Echogenic Strands

[attissy]

Hi everyone,
Once again I am hoping someone will be willing to share their wisdom with me! It always makes me feel better!

Here is what my last echo read (this is just the part that confuses and concerns me a bit!):

"Small echogenic strands seen in the left ventricular outlflow tract. These may represent several torn chordae of the mitral valve apparatus. However, very small strand-like vegetations on the ventricular surface of the mechanical aortic valve sewing ring cannot be excluded. This is a new finding"

The recommendation for this issue was to have a TEE and blood cultures (to rule out endocarditis). My cardiologist did the blood cultures, which were negative - thank goodness - but not the TEE. My question is what does it mean to have torn chordae? Mind you, my doctor never called me about any of these issues - I had to call his office and talk to his secretary. They are acting like the torn chordae is nothing, so is that true? Nothing to worry about? I am looking for a new cardiologist, because this lack of communication also happened in regards to my aneurysm. Am I overreacting or worrying for nothing!?

Any words of wisdom or reassurance are appreciated more than I can say!

Tiffany

 

[ALCapshaw2]

It is my Understanding that the TEE is the Best Way to visualize Small Strands. Actually, I think it is amazing they they even caught them in a regular TransThoracic Echo. So YES, I would encourage you to go ahead with the TEE, preferably performed by a Cardiologist who has seen strands before and knows what to look for.

Most Cardiology issues (90%) deal with Coronary Artery Disease and many Cardiologists do not see a lot of Valve Patients. Finding a Cardiologist that has a good grasp of Valve Issues can be 'difficult' but is definitely worth the effort. From my perspective, the Surgeons (at Major Heart Hospitals) are the Real Valve Experts since they are the ones who end up fixing the more complex Heart issues. Actually, it may be a good idea to ask your Surgeon if he can recommend a Cardiologist(s) that has a good grasp of Valve Issues. Good Luck in your Quest!

 

[Arlyss]

Valvular Strands

Valvular Strands

Hi Tiffany,

I am so glad that you are proactive about getting your reports. It is so important because it gives you the opportunity to pursue answers until you find the help you need.

My husband had valvular strands on the intake side of his mechanical aortic valve, but we did not know it until some of them broke off and went to his right brain, causing a massive stroke.

I do not want that to happen to anyone else, ever.

Here are some medical paper links to help you:

http://bicuspidfoundation.com/Evaluation_of_Prosthetic_Heart_Valves_Van_den_Brink.pdf

http://www.ncbi.nlm.nih.gov/pubmed/12514645?dopt=Abstract

http://www.ncbi.nlm.nih.gov/pubmed/9692533?dopt=Abstract

As the first link above discussed, TEE detects valvular strands. The paper by Van den Brink is excellent and what all physicians dealing with prosthetic valve should understand. The entire paper is there and can be printed out.

The TEE images must be reviewed by expert eyes. I have seen the TEE images that found them in my husband - the strands are small white dots that move on the screen. They could be easily missed.

If someone has valvular strands, there may be some controversy about how to treat them. The only way that truly removes the threat of stroke from them is to remove the valve and the strands along with it. There is a school of thought that stroke from strands can be avoided by just anticoagulation treatment. I do not agree. My husband was fully anticoagulated with coumadin and his INR was in range and well controlled at the time of his stroke.

The odds of finding a physician who understands this increases if you are seen in a large medical center. I know someone, diagnosed after my husband was, who had strands and sought opinions in 4 major medical centers in the US. Three of them concurred that surgery should be performed to replace the valve. I was surprised that one center recommended only anticoagulation treatment and observation. This person proceeded to surgery in one of the three centers. He is doing very well today.

If the report you received were about my own heart, or I could go back in time before my husband's stroke, I would have a TEE as soon as possible. I would have it read by as many different experts as I needed to, until I got answers that made sense.

Best wishes to you,
Arlyss

 

[pamela]

Pannus tissue is also echogenic, meaning that it shows up more easily on the screen. I would inquire about the TEE and why no one seems to think it's neccessary.

 

[Marcia58]

I think you're wise to look for a new cardio, and I agree with having the TEE done, if only for your peace of mind.

As far as torn chordae, it turned out when I had my MVR that I had several stretched or torn chordae. As a result, one of my leaflets was, according to my surgeon, "swinging like a saloon door" and adding to my regurgitation.

