Hard to trust many doctors

[le19555]

I just turned 66 and have been diagnosed with severe AS. My symptoms are mild. Usually some chest tightness when I’m stressed and exerting. Mean gradient on echo 86 and av diam is 1.2. I feel my cardiologist who specializes in AVR is pushing me too soon to surgery so I went out on my own to find a surgeon who specializes in valve replacement surgery who had tremendous reviewed. I can walk two miles with some normal tiredness but. I thing major. Two questions... would you get surgery sooner than you needed too and what valve would you or have you received? I feel if I don’t do mechanical why not do tavr as there seems no difference in durability. I’m leaning mechanical if I do open heart because of the longevity. All replies welcome. Thanks.

 

[vp69]

I just turned 66 and have been diagnosed with severe AS. My symptoms are mild. Usually some chest tightness when I’m stressed and exerting. Mean gradient on echo 86 and av diam is 1.2. I feel my cardiologist who specializes in AVR is pushing me too soon to surgery so I went out on my own to find a surgeon who specializes in valve replacement surgery who had tremendous reviewed. I can walk two miles with some normal tiredness but. I thing major. Two questions... would you get surgery sooner than you needed too and what valve would you or have you received? I feel if I don’t do mechanical why not do tavr as there seems no difference in durability. I’m leaning mechanical if I do open heart because of the longevity. All replies welcome. Thanks.

why not consider the resilia tissue valve? It might last you out. or TAVR and a future valve in valve might do it as well

 

[Chuck C]

I just turned 66 and have been diagnosed with severe AS. My symptoms are mild. Usually some chest tightness when I’m stressed and exerting. Mean gradient on echo 86 and av diam is 1.2. I feel my cardiologist who specializes in AVR is pushing me too soon to surgery so I went out on my own to find a surgeon who specializes in valve replacement surgery who had tremendous reviewed. I can walk two miles with some normal tiredness but. I thing major. Two questions... would you get surgery sooner than you needed too and what valve would you or have you received? I feel if I don’t do mechanical why not do tavr as there seems no difference in durability. I’m leaning mechanical if I do open heart because of the longevity. All replies welcome. Thanks.

Welcome to the forum.
Personally, I would definitely get surgery now that you are severe, rather than wait, assuming the data that you have presented is accurate. You indicate that your mean gradient is 86. AS is considered severe once you are >40 mmHg mean pressure gradient. I am not aware that AV diameter is a metric for severity- do you mean AV area?, which would be in cm2.
When I crossed the line into severe AS, I had a choice to get the surgery now or wait for symptoms. I posted my question to the board about it. The conclusion I came to was to get the surgery and not wait. I cover my entire journey in this thread:

https://www.valvereplacement.org/th...to-severe-and-need-to-make-a-decision.887879/
My surgeon told me that it was a good thing that I got the surgery when I did, after he had opened me up and examined my valve. He said that I was a ticking time bomb, even though I had no symptoms and could still push hard cardio for 90 minutes+ straight prior to surgery.

There is very little to be gained by waiting and potentially a lot to lose. Sometimes those in severe AS experience sudden death. I would follow your cardiologist's advice and get the surgery. Especially since you are leaning towards a mechanical valve, which should last the rest of your life. If you wait, you risk getting structural damage to your heart that may not reverse. If you get your surgery sooner, if you have any structural adaptions in your heart, you are more likely to be able to reverse them once you have the new valve and the pressure is relieved from your heart, which is working very much in overdrive right now.

Anyway, I'd be happy to help in any way I can. It is not an easy thing to choose to get OHS when you feel good. I felt great prior to my surgery, but when I researched it in depth, it really became an easy decision.

 

[Chuck C]

Even if your symptoms are mild, once you have symptoms with aortic stenosis, the scientific literature, and the medical guidelines, indicate that it is clearly time to get valve surgery.

Please read the study I linked below:

" Severe symptomatic aortic stenosis is associated with a poor prognosis, with most patients dying 2–3 years after diagnosis "


https://www.ncbi.nlm.nih.gov/pmc/ar... aortic stenosis is,2–3 years after diagnosis.

 

[nobog]

86 mmHg is a huge # - and that's mean - you probably don't want to know peak.

 

[le19555]

86 mmHg is a huge # - and that's mean - you probably don't want to know peak.

127

 

[le19555]

127

Area 1.2

 

[Critter]

I thought my gradient at 60 mm was considered bad. You top mine, don’t know why valve surface area appears moderate and not severe. Go get your surgery you probably have crap hanging on valve waiting to be dislodged and potentially could mean lights out. I regret not doing mine sooner and being scared. That’s a steep drop off where you are on your gradient. Mortality rate will exponentially go up as time marches forward. Glad it’s in my rear-view mirror , good luck.

 

[Chuck C]

127

That is very high. One of the extreme dangers of a high pressure gradient is the enormous amount of pressure that creates inside your heart chamber. That number basically gets added to your blood pressure that is already in your system as part of your normal bodily function to create very high pressures inside your left ventricle.

 

[Chuck C]

I thought my gradient at 60 mm was considered bad.

