Cath Results in - Need some Feedback

[ron]

Hello Everyone,

I was diagnosed with a bicuspid valve with sever stenosis recently (0.8 cm). This was confirmed by 3 separate cardiologists via an echocardiogram.

I had a right and left heart cath today (angiogram?). The docotr told me that my arteries looked fine, but that there is a possibility that my aortic root is enlarged. He said that he believed this because it was harder than normal to move the camera device around my heart when doing the cath. He stated that the CT scan would be able to confirm this or not.

On a side note, during the previous echo, I asked him about anuerysms. He said that, according to the echo results, my aortic root looked fine. 2 other cardiologists said that my heart was slightly enlarged, but it was not a cause for concern.

I am curious if anyone has any feedback on this. Insight? opinions?

I am feeling a little depressed. I am crossing my fingers that I only would have to go through a valve replacemnt. Now I don't know...

 

[ron]

A bit more info

A bit more info

A bit more info...

The echocardiograms measure my aortic root as follows:

31mm
3.8 cm

Also, I have moderate left ventricle hypertrophy. I read that this might relate to an enlargement.

 

[ALCapshaw2]

Welcome Aboard Ron !

You need to know that Aortic Aneurysms are often associated with BAV, especially if you BAV is congenital. This may be the result of a Connective Tissue Disorder (CTD).

The Gold Standards for checking for Aortic Aneurysms are either a Chest CT or Chest MRI.

It is in your Best Interest to find a Surgeon with considerable experience dealing with BAV and doing surgery of the Aorta (which is a step above 'mere' valve replacement). It would be especially helpful for the surgeon to know how to recognize signs of Connective Tissue Disorders and how to deal with them. Such Surgeons are typically found at the Major Heart Centers such as Stanford in San Francisco or UCLA in LA.

Many Surgeons and Cardiologists use an Effective Aortic Valve Area of 0.8 sq cm as their 'trigger' for recommending Aortic Valve Replacement so 'you are there' and your 3 tests/opinions would seem to confirm that diagnosis.

You also need to know that in the Right Hands (of an experieced Aorta Surgeon), the risk of Valve Replacement plus Aneurysm repair are very nearly the same as Valve Replacement by itself.

Dr. Craig Miller at Stanford is a well known and respected surgeon who has been used by several of our members with similar conditions. You can find many posts from other members who have used Dr. Miller by doing a Search on VR for keyword "Miller". You may also want to do a Google Search to find links to his background and interests.

'AL Capshaw'

 

[ron]

Hello Al,

Thanks for your input. You seem to know quite abit about the topic.

What's your opinion of the Aortic root? If I have 3 cardiologits saying it's OK, then does that mean chances are in my favor? I know that the CT/MRI is the best way to determine, but I am just curious what you think...

Ron

 

[normofthenorth]

Ron, I think hypertrophy doesn't just relate to enlargement, I think it IS enlargement. Many of us have that in the LV after spending some time with AV stenosis. The LV gets bigger and stronger and thicker-walled in order to force blood through a narrowed opening. Up to a point (judgment call, might as well trust the judgment of your local experts I think), it "atrophies" back to normal size, strength, and thickness after the stenotic AV is replaced with one that has a reasonable-sized opening.

Many people who get AVR surgery, especially the BAVers, also have enlarged Aortic Roots that need attention. I had a couple of CTs, lots of echoes & stress-echoes, and a both-sides angio/cath. When I went under in the OR, I was expecting a Dacron graft to replace my over-sized AR. When the hotshots saw it "up close and personal", they decided that it wasn't that bad, so they just "took a tuck" instead -- kind of like taking in the hem of a pair of pants, AFAICT. I don't think the graft adds significantly to the complexity of the op or of the rehab.

Be careful what you wish for, but I'd prefer that they repair or replace everything that's going to need surgical attention in the next couple of decades "as long as they're there".

 

[ron]

Hello Norm,

Thanks for the info. I have heard the same thing about the hypertrophy enlargement. Fixing the cause of the problem (the stenotic valve) being the best way to puch things in the healthy direction.

I am coming to rips with the possibility of a dual procedure surgery, or a future surgery as well. And I agree with you, if this **** is gonna happen, I prefer a "one and done" incident.

Thanks for your response. Now I need a CT before I can confirm the condition of the aorta, and schedule meetings with surgeons.

 

[ALCapshaw2]

YEP, "one and done" is definitely preferable to just replacing the defective valve and having to come back at some later time to repair / replace an enlarged aorta. Most Sugeons "get this". Just be sure to find a surgeon with the requisite experience to assess 'the big picture'.

'AL Capshaw'

 

[ron]

Hello guys,

So I guess my question is...

Do you think that the root could be enlarged, even if 3 echocardiograms said it was OK?

Ron

 

[normofthenorth]

I say yes. That's why echo isn't one of what Al called "The Gold Standards for checking for Aortic Aneurysms".

And it's a bit misleading even to call the AVR-plus-AR-replacement "a dual procedure surgery". Many standard valves come in a variant form that includes an already-attached Aortic Root, and the combination also has a single name -- Bentall procedure, IIRC. (Many surgeons prefer to stitch together a separate valve and root, but that's just because that's also pretty simple -- as heart surgery goes! ) So it's kind of a somewhat larger single remove-and-replace operation.

 

[normofthenorth]

Another bit of good news, if you do need your AR replaced: My fave recent (2010) study on the durability of a specific tissue valve ("mine"!), lists a bunch of "independent predictors of late death" among the study's 1134 patients.

"Replacement of the ascending aorta at the time of AVR" is listed among the five variables that "had no effect on mortality by multivariable analysis." (The paragraph begins by referring to "late death", but I can't find a detailed breakdown of their prompt mortality results, maybe because the numbers are so much smaller than the "late death" -- i.e., a huge majority survived the AVR, but EVERYBODY eventually dies.) Put simply, the patients who got the Bentall procedure seemed to live just as long as those who got the simple AVR.

