Interpretation of MRI results

[shanwow1]

Hi everyone. I haven't posted in awhile but I just got the copy of my reports from my exams back in March and I need some help interpreting them.

Background: Bi-cuspid aortic valve with regurgitation and pseudo-coarctation of the descending aortic arch.

MRI report details of note:
- Bicuspid aortic valve with apparent fusion of the right and left cusps
- Regurgitant fraction = 30%
- Left Ventricle:
- Ejection Fraction = 57%
- End Diastolic Volume Index = 83 ml/m2
- End Systolic Volume Index = 36 ml/m2

My question about this is that the report concludes that my left ventricle size is normal, but when I looked at normal values for LV End Systolic Volume Index it says anything over 25 ml/m2 is abnormal. I was looking here: http://content.onlinejacc.org/article.aspx?articleid=1838843 under 4.2 Table 11, level C. I had an MRI in 2011 that indicated a slight enlargement of my left ventricle, but I don't have a copy of that report in my possession. Clearly one of the reports is wrong?

I also had a Cardiopulmonary stress test which indicated "Low aerobic exercise capacity with heart rate limits to exercise reached, suggestive of cardiovascular limitation". However it does indicate that this could be due to "marked de-conditioning", ie. I'm out of shape, which my cardiologist seemed to think was the reason for this result as I hadn't been doing much physical activity at all. But I am only 26, on the lower end of normal weight range for my height, I've always been somewhat active and my lung capacity was normal. So I'm not sure I agree with her assessment.

I have always been somewhat unclear on my symptoms, and maybe that is an indicator that they aren't that bad? But what I have noticed is that while I don't seem to be forced to stop doing certain things such as walking hills, climbing stairs, jogging short distances etc, I do tire much more easily than I would expect for someone my age and have to take frequent breaks. I have noticed myself getting short of breath at rest (what I would characterize as being overly aware of my breathing and needing to take a few deep breaths). I get palpitations lasting 10-15 seconds a few times a week. I have also noticed chest tightness/heaviness that is similar to when you are starting to get a chest cold, but it never develops into anything. That happens both at rest and on exertion.

So at my appointment in March, my cardiologist essentially said there is nothing that indicates I need surgery right now, and she wanted me to improve my fitness level in order to re-do the stress test and find out if I get similar results. She wanted to see me again in 8 months. I have just moved back to Edmonton from Vancouver so I need to be referred back to my original cardiologist. I know nobody on here is a doctor but I need an opinion on whether I should be pushing to see the cardiologist very soon, or if I'm overreacting and I should just wait until my next regularly scheduled follow up appointment?

My biggest fear is that I will go to my next follow up, they see that my left ventricle is enlarged and that there was a mistake, and that this damage will cause my recovery time and possible complications from surgery to be much worse.

I appreciate any and all advice. Thanks for reading!

 

[Eva]

I can respond to one of your worries; ice, regarding your left ventricle. My left ventricle shrunk to its original size right after my surgery!

The fatigue I felt just before I needed or was told I needed surgery was overwhelming! I had to force myself to change my clothes after wake up! I was short of breath talking on the phone or just resting watching the TV.

If you are really worried and you trust your cardio, maybe you request to be seen after six months instead of 8.

Good luck.

 

[river-wear]

I'll second what Eva said. If your LV "might or might not" be slightly enlarged, waiting 6-8 months for a follow-up shouldn't damage your heart. Everyone is different of course, but mine was somewhat enlarged for years, but my heart function was good, so we waited. When my EF began to decline, my cardiologist said it was time to do something. Now that I'm "fixed" it's expected that my heart will go back to normal function.

 

[shanwow1]

Thanks Eva and river-wear. I actually feel much better now that I realize another couple of months isn't going to make a big difference. I will continue to monitor and stay on top of things but go back to life as normal for now. Just out of curiosity, do either of you happen to know what your Left Ventricle End Systolic Volume Index and Ejection Fraction were before surgery?

 

[river-wear]

I'm not familiar with the Left Ventricle End Systolic Volume Index, but my LVEDD was 5.9cm and LVESD was 4.1cm. I believe those acronyms are for Left Ventricle End Diastolic Dimension and Systolic Dimension. My EF was estimated at 46% via TTE, but when they did a TEE (more accurate) it was 50%. The lower limit for normal is 50%.

