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[Don]

Gradient & Logistics

Gradient & Logistics

Hi Ram,
In responding to my reply to your post you asked a couple of questions:
GRADIENT, Peak and Mean: I thought I would verify what I believed it meant prior to answering your question so I looked it up in my CCF and Mayo Heart books. Could not find it in either. ??? My understanding is that the gradient measures pressure across the heart valve. To get an equal amount of blood through a smaller opening, i.e., a stenotic opening, the heart has to push (work) harder. The peak gradient is the high they measure when testing; the mean is, of course, the average pressure. The higher the numbers the more strain on your heart, with the resultant consequences; the lower the number the better (up to a point of course). (You might ask this web site's members for a better explanation than I was able to give you at this time.) Previously I had focused primarily on AVA. As I was coming out it at CCF I asked a nurse about my AVA. She said she didn't know but to look at my great gradient numbers! Maybe she was giving me a snow job, but I now watch the gradient as well as the Aortic Valve Area.
LOGISTICS: I was really really worried about the logistics of getting from the El Paso airport to Cleveland Clinic, and more so about getting back. My son, on his own, even looked into the cost of chartering a jet for me, but the cost was unthinkable. I expressed my concerns to my local PCP (who had just visited CCF) and he simply stated that if all of those Arabs can make it from their countries to Cleveland Clinic, I certainly could handle the trip. It turned out to be a piece of cake. On the return trip the airport terminals furnished a wheel chair in Cleveland, DFW and ELP. Everyone was extremely helpful. Coming back was easier than going out. (But I did wait 8 days prior to making the return trip; looking back I think 2 days would have been more than enough.)
The logistics were pretty easy, but you couldn't have convinced me of that prior to making the trip.
QUALITY OF LIFE: I feel that your comment on being more concerned about Quality of Life than SD deserves a comment. Whatever could cause SD will almost certainly adversly your quality of life if it doesn't kill you. So you really do not have a choice between the two outcomes.
I hope that you get a better explanation of "gradient" than I was able to give you without my doing additional research.
Another caution: If your valve problem is due to bi-cuspid, I believe that your chances for an aortic anuerysm are increased. Make sure that your doctor(s) examine you properly for this prior to your valve operation. (I was unaware of this risk prior to my surgery; I understand that awareness of this risk is newly evolving.) (Check "Arlys" on this web site.)
Rereading all of your previous posts, I continue to feel that the flags raised by Bill and John are worth your consideration. If I can be of any further assistence, just let me know.
Best wishes -- just do not wait too long.
Don
AVR; 4/02; CCF; Cosgrove; Bovine Tissue

 

[wweir]

Ram,

I just finished reading through the posts. I also had a bicuspid aortic valve with aortic stenosis, so like others I have been there and done that. I must tell you I agree the most with Bill Aldridge?s comments to you. What concerned me Ram with your report was the size of your calculated aortic opening and pressure that appear to be in the "severe" range and as Bill stated you don't want to get to the point of damaging the heart. I was told that once it gets below 1 sq/cm they want to operate. I was at .8 when they did mine.

Like Bill I never had any symptoms either but I did get a list of things to look for from the doctor. The one symptom, the doctor told me, that bothered me the most was the ?Sudden Death? one. When I heard that I decided that it was really quite foolish to wait for symptoms to occur and it was time to get this thing fixed. Not an easy decision by any means at all, but a most necessary one.

You need to have a real good discussion, in my opinion, with your surgeon and maybe ask for a second opinion. I was quite surprised to read that they did not want to do a TEE on you. I was told that this was the test that was the most definitive. You may want to ask about that.

You have received a lot of great advice here, but you also need to talk, in some detail and loaded with questions, with the cardiologist and surgeon that will be handling you.

Keep us posted and good luck.

Walter

 

[mamsram]

whoa, what replys

Don, thanks for the detailed info. A long reply a lot of typing.
between you Walt and Evelyn I have a lot of food for thought.
I guess I had better do some serious planning on my next move.

As for choosing surgeons and hospitals. thats a difficult thing. when I discussed choices with my G.P. He suggested I have a discussion with the surgeon at New England Heart Center, which is a part of Catholic Medical in Manchester, N.H.. I had an interview that lasted 1 hr. and 20 min.. He was very patient, clear and ,of course intelligent. I also noticed his hands were not big. I think thats a +. He said the heart center is a part of catholic medical and all they do is heart surgery. I dont remember what his answer was about how many a year, but I think it may have been 120 valves a year. There are 3 surgeons that work there at the heart center. I asked my cardiologist if he worked at catholic medical and he does. All I think that in a small town area such as here in N.H. " One hand washes the other"
so my G.P. my card, and the surgeon all support each other.

So, then I can go away from where they are leading me, to nearby Brigham and womens, in Mass. 40-50 miles
My dilema is would a small place give better care than a large place? Does the small place not get recognition because of its size, yet could be more focused on the individual? Should I come right out and ask how many failures? how many lawsuits? How many reops? and then will I even be told the truth?

