Mitral valve RE-repair questions

[Keithl]

I am not expert, but TEE is not as accurate as a cat scan. As for being in your thirties and wanting tissue vs. mechanical you may want to do more research. Even at 58 I wanted one and done and went mechanical even though 2 surgeons and my cardio were pushing for tissue. While I don’t have ulcers I have gerd and have to be careful to avoid ulcers. As for robotic, do your research there. The DaVinci robot while impressive is notorious for being used by under qualified doctors that do not get sufficient training and thus create more issues than traditional surgeries.

Go to US New and World Report and research doctors, they have great ratings on hospitals and doctors. I am biased, but if you want the best go to Cleveland Clinic or Mayo in Rochester.

 

[Astro]

2014???? What year is this?

It is the latest guideline we have by the American Heart Association. I agree that it is a bit old. I think that the literature has moved on regarding the timing of intervention (particularly aortic valve disease). I haven’t noticed recent articles invalidating using echo for regurgitation. Ultrasounds continue to improve. The machines they use now are much better than 20 years ago.

There is variation between scans so it is not wise to rely on one scan. There is operator error and our hearts are not static. If you are more relaxed or stressed this can affect the regurgitation level but not between mild and severe. I think that it is reasonable to use a CMR as a second scan. Personally, I am basing my surgery for my aortic regurgitation only on echoes (several over a period of time). I don’t feel that a CMR is needed for me because the views have been good. I did have a CT angiogram to check my coronaries and aorta.

I don’t mind be questioned. The diverse opinions on this forum give it strength.

 

[pellicle]

I don’t mind be questioned. The diverse opinions on this forum give it strength.

agreed ... but a better question may have been "This article is 5 years old now, is there anything more modern which presents a different view" (*which I'm guessing that the answer is not)

 

[Midpack]

Hi! regarding accuracy of TTE and CMR, there is one important thing to take into account:

All consensus and guidelines, as far as i know, are based on echo measures. So let suppose (just an example) that echo usually overestimates real regurgitation volume by say 30% when compared with a more accurate CMR. What does this imply in practical terms? In my opinion not so much, because cut-off values of consensus/guidelines already have the same overestimation incorporated.

To sum it up, i beleive CMR measurements should not be used with consensus/guidelines based on echo measurements.

 

[tommyv44]

Look I have no skin in this game! All I'm saying is that when you look at the research objectively the ECHO is not the definitive test ABSOLUTELY!!. Just the operators alone can make the difference and that's not the only shortcoming. No one can argue with that. Why not have the MRI to be sure?

Look at the studies from Uretsky and Wolff and then tell me what your thoughts are.

Cardiologists are married to the ECHO and so are the Surgeons so you'll never change the Gravy train of OHS. I, for one, never want to be laying on that table if I don't have to be....doesn't hurt to have another piece of info does it?

There's avery strong lobby fighting against the Cardiac MRI because if any of these small case studies are correct then many people who have undergone OHS for Mitral Valve Regurgitation may have done it unnecessarily......

I don't trust many people and I certainly don't trust doctors who fight against giving their patients the straight skinny when it comes to MRI tor additional testing.

If it's a quality of life issue and I can't walk 10 steps without breathing heavily that's one thing but if I'm walking 5-7 miles a day happily with no signs of fatigue and no other signs of anything then I'm getting the MRI and not the Surgery.

 

[nobog]

They also use the New York Heart Classification:

The New York Heart Association (NYHA) Classification provides a simple way of classifying the extent of heart failure.

https://en.wikipedia.org/wiki/New_York_Heart_Association_Functional_Classification

 

[pellicle]

Look I have no skin in this game! All I'm saying is that when you look at the research objectively the ECHO is not the definitive test ABSOLUTELY!!.

please don't feel like anything is personal, I was just answering your question (which was ambiguously phrased and so I could have misunderstood your meaning.

based on your expression you may be more used to forums like reddit or other communications with NetKiddies ... this place is different, mostly because we're all older and perhaps due to some of us being highly educated.

So chill mate.

I'm unlcear if this was directed at me:

Look at the studies from Uretsky and Wolff and then tell me what your thoughts are.

but it would be nice if you linked to the ones you were specifically interested in for making my life easier (and you know, that citation style I was mentioning).

You say:

If it's a quality of life issue and I can't walk 10 steps without breathing heavily that's one thing but if I'm walking 5-7 miles a day happily with no signs of fatigue and no other signs of anything then I'm getting the MRI and not the Surgery.

to which I'll say plenty of people are feeling fine (Asymptomatic) before surgery and when they awake after sugery the surgeon explains to them that it would have all gone south pretty fast and soon if not for the surgery. Surgeons are risk averse and believe the data presented to them by medical imaging. They believe this because it has an established history of being correct.

