Echo Results

[Jim]

I finally received the results of my request to get copies of my echos for the past 4 years. I must say, I was somewhat encouraged to get these from a couple of individuals in the group.

Below is a listing of some of the important measures over time for the past 4 years. I was diagnosed w/ Aortic insufficiency and stenosis in March 2001.

LVID (ed) Normal readings = 3.5 > 5.5

Oct '01 5.8
Nov '02 5.5
Dec '03 5.5
Dec '04 5.7

LVID (es) Normal readings = 2.5 > 4.0

Oct '01 3.1
Nov '02 3.0
Dec '03 3.0
Dec '04 3.7

Aortic Valve Area

Oct '01 1.6
Nov '02 1.55
Dec '03 1.61
Dec '04 1.1

EF was 65% for all readings.

Conclusions on last report:

* Mild concentric left ventricular hypertrophy w/ normal systolic left ventricular function and normal left ventricular internal dimensions

* Aoritc valve is heavily sclerotic and calcified w/ at least moderate aortic insufficiency and mild to moderate aortic pressure.

* Left ventricular internal dimensions may have increased slightly compared to the previous study, but there is probably no significant change.

My official appointment w/ the Cardiologist is in March. Based on these reports, I would be surprised if he would suggest surgery at this stage; however, I am a little surprised by the latest aortic valve region reducing to 1.1. This is more in line w/ what I recall from my first report that is not included in the ones listed above. I basically want to get an idea of how far away I am from surgery.

For those persistent members that urged me to request my reports, thanks for encouraging me to be proactive. I definately feel like I will be more informed when I visit the cardiologist.

Jim

 

[perkicar]

Echo and Surgery

Echo and Surgery

From what I've read, the "must have surgery" valve area is 0.8 cm2. However, I think they look at other factors, such as your having other symptoms (like shortness of breath, fainting) as well as ventricular enlargement (or hypertrophy). My valve area was 1.1 cm2 at my last TEE in November. I'm expecting to hear something this week from CC regarding the records I sent them just before Christmas, so it will be interesting to see what they tell me then.
Carolyn

 

[Jim]

Echo results

Echo results

How many past readings did you have? Why did they decide to move you from Echos to a TEE?

As I mentioned in my e-mail, I am a little concerned about the progression of the Aortic valve size. I wonder if this could be due to a technician change in this last reading. Also, they stated in earlier reports that my aortic stenosis was "moderate" at 1.6. Although there are several classifications of this, I have not come across one stating that 1.6 was moderate. The ranges I have been seeing is 1.4 to 1.0 for moderate Stenosi (.8 to <1.0 is severe; <.8 is critical).

Thanks,
Jim

 

[bvdr]

Well it seems to me that your aortic stenosis is accelerating. You have probably read it here before but "the worse it gets, the faster it gets worse". I also believe that a person with both a stenotic and regurgitant valve will probably need it replaced sooner than a purely stenotic valve. This is because with the same size valve orifice the stenotic/regurgitating valve has less net blood moving forward than the valve with stenosis only.

My aortic valve was at 1.4 last March. My next echo is in March just like your's . I'll be watching for your post letting us if you have had any changes. I hope you stay where you are at for many years but don't be surprised if the pace picks up a bit.

 

[tobagotwo]

I would echo Betty's sentiments on this. And Perkicar's reading about valve opening as a surgical criterion agrees with mine, although many surgeons are willing to take a symptomatic patient as long as he is under 1 cm².

With the caveat that echoes aren't always accurate, nor done by the same technician, it is rather normal for the reduction in size to accellerate as cardiolytic apatite (calcification) accumulates. As such, the last reading may not be as far off kilter as you might wish. And calcification does interfere with the blood flow, even apart from the narrowing of the valve aperture, just as rocks slow the passage of water in a stream. The report doesn't seem to mention aoric regurgitation, but it almost naturally follows in a heavily calcified valve, as tha deposits eventually interfere with proper valve closure. The aortic insufficiency is usually a function of both the stenosis and the regurgitation by the time stenosis becomes severe (I believe yours is not listed as severe yet).

I would also look at your concentric left ventricular hypertrophy as a sign that your heart is working harder now. You do not want that hypertrophy to remain after your surgical recovery, so be aware of its growth and show your concern for it to your cardiologist. I had a similar statement in my last report before surgery.

Also, although you may be thinking that 65% is a good ejection fraction, in the situation of a calcified, stenotic valve, it is more likely to be a symptom of the hypertrophy than of good heart function. The heart has grown, like any other muscle would, to accommodate its workload. It is now operating very effectively for its situation. However, that growth will eventually cause other valves to leak, by misshapening your heart. It will itself become part of the problem, becoming large enough to interfere with its own function, eventually causing congestive heart failure. Please don't be upset by this statement, as it would not be likely to happen for quite some time yet. I'm just pointing out a likely trend over time.

