Increasingly Moderate Aortic Regurgitation?

[Homeskillet]

Hi all. Been a while since I've posted, but I do enjoy reading nightly. Tremendous info. on here.

As some may recall, I had my 2nd mitral valve replacement (w.in 1.5 yrs.) done last April. On-X 23mm. Have a handle on the INR/Warfarin thing now. Home test weekly.

Well, yesterday I had an echo done & they said I have developed moderate aortic regurgitation in a matter of 3 months (was not there in Sept. 2017 echo)!

Ejection fraction (EF) of left ventricle (LV) is down to 45%.

I have indeed been noticing shortness of breath again & heart beats hard upon exertion (back in gym again). I had stopped the carvedilol because it was wiping me out & my cardio said I could just try to go w.out it & see if that helped. Thinking perhaps I should not have done that now since he indicated that it raises EF (?). Regardless, I started back on it today.

Here's the copied results:

Summary:

The LV Ejection Fraction is: 45 %

Normal left ventricular size. Mildly reduced systolic function.

Diffuse, near global, left ventricular hypokinesis.

Normal right ventricular size and physiologic function.

Normal atrial dimensions.

Aortic valvular sclerosis without stenosis. Moderate eccentric aortic regurgitation.

Mechanical mitral valve prosthesis appears well seated. Mean prosthetic mitral valve gradient is 5 mmHg. Trivial prosthetic regurgitation.

Unable to estimate right ventricular systolic pressure due to lack of tricuspid regurgitation/measurable velocity.

No pericardial effusion.



*I am following up w. specialist in 3 weeks at university in Portland, OR (OHSU). Any input or insight when you have time would greatly appreciated. Simply cannot believe this....looks like another surgery is imminent if it's deteriorating that fast :test:!

 

[epstns]

Any chance of repeating the echo? That is quite a change in a short time period. Maybe a difference in how the tech read or took the echo?

 

[ottagal]

I agree with Steve. I have been the recipient of an echo with inaccurate measurements.
I would want confirmation first and then re-visit if this is the same.
Hang in there...always stressful to get a report with changes.

 

[Homeskillet]

This is the 3rd time I have heard this same suggestion now.

But, the echo report says that the tech got a very clear read. This, coupled w. my symptoms, makes me think that the reading is accurate.

But I will probably still pursue another echo. Good idea.

 

[epstns]

Most of us who have been going through this for long enough have had at least one echo with readings way out there somewhere. We've learned that this is more common than people expect, and we just want to confirm a change before acting upon it.

 

[Ryan CA]

I would concur with getting a new echo as a matter of course.....however; when I started becoming increasingly symptomatic prior to surgery, it was when my regurgitation increased. Even a small increase in Aortic Valve inefficiency will bring the symptoms you described. Your symptoms say more than anything in my mind.

Having another surgery sucks, but at least you have the piece of mind that you can come through it with great results. Good luck!

 

[dornole]

Well dammit. Don't curse too hard until you're certain, but . . .

Am I recalling right that you still have your native aortic valve - it's the mitral that was twice replaced? I believe I've heard that sometimes the change in the mitral valve function can affect the other valves. It seems like a while since your surgery for that to be it but possibly your heart is still reconstructing its flow and it could get better naturally or with medication?

It might be time for you to make the jump to the Mayo or Cleveland Clinic as you seem to be becoming a special case. Again, dammit. Good luck at OHSU and I'm still rooting for either Weird Echo, Disregard or Medically Treatable. Might as well root for the best as long as possible.

 

[Homeskillet]

Most of us who have been going through this for long enough have had at least one echo with readings way out there somewhere. We've learned that this is more common than people expect, and we just want to confirm a change before acting upon it.

Well, I certainly hope you're correct in this case :confused2:!

Seeing my cardio Thursday & plan to push for another echo as per the advice from several...& probably a TEE.

 

[Homeskillet]

I would concur with getting a new echo as a matter of course.....however; when I started becoming increasingly symptomatic prior to surgery, it was when my regurgitation increased. Even a small increase in Aortic Valve inefficiency will bring the symptoms you described. Your symptoms say more than anything in my mind.

Having another surgery sucks, but at least you have the piece of mind that you can come through it with great results. Good luck!

Agreed regarding the symptoms. This is what tells me the echo is most likely correct.

Since I would be high risk I am virtually certain we would be looking at another full-blown sternotomy. Barely made it through the last surgery. Guess we'll see what happens.

Appreciate the input.

 

[Homeskillet]

Am I recalling right that you still have your native aortic valve - it's the mitral that was twice replaced? I believe I've heard that sometimes the change in the mitral valve function can affect the other valves. It seems like a while since your surgery for that to be it but possibly your heart is still reconstructing its flow and it could get better naturally or with medication?

It might be time for you to make the jump to the Mayo or Cleveland Clinic as you seem to be becoming a special case. Again, dammit. Good luck at OHSU and I'm still rooting for either Weird Echo, Disregard or Medically Treatable. Might as well root for the best as long as possible.

Thank you dornole. You are correct that I still have my native aortic & my mitral has been replaced twice (in 1.5 yr.).

I guess the obvious overarching question is, "What on earth is lurking in the shadows undetected that keeps causing these uber-aggressive & rapid regurgitation issues?" (no strep nor rheumatic fever ever).

Of course, this was the fear when my tissue mitral valve failed in one year - and no one understands why. It's plumb weird that this keeps going on.

Not sure how easy it will be to switch to Cleveland Clinic based upon my VA hospital "insurance" - might be forced to stick w. OHSU. But, I do agree that if I can make the switch it would be in my interest.