But there are many tools for the job, some tools are chosen early because they are convenient and non invasive (such as a plain echo cardiogram), others like TEE and CT scans are more invasive (and expensive) and are held back for last (again due to risk minimisation).

Heart conditions seldom progress in a linear manner, its not like the red line, but the blue one.

 

[Astro]

Look I have no skin in this game! All I'm saying is that when you look at the research objectively the ECHO is not the definitive test ABSOLUTELY!!. Just the operators alone can make the difference and that's not the only shortcoming. No one can argue with that. Why not have the MRI to be sure?

Look at the studies from Uretsky and Wolff and then tell me what your thoughts are.

Cardiologists are married to the ECHO and so are the Surgeons so you'll never change the Gravy train of OHS. I, for one, never want to be laying on that table if I don't have to be....doesn't hurt to have another piece of info does it?

There's avery strong lobby fighting against the Cardiac MRI because if any of these small case studies are correct then many people who have undergone OHS for Mitral Valve Regurgitation may have done it unnecessarily......

I don't trust many people and I certainly don't trust doctors who fight against giving their patients the straight skinny when it comes to MRI tor additional testing.

If it's a quality of life issue and I can't walk 10 steps without breathing heavily that's one thing but if I'm walking 5-7 miles a day happily with no signs of fatigue and no other signs of anything then I'm getting the MRI and not the Surgery.

I had a careful read of the Uretsky study (Discordance Between Echocardiography and MRI in the Assessment of Mitral Regurgitation Severity).
I found it an interesting read. If you have two different observers measure the same person with MRI, there was better agreement than if two different observers measure the same person with echo. This supports MRI.
Their choice of outcome is flawed. They looked at the amount of left ventricle remodelling after surgery and related it to the severity detected by either MRI or echo. Their own study and a systematic review (Krieger, Quantitation of mitral regurgitation with cardiac magnetic resonance imaging: a systematic review) shows that MRI tends to measure less regurgitation than echo. This means that testing severe by MRI is a more severe disease than testing severe by echo. Therefore, you would expect MRI to have greater remodelling of the left ventricle post surgery.
The authors said that patients could be having surgery with only mild regurgitation because echo had over estimated their regurgitation. This argument has a problem. No one has surgery just because their regurgitation is severe on echo. There has to be development of heart decompensation such as symptoms and/or severe dilatation to warrant surgery. Otherwise a person can have ”severe“ regurgitation for years before surgery is warranted. Also, decisions should be based on more than one scan.
Overall, this study says to me that further studies are required. MRI has the potential to be more accurate. How to compare the two methods is the challenge. A third, golden standard, is really required. The authors overreached with their conclusions.

I am sorry but I couldn’t find the second study by Wolff. I can see that Wolff was one of the authors for the first study.

tommyv44 has brought up an interesting point. Further studies may confirm that MRI is the better test. However, I believe it is too early to mandate everyone to have one. Midpack’s point is also really important. The triggers for surgery based on MRI may be different than echo so further study is required.

 

[Astro]

Heart conditions seldom progress in a linear manner, its not like the red line, but the blue one.

View attachment 887238

My feeling with hearts is that it is even less predictable than the blue line! Add some random angles!

 

[Agian]

I'm updating the guidelines after I finish my coffee. This should iron out any confusion.

 

[pellicle]

My feeling with hearts is that it is even less predictable than the blue line! Add some random angles!

agreed ... I was being lazy

 

[pellicle]

I had a careful read of the Uretsky study (Discordance Between Echocardiography and MRI in the Assessment of Mitral Regurgitation Severity).

thanks for fishing that out ... again I was too lazy this time

 

[vitdoc]

