Clueless

[breakingwaves]

Well I am about to jump in here with both feet, I have only posted a little and now I am going to ask for your wisdom. I recently had an attack, ended up in the hospital where they did an up dated stress echo and told me right after that it would probably be one to two years for the aortic valve replacement and to earnestly get some ducks lined up.
I know that you guys are really good at knowing what's what, and because of you I now know I could ask for a copy for my test, which I did. I am hoping that I can share it here and you will give me some input on what this means.Thanks in advance!!

Two Dimensional Echocardilography: This study is technically difficult and required the use of IV Optison. the left venticular cavity size is normal.
wall thickness is increased, consistent with left hypertrophy. No regional wall motion abnormalities at rest. In fact,left ventricular ejection is hyperdynamic, estimated at 70 - 75%. the right ventricle is normal in size and functions normally. the aortic valve is probably trilealet. It is thickened, calcified, and restricted in motion. The peak velocity is 4.2 m/sec. This gives rise to a peak gradient of 73 mmHG and a mean gradient of 44 mmHG. These findings are consistent with moderate to severe stenosis. There is mild aortic insufficiency. The mitral valve is thickened. There is annular calcification with trace to mild regurgitation. The tricuspid valve is normal. There was trace to mild tricuspid regurgitation. there is no evidence of pulmonary hypertension. The left atrium is mildly The right atrium is normal. the aortic root is normal.
Stress 2-D Echo . with excerise there is an increase in contractablity throughout.
Final Impression of Echo Portion:
1. Negative stress echocardiogram for inducible ischemnia
2. Normal left ventricle size with left ventricular hypertrophy and preserved function. Left ventricular ejection is normal to hyperdynamic at 70 - 75%.
3. Moderate to severe aortic stenosis with mild insufficiency
4. Mitral annular calcification
5. Left atrial enlargement.

Treadmill -
the blood pressure rose from the 156/82d to 166/84. the peak rate was 143bpm, 85% of the age - predicted maxium. the double product was 23,738. The baseline EKG revealed sinus rhythm at 56 bpm. Normal intervals. Borderline voltage for left ventricular hypertrophy. Mom specific ST - T wave changes noted. with excerise there was 1.0m of hortizontal ST depression noted in the inferior leads, as well in Leads V-5 and V-6. there were no dysrthmias. the EKG changes perisited two minutes into recovery.

Please help me understand this and suggest questions for my cardiologist, I have no clue what any of this means, it sounds like lots of normal so why would they suggest open heart in another year or two?? what am I not knowing or understanding? I have read so much her and know you guys know what this stuff means and I would appreciate any feedback, so I can know where to go with the future.

I am sorry for any spelling errors, not one of my talents!

 

[Bill Hall]

Break - Your posting was a bit complex for me, since I am not a doctor and even having been through this, I don't have a great command of the numbers and technical jargon. So, I will say a few words and hope someone else will help. The important things I read was that your left atrium was enlarged and that you have moderate to severe stenosis. I don't know why or what about your attack (a heart attack?), but it might be important for you to explain.
Questions for the cardiologist:
1 - Any changes from your previous echo? Why do they predict 1-2 years?
2 - How enlarged is the left atrium compared to previous measurement?
3 - What symptoms to look for besides shortness of breath or tiredness?
Hope this helps.

 

[breakingwaves]

Thank you for you reply, yes it helps. I haven't had any experience with participating in what is going on, I have just taken or denied what is going on until I woke up one night two weeks ago with so much pressure on my chest I could hardly breath. Went to emergency. Before, I had just had an echo and my doctor GP said, oh we probably don't have to worry about this for at least ten years. It was the doctor who administered the tests in the hospital who said, two years at the most, I could have fallen off the table.

Now I feel somewhat of an urgency to at least figure out what is really going on, I raise my three grandchildren and they need me to be around for awhile. I had tuned in her every now and then, reading for the most part, but now I think it was time to come out of the shadows and start asking questions and I have long respected the compassion and guidance others have provided here and now I am wanting to learn. thanks again and I hope others will respond as well because the more I know the less I fear, and right now I am caught up in fear.

