (Porcine) route this time. The reason for this is as I am getting older (61 presently) it'll become more difficult to convince doctors/nurses that I can handle the dosing/protimes myself. I am very afraid of anyone else handling my Protimes and dosages. Too many mistakes are made and too many people end up in nursing homes because of clots/strokes or end up dead.

 

[Christina]

Christina, my mean gradient was 56 when I had replacement. Is the cardio going to run another echo when you go back in three months? Any chance that this one was wrong?
I know this is worrisome, but try not to worry.

Thanks Mary for answering.
He didn't say if he was going to do another Echocardiogram in June. He just wants me to come see him every three months. We'll see what happens in those coming months. I hope they will be able to control this with medicine because I have a European trip planned and paid for in September 08.
I am feeling pretty good though. Not anything like in 2000 before my first surgery. But we humans tend to compensate for the way we are feeling so what do I know. I know that I am SOB but that is also caused by sinus issues. It is difficult for me to breathe through my nose. I had sinus surgery in 1988 ( see my reply to BobH from about a week ago) and am afraid to go through a second surgery because I am on Coumadin now and let us not forget Heparin. They have to check all the Heparin supplies in this country because of contamination from China. Very scary in my opinion.

 

[ALCapshaw2]

Al,

I'll have to write this down and ask the cardio the root cause of my elevated gradient when I see him in June or put in another call and ask him to elaborate on this point.
Do I understand it correctly that Pannus growth is the same as scar tissue?
Does the On-X valve need to be anticoagulated?
If another surgery is unavoidable I am thinking of going the tissue (Porcine) route this time. The reason for this is as I am getting older (61 presently) it'll become more difficult to convince doctors/nurses that I can handle the dosing/protimes myself. I am very afraid of anyone else handling my Protimes and dosages. Too many mistakes are made and too many people end up in nursing homes because of clots/strokes or end up dead.

The On-X valve is current in FDA approved Studies to evaluate NO anti-coagulation (for LOW Risk patients) and LOW anti-coagulation (for Mild Risk patients). Bottom Line, until those studies are completed (in 2015) patients are urged to maintain the usual recommended INR's. That said, you would still benefit from the reduced clot potential from the new design (very little turbulence, harder / smoother leaflet sufraces, improved pivots, and the pannus barrier).

I *think* pannus growth is soft tissue growth, possibly due to the 'irritation' of having a foreign object (the valve) sewn into the oriface. (I'm 'guessing' a bit here.)

'AL Capshaw'

 

[pamela]

Pannus tissue cells precipitate out of the blood onto the less turbulent side surfaces of the valve and is a sticky collagen that your body uses to build connective tissue. It is an undesirable response to the inflammation around a sensitive, parchment tissue or keloidal scar. Unfortunately, the build up of cells is exponential, meaning that one begets two begets four, then eight and so on. My surgeon decided to replace the aortic root and valve in order to move the actual scar on the aorta further away from the valve, resulting in a more laminar surface inside the vessel.

 

[Susan BAV]

Christina, does your cardio think your valve is "too small" for you, as in it's not a good fit? Or does he think your natural valve opening is just small? Mine is 21mm, pretty small too, from what I've read here. If the small valve is the issue, and it's not the other situations suggested, is there a safe way to put a slightly larger valve in for you next time?

Also, regarding the possibility of pannus, does anyone know which test, an echo or a TEE, can better reveal pannus?

Hoping you get good answers and better news, Christina.

 

[queenie]

Christina, scar tissue and pannus are the same. One surgeon I interviewed looked at me the moment he entered the room and said "What is wrong with you is patient prosthesis mismatch- the size valve you have should only be in an 80lb.80 year old woman sitting in a rocking chair"--I replied" have you read my operative notes?" My root had to be enlarged with a pericardial patch in order to make a 19mm fit. Everything in my body is too small (my derrrier is not included in this however) I beg to differ with that opinion since I felt really good for the first two years after my surgery and only the last three with increasing gradients being detected on the echo correlating. I didn't know the gradient was increasing until this past December but, had been complaining to the cardio that I was increasingly tired. I like you am actually feeling pretty good right now. Since December I have made major lifestyle changes that are making me less tired. The Dr's have told me to take it easy so I am. I nap every day and am hardly working. I am living a sedentary life. So, sometimes I feel this is all a mistake---I'm fine---but, everytime I look at my echo reports I know fooling myself isn't going to change the facts. Maybe you do feel good because you have adjusted your lifestyle so your heart doesn't have to work so hard every day. If your cardio doesn't automatically do an echo in June demand one. The tighter the valve gets it seems to close off quicker. Has anyone else had that experience that the progression is faster towards the end? Take care Christina

 

[ALCapshaw2]

Queenie wrote:

"Has anyone else had that experience that the progression is faster towards the end?"

There is an old expression on VR.com that says:

" The Worse it Gets, the Faster it gets Worse"

That pretty well sums it up (which applies mostly to the Aortic Valve.
Mitral Valve Disease progression tends to be slower.)

'AL Capshaw'

 

[queenie]

Thanks Al* I didn't think it was my imagination.

 

[Christina]

Christina, does your cardio think your valve is "too small" for you, as in it's not a good fit? Or does he think your natural valve opening is just small? Mine is 21mm, pretty small too, from what I've read here. If the small valve is the issue, and it's not the other situations suggested, is there a safe way to put a slightly larger valve in for you next time?

Also, regarding the possibility of pannus, does anyone know which test, an echo or a TEE, can better reveal pannus?

Hoping you get good answers and better news, Christina.

Susan,

The surgeon put in a 21mm at my first surgery (8/7/00). Second one (8/18/00) he put in a 19mm and all the reports have stated that it has "seated" well during the almost 8 years since I've had it implanted. I've liked this valve much better than the Sultzer Carbomedics valve he first implanted. The 2nd one (St. Jude's) has done well for me. Now there seems to be a problem because the Mean Gradient has gone up and right now stands at 45.
The cardio said that the small valve could be the problem but he isn't sure, but there definately is something that isn't right.
I have decided not to worry about it but I can't help thinking about it a lot. I am feeling pretty good but do tire easily. I also don't always sleep well and wake up a lot during the night. Then I wake up in a fog and it takes me quite a while to get going. But that might have nothing to do with it. What do I know!

 

[ALCapshaw2]

Hmmm.....

I'd want to know WHY your Gradient is going up.

If your Cardio can't tell from your EchoCardiogram,
perhaps he should perform a TEE to get a better picture of how the valve is working.

'AL Capshaw'