Mini stroke post exercise?

[Patsman07]

Last Thursday I done a 40km race on the bike. Finished at the summit of a hill. Was strenuous enough but I've done similar races many times since my surgery 4 years ago. On the way home I felt a numbness in the left side of my face& tongue+began slurring my words. My friend who was driving took me to his house as his wife is a doctor. While there the left side of my face dropped so she rang an ambulance.

By the time the ambulance came all of my symthoms had disappeared except for a slight numbness in my left cheek+a lack of power in left facial muscles, which I still have 3 days later. Ct scans of my head+neck, echo of heart all came back clear so no bleed. My inr was 2.4, my range is 2-3 and I haven't been out of range in 3 years. Only explanation seems to be that a clot was broken off my valve during the cycling and caused this but can't understand how a clot developed with my inr in range?

Wondering if anyone has experienced something similar?

also worried that the hospital I'm still in is treating me as a regular stroke patient&staff seem to have very little knowledge about mechanical valves.

I'm 34 years old+have a st judes mechanical valve.

 

[pellicle]

interesting ... edited a reply post and its flagged unapproved. This software fukken stinks

Patsman, sorry to read this.

I have no personal experience, however I have worked with a fellow (who had the older tilting disc valve) who indeed had similar issues but only during "heavy training" ... he was a retired US Marine, so I guess you can take "heavy training" to mean just that.

Thanks for providing INR information (I assume it was taken at the hospital soon after admission.

Good that the CT scans are clear, so it would appear to be a TIA

I find the "explaination" to be dubious ... it seems pure conjecture as they would have no evidence to suggest a clot on the valve.

I have a different conjecture, my "friend" had problems with micro clot formation caused by high activity triggering the formation of thrombus, which is something which can occur on the (depending on the valve) opening and or closing of the leaflets; exactly like that brief jet which can occur when you block the garden hose with your thumb when its running.

I can send you a paper to read on that if interested, but to quote from that:
The flow can become turbulent at peak flow through the valve, and
such turbulence is thought to play an important role in clinical phenomena, such
as platelet activation and thrombosis formation and embolization.

His solution was to keep his HR below 160, and to move his INR up to 3, plus to take some platelet control (aspirin) prior to "going at it"

Let me know if I can help more.

 

[pellicle]

Patsman

while I had that article open I thought I'd take a few more seconds to post this from it:

Aluri & Chandran (91) and Lai et al. (92) numerically studied the affect of
valve closure on the potential for cavitation formation for MHVs. Because of the
complexity of the phenomena and the desire to focus on the detailed flow patterns
near the tips of the leaflets, they were also restricted to two-dimensional models.
Laminarization and turbulence are important phenomena in prosthetic heart valves
but have not yet been modeled together. Numerical methods capable of allowing
laminar and turbulent flow to coexist in the same domain are needed. At present,
variants of large-eddy simulation techniques appear to be the most promising for
predicting the turbulence and relaminarization that occur during the cardiac cycle.
...
IMPLICATIONS FOR THROMBUS FORMATION
In the vicinity of mechanical aortic heart valves, where peak turbulent shear stresses
can easily exceed 1500 dyne/cm2 and mean turbulent shear stresses are frequently
in the range of 200–600 dyne/cm2, and platelet activation and aggregation may
readily occur. Data indicating that shear-induced platelet damage is cumulative are
particularly relevant to heart valves. During an individual excursion through the
replacement valve, the combination of shear magnitude and exposure time may
not induce platelet aggregation. However, as a result of multiple journeys though
the artificial valve, shear-induced damage may accumulate to a degree sufficient
to promote thrombosis and subsequent embolization.
...

The clinical performance of the Medtronic Parallel valve is an example of the
effects of these flow patterns on the likelihood of thromboembolic complications.
This valve showed superior forward flow hemodynamics in an in vivo porcine
model, suggesting a good clinical performance. However, the Medtronic Parallel
valve performed very poorly in clinical trials, with approximately 20% of the
patients in these trials developing thrombosis. Patient and material factors were
statistically eliminated as potential reasons for the poor performance. Subsequent
in vitro analysis of flowthrough the valve pivot revealed regions of highly disturbed
vortical flow within this area during the leakage phase. Thrombi from explant
valves were localized within the pivots to these disturbed flow regions.
...

