What's a gradient?

[yankeeman]

Had my annual visit to the cardiologist today, and he said that my gradient -- which apparently measures how stiff my aortic valve is getting -- jumped up from 56 last year to 83 this year on the echo. He says that's fairly serious and as a result he has increased the frequency of my visits. He also asked me for the first time what kind of valve I wanted. I'm 57 and was hoping to put this off for four years until I'm 62. Does that seem possible given that number? (I have few symptoms)

 

[bvdr]

A gradient is the abnormally increased pressure that needs to generated in one chamber to pump the blood into the next. The greater the gradient the harder the heart is working to obtain sufficient cardiac output for the needs of the body. That might not be exact but as the valve becomes narrower the force to pump the same amount of blood through becomes much greater. I would think you are quite near having surgery done.

 

[yankeeman]

Thanks for your help on gradients

Thanks for your help on gradients

But I continue to be confused why if this reading shows that the valve is close to needing replacement why I have so few symptoms. I am occasionally winded when walking upstairs and have had a few instances of unexplained fatigue, but I wrote them off to lack of sleep (I work nights) I am tempted to ignore the numbers but I'm afraid of sudden death. (Doc says no more snow shoveling for me and forget about those pushups)

 

[bvdr]

Sometimes people may not think they have any symptoms because they appear so gradually and we unconciously make adjustments in our lifestyles to accomadate. We also make excuses.....I need to take off some weight, I need to start exercising more, I need to get more sleep, I've been working too hard..

Sometimes the heart has become severely damaged before there are any symptoms at all. I think that it has to be very hard to agree to surgery to fix a problem that hasn't been problematic with symptoms. Getting short of breath though IS a symptom though.

 

[bvdr]

Have you read the Guidelines for treating aortic stenosis? IT might help you judge where you are in regards to timing of surgery.

http://content.onlinejacc.org/cgi/content/full/48/3/e1?ct

 

[tobagotwo]

To tack onto to Betty's information, there are two gradients that are concerning, a peak gradient and an average gradient, both measured in millimeters of mercury, similar to barometric readings. The 83 must be a peak gradient, or they'd have you in surgery already.

Even as a peak gradient, that's quite high. You should be asking about left ventricular growth or hypertrophy from your echoes. You are close to surgery.

Do you have any symptoms? Don't deny them if you have them. Not owning up to them can cost you permanent damage to your heart, if the cardiologist thinks you have no symptoms, and can go longer without surgery. Or it could earn you an exercise stress test, which could definitely cause you problems if you do have symptoms you haven't 'fessed up to (maybe even to yourself).

Although we only have one, unlabeled gradient to go by, I would be asking the cardiologist what he's looking to see before he would advise surgery. I would be seriously considering a second opinion from a cardiologist from a different group or from a thoracic surgeon.

Cardiologists are notoriously slow to recommend this surgery. Now is the time to get involved. Be sure that you're not building up damage to your ventricle and atria. Waiting too long can lead to some of the damage being irreversible or to pulmonary hypertension that doesn't go away (many valve patients develop it, but get over it after the surgery).

I don't mean you're ready for surgery tomorrow, or that your cardiologist would wait too long, but I do mean you should be looking at it seriously, and not waiting until you're an emergency case to take some control.

Best wishes,

 

[ALCapshaw2]

I second all of the above responses.

First, if you don't have copies of ALL of your test results (especially echo's), I would collect them.

Look for changes or above normal numbers for your effective Valve Areas and Chamber Size.

Enlargement means that the heart is pumping harder than it should to overcome a smaller and smaller opening. Eventually this enlargement can become IRREVERSIBLE and you will have Permanent Damage to your Heart Muscles / walls.

Oh yes, all of this can happen with NO APPARENT SYMPTOMS, or symptoms that crept up so slowly that you are unaware of them (until you have your valve replaced and get an 'OH WOW!' experience, "So this is what it is like to be normal!"

MANY people who have SERIOUS valve disease report NO Symptoms. Go by the NUMBERS, and let a SURGEON decide on the best time to operate. They like to get in there before your heart is permanently damaged.

It's time to go Surgeon Shopping!

(You do NOT want to be selecting a surgeon from a gurney in some ER!)

'AL Capshaw'

 

[yankeeman]

Thank you Betty and Bob

Thank you Betty and Bob

for your help understanding the latest wrinkle in my ongoing valve issue. I was not aware of the peak gradient business. I will raise that issue with him ASAP. He did say the left ventricle is thickening, so symptoms are probably just around the corner. I have seen some fatigue.

