Diminished running ability after mitral valve surgery.

[Midpack]

Hi!

I did not have surgery myself yet, so I cannot comment on my personal experience. But I really enjoy running and I have followed these kind of discussions over the years with great interest. I read messages from many runners complaining that post- surgery they were unable to achieve the same performance level they had pre-surgery. Unfortunately, this seems to be the norm.

On the other side, I have read somewhere (may be here) that valve surgery is intended to save your life (and restore, hopefully, a normal life span). It is not intended to preserve you athletic level.

If you are a somewhat competitive person who likes to improve his running times (PBs) and have goals to keep motivation up, I beleive it is a good idea to reset your PBs and begin to compute them post-surgery.

Regards

 

[nobog]

Here's a blurb from an older Circulation article

https://www.ahajournals.org/doi/full/10.1161/circulationaha.108.778886

that supports several PPM points made above. The point about age and different aortic vs. mitral impacts resonated with me.

Clinical Impact of PPM​

Several studies have reported that aortic PPM is associated with less improvement in symptoms and functional class,30 impaired exercise capacity,31 less regression of LV hypertrophy,32 less improvement in coronary flow

​

I find it "interesting" that one is concerned about PPM (prosthesis-patient mismatch) yet some here will talk about valve-in-valve-in valve. Which if actually accomplished, leaves diddly squat for a EOA (Effective Orifice Area).

 

[V__]

I find it "interesting" that one is concerned about PPM (prosthesis-patient mismatch) yet some here will talk about valve-in-valve-in valve. Which if actually accomplished, leaves diddly squat for a EOA (Effective Orifice Area).

It would seem natural that different people have different levels of understanding and concerns...

Your point about nested valves seems quite important. That method is probably applicable when other alternatives are riskier. From what I understood, TAVR was first approved for risky cases when SAVR was not even applicable.

 

[JimHewes]

Thanks very much for all the comments! There are some knowledgeable people here. I'll need to digest it all some more. It gives me an idea or two to suggest to my doctor.

I expect if there were some sort of abnormal stenosis my doctor would have mentioned it. I can definitely believe that it would have to do with the annuloplasty ring reducing the inlet size. It feels like that, though I don't know and it could just be my imagination. My understanding is that an echocardiagram doesn't really measure the amount of blood flow.

Regarding the chemical unloading of oxygen at the target tissues, maybe. But I wouldn't expect the heart surgery to affect it. My blood is definitely getting oxygenated to 99% since it was checked on my treadmill test. Incidentally I did pretty well on my treadmill stress test which leads me to think that it's not a very good test for my situation. My test is the one that shows the difference, which is running, but the doctors don't have any test that includes actual running. Fast walking isn't a problem.

Some of you seem to know a lot about your own numbers like the MV area and peak gradient. Maybe I should try to find out mine. Though I might not have any baseline to compare with.

I think my cardiologist has run out of ways to test if it's a heart problem or not. I'm now scheduled to take some sort of lung test. But I know that I don't have any lung problem. I was hoping it could go something like, "Oh (1) we see what the problem is and (2) we should be able to fix that." But unless both of those are the case there's not much reason to chase it.

 

[pellicle]

From what I understood, TAVR was first approved for risky cases when SAVR was not even applicable.

I'm also pretty clear that was how it evolved too ..

 

[pellicle]

Some of you seem to know a lot about your own numbers like the MV area and peak gradient. Maybe I should try to find out mine. Though I might not have any baseline to compare with.

if it helps you feel better about things, I'm totally not aware of mine and don't bother getting into it. I leave that as something for the cardiologist. I prefer to focus on only what involves me:

• managing my INR
• understanding why thrombosis occurs
• knowing how my valve works and the major parameters that effect blood cells and thrombosis
• being aware of my limits through listening to my body (and that's actually a very personal learning process, just like teaching someone proper stretching technique)
• having enough understanding to double check what I'm being told when and if my numbers aren't right

If its outside of my control I'm less interested in it.

Best Wishes

 

[V__]

Thanks very much for all the comments! There are some knowledgeable people here.

I'm very happy you started this thread. Was educational for me as well

I expect if there were some sort of abnormal stenosis my doctor would have mentioned it. I can definitely believe that it would have to do with the annuloplasty ring reducing the inlet size.