The article's entitled "Hancock II Bioprosthesis for Aortic Valve Replacement: The Gold Standard of Bioprosthetic Valves Durability?" by Tirone E. David, MD, Susan Armstrong, MS, Manjula Maganti, MS, in Ann Thorac Surg 2010;90:775-781, abstract at ats.ctsnetjournals.org/cgi/content/abstract/90/3/775? .

 

[Lynlw]

When is your CT? It's hard to guess and can probably make it more stressful,than just waiting to see what the CT shows, but I personally believe if 3 echos measure it in the 3s it is probably in the 3s. Echos aren't the gold standard, but in our experience with echos (Justin has had over 60) they usually are pretty close, IF you only had 1 echo, I'd probably be more concerned it could be off since alot depends on techs and their measuring, but multiple ones showing close to normal size I would tend to think they are close to that.

Were the 31 and 3.8 done around the same time or were they done a year or more apart? Do you have the other measurements of your Aorta?

I'm a little confused about the possibility of the root being enlarged "because it was harder than normal to move the camera device around my heart when doing the cath" I would think it would be harder to move the cath around if it was stenosis and not bigger than normal..but i'm not an expert

Normally the root can be a little larger than the rest of the aorta, so unless it is over about 4.5 (depending on the rest of your Aorta measurements and how it compares to them) they probably would prefer to leave it alone. As Norm said IF they do repair/replace part of the aorta with the valve, it usually isn't what is considerred a dual procedure, if that makes you feel any better.

I would think the enlarged/hypertrophy ventricle would be more related to the stenosis of the valve and not any dialation of the Aorta.

 

[ron]

Another bit of good news, if you do need your AR replaced: My fave recent (2010) study on the durability of a specific tissue valve ("mine"!), lists a bunch of "independent predictors of late death" among the study's 1134 patients.

"Replacement of the ascending aorta at the time of AVR" is listed among the five variables that "had no effect on mortality by multivariable analysis." (The paragraph begins by referring to "late death", but I can't find a detailed breakdown of their prompt mortality results, maybe because the numbers are so much smaller than the "late death" -- i.e., a huge majority survived the AVR, but EVERYBODY eventually dies.) Put simply, the patients who got the Bentall procedure seemed to live just as long as those who got the simple AVR.

The article's entitled "Hancock II Bioprosthesis for Aortic Valve Replacement: The Gold Standard of Bioprosthetic Valves Durability?" by Tirone E. David, MD, Susan Armstrong, MS, Manjula Maganti, MS, in Ann Thorac Surg 2010;90:775-781, abstract at ats.ctsnetjournals.org/cgi/content/abstract/90/3/775? .

Thanks. Al. This is good to know - relatively speaking. In addition to the valve replacement, I have been trying to come to terms with the fact that there could be another surgery down the line. For better or worse, I like to always know what the worse case scenario is. This makes me more content for some reason.

Even if it was a straigth valve replacement, I was going to head to a top notch facility. I live in Las Vegas and - as my friend put it - nobody is flying in here to get a heart surgery. My brother is a pharmacist and my sister-in-law is a pediatrician in Philadelphia. They have spoke highly of a surgeon at U of Penn named Joe Bavaria. I am leaning toward him, the Cleveland Clinic, or UCLA. If you have any input on this, that would be great!

Thanks again...

 

[ron]

Were the 31 and 3.8 done around the same time or were they done a year or more apart? Do you have the other measurements of your Aorta?

I'm a little confused about the possibility of the root being enlarged "because it was harder than normal to move the camera device around my heart when doing the cath" I would think it would be harder to move the cath around if it was stenosis and not bigger than normal..but i'm not an expert

Normally the root can be a little larger than the rest of the aorta, so unless it is over about 4.5 (depending on the rest of your Aorta measurements and how it compares to them) they probably would prefer to leave it alone. As Norm said IF they do repair/replace part of the aorta with the valve, it usually isn't what is considerred a dual procedure, if that makes you feel any better.

I would think the enlarged/hypertrophy ventricle would be more related to the stenosis of the valve and not any dialation of the Aorta.

Thanks Lyn. I appreciate your input.

All of the echos have been done within the last 2 months. The last one I received was given by the same cardiologist that did my cath. I asked him about the potential for an anuerysm, and he said that the aortic root looked fine ( but he didn't give me numbers) That is why I was surprised when he told me that the aortic root might be enlarged while doing the cath. That is what is making me believe that it might not be enlarged. Of course, this is speculation until the CT gets done.

My last cardiologist is somewhat slow on paperwork. I have waited a week already for him to submit the referral to the CT place and it hasn't gotten done. I think I need to start pestering him everyday to make this happen. As Tom Petty said, "The waiting is the hardest part..."

 

[Lynlw]

Justin has had most of his heart surgeries at CHOP (childrens Philly) that altho not owned by the same group, is right next to /buildings interwined wih HUP and many of the doctors are on staff at both centers, Bavaria and a few other HUP surgeons are very good have alot of Aorta and compleex surgeries experience. IF you are going to travel, I think it is always helpful if there is family close by, would you be able to stay there right before or after discharge?

Can you just call and schedual your own CT? We do that alot, you usually just need to have the paperwork from he doctor that ordered it when you show up. Have you contacted any of the centers you are thinking about having surgery? If not i would start doing that and find out exactly what they want/need to start the process for a 2nd opinion, usually they'll want copies of all the tests including the cath on disks and not just the written reports so they can see and measure for themselves. IF your Cardiologist office is kind of slow, you might want to take care of getting the reports and disks and sending them out yourself.