Marcia

 

[Arlyss]

From the wording of Tiffany's report, it appears the reader is seeing some hair-like "strands" in the blood stream in the left ventricle's outlet.

A tear of the mitral valve chordae, so that small strands of chordae tissue are floating in the blood stream, is one thing mentioned as a possibility.

I am wondering if Tiffany has any symptoms that might indicate a mitral valve problem. I would think chordae tearing would have symptoms. I know someone whose mitral valve chordae failed and the symptoms came on quickly and could not be ignored.

The other possibility mentioned is that strands are coming off the aortic valve sewing ring. One reason for those strands could be endocarditis - with this infection, strands of "vegetation" may form and hang off the valve. This is why endocarditis also has the potential to shower the brain with particles and damage it in multiple places.

The other possibility for strands off the aortic valve is that they are composed of some kind of tissue, possibly collagen.

My husband's mechanical valve was being watched because of an increase in the pressure difference between one side of the valve and the other. In other words, blood was not getting though the valve as well as it once did - backing up a bit on the input side.

It was presumed the pressure increase was due to pannus, and the valve was checked periodically via echo with the understanding that at some point the valve would need replacement. The strands were not discovered - until after his stroke.

When the valve was taken out, there was indeed pannus on the sewing ring. However, the pressure across the valve dropped after his stroke, and it is speculated that a significant pressure difference was due to the strands, since it lessened after some of them had broken off.

The pannus had not impinged on the "hinges" and the valve opened and closed quite well until it was taken out.

These are all details we learned later - too late to undo the damage to his brain. I hope it will help Tiffany and others who read this to insist on getting answers to what is happening with their valves. There is an explanation, and it needs to be found in time to take the appropriate action.

Best wishes,
Arlyss

 

[ALCapshaw2]

Arlyss -

Long Time No See (or Read)...

It's good to see you posting again.

'AL Capshaw'

 

[attissy]

Thank you all so much for the advice and words of comfort. I knew I came to the right place!

Arlyss - It seems like you unfortunately have had a lot of experience with the "strands" and I am so sorry to hear of your husband's suffering. The links you sent me, especially the first one, were very educational. It is so disturbing to me that my cardiologist, or any for that matter, take issues with the heart so lightly at times. I often wonder if I panic because I ask for a copy of my test results and overreact to what I see, but after reading your posts I would rather overreact than under react. As for my mitral valve, the echo said that I have mild mitral valve prolapse and minimal mitral insufficiency, so it doesn't sound like there is an issue there. What kind of symptoms would I have if there was a mitral valve problem? Also, you mentioned that the strands could be made of collagen - would that be a less worrisome diagnosis? I am wondering what these strands could be that the doctor is not concerened about them in the least - what is he thinking they are. I am going to call him and try to find out if I need to worry, but I would have hoped he would have called me!

Al - Thanks also to you for the advice to find a cardiologist with more experience dealing with valvular issues. I work at a large healthcare system and should be able to find out which cardiologists have more experience in that area. I never thought of that!! Thanks!

Thanks to Pam and Marcia for your advice and wisdom as well. I am wondering, Marcia, if they saw any strands prior to surgery on an echo or a TEE?

I do plan on finding a new cardiologist ASAP, which is not going to be easy. The cardiologist I see now not only monitors my INR on a very regular basis, which keeps me in close contact with everyone in his office, but he was also my mother's and aunt's cardiologist, so I have known him a long time. But I have to think of my health first. Wish me luck!


Thank you all again!
Tiffany

 

[Juan P. Negret]

Good luck attissy.

 

[Cris N]

I do plan on finding a new cardiologist ASAP, which is not going to be easy. The cardiologist I see now not only monitors my INR on a very regular basis, which keeps me in close contact with everyone in his office, but he was also my mother's and aunt's cardiologist, so I have known him a long time. But I have to think of my health first. Wish me luck!

Thank you all again!
Tiffany

Good luck in finding a new cardio - I, too, think it would be a good idea. And, if you started home testing your own INR you wouldn't need him for that!

 

[Arlyss]

Regarding the composition of the strands, it does not matter if they are collagen or vegetation from infection (endocarditis), any particle that travels to the brain and blocks blood flow to cells causes a stroke or "brain attack".