Aha, I just checked my pre-surgery TEE results. It lists LV ESV / LV ESV Index as 74ml / 42m^2. I've never seen anyone mention that metric on here before, and I'm not sure how it could be converted to what you are asking, because I would think it's 1.76 ml/m^2 but that is wildly different from your report... hmm, I suspect the "42 m^2" might be a mistake that should have been 42 cm^2 because of the reported LV Area Diastolic on my report. That would make my measurement 176 ml/m^2. (shrug)

One thing to note is that echocardiograms can be quite operator-dependent. I just noticed they had measured my ascending aorta as 3.3cm. The surgical report said it was 4.0cm - so either they were off quite a bit or it grew that much in 3.5 months.

P.S. I had a 5+ (aka "torrential") leak across my valve. The surgeon couldn't believe I wasn't feeling really bad when I came in for surgery. I was still hiking in the Santa Cruz mountains on the weekends.

 

[river-wear]

This page has the "normal" ranges from a sample of 43 patients - take them with a grain of salt. As you will see in the note, the measurements will also vary by body surface area, meaning larger people will have higher measurements.

http://www.echobyweb.com/htm_level2_eng/normal_parameters_tt.htm

Based on the AHA guidelines, if I was really at 176 I should be dead. So I really wonder about my report! I must be reading it wrong. My post-surgical TTE report doesn't have that index number on it. (Different hospital.)

 

[shanwow1]

That is a strange measurement, 42m2 doesn't make any sense because that's supposed to be your body surface area, and if that was true you'd be a giant! I don't know where the 42 would have come from, but just 76 ml/m2 kind of makes sense if your ventricle was significantly enlarged? Who knows...

Those "normal" ranges are really interesting, even though they might not be entirely representative of a true "normal" (whatever that is). I also had regular left ventrical volume measurements (Diastolic = 146 ml, Systolic = 63 ml) which fall outside of the measurement and standard deviation on that chart. And I'm not a very large person so that wouldn't skew things. But as you said, even a slight enlargement isn't exactly a cause for grave concern, especially given my ejection fraction is within the normal range, so I'm not stressing too much about it. It's interesting to compare though.

 

[river-wear]

Okay, to compare, my LV volume measurements were 153ml diastolic and 74ml systolic. I'm 5'8" and 134 lbs - not a giant. You'll have to do your own conversion to metric

You know, looking at my report again, I think my LV ESV Index should be 42 (versus your 36) and the units are just messed up. So the LV EDV Index would be 87.

 

[shanwow1]

So actually we are almost identical in size, I'm 5'8'' between 135 and 140 lbs. Which actually makes the left ventricle measurement comparisons more interesting. I mean it's not exactly a full scientific study to compare to one person, but when you hear all these numbers you wonder, "well what does that actually mean for me?" I see that I'm not much below your measurements, which gives me a better sense of where I am on the road to surgery. I'm finding it hard to plan my life with this hanging over my head. I want to change career paths but my current one is stable with benefits and requires low energy output, whereas the new career path I want to take would require starting my own business with no security and a high level of energy required to do the job. So I don't know whether to start now or wait a few years until after my ticker is fixed. I think partly because of my age (26) they will try to put off surgery as long as possible assuming my body will bounce back well from it.

 

[river-wear]

It's good that you're planning ahead, but keep in mind a couple of things.

1) Echocardiograms (especially transthoracic) have a fair amount of error due to the operator, so measurements may vary a bit from test to test. Oh, that's right - you had an MRI. You may have echos for follow-up though.
2) You may have many years before you need surgery. I never really had symptoms, so we're different in that regard. You have the benefit of universal healthcare up there, so depending on what you find after your next doctor visit you may decide you have time to get your business off the ground before having to worry about taking some time off. I'm saying all this because it would be a shame if you put your life on hold to "wait" for your heart to get tired out - and then find out it takes ten years (or more).

Frankly, based on what I'd been told growing up and what the surgeon found, it's kind of amazing I made it to 46 without surgery.

Good luck with whatever you decide. At least you can try to relax until your next scheduled appointment.