Gradient after AVR 1 month ago is 28?

[Guest]

What was your gradient across your valve after AVR? Mine is 28 which is technically mild aortic stenosis at 1 month post opp. Doctor says it because he had to put in a smaller valve then he would have liked but it was the biggest valve my heart would allow or he would have had to cut into the heart and I would have needed a pacemaker. It is an on-x 21mm which should have a gradient of 10 or lower. So he said we will just have to watch the gradient over time. So basically I just went through a very painful surgery and he's telling me I'm back in the waiting room.

 

[Paleowoman]

At 4 days post AVR my mean gradient was 17 mmHg, peak gradient 33 mm/Hg. At 18 months post AVR my mean gradient is 18 mm/Hg, peak 35 mm/Hg so not much change. It was explained to me too that the gradient is that high because I have a small valve, 19mm, and there is also the ring the valve is attached to which means the 'effective orifice area' is relatively small. They don't call it stenosis though because the leaflets are not stiff or calcified. When my valve was bicuspid and the gradient similar at 7 years prior to surgery the gradient was increasing year on year by about 3 mm/Hg which is not happening now.

 

[Bonbet]

I am still in the waiting room, but I just don't understand why you would be? You have a mechanical valve which is not subject to the same deterioration as your native was so it should remain pretty stable, I would think. Now your heart may remodel some, depending on it's status pre-op, and hopefully that will be in the direction of getting more effecient. But given that the hemodynamcis are an artifact of your new valve size because of the opening's size - that opening doesn't seem likely to change with a future valve re-op, is it? Maybe your gradients will improve as your heart heals. My gradients vary from echo to echo depending on my hydration and the tech's ability to capture a clean image, All the way from 39 to 34. It must be very hard for you to be on the otherside and not feel like you've made progress. I am so sorry you have this added anxiety to your healing process. I hope it goes better for you as the healing process progresses.

 

[Paleowoman]

Hi Bonbet - the gradient shouldn't increase as it does when a person has a stenotic bicuspid valve becasue the valve opening is not restricted by stiff leaflets. The tissue leaflets, or mech system, will open easily and freely as it should. The gradient is simply due to the size of the valve, whether it's a mechnical one or a tissue one, and if the valve is small then the gradient is that high due to the size. They can't put one in with a larger opening or there would be what's called a patient prosthesis mismatch which leads to problems. Neither guest's new mech valve nor my new tissue valve should deteriorate any faster than a larger tissue or mech valve (and mech valves don't deteriorate AFAIK).

 

[cldlhd]

Did they say why that was the biggest valve they could fit? Is it because the left ventricle was enlarged or is that just the approximate size of the native valve?

 

[Paleowoman]

From what Iunderstand, cidlhd, they measure the space where the aortic valve is and that gives them the measurement for the replacement valve - if you watch a video of AVR you see them sizing the space for the replacement valve. It has to fit where the native valve was. At the start of AVR surgery they have a selection of different sized valves as this isn't something they can work out before they open you up. I remember asking the forum what would they do if they didn't have the right size valve when I was opened up and got some very amusing answers My left ventricle wasn't enlarged btw.

 

[Northernlights]

I would feel really annoyed about this. He could have done an enlargement of the annulus to put in a larger valve with a decent gradient, and there is absolutely no reason that that would have meant a pacemaker was necessary. Unfortunately a lot of surgeons don't like doing an enlargement and therefore aren't good at it and would rather leave the patient with patient- prosthesis mismatch (which always refers to a valve too small for the patient: the larger valve is always better, though obviously it has to fit). They actually have a good idea pre-operatively if this will be a problem from the echo, though it's not entirely accurate, hence the sizers. The valve size that can be fitted in depends on the size of your valve annulus, and is a problem for those of us with a small annulus, hence the need for enlargement.
I think it's something which should be discussed in advance with the patient, who should be able to make the choice if necessary for better haemodynamics at the price of a slightly longer surgery. Some hospitals have a general principle of no less than a 23 mm valve in women and 25 mm in men.

 

[ottagal]

Hi,
I am wondering if you are talking about your Peak gradient across the valve or the Mean gradient? That makes a difference. My Peak gradient is measuring 49 and mean gradient is 27.

 

[Bonbet]

Hi Bonbet - the gradient shouldn't increase as it does when a person has a stenotic bicuspid valve becasue the valve opening is not restricted by stiff leaflets. The tissue leaflets, or mech system, will open easily and freely as it should. The gradient is simply due to the size of the valve, whether it's a mechnical one or a tissue one, and if the valve is small then the gradient is that high due to the size. They can't put one in with a larger opening or there would be what's called a patient prosthesis mismatch which leads to problems. Neither guest's new mech valve nor my new tissue valve should deteriorate any faster than a larger tissue or mech valve (and mech valves don't deteriorate AFAIK).

Paleogirl, Yes, I understand that. My question was, considering those variables which are not variable, why would our guest assume an immediate re-op is the next step?

 

[Paleowoman]

Hi Bonbet - not sure that our guest is assuming an immediate re-op, or whether he/she has made a false or correct assumption about a future re-op. He/she wrote the doctor said to keep an eye on the gradient and that "basically…….<snip>…..he's telling me I'm back in the waiting room" which sounds like an assumption. I think our guest should go back to the cardiologist and get some good calrification and explanation on this. Pity 'guest' hasn't come back to us as we all wonder about this.

 

[Paleowoman]

I was just looking at stuff on the internet and found a link to this previous thread between two valvers on this forum five years ago about their post AVR pressure gradients: http://www.valvereplacement.org/for...18-pressure-gradient-over-aortic-tissue-valve

 

[ottagal]

I was just looking at stuff on the internet and found a link to this previous thread between two valvers on this forum five years ago about their post AVR pressure gradients: http://www.valvereplacement.org/foru...c-tissue-valve

Thanks for digging this up, Paleogirl!

I do recall seeing this post way back when. It is reassuring to be reminded of what the normal average Pressure Gradients are for bioprosthetic valves so we don't all start worrying for nothing.