10 yr old aortic tissue valve - results of stress echo - how worried should I be?

[tigerlily]

Hello everyone. It's been a long time since I was here. I've been busy living my life but I owe this group a lot. After a bout with pneumonia this past spring, I noticed some irregular heart symptoms, mainly breathlessness and sometimes when exerting myself, my upper arms felt a bit achy. I decided I should be evaluated by my cardiologist. My symptoms have gotten better and I don't notice the upper arm problem anymore so some of this may be about recovering from the pneumonia. I had an aortic valve replacement in March of 06 when I was 53. I chose to have a tissue valve replacement and I've done well with it. Today, the PA who ordered my stress echo called about the results but I wasn't available and my husband took the call. Of course, I didn't get in until after 5 and it's a holiday weekend so I have to wait to talk to someone. My regular doctor wasn't available to do the stress echo so a PA saw me and ordered the test. He told my husband that he didn't see anything alarming but I just looked up the test results online and to be honest, I'm a bit freaked out about this. I don't know what is normal for a 10 year old tissue valve. I know they don't last forever. I know none of you are doctors but I would appreciate your take on this, those of you with experience. When my aortic valve first started giving me trouble, 11 years ago, the cardiologist said there was nothing to worry about but this group told me I probably needed a second opinion which in a way, saved my life. I hope it's OK to post the text results. I didn't copy everything here. What I'm most worried about is the moderate aortic stenosis, the left atrium which is "severely dilated," and the mitral valve thickening. I've read some things that really frighten me concerning a severely dilated left atrium. The test said my exercise capacity was good. I didn't copy all my test results here but most of them. I don't know how to interpret most of the numbers. Does anyone know what a negative echocardiographic stress test means?

Summary:
1. The left ventricular chamber size is normal.
2. The EF is estimated at 55-60%.
3. There is moderate aortic stenosis.
4. Mild aortic regurgitation is present.
5. At peak stress the LV chamber size becomes smaller.
6. With peak stress the global left ventricular function becomes
hyperdynamic.
7. This was a negative echocardiographic stress test.


Findings Rest
Left Ventricle:
The left ventricular chamber size is normal. There is normal left
ventricular systolic function. The EF is estimated at 55-60%.

Left Atrium:
The left atrium is severely dilated. The left atrial diameter 4.7 cm is
severely abnormal for a female (severe range >/=4.7).

Right Ventricle:
The right ventricular chamber size and systolic function are within
normal limits.

Right Atrium:
The right atrium appears normal.

Aortic Valve:
There is moderate sclerosis of the aortic valve cusps. Mild aortic
regurgitation is present. The peak gradient across the aortic valve is
40mmHg. The mean gradient across the aortic valve is 21mmHg. The aortic
valve area by VTI is calculated at 1.11cm2. There is moderate aortic
stenosis.

Mitral Valve:
There is mitral leaflet thickening. There is mitral annular
calcification. There is mild mitral regurgitation observed.

Pulmonic Valve:
The pulmonic valve is not well visualized.

Pericardium:
The pericardium appears normal.

Aorta:
The aortic root appears normal.

ECG:
Normal sinus rhythm.
Findings Peak
Stress:
At peak stress image quality was good. At peak stress the LV chamber
size becomes smaller. With peak stress the global left ventricular
function becomes hyperdynamic. Patient followed a Bruce protocol. The
patient exercised into stage 3. The total exercise duration was 7
minutes. The study was terminated because of dyspnea. Sinus tachycardia.
Ventricular premature contractions. No ST-segment depression at greater
than or equal to 85% MPHR. The patient did not express feelings of chest
discomfort. The blood pressure response is adequate. Exercise capacity
is good. The patient achieved a level of 10 METS. There were rare
ventricular premature beats. There is no ST segment depression. This is
a negative electrocardiographic stress test. This was a negative
echocardiographic stress test.


Aortic Valve
Name Value Normal Range
AV Vmax 3.15 m/sec -
AV peak gradient 40 mmHg -
AV mean gradient 21 mmHg -
AV VTI 71.5 cm -
LVOT Vmax 1.08 m/sec -
LVOT peak gradient 5 mmHg -
LVOT VTI 28 cm -
LVOT diameter 1.9 cm (1.7 - 2.5)
AVA (continuity Vmax) 0.97 cm2 -
AVA (continuity VTI) 1.11 cm2 -
AR PHT 481 msec -

Mitral Valve
Name Value Normal Range
MV E-wave Vmax 0.87 m/sec -
MV A-wave Vmax 0.74 m/sec -
MV deceleration time 215 msec -
MV E:A ratio 1.2 ratio -
LV lateral e' Vmax 0.12 m/sec -
LV septal e' Vmax 0.07 m/sec -
LV E:e' lateral ratio 7.2 ratio -
LV E:e' septal ratio 13.1 ratio -

 

[river-wear]

I'm 90% sure that "negative" results are exactly what you want. They didn't find anything to be concerned about. The other things you posted support that impression too.

FWIW, I had "severe" AR for 40+ years before it started to impact my heart's health and they did anything about it.