All valves currently in use, mechanical and bioprosthetic, produce relatively large turbulent stresses,
which can cause lethal and or sublethal damage to red cells and platelets, and
also produce larger pressure gradients and regurgitant volumes than normal heart
valves.

 

[SumoRunner]

I had a minor stroke on my 39th birthday. This was prior to valve replacement, so I was not on drugs, but I had a valve defect since childhood. I was running on an indoor track and then lifted weights for a bit, but after doing a set of pull-ups I got a little dizzy and my speech came out all garbled.

I went to the showers, had no problem doing the combination lock, showered, got dressed and drove myself home. My speech was almost normal by the time I got to the hospital 2 or 3 hours after the event. I spent the next couple days there and they found nothing.

They conjectured that the high thoracic pressure from the pull-ups flecked off a bit of calcium that had built up around the defective valve and coursed it's way through the arteries until it settled in the speech center. Why there instead of the left big toe, I wondered? Perhaps it had done so before, I was told, but toes don't create havoc like the brain.

 

[pellicle]

also, from another article, the levels of pressure of threshold importance are this (note the per second aspect and think about the milliseconds involved):

Platelet stress accumulation during forward flow indicated that no platelets
experienced a stress accumulation higher than 35 dyne

 

[pellicle]

... I was not on drugs... I was running on an indoor track

so, its not just the Russians ;-)

 

[Warrick]

I posted here and it says I have in the todays posts stream but it appears to have disappeared into thin air...... after it told me it was spam and has to be approved

Will it turn up or should I be writing it again??

 

[Patsman07]

Thanks for the replies. Could you send me a link to that paper Pellicle please. From what you've posted already it seems that thrombosis occurs due to the cumulative effects of repeated intensive exercise. Have i got that right?

That would make sense in my case. I wonder if any similar studies have been done on the st judes valve rather than the older type valves.

 

[pellicle]

Hi

Could you send me a link to that paper Pellicle please. From what you've posted already it seems that thrombosis occurs due to the cumulative effects of repeated intensive exercise. Have i got that right?

yes, but that thrombosis is a "floating ball" that moves through the blood (not stuck on a surface) type. They can snowball before they're broken down by the body, just big enough to block something in the brain (as I understand it)

Well I can send links to the abstracts, but they're behind paywalls, I downloaded them from the link we had at the University I used to work for so I can send you actual PDF's if you like

This one compares my ATS valve and your St Judes
https://www.ncbi.nlm.nih.gov/pubmed/17655477

the one I quoted from is this one:
https://www.ncbi.nlm.nih.gov/pubmed/15255773

let me know by email (hotmail) if you want copies of the PDF

 

[pellicle]

PS: I would think it prudent to consider a slightly higher INR during events and maybe a bit of asprin (an anti-platelet drug) to see how that goes ... it worked for the other guy.

 

[Patsman07]

Thanks Pellicle really appreciate it.

 

[Patsman07]

Just to update this thread for people's future reference. Had an mri scan which showed that I had a very small stroke. So it has been recommended that i increase my inr to 3.0 and stop exercising to max heart rate incase the thrombosis has been caused by the increase in turbulence. This advice was given to me by the head of a stroke unit. I plan to follow up with my cardiologist and get a second opinion from him.

 

[user 16827]

really interesting post this one,

I race mountain bikes, i often have confusion post race and also after long ( not necessarily hard but long 5hr ish ) training rides

i have had 2 acute episodes since my surgery with garbled speech, both lasted approx 2 hours

during races i sometimes experience short episodes where i can't seem to separate reality from dreams
its hard to explain the weird feeling i get, although im fully aware its happening

i had put this down to migraine or dehydration ?

Having read the post & links from Pell i am now thinking it may be a turbulence issue

i often see 180bpm during hard efforts and threshold is around 170 for long efforts

i will look more into this topic & possibly consider going into older age in the slow lane :Face-Uncertain:

 

[pellicle]

It is indeed an interesting topic (even though I'm just a passive participant at this point)

Patsman07 : myself I'd be inclined to take seriously the comment from the head of the stroke ward slightly over and above the thoughts of your cardio. My reasoning is that the cardio is someone who's specialised in exactly cardio, strokes caused by that and how are probably quite likely outside his domain knowledge (which is more observing and understanding if there is trouble for the heart (which there isn't) and when (if) another surgery is needed. I observe that we now have "electrocardiology sub specialties" where they just focus on pacemakers. -> knowing more and more about less and less until they know everything about nothing much. (you may guess that I'm not a fan of speciality at the detriment to generality because reductionistic approaches have flaws).