 

[Bryan B]

2. Normal left ventricle size with left ventricular hypertrophy and preserved function. Left ventricular ejection is normal to hyperdynamic at 70 - 75%.
3. Moderate to severe aortic stenosis with mild insufficiency.
4. Mitral annular calcification.
5. Left atrial enlargement.

BW,

The things that grab my attentions are:

Ventricular hypertrophy (muscle wall of heart is thickening)

Moderate to severate aortic stenosis with mild insufficiency. (aortic valve is not pumping at full capacity)

Mitral annular calcification (not sure what to tell you about this)

Left atrial enlargement (again, muscle is enlarging from overwork)

Personally, I would want to discuss these results with a surgeon and get his or her take on what timeframe s/he feels would be appropriate given these results.

 

[breakingwaves]

Thanks, the enlargement did make me wonder, and I wonder from what the tests were, if in more than one place it is malfunctioning? I only have heard the aortic valve mentioned. does the malfuncion in the aortic vavle cause these other things to occur, please pardon my questions if they appear too dumb.

 

[hensylee]

welcome, Break - being clueless is the reason nearly every single one of us is here. When I came in, I was looking to find out what happened to me. Turned out I was in the wrong site but here it is 5 yrs later and I am still hangin around. I didn't even put my first name in for maybe a year.

You will get the education you need, then you will get leads to where you need to go to find out more.

Knowing one's own personal position in this health world that is so unfamiliar to us all (nearly all, anyhow) is the key that you need for yourself. Nobody in here might have that key for you, but we sure have lots who will help you unlock the door.

We are glad to have you as a member.

 

[ALCapshaw2]

It's time to start thinking about what type of valve you would prefer (read the Valve Selection Forum) and then start interviewing SURGEONS, looking for one who has lots of experience with the valve type(s) you prefer.

Cardiologists and Surgeons are constantly doing battle over WHEN to intervene. I am firmly in the Surgeons camp, i.e. to have surgery BEFORE your *enlargement* and *thickening* become PERMANENT DAMAGE to your heart. I vote for letting the SURGEON decide on when to operate!

I see 3 areas of concern:
Enlargement
Thickening
Aortic Valve Pressure Gradient and limited motion.

I don't remember the normal range for those pressure gradients, but your numbers seem on the high side to me. Definitely worth asking a SURGEON for his opinion.

Your cardiologist can give you a referal to a surgeon or you can start doing your own research and request an appointment as a self referal. Take a copy of your test results with you, including a TAPE of your echo for the surgeon(s) to review.

I would start ASAP. As one of our members noted, "when a valve starts getting worse, the faster it gets worse" or something to that effect. I had my surgery 2 months after I was told "It's time" and I believe I got there "just in time" as my aortic valve was nearly closed.

Another concern is that it appears that 'permanent enlargement' can cause arrhythmias post-op. Better to avoid that complication (and treatments) if possible.

'AL'

 

[PapaHappyStar]

At your mean and peak gradients coupled with the mild insufficiency many heart pros will advise elective surgery, the choice is yours ... I havent been through surgery yet so cant tell you about post surgical experience, but if you have had a major valve related health incident then in my opinion ( as a fellow patient ) you should opt for surgery.

If your attack was not valve related then ask what caused it. If it is coronary artery related they do the valve replacement if they need to do a coronary artery procedure.

At this point as the others mentioned you can probably opt for surgery by shopping around for cardioloists and surgeons who offer you that option. I dont know where you went for the initial tests but you should go to one of the larger cardiac centers for a second opinion, my own experience is if echo techs are not experienced in doppler echocardiography across valves the results might not be consistent or valid.

There are many links for self study on this forum in reference sources section:

http://www.valvereplacement.com/forums/forumdisplay.php?f=21

I found some useful info here as well:

http://www.acc.org/clinical/guidelines/valvular/jac5929fla16.htm

Please ask questions if you need further info or clarification

Hope you find this useful, and wish you the best in your search for treatment.

Regards,
Burair

 

[Eloise]

Hi there breakingwaves!
You'll love this place! I have no ability to understand what your tests mean.I would do as much research as possible,there are some great web-sites like "web.md" that EXPLAIN medical conditions in understandable English.Don't ever hesistate to ask your doctor questions,and don't give up untill you feel you understand exactly what your condition is.

