High gradients after surgery?

[MarkZ]

I’m 4 weeks post AVR and ascending graft. I had my first echo yesterday and it revealed a mean transvalvular gradient of 24 (peak 40). An improvement over my presurgical values of 51 (peak 77) but still high as far as I can tell. Valve area is 1.6 which seems ok.

Should I be concerned? As far as I can tell from the literature, anything over 20 is considered “high” gradient. I’m having trouble interpreting the significance of this. I feel fine so the notion of reoperation doesn’t make sense to me. I spoke briefly with the cardiologist who only suggested doing the echo again in 6 months.

 

[Paleowoman]

Hi @MarkZ - my pressure gradients have been high post AVR, initially mean was 18, peak 33, but at 2 years peak was 21, peak 46, and at 5 years it was mean 35 and peak 56, and has stayed like that, now 7 years post op - it's virtually the same measurements as pre surgery. At three years post op I was referred to a cardiac surgeon who, after transoseophageal echo and 'expert' echo discovered that the high gradients are because the valve is too small for my body size, it's a 19mm valve, as a result I have moderate patient prosthesis mismatch. I have regular annual echos to keep an eye on things. Cardiac surgeon says to keep an eye on the effect of this on my heart via the echos rather than focussing on the pressure gradients.

See how your pressure gradients progress and make a fuss if you are concerned or get symptoms.

 

[MarkZ]

Did your cardiologist indicate why it’s progressively getting worse? I would think with a mechanical valve things shouldn’t change that drastically over time. Unless you’re getting progressive hupertrophy of the ventricle or something like that?

 

[Paleowoman]

No, no indication of why the pressure gradients got progressively worse although they have stabilised for the past three years at the current mean of 35, peak 56. In annual echos they keep a specific eye on the ventricles, atria and heart size and also an eye on the valve leaflets themselves - everything is okay there. My Effective Orifice Area is 0.76 It's as though the pressure gradients don't seem to mean so much....a mystery. I have a tissue valve.

 

[bluetux]

In the case of the mechanical valve, the mean gradient will most likely fall below 20 in 3-6 months, physical movement is highly recommended, 10000 steps daily would be desirable.

 

[Chuck C]

In the case of the mechanical valve, the mean gradient will most likely fall below 20 in 3-6 months, physical movement is highly recommended, 10000 steps daily would be desirable.

I had a St. Jude mechanical valve in March and had an echo upon release from the hospital. My gradient had fallen from 46mmHg to 9mmHg 7 days following surgery.

 

[bluetux]

The mean gradients are inversely proportional to the size of the valves, the large ones of 25 or 27 mm result in gradients below 10 mmHg. Your result is truly exceptional only 7 days after surgery. In my case, with a 23 mm valve (the most common, I think), the mean gradient decreased from a much higher value = 61 mmHg to 17 mmHg 6 days after surgery, to 20 mmHg after one month, to 14 mmHg after 3 months. Also the severely dilated and concentrically hypertrophied left ventricle fully recovered after 6 months. Also the mean gradient can vary depending on the state of the heart and other factors. Anyway, the state of the heart is more important than the variation of the gradients

 

[Chuck C]

physical movement is highly recommended, 10000 steps daily would be desirable.

I totally agree about the steps. It is a fun metric to track using a stepping app, which most phones now come with and easy to download if not. My goal is 14,000 steps per day. Today was a good day.

 

[Warrick]

Which part on an echo report is the gradiant?

 

[bluetux]

AV mean PG 7.2 mmHG

 

[Chuck C]

Which part on an echo report is the gradiant?View attachment 887904

Your mean AV PG (aortic valve pressure gradient) is 7.2mmHG
and your max AV PG is 13.7 mmHg

Those are great numbers!

Also, your AVA (aortic valve area) of 2.3cm2 is very good, the larger the better, which is probably why your gradient is so nice and low. My AVA before surgery was .87cm2 and 2.0cm2 after surgery with my mechanical valve in place.

In the notes they indicate trace regurgitation in a couple of your valves. The majority of people, even those without valve disease, have trace regurgitation in one or more valves, and it is not something to worry about.

I imagine that they are keeping a close eye on your mildly dilated ascending aorta at 4.0cm.

 

[MarkZ]

So I met with my cardiologist today who said he is absolutely not worried about the gradient. He didn’t tell me why, but ok.

My EKG came back as abnormal with the message “possible inferior infarct” in the signed out report, which is scary as hell. The cardiologist said EKG abnormalities are “to be expected after surgery”. These tests have not been reassuring.