Of the three main measures of severity, aortic valve area, pressure gradient, and peak jet velocity, with me personally, my valve area was the least consistent. My pressure gradient and peak velocity had a linear increase over the course of 5 echos, but my valve area bounced around. First was 1.0cm2, then 2 months later 1.4cms, then 2 months later 1.1cm2. It is a calculated estimation that usually is derived using the continuity equation, and dependent on very precise measurements of the LVOT and other measurements. If the LVOT is off by just 1mm it can throw off the valve area considerably. All of this to say that I think that valve area is often not very accurate, and I would rely more on the other two metrics when there is discordance. There is also another one which is very good called the dimensionless index, or DI.

 

[Chuck C]

It would be good to have some additional info, so that we may give better guidance.

Is this a diagnosis out of the blue, or have them been tracking your AS for some time?

You have a very large discordance between your valve area and your pressure gradient. Something is off. Do you have a series of echos which point to a gradually increasing gradient, or is this just all of a sudden?

They also would have measured your peak jet velocity. Or your echo might just refer to it as peak velocity. Can you please share this value?

Does your echo have a DI or dimensionless index?

If this is your first time echo, such discordance as yours should warrant another echo soon. However, if this values show a gradual progression to this point, then your severity is more conclusive based on your gradient. Your valve area would suggest you are in the moderate range, but your pressure gradient suggests that you are very severe.

 

[le19555]

Of the three main measures of severity, aortic valve area, pressure gradient, and peak jet velocity, with me personally, my valve area was the least consistent. My pressure gradient and peak velocity had a linear increase over the course of 5 echos, but my valve area bounced around. First was 1.0cm2, then 2 months later 1.4cms, then 2 months later 1.1cm2. It is a calculated estimation that usually is derived using the continuity equation, and dependent on very precise measurements of the LVOT and other measurements. If the LVOT is off by just 1mm it can throw off the valve area considerably. All of this to say that I think that valve area is often not very accurate, and I would rely more on the other two metrics when there is discordance. There is also another one which is very good called the dimensionless index, or DI.

I am getting another echo. There is a discrepancy with mean gradient and valve area. Also my LV ejection fraction is 65 and normal size.

 

[le19555]

It would be good to have some additional info, so that we may give better guidance.

Is this a diagnosis out of the blue, or have them been tracking your AS for some time?

You have a very large discordance between your valve area and your pressure gradient. Something is off. Do you have a series of echos which point to a gradually increasing gradient, or is this just all of a sudden?

They also would have measured your pet jet velocity. Or your echo might just refer to it as peak velocity. Can you please share this value?

Does your echo have a DI or dimensionless index?

If this is your first time echo, such discordance as yours should warrant another echo soon. However, if this values show a gradual progression to this point, then your severity is more conclusive based on your gradient. Your valve area would suggest you are in the moderate range, but your pressure gradient suggests that you are very severe.

Only one echo.

Echo below;
M-Mode and 2D Measurements (in cm)
Echocardiogram Dimensions
RVIDias-d [cm (<4.2)]: 3.4
LVIDias-d [cm (3.6-5.2)]: 5.4
LVISys-d [cm (2.3-3.9)]: 2.8
IVS-d [cm (.6-1.1)]: 1.4
LVPW-d [cm (.6-1.1)]: 1.1
LA diam [cm (1.9-4.0)]: 4.2
Aortic root diam [cm (2.0-3.7)]: 3.6
Aortic Cusp Separation [cm (1.5-2.6)]: 1.7
LA vol [cc/m squared (< 28)]: 35
LVOT Diameter [cm (1.8-2.2)]: 2.6
IVC diam: 1.5
E/A Ratio: 0.9
DT: 188 msecs
Estimated EF [% (55-70)]: 60-65

INTERPRETATION
1. Good quality 2-D, M-mode, and Doppler exam. The rhythm is
sinus.
2. The left ventricle is of normal size and systolic function
with an ejection fraction of 60-65%. There are no wall motion
abnormalities. There is asymmetric septal hypertrophy.
3. The left atrium is mildly to moderately dilated.
4. The right atrium is of normal size.
5. The right ventricle is of normal size.
6. The aortic valve appears calcified with a peak gradient of 127
mmHg, mean gradient of 86 mmHg, and area of 1.2 centimeters
squared consistent with moderate to severe stenosis and mild
regurgitation.
7. The mitral valve appears normal with no stenosis and mild
regurgitation.
8. The tricuspid valve appears normal with no stenosis and
minimal regurgitation with an estimated right ventricular
systolic pressure of 38 mmHg.
9. The pulmonic valve appears normal with no stenosis and minimal
regurgitation.
10. The pericardium appears normal.
11. The aortic root is of normal size.
12. The inferior vena cava is of normal size.
13. The interatrial septum is not well visualized.

CONCLUSIONS: There is a normal left ventricular ejection fraction
of 60-65%. The left atrium is mildly to moderately dilated. There
is severe aortic stenosis. There is mild aortic and mitral
regurgitation.

 

[Chuck C]

There
is severe aortic stenosis.

