I'm a little worried! Valve leakage!!

[coffeelover]

Hi all! Just wondering if anyone knows about valve leakage with Mechanical Aortic Valves. I just had a biannual Echo on my last Cardiology Checkup... I'm several years post-op AVR, and my last Echo showed mild to moderate valve leakage with flaps closed. I have a small valve 19mm.could this leakage be part of the normal valve flow Dynamics with a size 19mm valve.? Should I be worried? Cardiologist days that we will "keep an eye on it". Yearly echoes from now on. I don't have any symptoms.

 

[pellicle]

I guess that I'd be interested to know where the leakage is coming from, as well as how much. Now while I personally don't know much about what leakage numbers mean some participants here do.

Yes 19mm is one of the small sizes, so possibilities such as

• thrombosis obstruction
• panus ingress as well as
• paravalvular leak

come to mind ... all of which have treatment options. However I'm going to go with more monitoring before you get any anxiety happening

 

[Astro]

Hi coffeelover (I love coffee as well),

Some trivial regurgitation is normal for a mechanical valve but not mild to moderate regurgitation.

You probably know this stuff but I didn't and many on the forums won't. The Top Hat mechanical aortic valve sits supra annular. As the diagram below shows, it sits a bit above the narrowest part of the outlet. This allows a larger valve to be used - useful in petite people. It is sutured in place.

It is very rare for a mechanical valve to structurally fail. This means that something else is probably going on.

Firstly, is the measurement real? The next scan will show.

Secondly, I agree with Pellicle's list of possibilities:

1) Thrombus obstruction - clot sitting in or around the valve. Not a great thing. Needs treatment.

2) Pannus - growth of tissue that it is starting to interfere with the valve

3) Paravulvular leak - blood is flowing backwards around an edge of the valve where it is sutured in. A paravulvular leak would have been obvious on the echo.

Personally, I would ask your cardiologist some questions. What is causing it. Are they sure? (A wait and see approach with a thrombus sounds like a bad idea. It is not always easy to tell thrombus apart from pannus). Once you know what the cause is, what are the treatment options? Should the surgeon be involved in the discussions?

Hopefully, someone on these forums who had a similar experience, will add further insights.

Best wishes. A mild to moderate regurgitation itself shouldn't give you any symptoms. What is causing it is the question.

 

[nobog]

A couple of things to remember about measuring regurgitation:

at 120bpm diastole is about 250 ms (milliseconds)
at 70 bpm diastole is about 557 ms
at 50 bpm diastole is about 840 ms
(diastole is the leakage portion for an aortic valve)

so the amount of leakage is much greater, as a % of stroke volume, at lower beat rates because the rate stays about constant.

Cardiac output also effects this calculation:
70 bpm at 5 lpm (assuming leakage of 7 ml/pulse, 70 ml per pulse stroke volume) = 10 % regurgitation
70 bpm at 2.5 lpm (assuming leakage of 7 ml/pulse, 35 ml per pulse stroke volume) = 20% regurgitation

The other variable is pressure - the higher the pressure the greater the leakage, backflow will remain "mostly" constant (we're talking mechanical valves here).

In the end it depends on how you look at the regurgitation - either as an absolute value or as a % of stroke volume.

Hopefully your Cardiologist understands this.

 

[Astro]

A couple of things to remember about measuring regurgitation:

at 120bpm diastole is about 250 ms (milliseconds)
at 70 bpm diastole is about 557 ms
at 50 bpm diastole is about 840 ms
(diastole is the leakage portion for an aortic valve)

so the amount of leakage is much greater, as a % of stroke volume, at lower beat rates because the rate stays about constant.

Cardiac output also effects this calculation:
70 bpm at 5 lpm (assuming leakage of 7 ml/pulse, 70 ml per pulse stroke volume) = 10 % regurgitation
70 bpm at 2.5 lpm (assuming leakage of 7 ml/pulse, 35 ml per pulse stroke volume) = 20% regurgitation

The other variable is pressure - the higher the pressure the greater the leakage, backflow will remain "mostly" constant (we're talking mechanical valves here).

In the end it depends on how you look at the regurgitation - either as an absolute valve or as a % of stroke volume.

Hopefully your Cardiologist understands this.

This nicely explains why exercise tolerance is well preserved in aortic regurgitation, even when severe (until the heart finally starts decompensating). The high heart rate, high cardiac output and vasodilation from exercise tend to improve the proportion of blood that goes forward and stays forward.

 

[coffeelover]

Thank you everyone for sharing your information and comments.I will definitely be asking more questions on my next visit!