Please don't shovel snow. No one with stenosis above the mildest levels should be using a shovel seriously.

Best wishes,

 

[Jim]

Echo Report

Echo Report

Bob and Betty, thanks for your feedback. Although the report does not mention aortic regurgitation, I remember my cardiologist mentioning that I do have this.

The reading that seems a little strange is the "Aortic Peak Velocity". In previous readings it was 3.5, 4.0 & 4.2. The latest reading has it at 1.0. The normal range is .5 > 1.8. Its strange why it would be outside of normal on previous readings and drop dramatically within normal on the last reading. Also, the peak/mean gradient for my Aortic valve was 51/28, 63/36, 70/35 and 64/30. Any insight into this would be helpful.

Thanks for your advice. I have accepted the fact that I will need to get this surgery sooner rather than later. I would be surprised if it would be this year, but one never knows. As far as the snow shoveling goes, it was over 70 for 3 days this week in Virginia. If we do get a big snow, I am sure my wife would like to get some excercise of shovelling.

Jim

 

[Jim]

Betty, I forgot to ask. When the day does come, I have been thinking about going to Duke for the surgery since it is only 2.5 hours away from Richmond. I heard a lot of good things about the hospital. What has your experience been like w/ Dr. Glower as a surgeon and the hospital?

Jim

 

[perkicar]

How many past readings did you have? Why did they decide to move you from Echos to a TEE?


I've had yearly echos since 2001. I had an evaluatory echo in 1997, I think but no one acted very concerned about it then. I had breast cancer with reconstruction in 1991, so I have an implant on the left side, which makes it a challenge for them to get a good echo. This was my first TEE, done mostly so they could get an unobstructed view of my valve from many different angles without having to work around my implant.
I did hear from CC today and will be going on the 15th of February for a full workup there, with everything from CT scan to Heart Cath. But don't compare my case 100% to yours, I have a pretty unique history (Hodgkin's Disease with radiation in 1978, breast cancer with chemo in 1990) so have alot of factors playing into my problems. I've heard great things about Dr Lytle, so will be relieved to finally get to meet him and hear what he has to say about my situation.
Carolyn

 

[perkicar]

Shovelling Snow!

Shovelling Snow!

[
Please don't shovel snow. No one with stenosis above the mildest levels should be using a shovel seriously.

Best wishes,[/QUOTE]

Wow, I felt guilty/lazy about hiring the neighbor kids so shovel mine the last time it snowed here (13 inches right before Christmas!). But I figured I should be out there shovelling and I'm glad to know I listened to my gut!
Carolyn

 

[bvdr]

Jim, the terms "insufficiency" and "regurgitation" are often used inter-changeably. So where you report mentions moderate aortic insufficiency you could read it as moderate aortic regurgitation and the meaning would be the same.

Duke is considered to be the #3 heart hospital here in the U.S. and Dr. Glower is not only easy to talk to but is also a very highly qualified surgeon. I only saw him once in his office before I had valve replacement and then twice a day when I was in the hospital there. He discharged me to the care of my local physicians and I haven't ever seen him since. I may schedule an appointment to talk things over with him if my March echo shows any significant change. I would feel comfortable with him doing a second valve replacement on me if it one day becomes necessary.

Duke is a little less than two hours from our house and if you are only slighly farther then it really makes sense to seek out the best.

 

[tobagotwo]

EHHhhh... Mild disagreement. Insufficiency indicates that the aorta is not filling completely with each beat of the heart, and doesn't indicate the reason.

I do agree that the reason is usually a mix of stenosis and regurgitation, which had prompted my earlier comment.

Best wishes,

 

[Bryan B]

Jim,

I'll just echo what Betty said about Duke. If and when the time comes that I need another heart surgery I would not hesitate to go back to Duke. I live in Nashville, TN but lived 30 minutes from Duke for 30 years before moving to Nashville. It was well worth the trip in my opinion...I even go back to Duke for my cardio followups. My surgeon was Dr. Jaggers (chief of pediatric cardiac surgery) and he is an excellent surgeon. I selected Dr. Jaggers because I chose to have a Ross Procedure and I also had my VSD repaired, and since his specialty is congenital heart disease he was the man for me. Dr. Glower would be an excellent choice as well. Good luck to you!

 

[Jim]

Thanks for sharing your comments about Duke. Another reason I want to go there is to get minimally invasive surgery. I am the type of person that reads my e-mails while on vacation. If I can shave 2-4 weeks off the recovery period, even better.

Jim

 

[PapaHappyStar]

The reading that seems a little strange is the "Aortic Peak Velocity". In previous readings it was 3.5, 4.0 & 4.2. The latest reading has it at 1.0. The normal range is .5 > 1.8. Its strange why it would be outside of normal on previous readings and drop dramatically within normal on the last reading. Also, the peak/mean gradient for my Aortic valve was 51/28, 63/36, 70/35 and 64/30. Any insight into this would be helpful.