I have learned that neurologists are very aware of this, and typically look to the heart as a possible source of stroke that is "embolic" - caused by particles traveling to and blocking a blood vessel in the brain.

So strands, blood clots (from atrial fibrillation, "holes" between heart chambers, prosthetic heart valves, among other things), bits of calcification.... whatever it might be, can cause injury if it travels to the brain.

Endocarditis and valvular strands both have the potential to send a shower of particles, hitting various parts of the brain at once and having the same effect as multiple strokes.

The paper by Van den Brink was not published until after my husband's stroke had already happened. But it is out there now, and I hope it will help many people.

Strokes vary a great deal in their impact - from mild to so severe that the person may enter and remain in a coma for months or years.

The world of the injured brain is one that no one would choose to enter, and my wish for us all is that one vital part of us - our hearts - need not be the source of injury to another - our brain. Stroke is the first leading cause of disability and ranks third in causing death in the US.

I concur with all who have encouraged additional cardiology opinions - it may take several to find the help you need. I will mention again that the odds of someone having expertise are increased in a major medical center that sees a broader cross section of people and thus a greater variety of things that happen to them.

Best wishes,
Arlyss

 

[Marcia58]

Tiffany,
I replied earlier, but timed out before it got posted.

My last pre-op echo was in Dec. 08, when I was still basically asymptomatic, and showed nothing like that. I suddenly developed SOB, edema, and palpitations over a 1-2 day period in mid-Feb. I'm wondering if that's when the chordae finally tore.

Marcia

 

[skeptic49]

The world of the injured brain is one that no one would choose to enter, and my wish for us all is that one vital part of us - our hearts - need not be the source of injury to another - our brain. Stroke is the first leading cause of disability and ranks third in causing death in the US.
Best wishes,
Arlyss

Yes, I have seen the effects of stroke in my family.

After reading the paper and abstracts, I'm unclear about the treatment for strands. Is valve replacement surgery always called for?

Jim

 

[attissy]

I have a call in to my cardiologist's office to see what he has to say - since so far he has said nothing! I also started asking around for a new cardio in the healthcare system I work for and my sister has done the same in her hospitals (We work for competitors - which actually comes in handy!)

This site has helped me so much over the years, both by educating me and by comforting me when I need it most. I am so glad I found this site when I did! I will keep you posted as to what my cardiologist says!

P.S. What happened to you Marcia and to your husband Arlyss is so scary - both happened so fast. Thank you again so much for sharing your experiences with me.

Tiff

 

[attissy]

I have a little update.

I finally had a chance to talk to my cardiologist and he said that the strands are remnants from my native aortic valve - nothing to worry about and nothing needing followup. I asked why he hadn't seen these before and he said that the technology of echocardiography is continually advancing, so we are seeing things that in the past we would not have been able to see - which sounds logical, I guess. I did not get to ask him why he didn't mention this possibility on the echo report though.

I am still going to find a new cardiologist, but I do feel a little better after talking to him. Not sure if I really should feel better, but he sounded very confident that there is nothing to worry about. Hopefully he knows what he is talking about!

 

[Arlyss]

If someone told me that there were "remnants from my native aortic valve" floating in my LVOT (left ventricular outflow tract), I would have many questions and concerns.

I would not be at all satisfied if told that today we are seeing things we could not see in the past from an echo through the chest.

And I would not accept being told that there is nothing to worry about or follow up.

If I am a patient in a situation like this, I am taking all the risk. However well intentioned, if someone is wrong, I will be the one who pays the price.

My first question would be, are strands really there? I would have a TEE done, I would get copies of the images on CD, and I would have those images read by expertise at least one major heart center.

In a situation like this, if I were the patient I might consider having the TEE reviewed by heart surgeons, rather than cardiologists. Expert heart surgeons in large practices see a variety of things. If there is anything unusual, they might be most likely to recognize it.

I will repeat again that I do not want anyone to have a preventable stroke from tissue strands associated with valves, and encourage everyone to leave no stone unturned in understanding what is going on with the heart valves.

Best wishes,
Arlyss

 

[Cris N]

Good points Arlyss.

 

[attissy]

Thank you Arlyss for making me take another look at things. I have an appointment with a new cardiologist from The Wisconsin Heart Hospital who comes highly recommended by many. I know you are right, I need to take responsibility for my health or else I will the one paying for it. Thanks again! I will keep you posted!

Tiffany