I have become more comfortable with the thought of having my chest cut open as a result of VR.com and am grateful to everyone who has been kind enough to take the time to write.

There are a lot of frightened people out here who are grateful.
Jon T.
Worcester Mass.

 

[davidfortune]

People are different. This shouldn't be a revelation to any of us. Some thin people have coronary artery disease, some fat smokers live without CAD or lung cancer. Some non-smokers get lung cancer.

People are different. Our bodies respond, adapt, and quit at different levels. The heart deals with diminished efficiency (which is what regurgitation is all about) differently in different people. Too many factors (some of which are unknown and will always remain so) to be able to definitively determine causality.

Why do some valves degenerate faster than others? Genetics? God's Providence? Exercise (or lack of) History? Smoking? Cholesterol? Bad Juju? There is often no way to determine. It just is. Sometimes we think we know the reason but really we just have a theory since proof requires repeatability.

Interesting comment from the Doc re: artificial valve always having moderate regurg. I would ask for clarification on that one. What does he mean by artificial? I don't believe that is true for some bioprosthetic valves or for an autograft in the case of AVR.

Trace, Mild, Moderate, Severe.... These are opinions and in most cases educated guesses. Unless you have a MUGGA the interpretation of regurgitation is based on skill of the technician (Huge factor), quality of the echo (Huge factor), and experience of the doc interpreting (Huge factor). There is reasonable variability among all three of these to cause the classification to be a reasonable estimate.

I concentrate more about symptoms or heart measurements.

As others have said sometimes size matters sometimes it doesn't. Relative size always matters if you are lucky enough to have enough history. If your aorta is 1.5 times its normal size that is bad. If you know what normal is for you. If not they can guestimate based on body surface area but it is an estimate.

There are many indicators for surgery and each of us reach that threshold differently. Symptoms and size don't always match.

I would also be looking at the size of the left ventricle. Two measurements here End Systolic Diameter (the smallest size of the ventricle when it squeezes the blood out) and End Diastolic Diameter (the largest size of the ventricle whe it relaxes). When these start increasing it is time to look toward surgery before permanent damage is done (EVEN IF YOU DON"T THINK YOU FEEL ANYTHING).

Rational vs emotional. Hard to reconcile hard cold numbers with how we think we feel. Analytical side of me said "Time to have surgery based on the numbers" Emotional side of me said "I really don't feel anything - at least I think I don't except I get a little winded (translate SOB) going up a flight of stairs but that's just because I'm older and out of shape right???? - NO!!!. SO anyway emotional side got a HUGE jolt by seeing the video of the TEE done a month ago. Surgeon pointed out left ventricle and said it should be This big (approx) and it was THISSSSS big!!! FREAKED ME OUT!!!!!! A picture is worth 1,000 words. Video is worth 1,000,000!!!! Emotional side got on the surgery bandwagon forthwith.

I am going to make the suggestion to my cardio that this is an extremely convincing tool for those of us that don't "Feel" ready.


Best of luck.

 

[Ross]

Yankeeman---Email message for you from a non member. He wanted me to make sure you get this:

Greetings:

I have not registered but I may in the future. Please point out to yankeeman that his jump in gradient could be as simple as a measurement error. Perhaps he needs to get another test at another facility to clear his mind. If the follow-up test refutes the gradient increase, then his insurance will probably pay for the additional test. Surgery is not something to rush.

By the way, my condition is BAV with some symptoms. No more 100-mile runs for me.

Tom
SW Idaho

 

[yankeeman]

The possibility of errors is alarming

The possibility of errors is alarming

Thanks to the person who suggested the test be rechecked. I was alarmed to hear that the next trip to the cardiologist will NOT follow an echo test. That would seem to reduce the usefulness of the visit...I'm afraid it will just be a chance for a pitch on the desirability of surgery. His listening to my heart beat is very interesting but not scientific.

While we're on the subject of surgeons...does anyone have a reliable way of finding out who the best valve replacement surgeons in Boston are? I've seen some of the lists that claim to have the best doctors and they are pretty useless. Seems probable that Brigham & Womens and Mass. General are probably the best hospitals.

 

[tobagotwo]

Those two institutions are always in the top ten, maybe the top five. 'Nuff said.

