Echo says Patient Prosthesis Mismatch

[Roberta]

Hi Folks,

I am hoping someone can help me here? I had aortic valve replacement with a bovine tissue valve just over 2 years ago.

I just received my echo and have an upcoming yearly follow up visit with the cardiologist.

This current echo now states in the interpretations summary:
Patients prosthesis mismatch is present. The AVA is .63 cm2.
I am confused. :confused2:
Wouldn't this have shown in the previous echos post op. ?
If the surgeon put in a 21mm aortic valve why would it now have an effective valve area showing .63 cm2.
By the way, I am petite in size.

Any ideas or input would be so greatly appreciated. Should I be concerned? What questions should I ask the cardiologist?

Thanks so much!

 

[Lynlw]

Do you hve copies of your earlier reports what are the measurements then?

 

[Roberta]

Do you hve copies of your earlier reports what are the measurements then?

Thanks for the question, Lyn.
I just looked through the last 2 echos since my surgery and there is no mention of mismatch and no actual measurement of the bioprosthetic aortic valve on the 2 previous echos. The previous echos say the bioprosthetic valve is well seated and it says the pressure gradients are normal for this type of valve. That's it.

I am confused???

 

[Jkm7]

Techs make mistakes and those interpreting can also make mistakes.
Don't take any of this seriously until you speak with your cardio. Unless he/she totally convinces you all is well, request a new ECHO with another tech.

 

[Roberta]

Techs make mistakes and those interpreting can also make mistakes.
Don't take any of this seriously until you speak with your cardio. Unless he/she totally convinces you all is well, request a new ECHO with another tech.

Jkm7,
Thank you...I needed to hear that. I am going to try and stay calm, because those measurements certainly sound like I would be heading to surgery (again) sooner than later.
I will talk to the cardiologist and ask for another echo. Great suggestion.

 

[sarahsunshine]

Hi Roberta!

Out of curiosity, How do you feel? are you tired? have chest pains? get tired quickly? any of the symptoms you had pre-surgery?

I ask this for a very simple reason. Doctors make mistakes when they start relying on programs and forget to look at the patient.

Case in point (non-heart related but petite-sized related):

A friend of mine (5’0 on a good day and very thin – she tries desperately to gain weight in a healthy way) went to the doctors. She sat in a gown on the exam table, the doctor came in, said “Hello”, went to her computer, and started talking to her about being obese and weight loss programs. My friend, who fortunately is quite confident in herself), started laughing, she then interrupted the doctor, saying, “Look at me… does it look like I need to LOSE weight?” It seemed that the nurse had accidentally converted her height wrong, making her 10” shorter than she actually was.

So not only was the height extremely off and not noticed (50” or 4’2” instead of 5’0” – which the doctor should have noticed if she looked at her), but If I didn’t know her better, I would be more worried about anorexia than obesity in my friend’s particular case and the doctor would have seen that from looking at her!

All that goes to say, don’t panic! Ask for another Echo, ask for another interpretation, ask your doctor if this is actually reasonable considering you have no (assumption on my part) symptoms and there is no record of anything similar in previous echos.

Hope to hear a happy update!

 

[Roberta]

Hi Roberta!

Out of curiosity, How do you feel? are you tired? have chest pains? get tired quickly? any of the symptoms you had pre-surgery?

I ask this for a very simple reason. Doctors make mistakes when they start relying on programs and forget to look at the patient.

Case in point (non-heart related but petite-sized related):

A friend of mine (5’0 on a good day and very thin – she tries desperately to gain weight in a healthy way) went to the doctors. She sat in a gown on the exam table, the doctor came in, said “Hello”, went to her computer, and started talking to her about being obese and weight loss programs. My friend, who fortunately is quite confident in herself), started laughing, she then interrupted the doctor, saying, “Look at me… does it look like I need to LOSE weight?” It seemed that the nurse had accidentally converted her height wrong, making her 10” shorter than she actually was.

So not only was the height extremely off and not noticed (50” or 4’2” instead of 5’0” – which the doctor should have noticed if she looked at her), but If I didn’t know her better, I would be more worried about anorexia than obesity in my friend’s particular case and the doctor would have seen that from looking at her!