Whew these are my present day thoughts-- thanks people

 

[Gisele]

Hi Ram

Hi Ram

I'll join Bonnie and walk you down the hall. Can't say that I would sing to you though....it would probably kill ya! LOL

Wishing you well. Not sure where I would choose to go though. I didn't like New England Medical Center in Boston, but then again my surgery was over 20 years ago. I think a lot has changed. I didn't care for the group of people walking in my room, standing around my bed discussing me, and examining me. For all I knew they could have been maintenance staff. Was too young and naive to say anything though. Personally, I prefer a "friendlier atmosphere" normally found in a smaller setting. Big decision though.
Curious about your EF. Mine is 55%, but the report lists that as normal. I have shortness of breath. Hmmm. I think it depends on who reads the echo as to how they interpret it. Also mine lists pulmonary insufficiency. Is this slightly more than trace regurgitation listed for my other valves? Haven't had much time to research this yet.
Also anyone have any idea what "midly dilated left ventricle with low normal systolic function" and "abnormal diastolic filling pattern consistent with but not diagnostic of abnormal left ventricular relaxation" mean?
I have been meaning to look this all up but I have been too busy to do so.
Ram, keep us all posted. Good luck.

 

[John Cochran]

Giseles wrote:

Also mine lists pulmonary insufficiency. Is this slightly more than trace regurgitation listed for my other valves? Haven't had much time to research this yet. Also anyone have any idea what "midly dilated left ventricle with low normal systolic function" and "abnormal diastolic filling pattern consistent with but not diagnostic of abnormal left ventricular relaxation" mean?

Gisele,
Your ejection fraction (EF) of 55 percent is what is meant by "low normal systolic function." Systolic function is the pumping cycle of the heart. EF is the percentage of blood pumped from the ventricle in a single cycle. Since you have some LV dilation, the EF drops simply because the ventricle now contains more blood. A "normal" EF is generally in the 55 to 70 percent range, although the Cleveland Heart Foundation says it is 50 to 70 percent. The statement "abnormal diastolic filling pattern consistent with but not diagnostic of abnormal left ventricular relaxation" means that during the resting cycle of your left ventricle, as it is filled by the left atrium, the pattern of filling is somewhat unusual. They were unwilling to say for sure what the cause is, hence the weasel-words "consistent with" your left ventricle not fully relaxing, or relaxing in an ususual way. None of this alone seems to be any reason for great concern, but you should certainly ask your doctor for greater clarification. However, since you have pulmonary insufficiency (which is in the right ventricle) and you report shortness of breath, they may need to assess the EF of your right ventricle (EF alone generally is used in reference to the LV). Your pulmonary valve is the one your blood flows through on its way to your lungs.

I'm not sure if I made this any clearer, or simply added to the confusion, but I hope this clarifies it for you a little.

Best,
--John

 

[Gisele]

John, Thanks so much

John, Thanks so much

You have clarified this. I do have my appt in two weeks to see my doc as he moved up my appt after he saw my echo results. I saw him yesterday for a brief second (he squeezed me in) so he could listen to my valve as he believes I threw a small clot but it was a quick visit and there was no time to discuss my echo.

I was told to take dyazide 37.5/25 daily for my shortness of breath. I think it has helped only slightly.

Again, thanks so much.

 

[mamsram]

Gisele, hi

I'm sure Dr. John's medicine was helpful. A good explanation, hey.

I laughed aloud when I read about the maintenance men checking you out. It must have been a teaching hospital. I guess there are some negative thoughts about teaching hospitals, but guess none of us are born with knowledge.

I am leaning toward the small hospital, because of the possibilty of their being more focused on the individual. and I liked the surgeon's demeaner.

I followed your coumadin battle on that posting area and hurt, for what you were going through. I hope that is settling down and you are over those dreadful headaches. There are moments when life can be a horror-show, so we must appreciate and be aware of the beautiful things that life brings. I am in awe of Nancy and Ross handling there situations as well as they are. I guess I am an admirer of their strength. There are so many stories out there.

I am pleased to hear from you and trust that you are better.
God be with you.

 

[Gisele]

Ram

Ram

Thanks for your encouragement. One more humorous piece of info from my stay at NEMC (although at the time it wasn't funny) my inhalation therapist would take me for walks and one of the areas was the stairwell where let's face it-had an echo. I asked her one day what that ticking sound was (no one told me anything about my valve and what to expect-boy things have changed a lot over the years). Her reply was: I am not sure but I will ask the doctor. Of course she never answered my question and today we all know that sound as that of our ticking valves.

INR's seem to be improving and my outlook on all of this is that I am so fortunate. There are so many others out there so much worse than me that I can deal with any little bumps thrown my way.

I agree with you regarding Ross and Nancy. They are truly special people and I admire them both. We are lucky to have them on this board.

Keep me posted on how you are doing and if you are going to Catholic Medical in Manchester. Who knows, I might stop in to see you up there! Do you think Bonnie might come with me?