FWIW, I think it's only one possible scenario ("too tight ring"). For example, if the leaflets are "stiff", they will impede the blood flow. The outcome also depends on the technique. From this paper:

Functional Mitral Stenosis​

In cases where it has been necessary to perform excessive leaflet resection, the posterior leaflet can form a stiff, nonpliable shelf, creating functional mitral stenosis. Mitral stenosis can also occur due to excessive downsizing of the annuloplasty, especially if using a complete ring. This can result in excessively increased mitral valve gradients.​

My understanding is that an echocardiagram doesn't really measure the amount of blood flow.

Well, echo measures EOA and gradients, which are directly related to the blood flow. (E stands for "effective". So, for example, if the valve leaflet is barely moving, the valve would not be opening much. Then effective area would be low - it's as if the orifice area were small in this case.)

Some of you seem to know a lot about your own numbers like the MV area and peak gradient. Maybe I should try to find out mine. Though I might not have any baseline to compare with.

I've seen thresholds for such numbers ("indexed" EOA and gradient), that define/classify the stenosis and its degree. Except IMHO there is a caveat that echo done at rest may not reflect the status during the exercise. It's your call though, if you want to dive into these details.

I was hoping it could go something like, "Oh (1) we see what the problem is and (2) we should be able to fix that."

Would agree that solving a solvable problem would be nice in this case. (No sarcasm or joke intended.)

 

[dornole]

You didn’t run during the stress echo? They made me run until I couldn’t run any more.

 

[JimHewes]

You didn’t run during the stress echo? They made me run until I couldn’t run any more.

The stress test starts out with you walking. Then it progressively increases the speed and increases the angle upward. By the time it got to a pace that was about between fast walking and running the angle was already pretty high and I was done at that point. Couldn't go more. So it was never like running on flat ground.

 

[carolinemc]

Thanks very much for all the comments! There are some knowledgeable people here. I'll need to digest it all some more. It gives me an idea or two to suggest to my doctor.

I expect if there were some sort of abnormal stenosis my doctor would have mentioned it. I can definitely believe that it would have to do with the annuloplasty ring reducing the inlet size. It feels like that, though I don't know and it could just be my imagination. My understanding is that an echocardiagram doesn't really measure the amount of blood flow.

Regarding the chemical unloading of oxygen at the target tissues, maybe. But I wouldn't expect the heart surgery to affect it. My blood is definitely getting oxygenated to 99% since it was checked on my treadmill test. Incidentally I did pretty well on my treadmill stress test which leads me to think that it's not a very good test for my situation. My test is the one that shows the difference, which is running, but the doctors don't have any test that includes actual running. Fast walking isn't a problem.

Some of you seem to know a lot about your own numbers like the MV area and peak gradient. Maybe I should try to find out mine. Though I might not have any baseline to compare with.

I think my cardiologist has run out of ways to test if it's a heart problem or not. I'm now scheduled to take some sort of lung test. But I know that I don't have any lung problem. I was hoping it could go something like, "Oh (1) we see what the problem is and (2) we should be able to fix that." But unless both of those are the case there's not much reason to chase it.

I think his is going this route due to heart and lungs are interconnected and if there is a heart issue it will affect your lungs, and you would not always be aware of it.

 

[QuincyRunner]

