Which test is most crucial to decide about AVR ?

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plsflgood

Member
Joined
Dec 27, 2011
Messages
24
Location
California
Of course, the decision about whether to undergo an AVR, or not, is based on overall assessment, which is based on many tests etc. But still, which test provides the most information to make a decision:
1. Echo cardiogram
2. Angiogram (including lung pressure measurement)
3. Patient's symptoms
4. Something else ?
 
I suspect you might get different answers from different folks. In my case, I had a known BAV so was having yearly echos until the valve area got down to about 1 cm2. Then I had them every 6 months. But my cardiologist was very clear that he was not so concerned about the numbers as he was about the presence of symptoms. As long as I had no symptoms and there was no evidence of damage or impending damage to the heart itself, he felt the risks of surgery and going on anticoagulant therapy ( i already knew I wanted a mechanical valve) outweighed the benefits at that point. I was instructed to let him know immediately when/if I developed symptoms. When they developed, I let him know and that was the deciding factor to get the AVR. After the decision was made, I had another echo and a cath to get more details to get a good preop baseline and also a CT/angiogram of the chest to check for a suspected aneurysm.
Actually, I wanted to have the surgery before I had symptoms, while I felt good, but he did not recommend that in my case. Regardless, it worked out very well.
 
I think the echo cardiogram shows the valve problem very clearly because it actually shows blood flow in velocity which can be converted to pressure.
 
Cardiac MRI with contrast. Probably, the most expensive one of all the tests. Mine was done at NIH as a part of a study, but it shows everything in 3-D and makes it very easy for any medical professional including mere mortals like us to be able to see things exactly.
 
Actually cardiac MRI is horrible for aortic stenosis, I assume its the same for aortic regurgitation. When an echo had my valve at moderate to severe (1.08cm) the cardiac MRI report had mild stenosis. My cardiologist said they don't use MRI at all to measure aortic stenosis, for that they rely on the echo.

Now for an aneurysm I believe cardiac MRI with contrast is best.
 
I Had no symptoms, but doc heard murmur. So for year and a half I went in for echos and Ct Scans which were used I think because they were looking at artery for increase in size. They then did an angiogram and doc came in and said it showed the valve was not closing all of the way and it was time to replace. They had been uable to tell if BAV and even did another CT scan a few days beofore surgery to try to see. Turned out it was not a BAV and the artery was left alone when they got in there even though it was showing 5.0 in size. The doc who did the surgery said the valve was just flapping in the breeze. So, I am quessing it is a combination of tests that show them. Good news was angiogram showed arteries clear, so no extra work.


What was interesting is that the doctor had a hard time finding the murmur on the next few appointments. And the surgeon had issues with surgery as the heart was enlarged due to valve.
So, I was lucky doc caught it the one time.


Since I did not find this place until after the surgery, I did not know to ask for numbers on how bad it was leaking. The pressure numbers?
 
Actually cardiac MRI is horrible for aortic stenosis, I assume its the same for aortic regurgitation. When an echo had my valve at moderate to severe (1.08cm) the cardiac MRI report had mild stenosis. My cardiologist said they don't use MRI at all to measure aortic stenosis, for that they rely on the echo.

Now for an aneurysm I believe cardiac MRI with contrast is best.

Two things, Cardiac MRI = very expensive, Echo = much cheaper.

It is a very interesting point you are making. I will provide a rebuttal with the following. Each cardiac MRI has a purpose of the study. The test is capable of taking an image of the cross-section of your body/organs/etc. They can look at your valve itself opening and closing and even get leaflet shots if this is what they want to see. Heck, they could get shots of your leaflets cross-sectionally if they slow your heart-rate down and have an experienced enough technician and new enough closed MRI equipment. Either way, if the MRI study's purpose was to look at your aorta for aortic aneurysms, etc., they might spend most of the 40-60 minutes looking at that and then use approximation techniques and less imaging for Aortic Valve Area, etc.

On the other hand, I agree that Echo (doppler test) done by an experienced technician who gets all the angles right will measure the blood speed through your valve with highest accuracy and then using the formula will calculate the Aortic Valve opening precisely. Of course, the problem with echo's a lot of times is that everything is calculated and approximated. So, a 15 degree angle in the technician's doppler usage will also skew the velocities and the results.

For example, my AVA (measured with the echo) over past 2-3 years went up and down .1-.2 cm^2 every year. We went from 1.2 cm^2 2-3 years back to 0.9 cm^2 to 1.0 cm^2 to 1.1 cm^2 this year (this is all for my AVA). Hence my cardiologist wanting the cardiac MRI to confirm results. In his words 1.2 to 0.9 change is reasonable and we need surgery soon. 0.9 to 1.0 is about same, so lets keep an eye on it. 1.0 to 1.1 wait a second it was 0.9 a year back, lets use a different test to confirm things. He personally reviewed all the echo results and even double checked them, but there can be such thing as machine imprecision or technician's error.
 