 

[EVELYN]

Hi Mams

I was just reading your post and a flag went up in my brain.....You said that your surgeon did 120 valves a year....Personally, I don't think that's a very large number....I know Tyce's surgeon does about 3 valves/bypasses a day. They do surgery at 8, 12, and 5 and have 2 or's going. While it sounds rather like a machine shop, we felt the more experience the better. St. Francis is a heart center, that was very important to us, too. Care is important, but you don't want any screwups before you get to that care. I certainly would ask lots of questions, we sure did!!

My girlfriend from Hampstead, NH had brain surgery and Brigham and Womens and still goes back there for scans, etc. She very much likes it and her drs. If you'd like to chat with her, I can send you her phone number.

Evelyn

 

[joy]

Hi Ram, I have to agree with Evelyn on this one, the more experience the better. I wouldn't feel comfortable with someone who did 120 surgeries a year. Like Tyce's surgeon, my surgeon did at least 3 per day, They had 15 in the week that I had mine! I was the first one of the week, though and that was good. I would look into the bringams and women's, if they have more experience that would be the way I would go!

 

[Ross]

I know Tyce's surgeon does about 3 valves/bypasses a day.

Wait until he gets a load outta me! He'll be hurting his average big time. If all patients were I, these Surgeons would only get 1 a day.

 

[John Cochran]

Since my surgery lasted 14 hours (with two surgeons) they'd need days with 42 hours in them to do 3 per day!

--John

 

[joy]

Now boys, do I have to seperate you two from the rest of the group? I think evelyn was sort of generalizing. Not all patients are easy, some are very stubborn(you know who you are, ross and john!) Just kidding. Mine only took 4 hours...seemed like an eternity getting into the OR, though, especially in pre op, those needles going in and out of me, youch! THen they gave me the stuff that made me feel like I was drunk, and I was happy. I still remember the big brown lights in the OR...the last thing I remember before gagging on the vent. Well, take it easy, and I hope that you find the right place for your surgery...everyone is different, we all like different things. Take care!
Joy

 

[EVELYN]

ROSSMAN----I KNOW YOU'RE FEELING BETTER BECAUSE YOU'RE BACK BUSTING MY CHOPS AGAIN!!!! THAT'S GOOD. Tyce's surgeon would probably take one look at you and RUN!!! (Just kidding---well.....) I can tell you they schedule---is that a better term, Rossman, 3 a day and they have at least 2 or's going. When Tyce went in for his surgery, they had 8 beds set up with people being prepped at various stages....I truly did feel as though we were in Detroit on an assembly line!! His surgeon did one valve, one bypass and one valve/bypass on the same day....twas truly unbelievable!!! When I was leaving the hospital that night, he was wheeling another into CCU!! Scary when you think of it, isn't it!!! Can't imagine what his annual income is, can you???? We didn't even see him when he went back for his visit in 4 or 6 weeks.....we saw a PA---he was guess where???? And he is only one of 4 or 5 in his group!!!


Their CCU unit had about 20 beds and one nurse per 2 patients....VERY good care, too!!!
Ev

 

[Ross]

Tyce's surgeon would probably take one look at you and RUN!!!

Dr. Novoa does run and that's not a joke! His last words to me before he signed off for me to go to rehab were, " I never want to see you again". Does the phrase "Biting off more then you can chew" remind you of anything?

From what my wife and brother tell me, there was a point where Dr. Novoa was considering flying me back to Cleveland. He came to Lyn and told her things were way too complicated and he didn't think he could help. Lyn stomped on him with both feet and made him get his act together. They played hide and seek at rounds time. If Lyn was with me, he wouldn't come around until she was gone. He was terrified of her. Honest!

 

[EVELYN]

I HOPE YOU APPRECIATE THAT WONDERFUL WOMAN THAT YOU BELONG TO!!!! She is DEFINITELY a candidate for SAINTHOOD!!!

ME

 

[John Cochran]

Joy wrote:

Now boys, do I have to seperate you two from the rest of the group?

Joy,
If you are thinking about separating Ross and me from the rest of the group, there are a few things we'll need which we expect you to supply:

--our own aircraft (nothing less than a Beechcraft Duke, please)
--5 nurses apiece, which we will hand-pick
--our own traveling M.A.S.H. unit
--a mobile Dairy Queen
--masseuse
--anything else Ross thinks we'll need


--John

 

[Ross]

Umm, nope. I think that about covers it John.

 

[azpam]

Ross, John, and Joy...... your humor is so good!! keep it up! You all are wonderful folks! LOL

 

[mamsram]

Gisele and Evelyn,

Gisele, Bonnie?? Would you call yourselves "the dangerous duo?" The halls would indeed be hallowed.

Evelyn, Wow, hampstead is nearby. I will keep your offer in mind when and if I feel I need a helping mind on Drs., travel, etc. should I decide on Brighams and womens. If you give me the tel.# e-mail me, with it.
I appreciate your help, even the dog offer, its just that I move slowly and weigh my options. ex. with the dog, I was so upset hearing of the life- span I don't know if I would want to get attached again, but of course my life span isnt any better than a dog now, Huh? OH, by the way, when my daughter sat on the dog and revved his ears and said he was her motorcycle--she was 4 years old.