2nd surgery possibility-ECHO results

[bugchucker]

Here are my Echo results. I've been told that a second surgery is likely in the next 12 months. I'm no doctor and I realize no one else here is either. Just looking for an insight. What questions should I be asking? This is worse than I had anticipated.

Thank you in advance,

Phil
[h=2]Narrative[/h]
Transthoracic
Echo Report


Echocardiography Laboratory

CONCLUSIONS
Prior Echo - 6/10/15. since this study, gradient across aortic valve
has increased
Aortic valve area calculated from the continuity equation is 1.0 cm².
Transvalvular gradients are - Peak: 67 mmHg, Mean: 46 mmHg.
Normal left ventricular size, thickness, systolic function, and
diastolic function.
Normal regional wall motion.
Left ventricular ejection fraction is visually estimated to be 70%.
Trace tricuspid regurgitation.
Estimated right ventricular systolic pressure is 35 mmHg.

PHILIP
Exam Date: 02/17/2017
15:00
Exam Location: Out Patient
Priority: Routine

Ordering Physician: GANCHAN, RICHARD P
Referring Physician: 034603, GANCHAN
Sonographer: Sutee
Dismanopnarong, RCS

Age: 45 Gender: M
MRN:
DOB:
BSA: 1.97 Ht (in): 70 Wt (lb): 175
Exam Type: Complete

Indications: Presence of prosthetic heart valve
ICD Codes: Z952

CPT Codes: 93306

BP: 106 / 70 HR:
Technical Quality: Fair

MEASUREMENTS (Male / Female) Normal Values
2D ECHO
LV Diastolic Diameter PLAX 4.9 cm 4.2 - 5.9 / 3.9 - 5.3
cm
LV Systolic Diameter PLAX 2.4 cm 2.1 - 4.0 cm
IVS Diastolic Thickness 0.93 cm
LVPW Diastolic Thickness 0.77 cm
LVOT Diameter 2.2 cm
LV Ejection Fraction MOD BP 70.6 % >= 55 %
LV Ejection Fraction MOD 4C 62.2 %
LV Ejection Fraction MOD 2C 79.2 %
IVC Diameter 1.8 cm

M-MODE
Aortic Root Diameter MM 3.3 cm

DOPPLER
AV Peak Velocity 3.6 m/s
AV Peak Gradient 51.2 mmHg
AV Mean Gradient 35.7 mmHg
LVOT Peak Velocity 1 m/s
AV Area Cont Eq vti 1.1 cm²
MV Velocity Time Integral 22.9 cm
Mitral E Point Velocity 0.9 m/s
Mitral E to A Ratio 1.3
Mitral A Duration 111 ms
MV Pressure Half Time 81.6 ms
MV Area PHT 2.7 cm²
MV Deceleration Time 281 ms
TR Peak Velocity 250 cm/s
PV Peak Velocity 1.1 m/s
PV Peak Gradient 5 mmHg
PV Mean Gradient 3.1 mmHg

* Indicates values subject to auto-interpretation
LV EF: %

FINDINGS
Left Ventricle
Normal left ventricular size, thickness, systolic function, and
diastolic function. Left ventricular ejection fraction is visually
estimated to be 70%. Normal regional wall motion.

Right Ventricle
The right ventricle was normal in size and function.

Right Atrium
The right atrium is normal in size. Normal inferior vena cava size
without inspiratory collapse.

Left Atrium
The left atrium is normal in size. Left atrial volume index is 27
mL/sq m.

Mitral Valve
Structurally normal mitral valve without significant stenosis. Trace
mitral regurgitation.

Aortic Valve
Known bioprosthetic aortic valve. Transvalvular gradients are - Peak:
67 mmHg, Mean: 46 mmHg. Aortic valve area calculated from the
continuity equation is 1.0 cm². Dimensionless index is 0.27. Vmax is
4.10 m/s. No aortic insufficiency.

Tricuspid Valve
Structurally normal tricuspid valve without significant stenosis. Trace
tricuspid regurgitation. Estimated right ventricular systolic pressure
is 35 mmHg. Right atrial pressure is estimated to be 8 mmHg.

Pulmonic Valve
Structurally normal pulmonic valve without significant stenosis. Trace
pulmonic insufficiency.

Pericardium
Normal pericardium without effusion.

Aorta
The aortic root is normal. Ascending aorta diameter is 3.3 cm.

 

[Paleowoman]

Hi Phil - did you see your cardiologist ? Was it he/she who said surgery likely on the cards during the next 12 months ? I can see your pressure gradient has risen to severe/critical. As you know, my pressure gardient is rising since I had AVR and I am having six monthly echos to monitor this. One thing I notice about your echo: the aortic valve area has been calculated. You might want to check how this was calculated. I was told this cannot be calculated accurately on a prosthetic aortic valve using the software with the echo machine. One of the technicians explained that to me when I asked for my valve area size. Then another technician subsequently did the calculation using the echo machine and came up with a result of 0.8 cm2 - I complained to cardiologist about how low that was and a senior technician re-did the report removing the valve area size with this note: "Prosthetic aortic valve area calculations have been removed from report as it is computer generated and not applicable to any prosthetic valve replacements." My subsequent echos havenow been done by cardiologist expert in echocardiograms - he was able to work out the valve area size using a formula he has which does not come with the echo machine (mine is now 1.2 cm2 - very different from what the echo machine miscalulated). Maybe your valve area size is accurate but, as I say, you might want to check this out. Presumably you are going to be having another echo in six months or less ?

 

[dornole]

Hope you don't have to go to surgery so soon. Are they going to do a TEE (maybe in six months) to confirm this result?

If it's any consolation, I had a "bad echo" followed by a TEE in 6 months. That more accurate TEE test showed I'm still ok, come back in a year.