All that goes to say, don’t panic! Ask for another Echo, ask for another interpretation, ask your doctor if this is actually reasonable considering you have no (assumption on my part) symptoms and there is no record of anything similar in previous echos.

Hope to hear a happy update!

Hi SarahSunshine,
I hope you don't mind, but I did get a good chuckle out of your story. I am hoping this is the case with me in that they haven't really haven't taken my size into account. It still worries me that the valve area shows as being .63 cm2.
I certainly appreciate the reassurance.

I will keep you posted.
Thanks so much.

 

[markp66]

Roberta, hopefully this is a mistake or at least not as bad as the report says. what kind of tissue valve do you have?

 

[sarahsunshine]

Hi SarahSunshine,
I hope you don't mind, but I did get a good chuckle out of your story. I am hoping this is the case with me in that they haven't really haven't taken my size into account. It still worries me that the valve area shows as being .63 cm2.
I certainly appreciate the reassurance.

I will keep you posted.
Thanks so much.

My friend would appreciate your chuckle! She found it rather humourous as well.

That being said, A good discussion with your doctor MAY reveal that there is a problem, but considering the little information that I have, that seems unlikely.

 

[Roberta]

Roberta, hopefully this is a mistake or at least not as bad as the report says. what kind of tissue valve do you have?

Mark66
I have a Carpentier Edwards Perimount Bovine Valve. I noticed you ended up having surgery 4 years after your first. May I ask what type of tissue valve you had that needed replacing? I hope you are doing well!

 

[ElectLive]

I just looked through the last 2 echos since my surgery and there is no mention of mismatch and no actual measurement of the bioprosthetic aortic valve on the 2 previous echos. The previous echos say the bioprosthetic valve is well seated and it says the pressure gradients are normal for this type of valve. That's it.

I am confused???

Forgive me if you've already checked this, but for the last 2 echo reports, do you have a "data" sheet of measurements in addition to the interpretations summary? Is there any indication of "AoV Area, Vmax" or "AoV Area, VTI"? If not, perhaps you don't have the full report including all the data, but in any case, measuring the aortic valve area is standard procedure and should certainly be documented somewhere.

By the way, for the Edwards valves, an "average" echo measured valve area at size 21 mm (1 year post-op) is around 1.7 to 1.9 depending on specific model. Everyone is a little different, though, so not at all odd to see numbers above or below that, but certainly .63 seems way off. Mismatch seems very out of place.

 

[Roberta]

Forgive me if you've already checked this, but for the last 2 echo reports, do you have a "data" sheet of measurements in addition to the interpretations summary? Is there any indication of "AoV Area, Vmax" or "AoV Area, VTI"? If not, perhaps you don't have the full report including all the data, but in any case, measuring the aortic valve area is standard procedure and should certainly be documented somewhere.

By the way, for the Edwards valves, an "average" echo measured valve area at size 21 mm (1 year post-op) is around 1.7 to 1.9 depending on specific model. Everyone is a little different, though, so not at all odd to see numbers above or below that, but certainly .63 seems way off. Mismatch seems very out of place.

Elective, thank you very much for the good information. Now I think I am more confused than before.
These are the measurements that I have from this echo regarding the aortic valve:
Ao max PG 33.3 mmHG
Ao Mean PG 17.9 Hg
AVA (V,D): .63. cm2
Aortic Root. 3.1 cm

The previous echo reports only show the mean and peak gradients, as well as measurement of the aortic root, but no actual AVA measurement which I find strange.

How did you arrive at the conclusion that mismatch seems very out of place? Thanks so much for your help.
This has been very disconcerting for me to say the least.

 

[ElectLive]

Mismatch would only happen if the valve you received had too small an opening in relation to your body size. Problem 1 - If this were true, it should have been discovered much earlier. Problem 2 - The average female BSA is 1.6 (you said you are petite but let's just start with average) and to avoid PPM (mismatch) the ratio (Area/BSA) is supposed to be greater than 0.75. That means that your valve opening needs to be at least 1.2 which as I said in my last post should have been the case. Plus, you are petite, so the opening would need to be even smaller to be true PPM. Problem 3 - Whatever your actual BSA is and your actual valve opening is, a measurement of .63 is at severe stenosis stage which generally only happens after valve thickening and calcification, both of which should have been noted if that were the case. You are also only 2 years out so yet another reason why this would be unlikely.