Try to enjoy the long weekend. (Easier said than done, right?)

 

[AZ Don]

I've learned from experience that no matter how much I try to understand the numbers (and I have tried) I am not going to see the full picture clearly without consulting a specialist. If the PA is working with your Cardiologist then I would expect they should have a good understanding of the results. If they are working with your regular Dr., then maybe not as much. Moderate stenosis is only moderate, and should not be a significant concern. While the left atrium is severely dilated, it is only just at the definition of severe. As you know, sooner or later it is likely you will have to have your valve replaced. Based on moderate stenosis and no symptoms I would guess that it is not time yet. My suggestion is to try to enjoy your weekend and talk to your Cardiologist when you can next week.

 

[Paleowoman]

Hi Tigerlily - I can't interpret your echo since I'm just a patient like you.

I had my aortic valve replacement two and a half years ago, got Edwards Magna Ease valve 19mm. At last echo in May my peak pressure gradient was 40mmHg and mean pressure gradient 21mmHg (both the same as your current measurements) and my EF was 60%. I was told that the aortic valve area in a bioprosthetic valve cannot be calculated by VTI, but mine calculated by VTI was 0.8cm2 (the report in which the VTI area size was given was then redone with the explanation of why VTI cannot be calculated in a replacment valve). When it was subsequently measured by a cardiologist expert in echoes he said my aortic valve area size was 1.2cm2. (I don't have any symptoms and had no problems in a stress echo but I do have mild left ventricular hypertrophy which I didn't have before AVR which is why I am having repeat echoes).

If you are worried you should see your cardiologist again and tell him your worries. It's no good wondering and worrying about this thype of thing. Did they shcedule a repeat echo for you ?

 

[BackDoc]

I am not a cardiologist, however, being a doc, I think other doc's will explain things to me better then if I wasn't. From my understanding as long as your EF is greater theh 50% and there is no severe regurg, or stenosis you are good. I would be willing to bet that your cardio tells you all is still good.

 

[BackDoc]

I am not a cardiologist, however, being a doc, I think other doc's will explain things to me better then if I wasn't. From my understanding as long as your EF is greater theh 50% and there is no severe regurg, or stenosis you are good. I would be willing to bet that your cardio tells you all is still good.

 

[tigerlily]

Thank you all so much for responding and giving me your insight. I'm a horrible worrier and when I read the test results without the help of my doctor (missed the phone call) I was sure I would be dead in 5 years or less. I'm obviously not an optimist. That comes from having lived through some very tough things in my life but I really should try to see the positive. For all I've been through, I'm still here so I need to look at things that way. I really can't thank you all enough, this helps me so much not to panic.

 

[epstns]

Hi, Tigerlily. Sorry to have you come back to us under stressful circumstances. I can't add much to the posts above, but I can vouch for the fact that the prosthetic valves "indicate" smaller calculated areas than we would expect, yet they work just fine that way. I just reviewed an echo done on mine last week (for another reason than valve evaluation), and the tech at a very highly regarded "center of excellence" hospital found my valve to be 1.3 cm2 also - about the same as Anne's. I don't know what the real dimension is, but none of the docs who have reviewed my echo's over the past 5 years have ever felt it to be anything but "just where we expect it to be."

I know what you're going through, as I am experiencing similar mind problems over a couple of medical issues. They psychologists call this "over-exaggerating." The mind thinks of each decision point in a decision tree, then assumes the worst possible outcome for each and follows the path to a mental picture of disaster. Those of us prone to this phenomenon have to work extra hard at controlling our own thoughts, as we know in our rational minds that this "worst of the worst cases" scenario is extremely unlikely to occur. We need to instead focus on seeing, in our mind's eye, the normal outcome at each decision point. In doing this, we will envision the statistically likely result. The more we focus on this "normal" outcome, the more calm we can become and the more likely we see this to be coming for us.

I've also found it helpful to go back to how we managed our long stays in The Waiting Room prior to our valve surgeries. We made our plans, then put them on the desk and just focused upon the immediate next step in the plan. As long as we did that next step when and how it was planned to be done, we stayed on path to attaining our goals. Hang in there -- you've been through a lot of this, and you can master this too.

 

[Paleowoman]

I just reviewed an echo done on mine last week (for another reason than valve evaluation), and the tech at a very highly regarded "center of excellence" hospital found my valve to be 1.3 cm2 also - about the same as Anne's. I don't know what the real dimension is,

My aortic valve area size calculated by VTI was 0.8cm2. It was explained to me that VTI is a computer generated calculation and is not accurate for prosthetic valves. When I had another echo done by a cardiologist who is a "national and international" expert in echocardiograms, he used a differenet method to give the "absolute aortic valve area size" which he says is 1.2cm2 with me.

Just thinking Tigerlily - do you have a previous echocardiogram report to which you can compare the measurements in this recent one ? If there has been change that may be more significant.

 

[tigerlily]

My aortic valve area size calculated by VTI was 0.8cm2. It was explained to me that VTI is a computer generated calculation and is not accurate for prosthetic valves. When I had another echo done by a cardiologist who is a "national and international" expert in echocardiograms, he used a differenet method to give the "absolute aortic valve area size" which he says is 1.2cm2 with me.