My story as a lifelong runner who received a mechanical mitral valve at 53 (12 years ago) is very similar to what I have been reading here. I am especially appreciative of Woodcutter's theories as a hydraulic engineer. His explanation in somewhat technical terms really fits the sensations I feel that have limited my ability to run faster (other than my age and general physical decline). Although I am happy to be able to run at all post surgery there has been a very steep decline in my race times and even my enjoyment of racing. There was a time when I could run 5-minute miles for a 10K and 5:30 miles for a full marathon with seemingly no pain and no gasping for air. Even in my 40's in the decade prior to my OHS I could run 16 minute 5K's. The tightness I feel in my chest now when running a 9-minute pace reminds me of a time in the early 80's when I was training hard to try to qualify for the U.S. Olympic Trials in the marathon. Many other hopefuls at that time were moving to Colorado to train at altitude (which is an established method to strengthen the cardiovascular system and increase the amount of oxygen in the blood) but with a family and a job I neither had the money nor the time to pursue that route. Instead I used this piece of equipment that looked like a scuba diving tank connected to a mask that I wore while out on training runs around Columbia, South Carolina. I'm sure I looked like a freak but the system was clearly mimicking high altitude by restricting oxygen. They make similar masks today for runners to simulate high altitude training but without the bulky tanks. Anyway, I say all this to say that the restriction of oxygen and the tight chest and fighting for each breath that I experienced with that contraption on is exactly the same feeling I've been getting the past 10 years whenever I go above an aerobic pace and venture into the anaerobic world, which of course occurs at a much slower pace than it used to. I'm sure my advancing age is a big culprit here but the actual tightness in my chest, no matter how much I run or how fit I get, is a constant, and I always visualize that my rigid mitral valve is not letting enough blood (oxygen) through. Which as I have learned in this discussion, has actually been the case. Thanks to you all.

 

[nobog]

and I always visualize that my rigid mitral valve is not letting enough blood (oxygen) through. Which as I have learned in this discussion, has actually been the case. Thanks to you all.

I wouldn't place a bet on that, mitral valves are typically large (> 25mm) and the velocity is lower through the mitral valve (compared to the aortic valve) so something else might be going on.

 

[Woodcutter]

QuincyRunner: my experience largely aligns and mirrors yours.

nobog: I agree that, when all other parameters are equal, a larger area corresponds to lower velocities. Simple continuity: the volume/time in equals the volume/time out.

However, it's pretty rare for all the other parameters to be equal. For example, a typical aortic valve area will be 3-4 sq cm and a typical mitral valve area will be 4-6 sq cm. It's quite easy to reduce the mitral area by 50% with a replacement mechanical valve. The mechanical valve is round and the native valve is not. The mechanical valve has the cuff and leaflets. (note: annuloplasty rings have many variations that are selected to conform to the non-round shape of the native mitral cavity).

So it's not hard to reduce the effective mitral area to less than the aortic area. Same continuity view yields a now greater pressure drop across the mitral. Difference is that the pressure drop across the aortic is retained in the ventricle by the "check valve" function of the mitral whereas the pressure drop across the mitral will be felt through the pulmonary veins back to the lungs (because there is no "check valve" to stop the backpressure.

Mitral valve isn't considered stenotic until something less than 2 sq cm (I'd have to look it up!). But . . .. cardiac output needs to increase significantly during exercise (run/bike/ski/swim/paddle/etc). Tremendous variability in this but it wouldn't be unusual to need 4-8 times as much flow. And a key is that across an orifice, flow and pressure have a 2nd order relationship. My personal experience is definitely that you can reduce the mitral are enough to feel it in the lungs!

 

[nobog]

QuincyRunner: my experience largely aligns and mirrors yours.

nobog: I agree that, when all other parameters are equal, a larger area corresponds to lower velocities. Simple continuity: the volume/time in equals the volume/time out.

Mitral valve isn't considered stenotic until something less than 2 sq cm (I'd have to look it up!). But . . .. cardiac output needs to increase significantly during exercise (run/bike/ski/swim/paddle/etc). Tremendous variability in this but it wouldn't be unusual to need 4-8 times as much flow. And a key is that across an orifice, flow and pressure have a 2nd order relationship. My personal experience is definitely that you can reduce the mitral are enough to feel it in the lungs!

You have to remember systole and diastole are not 50/50. Its more like 40/60 at 70 bpm. That means there is more time to get the exact same amount of flow through the mitral valve. This is a floating scale and it is closer to 50/50 once you get past 120 bpm, but in general, flow though the mitral valve is slower than through the aortic. And... as mentioned, the mitral valve is bigger than the aortic to start with, so EOA is usually not an issue. BTY, 3 lpm is very low, 10 lpm is very high, so about 3X for a range (5 lpm is considered normal at rest).

 

[V__]

You have to remember systole and diastole are not 50/50. Its more like 40/60 at 70 bpm. That means there is more time to get the exact same amount of flow through the mitral valve. This is a floating scale and it is closer to 50/50 once you get past 120 bpm, but in general, flow though the mitral valve is slower than through the aortic.