No test is 100% accurate or shows exactly the same things in the same way. There are too many variables, as noted above. That is exactly why docs have us undergo a variety of tests, consider the results, and then look at the patient's level of activity/lifestyle, age, symptoms, what they see for themselves, etc. and take it ALL into account when making a recommendation for surgery. They treat patients, not test results.
A personal example of imperfect testing: my surgeon thought, when he reviewed the cath/angiogram CD, that he saw a possible aneurysm. I had a CT/angiogram with 3D reconstruction to confirm but it did not show anything unusual. When he got in there to do my AVR, he could see for himself that I did, indeed, have an ascending aortic aneurysm, which he repaired as well. We had talked about this possibility ahead of time but i did not know until after the surgery if I had an aneurysm or if I didn't.
Personally, I want a doc who is going to look at ME as well as my test results.
 
And the final test is when the surgeon tells you after surgery that your valve was way worse than they thought. He said I should actually notice the increased blood flow. That hasn't actually happened yet. Maybe once I get back to full activity.

The impression I got through all of my tests is that it's just plain hard to get a good view of the valve so they count on things like pressure gradient to deduce if there is a problem.

In my case they did have a perfect 3D model of my aorta that the doc could rotate on the screen. That was all I needed to see to know I was having surgery.
 
Your condition will likely be tracked with echocardiograms until it gets to a final decision point for surgery. It's the primary diagnostic tool for gauging valve disease progression, an din the hands of a good echo technician, it can be extremely accurate.

At that juncture, a TEE (trans-esophogeal echocardiogram [down your throat]), a cardiac MRI (sometimes called an MRA - magnetic resonance angiogram), or even a cardiac catheterization may be requested, as they are generally held to have even greater accuracy, and offer a cross-check by a different technology. Some cardiologists will order a stress test or exercise stress test as well, but that is not recommended by the AHA or the ACC for aortic stenosis (unreliable results and some danger to the patient - see their website), so I have entirely refused them myself.

You may opt to avoid any of these, if your cardiologist agrees that you're within the guidelines for surgery (valve area less than 1 cm² with concurrent symptoms, e.g., shortness of breath, angina, palpitations, etc.), or if your thoracic surgeon agrees. The TEE and the MRA are the least invasive. I've had an MRA, and it was a piece of cake (and I'm claustrophobic). I've always turned down TEEs (some people say no problem, others are not so enthusiastic - I tend to choke, so I requested the MRA instead).

However, once the decision for surgery is actually made, it's extremely likely that you will be required to undergo cardiac catheterization a day or so before surgery, to ensure that your valve situation is bad enough that the surgery is required. I've never had a result that varied significantly from the regular echocardiogram, and in truth, the surgeon's estimation of the actual site at surgery time has been right in tune with both. However, it can happen, if the echo tech was not competent, so I guess it's worth the extra check.

Best wishes,
 
plsflgood my first thought after reading your post was...ALL OF THE ABOVE. I think a good cardiologist and/or surgeon will take all things into consideration. Having said that I think the echo is most used to follow the progress of valve deterioration over time. If you have aortic disease (root or ascending aorta) then a MRI or CT Scan will probably be used to get an accurate measurement of the dilation.

I developed dilation of my aortic root and ascending aorta a few years after my first surgery. They weren't too concerned at the time but with each echo there was a steady increase in size and my regurgitation was increasing. They ordered a MRI to get a more accurate reading and the dilation was larger than what the echo had shown. When I had my consult with the surgeon he ordered a CT Scan (he said a CT Scan is the "gold standard" for measuring aortic dilation) and the dilation was significantly larger than what the MRI showed. When he actually performed the surgery it was even larger than what the CT Scan showed. But for purely diagnosis of the valve I personally think an echo and TEE will give the cardiologist/surgeon the information he needs. If anyone is interested here is what the differences were in my measurements for my aortic root / ascending aorta by each method of measurement. These tests were all taken within approximately 3 months from my actual surgery in chronological order. The echo was mainly to measure the regurgitation of my valve (moderate to severe) but they attempted to get a reading of my dilation as well.

Echo: Root - 4.3 / Ascending - 4.7
MRI: Root - 4.8 / Ascending - 5.4
CT Scan: Root - 5.2 / Ascending - 5.8
At Surgery: Root - 5.4 / Ascending - 6.0

As you can see the CT Scan was the most accurate of the 3 tests. The MRI results got me a date for a surgical consult and the CT Scan results got me a date with my surgeon within 3 weeks.
 
