Left Ventricle Remodeling after AVR

[SCOTTT]

There are different criteria used for deciding when to fix a valve. Regurge and stenosis act differently on the heart muscle. With high gradients the muscle thickens more than dilates. With regurge more dilation than thichening at least initially. The trick is to go in when the heart has not developed irreversible changes. When I was 29 it was noted that I had developed changes on my ECG suggestive of impending irreversible strain on the left ventricle.I had a gradient of 70mm of mercury across the aortic bicuspid calcific valve. Surgery was scheduled in a few months. I persisted in playing basketball and had a syncopal episode in a game. I decided to stop playing until the surgery. I ran into the cardiologist in the hospital we both worked and mentioned the fainting episode. He freaked out and pushed Abup the surgery. Apparently a not uncommon exit from the mortal coil with aortic stenosis is sudden death from arrhythmia. After the surgery my ECG changes reversed along with the wall thickening. But if one waits too long this does not always happen. Moral of the story get a good cardiologist.

Absolutely correct on the differences between tracking an aortic valve with AR vs AS. In 2001 we used a flowchart published by the American College of Cardiology to aid in our decision:

When I first walked in the door in 2001 I was considered in the middle 'Stable' path even though my LVED measured 67mm. The key to my long wait was that I was completely asymptomatic, and I ended up with 5-6 stress echos (standard Bruce Protocol) lasting 21 minutes over the subsequent 12 years of waiting. I finally had AVR when my LVED reached 76mm as I still hadn't developed any symptoms and I could still ace the treadmill test. My cardiologist was tearing his hair out towards the end, but was still able to rationalize the decision to wait based on my treadmill test results.
In 2014 the ACC released a new set of guidelines for AR and they seem to have taken a more simplified, conservative approach:

Had the 2014 chart been published before 2001 when I received my first echo results then I would have most likely had AVR in 2001. In 2001 the decision for me to wait wasn't a unanimous one as 3 out of 5 doctors that I consulted suggested waiting as opposed to the two that advised surgery in 2-4 weeks time. The two doctors who advised surgery weren't wrong, in their opinion they just had no history on my valve progression and wanted to err on the side of caution. The cardiologist that I eventually chose was the one who told me to read the ACC document and understand the path/risks that I would be taking with my decision. It made perfect sense at the time and I have no complaints either his or my decision or outcome.
Back to Heart_Fit's original concern on remodeling: If the 2014 guidelines are being followed (for AR, I don't know if he had AR or AS) then he most likely had surgery when his statistics were less severe than mine and his outcome should also be as good or better than mine. I am not a doctor and I do not know Heart_Fit's medical history. I only offer up my case as an example of successful remodeling even when severe LV dilation is present pre-AVR.

 

[afraidofsurgery]

Like the other comments, my left ventricle prior to AVR surgery was enlarged at 72 mm, after 6 mos was down to 5.3. All has been well since then, almost 10 yrs ago. I had severe regurgitation with a malformed valve (they think it was a bicuspid with poorly formed 3rd valve) that didn't close.

 

[johnmarkos]

That's fascinating! I've seen the second flowchart, because a couple years ago my cardiologist gave me a packet of material to study, because I'm a nerd. For the past year and a half or so, my LVEDD has been hovering in the 60-67mm range. My cardiologist and surgeon told me I should get surgery soon based on my indexed left ventricle volume after my cardiac MRI in November. It's at the high end of the transitional range. I have severe AR and a bicuspid aortic valve, but no stenosis or aortic aneurysm, as far as I know.

I agree with my doctors about surgery soon, BTW -- indexed volume makes sense to me as an indicator, along with progression of left ventricle enlargement.

In 2001 we used a flowchart published by the American College of Cardiology to aid in our decision . . .

 

[tom in MO]

Probably died from an arrhythmia. But one wonders what was said to the parents by the cardiologist. I would have expected he told them of the anticipated surgery. And probably there was some discussion about activity.
When they did not hear anything did they make any inquiries?
I always tell patients that the remember about themselves better than anyone else. If they don’t hear about something check on it. Sad story but probably plenty of blame to go around.

Absolutely.

My own story:

• My cardio forgot to call me about my last echo before surgery. It was bad. I had been going yearly.
• I also forgot to call the cardio for the results figuring they were OK like all the others. However in the past they told me.
• Luckily for me, my internist checked my chart at my physical and asked me if I had heard from my cardio. When I said I hadn't, he told me to get in touch with the cardio about my results. Didn't tell me the results though.
• My cardio called that afternoon (obviously he got a call from my internist) and told me I needed surgery. Talk about a wakeup call when your doctor calls you at work
• When I asked how long do I have, he said "Have your valve replaced in 2-3 months. You need to come in for an appointment as soon as possible" When pressed, he used his catch phrase "You don't want wait too long and suffer the symptom known as sudden death."