FWIW, when I tried to look up the relative ration, I found this paper.

It seems the statements are quite correct for a normal case without complications. In case of complications, the systole and diastole times might cross at lower HR.

 

[JimHewes]

Wow, some of you guys are really fast. KyleR running 5:50 pace in a half marathon. QuincyRunner 5:00 pace in a 10K!! I was never in that class. I played a couple sports in high school but then didn't really start running until my thirties. As I mentioned at 40 I could run a 10K at 6:57 pace. At 60 I could run one at 7:34 pace, still with severe mitral regurgitation. And I assume I could have run 8:00 pace or so by age 63 though I slowed down on purpose because I discovered the regurgitation had become severe. But now after surgery I would estimate I'm probably running at least 11 minute miles though I haven't timed it. And it's more difficult and I've been limited to about 5.5 miles so far. So I guess I might not have minded so much a reduction in pace of 30 seconds as in Woodcutter's case. But it's worse than that.

And I do feel some, what you might call chest pressure when running. Particularly when I haven't run for a while. Though it feels to me more like a soreness. Never had anything like it before the surgery.

Key point is that around 35 mm HG pressure, lung problems develop. What they had me do was a type of stress echo. They put the ultrasound equipment and a bed right next to the treadmill/EKG and had me run.

I've had three stress tests in my life and in all three I only had an EKG. Never a stress echo. I guess that's what I would want. A test to show how much blood I'm pushing while running on flat ground at the fastest pace I can go continuously.

What seems strange to me is this. I was told that once you get to severe regurgitation your heart tries to compensate by getting bigger. It eventually grows to a larger size and then fails. Though in my case my heart was still normal size. But now that running is so difficult and I can't go as fast, isn't my heart trying to compensate even more? How is it more efficient, and if it is more efficient shouldn't I be able to run as fast? But since it's so difficult now shouldn't my heart want to get even larger now? That I don't get.

Another thing that seemed strange was that when I initially brought up with my cardiologist this trouble when running I expected he would have had some knowledge about it. But he didn't seem to. That is, in 50 years of heart surgery shouldn't there be statistics on how well runners do before and after valve repair/replacement? I was just looking to see if my case was unusual or was expected.

I mention it only in case you notice any positional issues or persistent dry coughing along with shortness of breath, that could indicate mitral stenosis.

Yes, I have been having a dry cough but it only started recently, maybe a few weeks.My surgery was 15 months ago. It's a little annoying when trying to sleep. I'll bring it up next time I meet with my cardiologist. I have no shortness of breath at rest though.

 

[Woodcutter]

Here's an older paper with some testing and analysis on the systole/diastole timing.

https://journals.physiology.org/doi/full/10.1152/ajpheart.00404.2004
As mentioned, the duration ratio mentioned approaches 1.0 as HR (heart rate) increases. For me personally, when I talk about my own running I am talking about HR > 120. Interestingly, this testing utilized a supine bicycle which I can certainly understand relative to the difficulties of measurment during exercise. I find this interesting because as a lifelong runner, I am also a "weak" cyclist. I generally run with my HR in the 130's peaking in the 150's (say for a 5k). I do not get my HR above 110 cycling.

 

[Woodcutter]

Jim: regarding the stress echo, I want to reiterate that it is difficult to capture the effect that I have been pointing out. I took a quick measurement myself this morning because I was thinking of your questions while I went for a 35 min run. Not fast, not slow, just an average run. It was about 9:30 pace and when I finished my HR was 136 . . . quite typical. 60 sec later it was 109 and after 2 minutes it was 91. Point is that a trained heart will slow down very quickly. You can see the challenges in trying to obtain echo measurements while literally running . .. . and measurements must be taken very quickly upon stopping or the heart is behaving quite differently. This is a training effect and not quite so apparent in those who do not regularly exercise.