I think its mistyped -- there is a simple relationship between the peak gradient and the peak velocity P=4*V^2 , P = peak gradient and V = peak velocity -- what they actually measure with the doppler is the velocity.

look at how your number go:

at 51 peak gradient, velocity: 3.57
at 63 peak gradient: velocity: 3.96
at 70 peak gradient: velocity: 4.18
at 64 peak gradient: velocity: 4.0

I dont see why your calculated AVA has dropped to 1.1cm^2 or why it was 1.6cm^2 before. The AVA depends on the flow as well -- the lower the flow volume through the valve for a certain gradient the smaller the area, its possible your net flow decreased although if your EF is the same that would mean the volume of blood in your heart decreased, then they say that the internal area of the LV increased slightly so I dont understand their computation.

I will find the source I used to check my own echos and check your numbers again -- maybe they are making a mistake. If you have more numbers they would help. I think moderate to severe stenosis is a lot different from the mild stenosis indicated in your previous reports and I would ask why the AVA is so different if all the numbers it is calculated from are still about the same.

Burair

 

[Jim]

Burair, thanks for your comments. It is a little strange and I think it may be an actual mistake. The person typing this report may have a problem distinguishing between 4 and 1 on the keyboard. This may explain the mistyped 1.0 where it should be 4.0 for the velocity and the aortic valve size would seem more likely to be 1.4 rather than 1.1.

As I follow your logic, you are saying that a valve w/ stenosis would cause the peak gradient to be higher than normal due to the blood travelling through a smaller area. Kind of like putting your thumb over a garden hose causing the water to have more pressure when leaving the nozzel.

Jim

 

[PapaHappyStar]

I read your profile, it says you have severe regurgitation as well -- the regurgitant jet reduces the net flow across the valve, I think the AVA calculation may be significantly off in your case because of this. I think modern AVA calculations use the logic that you mentioned -- the water hose -- there are two ways of increasing the pressure across the hose opening:

-- By putting your thumb over the opening of the hose i.e. decreasing the area and increasing the velocity ( pressure ) of the water.

-- By turning up the tap i.e. increasing the flow -- also increases the pressure across the opening of the hose.

If you decrease the opening area of the hose then you have to decrease the flow to keep the gradient the same -- this is what I dont see happening with your valve, unless they are using the regurgitant jet to correct the net flow, so the net flow decreases because of regurgitation, and the AVA calculated also decreases.

I am not convinced this logic is correct and the AVA calculation for mixed valve disease might very well be wrong.

You might want to read the ACHA guidelines for mixed valve disease:
http://www.acc.org/clinical/guidelines/valvular/jac5929fla16.htm#F

here is what they have to say about transvalvular gradients:

In patients with severe AR and mild AS, the high total stroke volume due to extensive regurgitation may produce a substantial transvalvular gradient. Because the transvalvular gradient varies with the square of the transvalvular flow (106), a high gradient in predominant regurgitation may be predicated primarily on excess transvalvular flow rather than on a severely compromised orifice area.

In effect the valvular area should be corrected for the effect of the regurgitant flow which should be subtracted from the net flow i.e. use the gross flow across the Aortic Valve for determining the stenosis.

In your case I think this whole discussion is academic -- I think you need to get a second opinion echo from a top notch cardiologist and a high class heart center to corroborate severe mixed aortic valve disease, then talk to a surgeon about your options.

 

[Jim]

Thanks for the info. I will definately take all of the information you gave me and do a little more research so I will be prepared to go over it w/ my cardiologist. So far, I have been pleased w/ the cardiologist I have. I can take some of his past comments and relate them to the reports now. Based on this, he seems to air on the side of caution.

If he believes the 1.1 on the aortic valve is correct, I will probably request another echo from a different person to be sure this is the case. I lose a lot of confidence in the numbers of my report when one of them looks to be typed in incorrectly.

Thanks again.

Jim

 

[bvdr]

Bob... . I think "insufficiency" really just refers to the fact the the valve isn't doing it's job and is allowing backflow. The fact that the aorta isn't getting all the flow is because it is "regurgitating". Gosh, I do love these kinds of conversations....truly, I find them stimulating.

Jim, do give Dr. Glower a call. His specialty is minimally invasive surgery and is recognized in his field.

 

[Jim]

Thanks Betty. I am going to get the echo results straightened out w/ my cardiologist and try to pin him down on his best guess of when he thinks the "date" will be. When the time nears, I will definately give Dr. Glower a call.

Jim

 

[ALCapshaw2]

Jim,

IMHO, it is better to let the SURGEON choose the timing.
(Many) Cardiologists like to drag their feet until the last possible moment before recommending surgery, resulting in PERMANENT DAMAGE to the heart muscle / walls from enlargement or other complications. Arrhythmias due to enlargement are another by product of waiting too long. I can testify to that one!

'AL'