Add to all of this the new information from your last post that your mean gradient is 17.9 which is normal, not even mild stenosis. And I can't imagine there not being any measurements of the valve area previously, it's 1 of the 2 most important things to measure when monitoring a bioprosthetic valve.

So, something just seems completely off, and sorry I don't know for sure what it is. This a wild guess, but I wonder if there's any chance that the valve area was actually 1.63 - which would seem to fit pretty well with normal expectations on size.

Anyway, in addition to clearing up the most recent echo confusion, I'd verify the previous echo's too - maybe they did the area measurements but just left them off. Good luck getting this mystery resolved!

 

[Roberta]

Mismatch would only happen if the valve you received had too small an opening in relation to your body size. ...
So, something just seems completely off, and sorry I don't know for sure what it is. This a wild guess, but I wonder if there's any chance that the valve area was actually 1.63 - which would seem to fit pretty well with normal expectations on size.

Anyway, in addition to clearing up the most recent echo confusion, I'd verify the previous echo's too - maybe they did the area measurements but just left them off. Good luck getting this mystery resolved!

Thank you so much ElectLive! Your explanation makes complete sense. I bet you are bang on with the typo of .63 for 1.63. I do plan to get to the bottom of this for my own peace of mind. You have no idea how much this post and explanation helped me (I actually slept last night!).
I see my cardiologist in a few weeks and will hopefully get this cleared up. I will keep you posted.
Thanks everyone!

 

[Lynlw]

Thank you so much ElectLive! Your explanation makes complete sense. I bet you are bang on with the typo of .63 for 1.63. I do plan to get to the bottom of this for my own peace of mind. You have no idea how much this post and explanation helped me (I actually slept last night!).
I see my cardiologist in a few weeks and will hopefully get this cleared up. I will keep you posted.
Thanks everyone!

besides everything elec said, How is your left ventricle, size, vol etc, chances are if you had stenosis that bad, they would be showing problems too. Justin's had a few heart surgeries, his is the pulm side/right side of heart but they cant get good pictures of his valve/conduit, but the one time we knew there had to be a problem and somewhere was narrrowed/blocked was because everything was backing up into the right ventricle so it was getting larger and so he had further testing. I would imagine if they Aortic valve opening was that small, the left ventricle numbers would show it

 

[ElectLive]

I should also mention that I had an echo a few weeks ago with a medical student present. The student was observing only and was bacially getting a step by step tutorial on things NOT to do. It was actually pretty fascinating from my perspective because it ended up being a play-by-play of how to do an echo. But anyway, the final lesson was very simple - look at the results and compare to the patient and the patient's charted history to ensure no measurement oddities or errors. Now, while I was very impressed overall by the capabilities of the "instructor" doing my echo (I've had an echo every year of my life so I do notice these things), I had also received a question midway through from him with a very puzzled tone attached: "You don't have a pacemaker, do you?"

:confused2:

Well, it's obviously in my chart that I do, and it had been clearly documented on my previous echo (by the same person), plus not only that, I have a very noticeable pacemaker incision scar with a complementary pacemaker sized lump directly beneath in the exact same area of my chest as my heart, mere centimeters away from the transducer he'd been applying for the past 20 minutes. Everyone has their bad moments.

 

[Roberta]

Lyn,
Good question. The left ventricle is normal and not dilated. Basically everything else other than moderate pulmonary regurg. and trace tricuspid and mitral valve regurg. that has been noted on all previous echos.
It certainly appears that this is a technician error. At least that is what I hope!
Thanks for the additional story, Electlive.

 

[Bina]

My first thought was also that the valve area reading could have been 1.63 and not .63
(tech errors do happen).

 

[Bill B]

I'm kinda glad they don't send me the echo report directly. I just wait until I see my cardiologist and he goes over it with me. There have been a number of oddball "interpretations" that didn't make sense to my cardiologist or me, and we've resolved them together.

 

[Roberta]

Thanks Bill and Bina for your input.
Well, it looks like I am going to have to be a bit more patient regarding this echo report. My cardio appt. was cancelled for next week and has been rescheduled to May!