I exactly went through this scenario with my mitral insufficiency. Mitral leakage had been noted for years on echo. But I was not symptomatic and my heart was not dilating. Finally after about 10 years of watching I suddenly had decompensation within a week. As I mentioned in a previous post I was set to have my forth open heart to replace the mitral valve. At the last minute I ended up with a mitral clip which for me was wonderful and worked. So unless there has been a huge change in cardiology practice surgery for mitral insufficiency is still based more on function than just on a measure of leakage. I had long conversations about this with my cardiologist over the years. He told me early on that he wasn't worried about my repaired aortic valve and repaired aorta but was mostly following me for the status of my mitral. My valve leaked probably from changes in the anatomy of the heart related to all the previous aortic surgery.
The accuracy of the exact amount of leakage never was a big issue. I also had many conversations with the head of the cardiac testing section about echos.
He told me that the measure of leakage was more qualitative then quantitative with echo. I would go over my studies with him. But again the decision for intervention was never made solely on the degree of leakage. The change in leakage was more to see trends then to get absolute numbers. One side benefit I got from the clip and reduction of leakage was the spontaneous resolution of A Fib that I had been in for about a year. Probably the strain on the left atrium was decreased along with it's size which resulted in the normal sinus rhythm. Maybe if resolution of mitral insufficiency could be correlated with significant resolution of A Fib that could give another reason to fix the leakage perhaps earlier. But this is just a conjecture at this time.

 

[tommyv44]

please don't feel like anything is personal, I was just answering your question (which was ambiguously phrased and so I could have misunderstood your meaning.

based on your expression you may be more used to forums like reddit or other communications with NetKiddies ... this place is different, mostly because we're all older and perhaps due to some of us being highly educated.

So chill mate.

I'm unlcear if this was directed at me:

but it would be nice if you linked to the ones you were specifically interested in for making my life easier (and you know, that citation style I was mentioning).

You say:


to which I'll say plenty of people are feeling fine (Asymptomatic) before surgery and when they awake after sugery the surgeon explains to them that it would have all gone south pretty fast and soon if not for the surgery. Surgeons are risk averse and believe the data presented to them by medical imaging. They believe this because it has an established history of being correct.

But there are many tools for the job, some tools are chosen early because they are convenient and non invasive (such as a plain echo cardiogram), others like TEE and CT scans are more invasive (and expensive) and are held back for last (again due to risk minimisation).

Heart conditions seldom progress in a linear manner, its not like the red line, but the blue one.

View attachment 887238

Look I'm just a little passionate because this test saved me from surgery! My cardiologist fought me tooth and nail before he would give me a script for the MRI.....not very professional and then tried to scare me with the dangers of CHF. He was my physician for 10 years and I shudder to think of how many people wind up with surgery they don't need because they don't get a test that would more definitively measure the amount of regurgitation.

He said I had moderate regurgitation and he worried that it was worse and thought it probably was so he recommended a MV repair....I did some research and asked him for the MRI and that's when he became very defensive.

My new cardiologist is Dr. Uretsky and he's a pioneer in trying to get the cardiac army of ECHO believers to consider another test...what's the harm and look at the study that demonstrates I believe quite clearly that the ECHO overestimates regurgitation quite frequently.

Just get an MRI and see right? Why would an educated physician fight me on this and worse still tell me he was unaware of the study??? I'm a consultant and could find it....he's the Cardiologist WTF!

I mean nothing personal about any of this just a suggestion to look at some data that's out there. Or not!

Tom

 

[tommyv44]

I had a careful read of the Uretsky study (Discordance Between Echocardiography and MRI in the Assessment of Mitral Regurgitation Severity).
I found it an interesting read. If you have two different observers measure the same person with MRI, there was better agreement than if two different observers measure the same person with echo. This supports MRI.
Their choice of outcome is flawed. They looked at the amount of left ventricle remodelling after surgery and related it to the severity detected by either MRI or echo. Their own study and a systematic review (Krieger, Quantitation of mitral regurgitation with cardiac magnetic resonance imaging: a systematic review) shows that MRI tends to measure less regurgitation than echo. This means that testing severe by MRI is a more severe disease than testing severe by echo. Therefore, you would expect MRI to have greater remodelling of the left ventricle post surgery.
The authors said that patients could be having surgery with only mild regurgitation because echo had over estimated their regurgitation. This argument has a problem. No one has surgery just because their regurgitation is severe on echo. There has to be development of heart decompensation such as symptoms and/or severe dilatation to warrant surgery. Otherwise a person can have ”severe“ regurgitation for years before surgery is warranted. Also, decisions should be based on more than one scan.
Overall, this study says to me that further studies are required. MRI has the potential to be more accurate. How to compare the two methods is the challenge. A third, golden standard, is really required. The authors overreached with their conclusions.

I am sorry but I couldn’t find the second study by Wolff. I can see that Wolff was one of the authors for the first study.

tommyv44 has brought up an interesting point. Further studies may confirm that MRI is the better test. However, I believe it is too early to mandate everyone to have one. Midpack’s point is also really important. The triggers for surgery based on MRI may be different than echo so further study is required.