I'm glad to hear that they are ordering another echo. I had discordance as well, but it was minor- my mean pressure gradient was 45 mmHg, when my valve measured at 1.1cm2. This is not uncommon. But, your discordance is very large and something is off. There is almost no way for an aortic valve area of 1.2cm2 to produce the pressure gradient of mean 86 and peak of 127 mmHg. Interesting that your echo does not seem to include peak jet velocity. That is typically standard. I'm not sure if this was just done at your local clinic. It might be worth travelling a little to get it done at a highly ranked cardiac institution. Sometimes little things, such as whether they are measuring the LVOT from the inside wall, or the outside wall, can throw things off a lot. The ranked clinics are less likely to make these type of errors than the small ones in my experience.

 

[Critter]

Natural history of aortic stenosis
Schematic representation of the natural history of aortic stenosis and of the major impact of aortic valve replacement. Survival is excellent during the prolonged asymptomatic phase. After the development of symptoms, however, mortality exceeds 90 percent within a few years. Aortic valve replacement prevents this rapid downhill course.
This is a sobering graph how when you have symptoms the survival slope gets pretty steep. Source above is from UpToDate.

 

[Critter]

Natural history of aortic stenosis
Schematic representation of the natural history of aortic stenosis and of the major impact of aortic valve replacement. Survival is excellent during the prolonged asymptomatic phase. After the development of symptoms, however, mortality exceeds 90 percent within a few years. Aortic valve replacement prevents this rapid downhill course.
This is a sobering graph how when you have symptoms the survival slope gets pretty steep. Source above is from UpToDate.

Rats could not get graph to upload

 

[ashadds]

Echos depend on the tech actually, have you done a second echo OP ? Its unlikely that multiple tests could be wrong, they also look at trends serially from multiple echos before taking decisions.

If your second echo is different it could be that the first one was perhaps incorrect ?

 

[Amy]

My symptoms are mild.

Just want to say that the onset of symptoms can be so gradual, you might not even be aware of it. I was also able to walk three miles a day pre-op, and thought I was in good shape. After the surgery I realized I hadn’t been walking as briskly as I thought, and the hills had really been getting me out of breath.

 

[cldlhd]

Only one echo.

Echo below;
M-Mode and 2D Measurements (in cm)
Echocardiogram Dimensions
RVIDias-d [cm (<4.2)]: 3.4
LVIDias-d [cm (3.6-5.2)]: 5.4
LVISys-d [cm (2.3-3.9)]: 2.8
IVS-d [cm (.6-1.1)]: 1.4
LVPW-d [cm (.6-1.1)]: 1.1
LA diam [cm (1.9-4.0)]: 4.2
Aortic root diam [cm (2.0-3.7)]: 3.6
Aortic Cusp Separation [cm (1.5-2.6)]: 1.7
LA vol [cc/m squared (< 28)]: 35
LVOT Diameter [cm (1.8-2.2)]: 2.6
IVC diam: 1.5
E/A Ratio: 0.9
DT: 188 msecs
Estimated EF [% (55-70)]: 60-65

INTERPRETATION
1. Good quality 2-D, M-mode, and Doppler exam. The rhythm is
sinus.
2. The left ventricle is of normal size and systolic function
with an ejection fraction of 60-65%. There are no wall motion
abnormalities. There is asymmetric septal hypertrophy.
3. The left atrium is mildly to moderately dilated.
4. The right atrium is of normal size.
5. The right ventricle is of normal size.
6. The aortic valve appears calcified with a peak gradient of 127
mmHg, mean gradient of 86 mmHg, and area of 1.2 centimeters
squared consistent with moderate to severe stenosis and mild
regurgitation.
7. The mitral valve appears normal with no stenosis and mild
regurgitation.
8. The tricuspid valve appears normal with no stenosis and
minimal regurgitation with an estimated right ventricular
systolic pressure of 38 mmHg.
9. The pulmonic valve appears normal with no stenosis and minimal
regurgitation.
10. The pericardium appears normal.
11. The aortic root is of normal size.
12. The inferior vena cava is of normal size.
13. The interatrial septum is not well visualized.

CONCLUSIONS: There is a normal left ventricular ejection fraction
of 60-65%. The left atrium is mildly to moderately dilated. There
is severe aortic stenosis. There is mild aortic and mitral
regurgitation.

Just curious what area you are from and where you were planning on getting your surgery at? Assuming you want to share the info

 

[pellicle]

Hi
firstly I don't really understand the data you quoted, because its not really my area.

two questions... would you get surgery sooner than you needed too and what valve would you or have you received? I feel if I don’t do mechanical why not do tavr as there seems no difference in durability. I’m leaning mechanical if I do open heart because of the longevity. All replies welcome.

To your questions:

1. I would be inclined towards sooner
2. Given your age I don't really see a compelling case for either type of valve replacement under the category of Standard OHS (meaning bioprosthesis or mechanical). However given you don't have a specific complaint with mechanical then I would also lean that way as (short of aneurysm) its the only one on the table that gives you the highest probability of longer durability than your expected lifetime. As long as you don't have any issues with AC Therapy that's where I'd go (and what I have had on my 3rd and hopefully final OHS)

Best Wishes