leadville : its interesting the phenomenon you describe. I think I felt things like that in the ski season prior to my OHS when I still had a calcifying aorta (my homograft) but also put it down to "pushing my limits" light headed-ness sometimes it would persist for some hours after a strenuous hill climb (yes, cross country skiing). As it happens subsequent to my surgery to give me the mechanical I have simply striven for endurance strength not peak, and so (looking at my garmin) 90% of my exersize time is between 130 and 150, with occasional bursts to 160 (and if my strap is not mistaken 178, although I mistrust it).

I would be VERY interested to hear if either of you (or anyone else) does d-dimer blood tests to see .. I think this is an under researched area because as HV Replacement patients I'd say being exersize oriented makes us a small minority of the HVR community. Indeed since returning to Australia 3 months ago all I've been doing is hill walking daily (well and home reno, motorcycle maint and taking my bike on rides visiting friends).

Best Wishes

 

[Patsman07]

Hi leadville,

sorry to alert you to this bad news but hopefully in the long run it'll be for the best.

Just when you say "confusion" I thought I should add this- about 14 months ago I got home from one of our Thursday night races. My wife was in bed as were our two children. I made myself something to eat and turned on the TV . My thoughts began wandering to what happened during the race, cycling to the race and then I couldn't remember what I had been doing prior to the race. Then I realised I couldn't remember a single thing that had happened that day other than the race.

I woke my wife up and told her this. She asked me if I could remember going to a neighbouring town to go shopping-i couldn't. Nor could I remember the police checkpoint we passed through on the way.

We got a babysitter and went to A&E. On the way the memories from that day came back to me. I presumed I had a clot or something to do with my inr being too high/ low. After much investigation, everything came back clear and I was told I had intransigent global amnesia, which is basically temporary memory loss for virtually no reason&Was nothing to do with my valve&could have happened anyone.

Looking back now, after what happened me last Thursday, I have to say the circumstances of both events are too similar to ignore.

 

[Patsman07]

Pellicle I haven't had such a test as far as I know but I'll ask at my next appointment.

you may well be right re: cardiologist v stroke unit doctor. My reasoning was that it is the mechanical valve which more than likely caused the clot ( whether through turbulence or a clot forming on the valve surface) and the cardiologist would know more about that than the stroke specialist.

 

[pellicle]

Pellicle I haven't had such a test as far as I know but I'll ask at my next appointment.

...My reasoning was that it is the mechanical valve which more than likely caused the clot ( whether through turbulence or a clot forming on the valve surface) and the cardiologist would know more about that than the stroke specialist.

I wouldn't count on it, its pretty much well outside their field. Why not ask some pointed questions in that direction (such as what experience or readings he's had with athletes and that article. Myself I'm inclined to print those and bring them in with a highlighter pen marking key points for discussion. So far I've never had a bad reaction.

Also that article mentioned that both tissue and mechanical had similar issues with valve opening and closing pressures.

 

[pellicle]

also Patsman07 , the response by the stroke specialist isn't far away from what I suggested in my earlier post of upping your INR briefly (pre event) and adding some anti-platelet such as 80mg of aspirin.

Are you self managing (or at least self testing)? If so he probably didn't suggest that because for INR clinics it would be impossible to manage and its simpler to just say "move it up" when it perhaps isn't needed most of the time ... right?

Like I wear gloves and a jacket on my motorbike, but not all the time

 

[pellicle]

Here are drop box links to those above mentioned articles as PDF files of the full articles

https://www.dropbox.com/s/uuz1jym7c...view_fluid_mechanics_of_heart_valves.pdf?dl=0

https://www.dropbox.com/s/061x8acap4re52b/dumont_2007_comparison_bileaflet_mhvs_cfd_fsi.pdf?dl=0

you shouldn't need to sign up for dropbox (although it will ask) and it may not work from a phone

search on keyword dyne within them to get to the meat of the meal

 

[user 16827]

Patsman07 your description of confusion is identical to what i experience post race
maybe we need both need to get into the slow lane ( if my ego can cope with that lol )

pellicle I have never had the d-dimer blood test,
having done a little more reading about this i do think your exercise HR range is in the sweet spot