 

[bluetux]

Regarding the mean gradient values of aortic mechanical valves (MPG), there is a fairly recent and suggestive study for brands ATS, BICARBON and ON-X. The measured values for valves between 18 mm and 25 mm at 6 months after surgery were 17.04±8.4 mmHg for ATS, 21.5±12.9 mmHg for BICARBON and 17.3±7.6 mmHg for ON-X.
For example, for ON-X: small valves (18-19 mm), MPG was most in the range 18-27 mmHg, for medium valves (22-23 mm) MPG was most in the range 9-18.5 mmHg and for the larger valves (24-25 mm) MPG was most between 7.5-8.5 mmHg. So, a value considered by some to be high (for example, 18 mmHg for a 19 mm valve) is actually a satisfactory value for that valve. Also, a MPG value of 24 mmHG is found in practice in small and even medium valves, although in the literature a value of 20 mmHG is considered high. More important are the functioning and dimensions of the heart.

https://pubmed.ncbi.nlm.nih.gov/33355803/

 

[bluetux]

My EKG came back as abnormal with the message “possible inferior infarct” in the signed out report, which is scary as hell. The cardiologist said EKG abnormalities are “to be expected after surgery”. These tests have not been reassuring.

One or more of the following factors can mimic a heart attack on the electrocardiogram:
●Physiologic and positional effects
●Myocardial injury or replacement
●Ventricular enlargement

 

[Warrick]

@Chuck C not that close an eye on it, on the ascending aorta 2 more years till the next look so that’ll be 4 yrs unchecked, we have a public health system so I might pay for a scan later in the year for piece of mind.

 

[MarkZ]

Regarding the mean gradient values of aortic mechanical valves (MPG), there is a fairly recent and suggestive study for brands ATS, BICARBON and ON-X. The measured values for valves between 18 mm and 25 mm at 6 months after surgery were 17.04±8.4 mmHg for ATS, 21.5±12.9 mmHg for BICARBON and 17.3±7.6 mmHg for ON-X.
For example, for ON-X: small valves (18-19 mm), MPG was most in the range 18-27 mmHg, for medium valves (22-23 mm) MPG was most in the range 9-18.5 mmHg and for the larger valves (24-25 mm) MPG was most between 7.5-8.5 mmHg. So, a value considered by some to be high (for example, 18 mmHg for a 19 mm valve) is actually a satisfactory value for that valve. Also, a MPG value of 24 mmHG is found in practice in small and even medium valves, although in the literature a value of 20 mmHG is considered high. More important are the functioning and dimensions of the heart.

https://pubmed.ncbi.nlm.nih.gov/33355803/

Thanks, this is helpful.
One thing I don't understand though is that my post-surgical gradients are about the same as my gradients from a year or two ago, and those ultimately were associated with the processes that led to my enlarged aorta, LV hypertrophy, etc. Would that therefore imply that with these gradients I might be at risk for further remodeling, like would the LV hypertrophy continue to get worse rather than better?

 

[bluetux]

Increased gradients are not a cause but an effect of the effort of the heart to pump blood; aortic stenosis was the cause of a great effort of the heart and for the hypertrophy of the ventricle. By the mechanical valve replacement, the obstruction has been removed, the pressure in the aorta has decreased, the heart is remodeling to normal and the ventricle recovers, probably the gradients will decrease over time, the movement is very important

 

[slipkid]

I posted about this already but last time I had an echo it was read completely wrong by the Dr who wrote it and not even noticed by my cardiologist. I only spotted the errors when I got the reports from my PCP.

It had all sorts of stupid shhht like my "trileaflet" aortic valve (which is now a mechanical On-x valve and my original valve was bicuspid in the first place fer chrissakes) suffered from stenosis, calcification, and had gradients of something like, jeez wish I could remember exactly, say 44mm mean and 65 mm peak (I can't remember the #s but they were way out of whack), and ALL of that if true should have been flagged as a concern (none of it was) and ALL of that if false (which it was) should have been redone/corrected in my record which is was not even though I called them out on it.

All I got was a lame bs excuse/apology from the radiologist who read it that he mistakenly cut/pasted from another report with the words trileaflet in it, and totally ignored the other mistakes that he made.

My PCP said I was entitled to a new cost-free echo done by those clowns but instead all my a-hole new cardio Dr volunteered to do was to do a new test a few months later (at my expense)....I firggin hate Drs. If you find a good one don't let him get away. I seem to be afflicted all my life by ***** hacks....

 

[Warrick]

 

[Chuck C]

View attachment 887909

Sir, this is no place for comedy and I'm sure that many here will take offense to your thinly veiled mean spirited attack on engineers.

Your post clearly is suggesting that the engineers who design smartphones are not doing their job property in providing the appropriate font enlarging features. Now, thanks to you, there are several engineers that will need to find a soft safe place to recover from this insult.

And, I noticed that the most prominent colors (colours for those across the pond) are yellow and red. That's clearly racist. Why not blue, or white