Thank you for finding this study for me.....I didn't want to ultimately have an in-depth discussion about this so much as just raise the level of awareness about this test which again made all of the difference for me....I wound up with Mild regurgitation (19 ML) and had no symptoms (decompensation) or dilation. I was lucky to come across this study and Dr. Uretsky (who is now my cardiologist) but maybe others wouldn't have found it. No one wants unnecessary surgery and some of the nightmares that can result from any surgical procedure never mind OHS.

I did find it odd that my cardiologist became so defensive about the MRI and fought with me before he'd give me the script.

Just another point of info....that's all....good intentions and regards for all.

Tom

 

[calguy]

I exactly went through this scenario with my mitral insufficiency. Mitral leakage had been noted for years on echo. But I was not symptomatic and my heart was not dilating. Finally after about 10 years of watching I suddenly had decompensation within a week. As I mentioned in a previous post I was set to have my forth open heart to replace the mitral valve. At the last minute I ended up with a mitral clip which for me was wonderful and worked. So unless there has been a huge change in cardiology practice surgery for mitral insufficiency is still based more on function than just on a measure of leakage. I had long conversations about this with my cardiologist over the years. He told me early on that he wasn't worried about my repaired aortic valve and repaired aorta but was mostly following me for the status of my mitral. My valve leaked probably from changes in the anatomy of the heart related to all the previous aortic surgery.
The accuracy of the exact amount of leakage never was a big issue. I also had many conversations with the head of the cardiac testing section about echos.
He told me that the measure of leakage was more qualitative then quantitative with echo. I would go over my studies with him. But again the decision for intervention was never made solely on the degree of leakage. The change in leakage was more to see trends then to get absolute numbers. One side benefit I got from the clip and reduction of leakage was the spontaneous resolution of A Fib that I had been in for about a year. Probably the strain on the left atrium was decreased along with it's size which resulted in the normal sinus rhythm. Maybe if resolution of mitral insufficiency could be correlated with significant resolution of A Fib that could give another reason to fix the leakage perhaps earlier. But this is just a conjecture at this time.

 

[calguy]

Hello I'm new to this forum. But my wife had her Mitral replaced because two Doctors said it needed to be replaced. When your not a Dr and they tell you all these things that could happen it scare's you. Dr Trento at Cedars did the replacement on my wife Nov 6 last year. They told us she would fill much better and have more energy. Far from it, she's tired all the time, so this pass week Dr Lala said one artery was blocked so they went up her arm and checked and nothing, no blockage at all. My wife is tired all the time and were losing trust with Doctors. I been married 47 years to her and hate what these Dr's are doing. Just my 2 cents.

 

[pellicle]

Look I'm just a little passionate because this test saved me from surgery!

or probably more likely just deferred it.

Passionate should drive your thirst to actually get educated and obtain knowledge, instead it seems to have fueled an angry rejection of anything anyone says (for example in your post above:

"I didn't want to ultimately have an in-depth discussion about this so much as just raise the level of awareness about this test which again made all of the difference for me. "

Myself I'll go with the interpretation that Astro put on that.

he's the Cardiologist WTF!

I don't know about where you live but here the process is

1. Cardiologist
2. Surgeon

The cardiologist only makes recommendations, the surgeon decides if surgery is required, not the cardiologist. I've often said that the Cardiologist is not the one you should be listening to, its the surgeon.

In Australia we have the idea of a "second opinion" ... don't fight him tooth and nail, go see another one.

And I'd be cautious about assuming your the expert in matters because you've read some (quite complex) papers. What's your background? Are you academically trained?

Either way, I'm happy you're relieved but there's no reason to go about picking fights with us here just be cause you (appear to be) terrified by the prospect of sugery. Most of us here have had surgery and recovered and now have lives free of the degraded valve of Damocles hanging over our heads.

When the time comes I hope your surgery goes well

Best Wishes

 

[pellicle]

Hi and welcome

When your not a Dr and they tell you all these things that could happen it scare's you. Dr Trento at Cedars did the replacement on my wife Nov 6 last year. They told us she would fill much better and have more energy. Far from it, she's tired all the time, so this pass week Dr Lala said one artery was blocked so they went up her arm and checked and nothing, no blockage at all.

this story sounds frustrating, its entirely possible that there is some other cause for her continuing tiredness, has anyone checked for an effusion yet? I'd seek another Dr and see what they say.

Also I'm glad that your wife recovered well from surgery.

Best Wishes

 

[calguy]

Thanks for your reply, will read and check into it before she's see's the Dr this week. Again thanks.