Pressure Gradient: What level when "time" for AVR?

[CATDOG]

From skimming some of the details in people's signatures, I haven't seen any pressure gradients as high as mine yet. What were everybody's "specs" when told that it is time for AVR? My Mean Pressure Gradient was measured at 61 mmHg, and the Peak is listed as 100 mmHg. (AVA calc .8-.9cm2, EF still very good/normal.) I'm assuming higher is not better, but really low is not good sometimes either...? This was a resting echo, not a stress test (which the cardio didn't want to do.)
Does this seem out of proportion? There does seem to be some variation between tests--better one year, then worse again.
Cat

 

[epstns]

I'm NOT the expert here, but although it seems that many hospitals and surgeons have varying statistics for valve area as trigger points for valve replacement, by most that I've heard you are near or at the point where they will begin discussing surgery with you. My aortic valve is now somewhere arount .8cm2 or so and it is being replaced March 1. I've seen that some charts list .6cm2 as "critical AS" but most cardio's will also consider the patient and their symptoms.

The reason we allowed my valve to go so long is that I had no real symptoms until the last few months. Even now, I only have "reduced exercise tolerance" as a symptom. I do not exhibit the "cardinal" symptoms of shortness of breath, fainting or chest pain. We still agree that it is time for replacement before any damage is done to the heart muscle, so off we go to the OR.

If you do not have any symptoms yet, they may still wait if you choose. At your valve area, though, they will probably operate if that is your preference. I think that any valve smaller than .8cm2 is within the insurance companies' approval parameters regardless of symptoms or lack thereof.

 

[ALCapshaw2]

I'm not sure of the exact gradient numbers for recommending surgery (but Lower is Always Better).
Your gradient numbers are definitely on the High Side from what I've seen.

Many Cardiologists and Surgeons use 0.8 sq cm Effective Valve Area as their "trigger" for recommending Aortic Valve Replacement.

 

[CATDOG]

The numbers have been a little unsettling. I'm not symptomatic with the traditional symptoms right now. The cardio said he wasn't really convinced that it was necessary yet, but did ask what I wanted--and I wanted to wait since I don't "feel at risk." My exercise endurance is lower than I'd like, so all I do now is walk once in a while. I'm just wondering if I should have taken the next step this year--even if just to have a plan lined up. So how long does it take to "get in" for a non-urgent case? Did most of you have things arranged within a few months? For those who were asymptomatic, once you took the referral step, did you feel pressured to go ahead at all?

 

[ALCapshaw2]

To my mind, Symptoms are a sign that DAMAGE is being (or has been) done to the Heart Muscles.

At some point, the heart will begin to enlarge (have your checked your chamber dimensions?).
There is a Point-of-No-Return where the Heart chambers may not shrink back to normal size, even with a successful valve replacement. Some members reported that their valves literally fell apart in the Surgeon's Hands even though they didn't think they were symptomatic. Others wrote off their lethargy etc to getting older or out of shape, only to discover that they had Much More Energy after their defective valve was replaced. This is why many of our members believe in the "Sooner is Better" philosophy.

I recommend that you get a Second Opinion, preferably from a Surgeon.
IMO, Surgeon's have a better 'feel' for timing of surgery.
Good Surgeons won't push you into surgery 'before your time'.

There is a 'famous VR saying' that goes:
The Worse it Gets, the Faster it Gets Worse.
This is especially true for Aortic Stenosis.
Some members have gone from 'Serious to Severe' condition in a couple of months.
In my opinion you would be wise to start interviewing Surgeons Now.

'AL Capshaw'

 

[epstns]

A quick note on the timeline for my "elective" valve replacement:

Asked cardio for referrals to surgeons in late December.
Met with two surgeons in early to mid-January.
Surgery scheduled for March 1.

So, here in Chicago, about 2 months elapsing between discussion with cardio and surgery. I could have gotten it done sooner if I wished, but work schedule is tight. If you are lucky enough to be in a city with several good choices of surgeons and hospitals, the scheduling shouldn't be a problem.

 

[neil]

basically agree with what the chaps have said above, good luck

 

[dick0236]

I hesitate about listing my "numbers" since I am not sure how relevant they are in "modern" terms. I just answered the thread on "sudden death" since my docs back then really got my attention with telling me I was a candidate for sudden death. FWIW my gradient across the Aortic valve was measured at 117mm and I had NO symptons. I have no idea how this number relates to current gradient measurments, but maybe it can help put some of this stuff into persepective. I had known for years that I had a severe "murmur", but I had to put a lot of trust in my cardio and surgeon that "now was the time"....glad I did.

 

[Mentu]

Listen to Al! Look, your pressure gradients should be near ZERO - your's are high. You are at a point when your valve area can drop really fast and, as it does, you pressure gradients will go up even farther. If you have seen fluctuations in calculations of valve area and measurements of pressure gradient, it is likely you were just seeing the results of echo-cardiograms being performed by different technicians and analysis conducted by different doctors.