Relative to aorta monitoring, the ACC/AHA Thoracic Aortic Disease Guidelines have a very informative summary of some of these issues (like us "old" folks above the age of 35 who are supposedly more radiation proof! :cool2: ):

"Selection of the most appropriate imaging study may depend on patient-related factors (ie, hemodynamic stability, renal function, contrast allergy) and institutional capabilities (ie, rapid availability of individual imaging modalities, state of the technology, and imaging specialist expertise). Consideration should be given to patients with borderline abnormal renal function (serum creatinine greater than 1.8 to 2.0 mg/dL)—specifically, the tradeoffs between the use of iodinated intravenous contrast for CT and the possibility of contrast-induced nephropathy, and gadolinium agents used with MR and the risk of nephrogenic systemic fibrosis. Radiation exposure should be minimized. The risk of radiation-induced malignancy is the greatest in neonates, children, and young adults. Generally, above the age of 30 to 35 years, the probability of radiation-induced malignancy decreases substantially. For patients who require repeated imaging to follow an aortic abnormality, MR may be preferred to CT. MR may require sedation due to longer examination times and tendency for claustrophobia. CT as opposed to echocardiography can best identify thoracic aortic disease, as well as other disease processes that can mimic aortic disease, including pulmonary embolism, pericardial disease, and hiatal hernia. After intervention or open surgery, CT is preferred to detect asymptomatic postprocedural leaks or pseudoaneurysms because of the presence of metallic closure devices and clips. We recommend that external aortic diameter be reported for CT or MR derived size measurements. This is important because lumen size may not accurately reflect the external aortic diameter in the setting of intraluminal clot, aortic wall inflammation, or AoD. A recent refinement in the CT measurement of aortic size examines the vessel size using a centerline of flow, which reduces the error of tangential measurement and allows true short-axis measurement of aortic diameter. In contrast to tomographic methods, echocardiography- derived sizes are reported as internal diameter size. In the ascending aorta, where mural thrombus in aneurysms is unusual, the discrepancy between the internal and external aortic diameters is less than it is in the descending or abdominal aorta, where mural thrombus is common."

My bicuspid aortic valve stenosis and ascending aorta aneurysm monitoring story is as follows: I had an echo done 35 times (one for each year of my life) prior to surgery. When the last echo measured part of my ascending aorta at 5.0 cm, a dramatic increase from years prior, a CT scan was ordered (which confirmed). A week later came the cardiac cath, followed 3 weeks later by my surgery, already scheduled before the cath. From now on, it will be yearly echo with periodic CT "as needed". Due to my shiny new pacemaker, MR is no longer an option, but so long as the radiation continues to suit me well :rolleyes2: , no problem and no real limitations from a cardio monitoring standpoint.
 
ElectLive,

Yes for yearly monitoring I will be having a cardiac MRI with contrast and only get a CT scan "as needed". My surgeon is one of the rare ones that follow his patients for life and I will see him annually for a MRI and checkup. I also see my cardiologist annually for an echo and checkup as well (6 month interval from surgeon checkup). I will ask my surgeon why he prefers a MRI over a CT scan since I fall within the "old folks" category. It could be that he is checking the valve as well but that is being monitored by my cardiologist...sounds like there might be some redundancy there.
 
I had murmur of the aortic valve since birth. When it was time to replace was when during a routine echo did audio and I heard the loudest shoush ever, my jaw dropped with a heavy thud to the floor. I have been sounding good since replacement, also with a St. Jude's aortic valve. I hope to never hear that again, but never is not forever, it can come back. But in the meantime, I am doing well. and getting some much needed weight off this year. So far, 20 pounds and will keep on going. That took me a year for the 20, got more to go. So cardio is happy with it also. Hugs for today.
 
I agree with the 'all of the above' in that, from my experience, everyone if different. I think predicting the time for surgery can be as nuch of an art as a science for cardiologists. I had no symptoms when they found a heart murmur. I then went on to an echos and a TEE for intial diagnosis of my moderate to severe aortic reguritation' with an estimate of surgery being needed in 4-6 years. I was then put on a six month cycle of echos and all was stable the first year, except I started getting symtoms (SOB mainly) and opted for surgery. When I got to my planned date a few months later, I was really feeling poorly and glad I was getting it done. My surgeon told my wife "your husband's valve was shot". So, even with good tests and some good 'numbers' they don't always mean the same path for everybody.
 
Personally, I find Cardian Echos to be very vague for anything that may be mildly complicated. I say this because Skyler had 2 valves that we were dealing with, as well as an aneurism in the ascending aorta. Echos are fine for getting estimates of pressure across one valve, but as soon as there are two valves that are one after the other they are lowsy. All estimates were WAY off so he had to have a TEE/cath a couple times in the 3 years before surgery. These came back, with flying colours.

But the Echo, TEE and MRI all have a very big limitation which is that they are all done when the body is AT REST. Skyler was dealing with an undersized valve (he got it when he was 4 months old, and he was 12.5yo). This meant that at rest, it was fine. But at the slightest bit of exercise he would have trouble (going up 6 stairs, taking a shower). I don’t remember the name of the test, but it was when they finally put him on the EKG with bike and oxygen/CO2 monitoring that the doctors finally said “It’s surgery time”. Why? Because he couldn’t even get his heart rate elevated sufficiently to do the test without passing out! Now why did it take 3 years to listen to us to get to that point? Who knows. But it did mean that he likely will not need another surgery since they were able to put in a 25mm On-X valve (after his 17mmm St. Jude). Effective Aperture Size is more than 3x bigger for the mitral valve, and boy does it make a difference!

So, yes, you can get data from all tests, but depending on your condition, some may give you more useful information than others, and it’s the combined results that will do best.
 

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