 

[DachsieMom]

Right after my surgery, my cardio thought I had a paravavular leak. My surgeon insists it’s impossible, and it’s just how my valve works (something about backwash). Perhaps just ask if that is a possibility? I have a st Jude valve conduit (valve connected with Dacron graft).

 

[pellicle]

Hopefully your Cardiologist understands this.

perhaps you need to draw them a picture ... they aren't all smart you know ;-)

 

[nobog]

Right after my surgery, my cardio thought I had a paravavular leak. My surgeon insists it’s impossible, and it’s just how my valve works (something about backwash). Perhaps just ask if that is a possibility? I have a st Jude valve conduit (valve connected with Dacron graft).

The St. Jude Valve "leaks" like all mechanical valves (there are a few exceptions like the ball and cage valve). They leak because 1) they need clearances just to work - you do not want them to stick and 2) because of the aforementioned "backwash" - this keeps blood from pooling in the intricate spaces where the leaflets go into the orifice. Just a few thousandths of an inch (.001) in clearance can make a significant difference in leakage - one the reasons these products are so expensive - for reference your human hair is approx. .003" in diameter.

 

[catwoman]

Coffeelover, have you had a TEE as a followup to your echo?
I have paravalvular leakage and have had 2 TEEs since my MVR surgery 16 years ago (St. Jude, 27mm). The first one in about 2005 or 2006 and the next one maybe 2-3 years later when I changed cardiologists. After my annual echo at the new cardiologist’s practice, he wanted to compare the current leakage to the previous results. The results remained the same and I’ve been told that unless it progresses, I’m OK.
I have annual echoes and EKGs.

 

[coffeelover]

Thank you everyone for sharing your thoughts, knowledge support. Catwoman I think the TEE sounds like a good idea. Something I should ask about at my next Cardiology Checkup. ..Nobog and DascjieMom thank you for the information about Backwash with flap closure. Good information to know!

 

[Keithl]

So I had my 6 month echo today and they warned me I would see some leakage on the report, but that at 6 months this is normal and it was not bad. She thought it might be coming from around the sticking area and that over time that should stop. I can pick up the images in a few days and will upload them to my surgeon in Cleveland for his opinion. Right now I am not worried.

 

[Astro]

So I had my 6 month echo today and they warned me I would see some leakage on the report, but that at 6 months this is normal and it was not bad. She thought it might be coming from around the sticking area and that over time that should stop. I can pick up the images in a few days and will upload them to my surgeon in Cleveland for his opinion. Right now I am not worried.

Sounds like you are in good hands.

 

[coffeelover]

Hi all, Just had another yearly ECHO ( I'm 9 years post AVR) and a mild to moderate leakage is again seen where and when the flaps close. It has been observed at every ECHO. Anyways, my Cardio says it is more than the trace amount you would normally see when the TopHat mechanical flaps close. I asked my Cardio what causes this and he Sort of said "due to the type and size of the valve". I don't have any symptoms, the heart looks like ok. Just wondering if I should consult a Cardiac Surgeon. I'm fine. I bike, swim, run...but gosh I am definitely concerned about the possibility of long term affects of this mild to moderate leakage. Any thoughts or advise you can share?

 

[nobog]

delete

 

[MdaPA]

Just had another yearly ECHO ( I'm 9 years post AVR) and a mild to moderate leakage is again seen

Just wondering if I should consult a Cardiac Surgeon. I'm fine. I bike, swim, run...but gosh I am definitely concerned about the possibility of long term affects of this mild to moderate leakage.

Did you compare the numbers from your prior echo(s), including your post-op echo, to the most current one? If no significant changes and your Cardio is on the ball and not concerned, then that just may be your "normal".

Catwoman I think the TEE sounds like a good idea. Something I should ask about at my next Cardiology Checkup

Did you ask your Cardio about having a TEE?

IIRC, most mechanical valves are designed to have some (trace-mild) leakage at leaflet closure, it's normal. The amount of leakage you are experiencing may be a bit high compared to others but that may just be the "normal" for you, especially if your heart is ok and you are not having any symptoms. If you are still concerned get a 2nd opinion and/or get that TEE.

 

[Warrick]

Does mild to moderate leakage cause the ventricle to enlarge or remodel? If so then wouldnt that necessitate replacement?

 

[coffeelover]

Good point MdaPA, it could just be that my valve closure leakage is higher than the other's trace amount, but the mild to moderate leakage is my normal.
I feel fine, no symptoms. And Cardiologist is watching it with yearly echoes.

 

[pellicle]

I feel fine, no symptoms. And Cardiologist is watching it with yearly echoes.

good news all round

 

[pellicle]

delete

like that'll happen here ... LOL