 

[tobagotwo]

Tea Leaf Reading

Tea Leaf Reading

Welcome to the Waiting Room, Breakingwaves. Some of my favorite people around here are also waiting for their revalving time to come around. You're in excellent company.

What follows is a pretty matter-of-fact reply, but don't take it to mean that I don't think you have feelings about this. In reading it, it sounds like I am giving a play-by-play on a baseball game or something similarly trivial. Please know I don't feel that way about it at all. We all see some things that make us unhappy, angry, frightened, or relieved on the road to getting our hearts and lives back. This is a good place, as you may already know, to let that out without it always bouncing off your loved ones.

The quote Al Capshaw was fishing for about valve deterioration is, "the worse it gets, the faster it gets worse." The rate at which the valve opening closes up increases as the size of the hole decreases.

Of course, the size of the opening is not the only issue in determining what your heart's status might be.

I'm looking at your echo results, and had to go get mine from the point in time that I was told to go see a surgeon, as they sounded similar. Obviously, I'm not an echo technician or a cardiologist, but here's my "tea leaf reading" of your echo from my bias point:

I gather your problem is a result of an illness earlier in life, as you have a "regular," three-leafed aortic valve with calcification, and a mitral valve following more slowly in its wake. Illness-caused calcification generally affects more than one valve over time. That is how mine has run, apparently from a viscious, unidentified virus I remember dealing with some twenty-five years ago.

The ventricular hypertrophy (muscular overdevelopment) is caused by your ventricle having to work harder to push blood through your smaller and less flexible aortic valve opening. It's "bulking up" from the exercise. Your high-normal ejection fraction is associated with this build-up. Short term, nature is using a good plan, but long term, it will cause enlargement and eventual loss of efficiency and function for your heart. That should go away after your valve replacement is done.

Ejection fraction is the percentage of the blood in your venticle that is squeezed out of it by the heartbeat. So, if 30% of the blood that started out in the venticle is still there after the beat, your ejection fraction (EF) is 70%. You would think that a higher ejection fraction should be good, but the top limit of normal is 75%, and EFs higher than that are usually associated with strain on the heart, Congestive Heart Failure, and other unhappy things.

Your valve is calcified enough to be losing flexibility, and it is not moving (opening and closing) properly. While the echo doesn't mention regurgitation (leakage of blood back through the valve after it closes), it seems that you must have some by reason from the description.

That inflexibility also raises the pressure needed to start blood through the valve as it opens, which is shown most in the peak gradient measurement. The other pressure measurement, the mean gradient, most reflects the size of the valve opening itself. It increases as the heart strains to get the same amount of blood through a smaller opening.

Calcification seems to weight the stenosis negatively. A number of us comparing notes found that our calcified valves were in much worse shape than the stenosis and gradients indicated before surgery. One comment was that the highly calcified valve literally fell apart in the surgeon's hand. My surgeon, who had said I was considered marginal for needing surgery, told me after removing and holding the valve that he didn't know how I was getting blood through it at all. So add some weight to the stenosis for the calcification.

Aortic insufficiency means that not enough blood gets pushed into the aorta to fill it completely when the beat has finished and the aortic valve closes. This is partly because of the difficulty getting blood through the valve, and partly because some of it leaks back (regurgitates) after the beat, because the valve no longer seals well.

There is a mention of trace to mild tricuspid valve regurgitation, but it is likely completely discountable, as regurgitations at the trace level tend to come and go in echoes, and may well not show up at all next time. Not to worry about that one.

There is some enlargement of the left atrium. The backflow of pressure through the heart causes the atrium to enlarge. Atrial fibrillation can also cause this, but you do not mention arrhythmias, so that may not be an issue for you. Enlargement of the atrium can contribute to atrial fibrillation and mitral regurgitation over the course of things, as the atrium's disproportionate size interferes with the rhythm of the heart contracting and stretches the opening that the mitral valve is designed to seal. However, that is not a given, and you don't mention having any afib, so that is to the good.

Also, the lack of pulmonary hypertension, and a total lack of involvement of the right side of your heart are very good things.