 

[ottagal]

HI Bugchucker,
I am not a physician, so my interpretation of your echo is basically based on my own' layman's knowledge.
I do know a number of factors come into play when deciding on when to do surgery. I am going to only speak directly to your pressure gradients.
Here is the classification system from echopedia:

Aortic jet velocity (m/s)	≤2.5 m/s	2.6-2.9	3.0-4.0	>4.0
Mean gradient (mmHg)	-	<20 (<30[SUP]a[/SUP])	20-40[SUP]b[/SUP] (30-50[SUP]a[/SUP])	>40[SUP]b[/SUP] (>50[SUP]a[/SUP])
AVA (cm[SUP]2[/SUP])	-	>1.5	1.0-1.5	<1
Indexed AVA (cm[SUP]2[/SUP]/m[SUP]2[/SUP])		>0.85	0.60-0.85	<0.6
Velocity ratio		>0.50	0.25-0.50	<0.25
[SUP]a[/SUP]ESC Guidelines.[2] [SUP]b[/SUP]AHA/ACC Guidelines.[3]

Recommendations for classification of AS severity[1]
Aortic sclerosis Mild Moderate Severe

Perhaps, compare your echo to the above.

I also, know from firsthand experience that not all echos are accurate. I would want an additional test such as a TEE (dornole mentioned this) or MRI to confirm the findings.

Good luck and thinking of you,

 

[Paleowoman]

I also, know from firsthand experience that not all echos are accurate. I would want an additional test such as a TEE (dornole mentioned this) or MRI to confirm the findings.

TEE would be a good idea, MRI however isn't accurate once you have a prosthetic valve, no matter that it is a bioprosthetic valve. The issue is the metal used in the stent which holds the leaflets is made of cobalt-chromium alloy, and I should imagine the metal of the wires in the sternum, interfere with the MRI images. It's not that you can't have an MRI, it's perfectly safe, but if you want to have an accurate assessment of the aortic valve it will not be accurate. (My cardiologist actually suggested I have an MRI which I would have liked - I'm one of those crazy people that like being in enclosed spaces, I find MRI very relaxing, but when I contacted an imaging centre about it I was informed that echo is the most accurate way to assess replacement valves, TEE being the most accurate).

 

[bugchucker]

Thank you all for your input. I have not yet seen my cardiologist, have an appointment for 3.20. I have to admit that looking at my results has set me back mentally...being pretty pathetic and feeling sorry for myself. Trying to pull myself out of it. I've never had a TEE, are you conscious for this procedure? I read a bit about it and it looks quite uncomfortable, but I agree I would like at the very least another Echo, but a TEE sounds like the ticket. I appreciate the input and caring responses.

Phil

 

[bugchucker]

Never mind, found this:

What happens during TEE?
Specially trained doctors perform TEE. It’s usually done in a hospital or a clinic and lasts 30 to 60 minutes.

• A technician sprays your throat with a medicine to numb it and suppress the gag reflex. You’ll lie on a table.
• A nurse puts an IV (intravenous line) in your arm, and gives you a mild sedative (medicine) to help you stay calm.
• The technician then places small metal disks (electrodes) on your chest. He or she attaches the electrodes by wires to a machine that will record your electrocardiogram (ECG) to track your heartbeat.
• The doctor then gently guides a thin, flexible tube (probe) through your mouth and down your throat, and asks you to swallow as it goes down.
• A transducer on the end of the probe sends sound waves to your heart and collects the echoes that bounce back. These echoes become pictures that show up on a video screen. This part of the test takes 10 to 15 minutes.
• When the doctor is finished taking pictures, the probe, IV and electrodes are removed and nurses watch you until you are fully awake. Then you can usually get up, get dressed and leave the clinic or hospital.

Having the breathing tube removed after my OHS was very traumatic, and this procedure is giving me great anxiety, but I will ask that it be performed to get a better idea of what is going on in there.

 

[bugchucker]

I've been researching my findings, but cannot seem to find any information about treatment other than surgery. I looked at several flow charts used to determine when or if surgery is necessary and they all seem to rely in part on physical symptoms. I guess I'm interested to know if these echo results can be managed behaviorally, i.e. better diet and exercise regime. I realize at this point I'm grasping at straws trying to postpone the eventual inevitability.

Aortic Valve
Known bioprosthetic aortic valve. Transvalvular gradients are - Peak:
67 mmHg, Mean: 46 mmHg. Aortic valve area calculated from the
continuity equation is 1.0 cm². Dimensionless index is 0.27. Vmax is
4.10 m/s. No aortic insufficiency.

Does "No aortic insufficiency" reduce the likelihood of surgery?

Thank you

Phil

 

[epstns]

Does "No aortic insufficiency" reduce the likelihood of surgery?

Unfortunately, no, it doesn't. Insufficiency means the same thing as regurgitation - where the valve allows backward flow when it should be fully closed. Your issue is the opposite -- the valve is not allowing full flow in the forward direction, much as a stenotic native valve does.

 

[Paleowoman]

Thank you all for your input. I have not yet seen my cardiologist, have an appointment for 3.20.

All the best for the appointment Phil - let us know how it goes.

 

[dornole]

Recently had TEE and had trouble coping with the throat numbing goo (made me gag a lot) so they just sedated me a little earlier and boom no more problem. Felt totally fine when I woke up. The first time I had one I don't remember any discomfort whatsoever.

Hoping you can put it aside and wait for the 20th -- tough I know.

 

[Paleowoman]

Oh dear - I thought 3.20 meant 3.20 in the afternoon (yesterday) - I now realise it's the American way of saying 20th March (in the UK we'd write 20/3 for the 20th March and 3.20 for the time of day.....). Sorry you have to wait another couple of weeks to see the cardiologist Phil - waiting is the worst.