Right now, your heart is doing its best to compensate for the reduced valve area. The immediate result of this is that the heart must increase the pressure necessary to move enough blood through the valve orifice that is growing smaller. In order to increase the pressure of blood flow through the valve, your left ventricle is becoming enlarged and the walls of the ventricle are thickening and becoming stiff. When surgery is postponed, the hypertrophy of the left ventricle can progress to a point where the damage is permanent leaving you unable to be as active as you might like to be after surgery. The primary problem is then called diastolic dysfunction; the left ventricle cannot fully relax so it can never fill completely thus reducing the amount of blood your heart can move at each beat and causing blood to back up intp your lungs. This can be bad enough that one must seek treatment for congestive heart failure.

Doctors like to see obvious symptoms but not everyone displays them at the same point in the degeneration of a heart valve. By the time I was recommended to my surgeon, I realized that I had displayed mild symptoms for at least a year and a half but I always found some other explanation for them and because they were mild, my cardiologist pretty much ignored them. He could not quite believe that my valve was deteriorating as fast as it did during that last 18 months. He only made an appointment for me with a surgeon when I began having chest pains. Today, at 16 months post op, I continue to very slowly improve but because of the diastolic dysfunction, my tolerance for exercise has not returned to normal; hopefully it will over the next couple of years.

Waiting for severe symptoms to appear can have costs which you will have to live with...not your cardiologist.

These numbers change a little depending upon source but all are pretty close to these:

Normal.......................Mean Pressure Gradient...close to 0 mmhg
Mild Aortic Stenosis.....Mean Pressure Gradient...less than 25 mmhg
Moderate Stenosis.......Mean Pressure Gradient...25-45 mmhg
Severe Stenosis..........Mean Pressure Gradient...greater than 45 mmhg
Critical Stenosis..........Mean Pressure Gradient...greater than 70 mmhg

Which one are you closest to?

Larry

 

[drivetopless]

My pressure gradients at time of surgery were around 48mmHg, but had been slowly creeping up. Peak gradiant was in the 60s. AO diameter was .7-.8cm2. The right ventrical had just barely started to enlarge about 1 year prior to surgery. I had become increasingly symptomatic with exertion and was tired of not being able to keep up with friends when we walked around.

I asked my surgeon how bad my valve looked when he replaced it, and he said it was bad, but not the worst he had ever seen. My goal was to put off surgery as long as possible without compromising the long term function of my heart (no irreversible damage), which hopefully is what happened (too soon to tell.).

Haven't been tested yet, but my pressure gradients should now be under 10mmHg.

Sounds like it might be time for you to talk to a surgeon for an opinion at the very least. Good luck!

 

[CATDOG]

Thanks for the replies! Consensus seems to be that it is time for at least a consult with a surgeon. Thanks for not making me feel like a hyperchondriac. I don't like the words "mild LV hypertrophy" and "suggest mildly impaired LV relaxation", though my own cardio seemed to think it was maybe worded a little too strongly. This fall was the first time the echo reports said anything like that--but it was a different tech and cardio doc reading it than usual. Before that, it was always the same doc reading it (mine), but a different tech each time.
Did everybody go to a local surgeon as a first surgical consult? Or did you go first to where you thought you'd probably want to actually have the surgery. I live close to 2 hospitals that do open heart surgeries, but I don't think they are really major centers, but I could be wrong. I'm not sure how good they REALLY are for valve surgery--especially for BAV, though I do not see anything in the echo report to imply any sign of aneurism, etc. I'm 4-5 hrs from Cleveland by car, so I might be interested in that direction, though the travel expense would be hard to budget for multiple trips and we'd have to fly home after any surgery, find somebody to stay with kids, pets, all the usual travel stuff. Thinking about all the extra stuff leads me to think maybe start with a local surgeon first. Summer sure sounds like a better idea than winter however, but maybe this summer is too soon. Ok, I'm thinking too much and maybe just need to concentrate on one thing at a time.
My next dr appt is in a month with the pcp so I will see if he will talk to the cardio again or just make the request.

 

[ALCapshaw2]

Yes, your numbers would suggest that it is time to be interviewing Surgeons.

If your BAV is congenital, there is a moderately high possibility of a Connective Tissue Disorder and the often associated Aortic Aneurysms so it would be wise to find a Surgeon with Experience recognizing and dealing with those issues. Such Surgeons are most often found at the Major Heart Centers. 'Local Surgeons' tend to see mostly Coronary Artery Bypass Graft patients and maybe a 'few' relatively simple Valve Replacements. Be sure to ask any/all surgeons you interview about how many BAV patients they see per year and how many surgeries of the Aorta they do per year. If it's only a few, I would keep looking. You might even just call their offices and ask those questions. If they don't want to tell you, it's probably because they see very few such patients and don't want you to know that.

The Head of the Connective Tissue Disorder Department at Cleveland Clinic is Dr. Lars Svensson.
You can find more information about his background by doing a Google Search.

 

[epstns]

As for the question of where I went for my initial surgical consult, I discussed surgery with my cardio and asked him for several referrals to surgeons he would send his parents to. (But. . . I forgot to ask whether he got along with his parents or not!)

I met with two of the three he suggested and chose the one with whom I was most comfortable. Comfortable not in a "friendly" sense, but in the sense of their qualifications, their experience and the reputation of the facility where they would operate. This process works for me. Of course, being in Chicago, all of the choices were local.