You are symptomatic (your attack, VH, and atrial enlargement), and may have symptoms that you're not aware of. For instance, angina is frequently not a pain in the left chest or arm as depicted in movies, but may also be an uncomfortable tightness at the base of the throat, neck pain, back pain, or (particularly in women) jaw pain. You may get shortness of breath (SOB), lack of ability to do what you used to do, low energy, or complete exhaustion at night, but attribute it all to age (I did). Of course, it gets hard to tell, because when you start to look for yourself, you can't always decide if symptoms are real or imagined.

Interestingly, There is no mention of a calculated valve opening on the report. Based on your peak and mean pressure gradients, I would ballpark it at less than 1 cm². Here's another area where your echo sounds familiar: Your peak gradient (the highest pressure point - which is what it takes to open up your calcified valve at the start of the heartbeat) was 73mmhg, mine was slightly less at 68mmhg. Your mean gradient (average pressure through the valve) is 44mmhg, mine was 45mmhg. Your ejection fraction (EF) is 70%-75%, mine was 77%.

Basically, you have my last presurgical echo report, taken less than three months before my AVR.

That means to me that you should be talking to a surgeon as soon as you can decide on a good one with lots of experience. My guess is that a surgeon will say you're closer than two years, probably less than one.

I suspect that the cardiologist wants you to keep your own valve as long as you possibly can, an increasingly unpopular position on this site, due to the possibility of long-term damage to the other parts of your heart. I also suspect that he thinks that, being a woman and a grandmother, you don't have a physically active life, so are less apt to "need" the surgery as soon as a man might (he obviously doesn't care for and chase after three, active children, or he'd have some idea of the stamina that takes).

Normally, a cardiologist doesn't tell someone to get their ducks lined up if he really thinks surgery is still a year or two away. He may be pushing you toward a surgical consult now because he's not sure and wants a surgeon's opinion without saying so.

I would also ask about the prognosis for your mitral valve. It isn't in need now, but if they forsee a mitral replacement or repair in your eventual future, it may affect your thoughts about what type of aortic valve you would want to have implanted.

As I said before, all this is tea leaves. I hope I didn't scare you, as I don't mean to. You're not an emergency, no matter how this all sounded. But if you take anything from this at all, please search out a good surgeon, and get a consultation with him very soon.

Best wishes,

 

[Harpoon]

Mitral valve is calcified and not working up to snuff which is putting additional stress on the left side of your heart which is thickening and hardening the tissues of the left atrium and ventricle.

Any time a valve isn't working properly there's additional workload being placed on the pumping chambers. You really have to understand how a heart pumps, the action and sequence of movements, to see how a "flaw" in one part of the system affects everything else. The mitral valve isn't going to get better on it's own and that will be a problem later on. The report suggests you have some time to prepare, at least a year if not more, and I agree with Al, you should be seeking out a surgeon and asking about your options for valve replacement. There are a number of choices in mechanical and biological valves as well as possible reconstruction proceedures (like the Ross) that may or may not be best suited for your needs. No option is perfect, they all have drawbacks and the best choice for you is based on your lifestyle, your age, your needs...

You'll also want to consider where you want to go hospital-wise. Some places are a LOT better for a variety of conditions than others. many heart centers do well enough for simple mitral and aortic valve replacements but there are a few centers (trying not to mention my hospital of choice here...) that are far superior when it comes to dealing with complex heart conditions and complications.

Ask around. You'll make a decision based on where you live, what's closest to you or where is the easiest place to go for surgery in addition to the quality of the doctors and their surgical teams...


Time to do some homework. =)

 

[Bill Hall]

Break - I enjoyed reading the excellent responses to your post. Just wanted to add a few additionals thoughts:
1 - The attack that you described is not a typical symptom of a valve problem, at least from reading this web site on and off for the past few years. Anyway, you need to get clear information on the attack.
2 - Bob H did a great job going through the details. He is not a medical professional, but sometimes I think he is better. Anyway, he mentioned that symptoms are not easy to recognize because you start to question whether they are real or imagined. A really good point.
3 - You should probably get the second opinion that others recommended, but not necessarily a surgeon, maybe another cardiologist.

 

[breakingwaves]

Hensylee

Hensylee

thank you, I have been watching, listening and amazed for over the past two years while after I was first told of this just trying to get generally informed. what has most amazed me was the compassionate, patience and teaching that occurs here on a regular basis. Especially to those that are soon to be moving towards surgery. bottom line some really great people care enough about others to provide strength and encouragement of others, what a group! I already feel better having benefitted from my own particular situation. I think you will be seeing and hearing more from me, and I am so thankful!