 

[AZ Don]

FYI,
There is a test called a MUGA scan that is more accurate in measuring ejection fraction. When my readings changed, my Dr. followed up with a MUGA scan to confirm.. In my case the ef measurement of 45 was accurate. My readings changed over the course of the year following my valve sparing aortic aneurysm surgery, but then stabilized. My aortic regurgitation went from trivial, to mild, and then moderate over the year.

 

[Homeskillet]

FYI,
There is a test called a MUGA scan that is more accurate in measuring ejection fraction. When my readings changed, my Dr. followed up with a MUGA scan to confirm.. In my case the ef measurement of 45 was accurate. My readings changed over the course of the year following my valve sparing aortic aneurysm surgery, but then stabilized. My aortic regurgitation went from trivial, to mild, and then moderate over the year.

Excellent (well, not your valve decline :confused2. Will inquire about this scan tomorrow w. cardio (added in to my notes).

But, at this point, I fully expect him to tell me that it's time for number 3 (OHS). Just too quick of a decline.

Thank you again.

 

[ottagal]

Excellent (well, not your valve decline :confused2. Will inquire about this scan tomorrow w. cardio (added in to my notes).

But, at this point, I fully expect him to tell me that it's time for number 3 (OHS). Just too quick of a decline.

Thank you again.

https://en.wikipedia.org/wiki/Transe...echocardiogram
Don't want to confuse you, but I understand TEE's are more accurate than standard echocardiograms. May want to ask about this. I am not sure if they are more accurate than MUGA scans regarding Ejection Fraction etc.
Of course, your cardiologist will decide what the best next step will be for you.
All the best!
We are thinking of you.

 

[Homeskillet]

https://en.wikipedia.org/wiki/Transe...echocardiogram
Don't want to confuse you, but I understand TEE's are more accurate than standard echo-cardiograms. May want to ask about this. I am not sure if they are more accurate than MUGA scans regarding Ejection Fraction etc.
Of course, your cardiologist will decide what the best next step will be for you.
All the best!
We are thinking of you.

Thank you ottagal. Good info.

Met w. cardio today & he looked over echo report. He said that he needs to take a closer look at the actual echo itself next week before making a determination (had it at another hospital than what he thought), but, that he doesn't think they will do anything until the aortic reaches the severe regurgitation level.

He also stated that my heart has been through major trauma in past 2 years & it's still recovering (I don't really buy into this explanation for the shortness of breath though).

He said that my echo from Sept. 2017 also showed mild/moderate leakage - hence, he doesn't think it will get any worse. Simply, he said that this could be my "new normal" due to being 50 yrs. old now & also having 2 OHS.

He also said that there is generally a +/- range of 5%-10% variable in EF readings from echo's (10% sounds a little high to me?). Considering putting me on lisinopril in conjunction w. carvedilol, but warned me that this would likely make me feel tired (he said that this would "take the load off" of my heart?).

Regardless, I am still pursuing a 2nd opinion from a university cardio & surgeon w.in a couple of weeks. I plan to push them to do more tests. My shortness of breath is quite limiting to what I can do - and I simply am not satisfied w. this being my "new normal."

Thank you all again for all of your invaluable input!

 

[ottagal]

Glad you are moving forward and making some concrete decisions.

I agree, I would want a 2nd opinion before I could put your current cardiologists's explanation and recommendations to rest.
Keep us posted!

 

[Homeskillet]

Saw 2 cardiologist today at OHSU (Portland) who both said that they don't think that I currently need another surgery at this time. They both said that they don't see moderate leakage from the aortic - and that they would only suggest a 3rd surgery if things got really bad.

Regarding my EF, she said that it's not normal, but that there's a 5% variable in readings of EF. They added low dosage lisinopril to my meds & agreed that I should also remain on carvedilol.

They told me to back off the weights. They both said that moderate weight lifting is okay, but not straining since it places pressure on the heart valves. They encouraged cycling, jogging, or stair master - but even then to not keep my HR too high for too long.

I will go back for a more detailed echo in 4 months. She said they use a high contrast that gives a perfect picture of the heart at the university. They really are on top of their game there.

She also okayed me to take supplements designed to raise EF (see here: https://www.drsinatra.com/best-heart...ts-to-consider). She said there's not a lot of clinical data on these supplements (e.g., CoQ10), but that she didn't think they would harm me. Not sure just yet if I will try these or not inasmuch as I realize that supplements can be dicey.

Concerning potential auto-immune disease, she said that she thought that I would be having more symptoms if this was indeed the case. I did inform her about a timeline of infections (e.g., staph, gum infection, etc.). What really impressed me was that she actually inquired about my time line. She was truly probing for clues & took time to answer my questions.

Just wanted to post an update - and thank everyone for all of the input. I raised several points to them today that was presented on here (even told them about the forum!).

 

[Homeskillet]

Oh, also, I inquired about the use of a 5-7 day split for amoxicillin prior to dental work & the cardio replied that she thinks I would be okay just abiding by the standard 2,000mg one hour beforehand.

I have 2 lower teeth that desperately need crowns since most of the tooth itself has worn away & could break off at anytime.

I asked her what to do if they broke before getting them fixed (it costs approx. $2,000 for both) - and she basically freaked saying, "If that happens immediately begin taking antibiotics, get to the dentist immediately, and then go see a cardio immediately thereafter!"

She was exceedingly concerned about this.

I am scheduled for next Wednesday to get the 2 crowns (just borrowing the $$), but am wondering if I should self-prescribe to take the 5-7 day split on my own just to be safe (I realize this would raise my INR though, which could also cause more bleeding from the procedure).

I do worry that the teeth will break in the meantime since this is still a week away - they're *THAT* fragile! Any thoughts would be much appreciated.