In my case there were multiple failures in the communication trail. My cardio didn't call. My cardio's nurse did check to make surehe had called. In the past, the nurse would call and say everything was fine. My internist didn't read the report upon receipt.

Humans make mistakes. My cardio apologized. I stayed with both doctors until they retired. Half my family is Irish so I have the Luck-o-the Irish I check up on all tests, even those I feel are unnecessary.

 

[Anand65]

Heart Fit, if the surgeon told your mother to pray over this, that's just dumb, because it implies something sinister may be going on. Hopefully, you have taken it out of context.

This may reassure you: A year after my AVR the echo showed both ventricles dilated. The cardiologist told me nothing to see... See you in two years. When I mentioned the ventricles (as you do in normal conversation) he rattled off some malarkey about the septum. Two years later, as in earlier this week, my echo showed 'remodelling' and now the ventricles are normal size. What this means is that things can normalise, but it may take some time.

He told me he was 'delighted'... that's nice. I like it when middle aged bogans talk posh.

Heart Fit, if the surgeon told your mother to pray over this, that's just dumb, because it implies something sinister may be going on. Hopefully, you have taken it out of context.

This may reassure you: A year after my AVR the echo showed both ventricles dilated. The cardiologist told me nothing to see... See you in two years. When I mentioned the ventricles (as you do in normal conversation) he rattled off some malarkey about the septum. Two years later, as in earlier this week, my echo showed 'remodelling' and now the ventricles are normal size. What this means is that things can normalise, but it may take some time.

He told me he was 'delighted'... that's nice. I like it when middle aged bogans talk posh.

Hi Agian!
Just curious if there was anything you specifically did during the period that could have played a part in the remodelling of the LV to its normal size. Were you on medications like betablockers and ACE inhibitors during this period? both these classes of medicines help in bringing back dilated LV to its normal size. Im sure you must have exercised a lot and eaten healthy during this period.
I havent been exercising a lot after my AVR. Just wondering if i have lost my window of opportunity to get the LV to come back to normal size.

 

[Protimenow]

I HATE when doctors don't do adequate follow-up. Perhaps it's partly on the office staff, which drops the ball, but ultimately it's on the doctor who ordered the test and received the results.

My former cardio schedules a visit a week or so after the Echo. If I'm not seen by him, I'm seen by a Nurse Practitioner in his office. If there's a problem (and, so far, there hasn't been), I expect to hear from him right away -- and you should expect to hear from your doctor, too. Waiting for you to call, and get a bad result, is not appropriate.

I'm sorry about this issue, and am glad that you asked for results -- before it was too late.

 

[Agian]

Hi Agian!
Just curious if there was anything you specifically did during the period that could have played a part in the remodelling of the LV to its normal size. Were you on medications like betablockers and ACE inhibitors during this period? both these classes of medicines help in bringing back dilated LV to its normal size. Im sure you must have exercised a lot and eaten healthy during this period.
I havent been exercising a lot after my AVR. Just wondering if i have lost my window of opportunity to get the LV to come back to normal size.

I was taking Atenolol 50mg daily and keeping my BP low. I think nature did the rest. I actually put on weight.

 

[BAV]

Prior to my AVR in October, 2013 my LVED was measured at 76mm. I had a biscuspid aortic valve with severe regurgitation (>50%) and it was replaced by a St Jude mechanical valve. Within 6 months my LVED decreased to 55mm and this spring (5.5 years post surgery) it was measured at 49mm. I am 54 years old and very active (ultra marathoner before and after AVR), so from my experience I would say that at 31 years old and as long as you have no other heart issues (infections, rate, pressures, CAD, etc) I would not worry.

Oddly enough, my surgeon was also concerned about my left ventricle dilation, enough that he told my wife post AVR that I could possibly need a heart transplant within 5-10 years. However my cardiologist wasn't worried at all as he'd been plotting my progress for 12 years and had seen several cases where the left ventricle remodeled back to normal range (<55mm) post surgery. In other words I also had two different doctors with two different opinions. Again, it's all dependent on the patient and circumstances involved. Had I shown rapid progression of my LVED then my cardiologist would have recommended surgery sooner. Since I was asymptomatic and my LVED was increasing slowly I was able to wait 12+ years for AVR and the remodeling resulted rapidly just as my cardiologist predicted. Please don't waste any time or energy worrying about the surgeon's comments. Focus instead on healing up and getting on with your life and your body will take care of the rest.

Hi Scott,

Do you mind me asking if you had Aortic stenosis or regurgitation?