 

[breakingwaves]

ALCapshaw2

ALCapshaw2

thank you for you information and opinion, this is exactly what I need to hear!

 

[breakingwaves]

PapaHappyStar

PapaHappyStar

thanks, I am just now realizing that it is time to put my player on the gameboard, and those links will definitely be followed up, I am a person who needs information in order to provide the courage to ask the right questions and your guidance is a big help!

 

[breakingwaves]

Eloise

Eloise

thank you for the welcome, it is so helpful to me to be among others that know specifically what I am talking about, my husband and friends don't know how to talk with me because in their mind this really isn't real.

 

[breakingwaves]

tobagotwo

tobagotwo

I can't even begin to express how thakful I am that you took so much of your time to explain these things to me, I printed to off so I can read it and digest it. I so need this kind of information, I am one to hear a array of information to better help myself come up with quesions and decisions and I didn't know where to begin! Sometimes a brick wall has to fall on me to put aside my very active life and say, okay I need to focus on this for my health so what you had to say is more useful than I can even verbalize.

I have always been the doer in the family which means I want to keep myself going for the others that need me to stay doing. My three kids are 8,9 and 11 and we just received custody of them 2 years ago from a very neglectful and life threathening situation so they are counting on me for a while to continue to stay well enough to help them through much emotional trauma.

Because of this I need to stay on the ball with my health, and the precise information you gave me was just what I needed to hear. It will provide the opportunity for me to form my own questions, and maybe ask more here. I tend to be lead by the doctors and sometimes that isn't always the best way, 2 years ago I had a cath and the aortic stenosis was not even mentioned until a diverticultis attack had a stomach surgeon refuse to operate on me until he had clearance from the cardio guy. You could have knocked me over because after my cath which took place after feeling angina, they told me no problems, my heart was in great shape! I believed them until the stomach guy sat me down saying he could hear the stenosis. Not even my GP mentioned it, I thought the discomfort I had in the hospital was all in my head, so it only goes to show.

I don't work with grudges though, I just want to move forward in a more informative way. No one to this date has mentioned anything about the mitral valve and enlargement and I picked up on the same thing after reading for myself the echo report, so at least I feel a little less crazy about that even with just these comments. a little like I felt as a woman who took my car to be repaired not knowing exactly where the engine was, LOL!

Thank you once again, and I hope if I have future questions you will be so kind as to clear up any misconceptions, sometimes it takes the real person going through it to better teach the reach person going through it. I am not against a good doctor though and will earnestly be looking for one who knows exactly where my engine is located! LOL!

 

[breakingwaves]

Harpoon

Harpoon

thank you, I did see that about the mitral valve and did think, whoa I have not heard a word about that, that is one questions I will be posing to the cardiologoist. I am also trying to do research about a hospital and seeking advice, and I am glad you mentioned about the hospital to fit the patient because I was not yet thinking that way. sometimes just a few words will get me to thinking in a broader perspective, thank you so much! I try to be a good student and learn from others.

 

[breakingwaves]

Bill Hall

Bill Hall

I also enjoyed the excellent information I received, and even though I won't be dragging the papers of responses with me, I will be studying them as I prepare for my visit so that I can now ask real questions.
Bob H, was so great going through all those details and for someone who needed to be in touch with reality, like me, it is a lifesaver.
My first stop is the new cardiologist that my GP and I talked about, the next will be what he sees as a possible surgeon, he has worked with some from the Washington Hospital Center, but I now know to ask, only because of all of you taking you time and care with me, if that is the right hospital for my operation. thank you so much!

 

[McCln]

Breakingwaves

Breakingwaves

I am glad that you are so responsible to get educated. Be sure, when you go to the new cardio that you get to know the surgeon soon and discuss of what needs to be done and options available. Good luck and keep us updated and welcome to the site. I come in when not walking or working hard. I work on the computer all day and sometimes hard to get on line when eyes are so tired that they are ready to pop out of my head. He! He! Have a great week and keep us informed on what you do find out.

Caroline
09-13-01
Aortic valve replacement
St. Jude's valve