I am also surprised no echo before the next visit. I agree it seems unlikely to move anything forward without new information. You should obtain your past echo records (allowed by HIPAA) and look at the progression. If it makes sense, there is not likely to be an error. The ventricular hypertrophy you mention is a sign of heart stress, and the SOB and fatigue are symptoms of stenosis. You are not symptom-free, but like many of us, keep relegating the symptoms to other causes (advancing age, out of shape, big meal, etc.).

Aortic stenosis is not a linear progression. It speeds up at the end, as the opening narrows. The worse it gets, the faster it gets worse.

Your cardiologist is unlikely to rush you to surgery. A second opinion is a good measure if you're uncertain. If it's a split decision, you may want a third. However, the hypertrophy is an undeniable telltale. You are getting close, and should look at your options (as you seem to be doing) before it must be done in a rush.

When the time is right, you will likely be scheduled for a cardiac catheterization, to determine how clear your cardiac arteries are, and to double-check the echo results. Often, it's done the day before surgery, but some cardiologists have it done sooner. Just don't wind up having to have it done twice because of timing issues.

Best wishes,

 

[Marguerite53]

All that Bob just said (and others before, too) AND that I can commisserate with you on the cardio appointment without the echo. My cardio is Stanford trained and very experienced and is consistently named as a top cardio in Portland (OR, not Mass ). She was always saying that she was listening for a click. If she didn't hear it she would call for an immediate echo, otherwise, every year was enough. It drove me nuts. I wanted the picture! But there are so many other things these doctors know and look and listen for. At some point, you have to trust their knowledge. That said, it was never good enough for me. I always found a way to get in for an echo every 6-8 months during the 3 years I waited. THe last echo was 4 months before surgery, by my design. She said it was time to start thinking surgery after that one.....I didn't think very long. The click, had in fact, become muted to her satisfaction (or dissatisfaction, I guess).

Yes, there can be errors. Was it a different tech doing the echo? but....I don't think there would be so much room for error with the gradient, though, do you really, guys?? I mean that is a clear point on the echo.....it shoots out and it can be pinpointed. Sometimes the math on the aortic valve opening size can be off, but the gradient? Hm.

Please. By all means, have them mail or fax you all of the echo reports you have had. It is quite helpful to learn to understand them, and to compare your progress.

Most importantly, in my experience, toward the end I really got very symptomatic very quickly and the valve size shrunk accordingly. It was very scary for me toward the end....mostly of my own melodramatic making. Absolutely DO NOT do anything that will cause you sudden bursts of elevated blood pressure. No moving pianos, no shovelling, no pulling hard, etc. etc..

Because of your age, you may get frustrated deciding on which type of valve. Since there is some thickening, and a surgeon may encourage you not to wait years, you might want to start familiarizing yourself with your options. That way, all subsequent visits can be educated ones.

Good luck! The science for all this is wonderful. You will find the right path and be "normal" sooner than you think!! Now's the time to read, read, read!!

Marguerite

 

[yankeeman]

Another question from Yankeeman for Marguerite53

Another question from Yankeeman for Marguerite53

Thanks for sharing your experiences that preceded your surgery. They'll help me to know where I stand re: when to go. The observation about no heavy lifting was prescient...my poor reading of 83 on the gradient recently followed a furniture moving experience from hell involving a sleep sofa moved five times in one day.

It would help me if you elaborated on what symptoms you experienced toward the end. You say you got symptomatoic very quickly. Please elaborate...Jon

 

[MSG Morrissey]

I Have an Aortic St Jude Valve

I Have an Aortic St Jude Valve

Doc's secretary called after a echo this week. says gradient "has changed" and I now need to come in in 6 months. What should I be asking, what does it all mean for a mech valve?

 

[KAJ]

I was one those people who had few symptoms. The changes were so gradual that I hardly noticed the difference other than getting winded from time to time.

Karl

 

[ALCapshaw2]

Just for clarification, from my Dictionary:

Gradient: (Physics) a change in a variable quantity (in this case Pressure, measured in mm of Mercury - mmHg) per unit length.

The Gradient across a valve is the difference in blood pressure (BP) across the valve, i.e. Input BP minus Output BP. This can also be measured (more accurately) during a cardiac catheterization / angiogram.

FWIW, your numbers sound to be on the high side to me (which would mean your heart is working quite hard to compensate for a narrowed opening). Most echocardiogram reports include the NORMAL range for each parameter so get those reports!

'AL Capshaw'