Couple other thoughts: I too would like to think that there would be 50 years of useful statistics on running and heart valves. Honestly V_'s listing a few weeks ago of a paper on post-annuloplasty mitral stenosis was the first I had seen! However, I think the reason is the obvious: the population of runners out there with valve replacements is not huge and the medical/scentific community have a much larger population with a higher priority. I.e. living life. I've mentioned my own attitude change due to my annuloplasty induced stenosis resulting in a literal inability to run. Not a run goes by that I do not remember believing I'd be running 6 min pace 5K's at 60. But I just as quickly/easily supersede this with literal happiness that I found a cardiologist who said "you will not make the Olympics but I will get you running again". (The surgeon who did my annuloplasty literally said to me {after seeing the echo results showing stenosis} "you will never run again").

 

[dornole]

Wow, some of you guys are really fast. KyleR running 5:50 pace in a half marathon. QuincyRunner 5:00 pace in a 10K!! I was never in that class. I played a couple sports in high school but then didn't really start running until my thirties. As I mentioned at 40 I could run a 10K at 6:57 pace. At 60 I could run one at 7:34 pace, still with severe mitral regurgitation. And I assume I could have run 8:00 pace or so by age 63 though I slowed down on purpose because I discovered the regurgitation had become severe. But now after surgery I would estimate I'm probably running at least 11 minute miles though I haven't timed it. And it's more difficult and I've been limited to about 5.5 miles so far. So I guess I might not have minded so much a reduction in pace of 30 seconds as in Woodcutter's case. But it's worse than that.

And I do feel some, what you might call chest pressure when running. Particularly when I haven't run for a while. Though it feels to me more like a soreness. Never had anything like it before the surgery.



I've had three stress tests in my life and in all three I only had an EKG. Never a stress echo. I guess that's what I would want. A test to show how much blood I'm pushing while running on flat ground at the fastest pace I can go continuously.

What seems strange to me is this. I was told that once you get to severe regurgitation your heart tries to compensate by getting bigger. It eventually grows to a larger size and then fails. Though in my case my heart was still normal size. But now that running is so difficult and I can't go as fast, isn't my heart trying to compensate even more? How is it more efficient, and if it is more efficient shouldn't I be able to run as fast? But since it's so difficult now shouldn't my heart want to get even larger now? That I don't get.

Another thing that seemed strange was that when I initially brought up with my cardiologist this trouble when running I expected he would have had some knowledge about it. But he didn't seem to. That is, in 50 years of heart surgery shouldn't there be statistics on how well runners do before and after valve repair/replacement? I was just looking to see if my case was unusual or was expected.



Yes, I have been having a dry cough but it only started recently, maybe a few weeks.My surgery was 15 months ago. It's a little annoying when trying to sleep. I'll bring it up next time I meet with my cardiologist. I have no shortness of breath at rest though.

The mitral stenosis cough is positional, much worse when lying flat than when sitting or standing. I had to sleep in a chair because I’d be coughing too hard to sleep.

 

[V__]

What seems strange to me is this. I was told that once you get to severe regurgitation your heart tries to compensate by getting bigger. It eventually grows to a larger size and then fails. Though in my case my heart was still normal size.

Good for you. I presume you just didn't get to this symptom yet. (Not to mention the following stage of cardiac failure.)

But now that running is so difficult and I can't go as fast, isn't my heart trying to compensate even more?

I think that compensation-by-dilation only works in case of regurgitation (b/c of backflow). If you are really exercise-stenotic, the enlargement probably won't happen.

How is it more efficient, and if it is more efficient shouldn't I be able to run as fast?

I can roughly understand it in the following way:

• The contractions must be more efficient.
• But, if you are exercise-stenotic, the blood flow during the in-fill phase has a (new) limit.

Another thing that seemed strange was that when I initially brought up with my cardiologist this trouble when running I expected he would have had some knowledge about it. But he didn't seem to. That is, in 50 years of heart surgery shouldn't there be statistics on how well runners do before and after valve repair/replacement? I was just looking to see if my case was unusual or was expected.

I think Woodcutter described it well. A typical study is focused on a typical patient. And you are probably in a much better shape than most. I just searched Pubmed, but found nothing about mitral valve and runners. It seems disconcerting, given that there are something like 40,000 surgeries in the US alone. So there should be some data on the topic you want. But the results are only available once somebody analyzes the data... There is also the topic of "sports medicine", where they worry about some features. But probably not the outright MVr.