Just thinking Tigerlily - do you have a previous echocardiogram report to which you can compare the measurements in this recent one ? If there has been change that may be more significant.

I do have one to compare to from 15 months ago. Everything was essentially normal. No red flags at all. I don't understand how things could change so fast. Your VTI is close to mine which is 1.11cm2 but I have no idea what that means. What is normal? I'm most worried about other changes in the heart like the mitral annular calcification, thickening of the mitral valves and the left atrium being severely dialated. All these things are worrisome.

 

[Paleowoman]

I do have one to compare to from 15 months ago. Everything was essentially normal. No red flags at all. I don't understand how things could change so fast. Your VTI is close to mine which is 1.11cm2 but I have no idea what that means.

By comparing the previous one with the current one I meanhave the numbers changed W was the pressure gradient and ejection fraction essentially the same 15 months ago or has it increased now ?

I was told that the VTI is a computer generated calculation and that it isn't accurate for prosthetic valves - I do not know why, but certainly my VTI at 0.8cm2 is less than my "abolsute aortic valve area" which is 1.2cm2. I've no idea if it is normal, but certainly with a native valve 1.2cm2 would be considered moderately stenotic, as would a pressure gradient of 40mmHg. But I don't know if that counts with a bioprosthetic valve - I suppose it would but I'm guessing.

 

[tigerlily]

By comparing the previous one with the current one I meanhave the numbers changed W was the pressure gradient and ejection fraction essentially the same 15 months ago or has it increased now ?

I was told that the VTI is a computer generated calculation and that it isn't accurate for prosthetic valves - I do not know why, but certainly my VTI at 0.8cm2 is less than my "abolsute aortic valve area" which is 1.2cm2. I've no idea if it is normal, but certainly with a native valve 1.2cm2 would be considered moderately stenotic, as would a pressure gradient of 40mmHg. But I don't know if that counts with a bioprosthetic valve - I suppose it would but I'm guessing.

Hi Paleogirl, My EF is exactly the same but the pressure gradients have changed to be moderate stenosis level. :-( I hope the EF is the most important thing to consider.

 

[dornole]

A "negative" test is always good news in medicine. . . unless you wanted to get pregnant !

Sorry you had this "worry gap" in between your test and your results, that's always a tough gig. Remember too, mitral valve is a different ball game from aortic and many of the "numbers" you know from your aortic valve do not apply at all, so keep an open mind about results for mitral valve and the whole left side of the heart. I'm getting my latest TEE results tomorrow myself. They look ok online but what the heck do I know. . . . if they were really awful though, they wouldn't have let me leave the hospital.

Hang in there!

 

[tigerlily]

A "negative" test is always good news in medicine. . . unless you wanted to get pregnant !

Sorry you had this "worry gap" in between your test and your results, that's always a tough gig. Remember too, mitral valve is a different ball game from aortic and many of the "numbers" you know from your aortic valve do not apply at all, so keep an open mind about results for mitral valve and the whole left side of the heart. I'm getting my latest TEE results tomorrow myself. They look ok online but what the heck do I know. . . . if they were really awful though, they wouldn't have let me leave the hospital.

Hang in there!

Thanks so much Dornole, I so needed the positive words today.

 

[dornole]

Just a quick note for you, I got my results last week, and confirmed something I *thought* was true that might comfort you - doc confirmed that enlargement of the left atrium is "just part of the deal" for mitral valve issues and they don't worry about it unless you develop afib. They look at the left ventricle and yours is good. Also remember that echos can vary quite a bit. For example my mitral gradient has varied back and forth from 7 to 9 to 12 and back to 7, and valve area from 1.2 to 1.8 and back and forth. I don't think that's actually happening . . . the TTE (external echo) is just not that accurate. My doc got concerned by my result in Jan, ordered a more accurate TEE (the one down your esophagus) and yay, no open heart surgery for me, come back in a year and have a regular echo.

Hope you're doing well and have the answers you need to set worry aside.

 

[tigerlily]

Just a quick note for you, I got my results last week, and confirmed something I *thought* was true that might comfort you - doc confirmed that enlargement of the left atrium is "just part of the deal" for mitral valve issues and they don't worry about it unless you develop afib. They look at the left ventricle and yours is good. Also remember that echos can vary quite a bit. For example my mitral gradient has varied back and forth from 7 to 9 to 12 and back to 7, and valve area from 1.2 to 1.8 and back and forth. I don't think that's actually happening . . . the TTE (external echo) is just not that accurate. My doc got concerned by my result in Jan, ordered a more accurate TEE (the one down your esophagus) and yay, no open heart surgery for me, come back in a year and have a regular echo.

Hope you're doing well and have the answers you need to set worry aside.

Dornole, you actually made me tear up a little bit reading this. It was the sort of encouragement I needed so much. Thank you and I'm so glad you are doing well. No worries for you, that's wonderful that the results of the TEE were so good.