MVP with Severe Regurgitation Update

[barry70]

Hello. I wrote on here a few weeks ago. This was my original post:

Hi,

I am 34 years old and have MVP with severe Regurg. I am aspymptomatic. Here are my echo results from last year (March 2004). I know I will need repair surgery one day. The controversial issue is when?? My cardio thinks not anytime soon, since my heart is handling things fine so far. Surgeons think otherwise and seem to be more aggressive to operate on young asymptomatic patients.

Also, I live in NYC. If there referrals for surgeons, I'd love to hear about that too. Any other thoughts/feedback would be appreciated! Many thanks in advance.

Left Atrium - 36.1mm
Aortic Root - 39.5mm
%LV Dimention - 46%
Septum - 12mm
LV Free Wall - 11.2 mm
LV Dimention Diastole - 46.4mm
LV Dimention Systole - 24.9mm (this is good I think).
LV Ejection Fraction 65%

Severe MR
No Tricuspid Regurg. or Atrial Septal Defect
Normal Mitral Valve inflow pattern

MVP on both leaflets
Borderline LV Hypertrophy
Normal LV Wall motion
Normal RV
No Pericardial effusion

*** Had a new echo today (and stress echo). Here are the major updates:

(1) EF now 73%
** (2) LV End Dimension Systole now 30mm (increase of 5mm)
(3) No pulmanary pressure issues
(4) Severe MR with prolapse of both leaflets.
(4) Stress test was normal - no blockages. Good exercise stamina.

Even though my LV Systole number is still well within "normal" limits, how concered should I be with the 5mm increase?? Any thoughts?

Many thanks!!

 

[tobagotwo]

Welcome back, Barry. I'm not an echo technician, but here are some thoughts:

The increase means your heart is adapting to the stress by bulking up, as any muscle would (hypertrophy). For a while, it keeps things going, becoming a supermuscle. Eventually, it gets too large, and then it begins to lose efficiency.

You're on the going-up side of that equation. Another way that it shows is that your ejection fraction (EF) is now 73%. A normal EF is between 50%-65%. As the hypertrophy becomes unmanageable, the EF gets extreme, and eventually spirals to CHF (a good ways off for you).

The use of the term "normal" really seems misleading to me. As I see it, the chamber sizes listed as normal are only really normal if there is nothing else remarkable about the heart - such as regurgitation or stenosis. The amount of expansion your heart has done vs its original size is of more concern than whether the size you are at now still fits in the normal column. It is more important what is - or was - normal to you and your heart. Sometimes you know from an earlier echo, if you have one old enough.

As an example, my ventricle went from the smallest "normal" size all the way to the largest "normal" size, and was only slightly above the normal limit when I had surgery. So while it looked like it was only slightly oversized, it had actually grown a great deal before the surgery. The concern is basically where do you stop it with the surgery, before damage occurs that does not reverse after surgery.

The fact that it's growing does indicate that you are progressing toward eventual surgery.

If you're truly asymptomatic, the cardiologists will take longer before they advise for surgery. It's up to you to decide if that's a good thing. If you become concerned, you can do that by getting a second opinion, perhaps from a surgeon. (Note: not getting a date for surgery from the surgeon - getting an opinion about your readiness for surgery.)

You do want to hold on to your original equipmant as long as it remains reasonable. However, based on experiences and postings, there is a vocal segment of posters on this site that feels that waiting too long happens too often. I tend to agree with that opinion most of the time.

Best wishes,

 

[barry70]

Thanks for your response. It is really appreciated. At the very least, I am going to get echos every six months now instead of every year. I may meet a surgeon or two also.

 

[tobagotwo]

Sounds like you're fit and atheleticly inclined. When your heart starts off in such good shape, it will often take much longer for any symptoms to show up. There have been cycling enthusaists who have been taken for immediate AVR surgery (i.e. within days), who had no symptoms at all when their checkup revealed a murmer. Mitral is different, but not that different.

If you do become symptomatic, consider bypassing the stress tests in favor of regular echocardiograms. I have posted advisements from the AHA and ACC sites that symptomatic valve patients should not be performing stress tests, as they are inaccurate for determining CAD and can be downright dangerous for the patient. Unfortunately, they seem to be every cardiologist's favorite toy.

Don't get too concerned by things yet. Your heart is still handling things well. Just adjust your thinking about it a little to be aware of the changes. As far as symptoms, be aware that angina comes in many flavors. Mine was just a slight tightness at the top of the throat, kind of a lump-in-the-throat feeling. Or my lungs felt like I was breathing cold air (in July?). In women, it can be neck or jaw pain.

Best wishes,

 

[doberman]

I am surprised that your surgeon and cardiologist don't agree. Unfortunately I don't know how to read your echo results but your situation is very similar to mine only that I am 45. I am going to explain what I went through and I hope it helps you in some way. I went to a cardiologist last year who had a similar view to yours. After my TEE he told me that I would require surgery some time in the next 10 years and that I would slowly develop shortness of breath and these symptoms would get worse over time. He also told me that no surgeon would operate on a man of my age in otherwise good health who had no symptoms, and he said that my valve was definitely not repairable. Not being satisfied with his diagnosis I went on to a cardioloigist who specializes in congenital defects in adults.He told me the opposite of my previous cardiologist. He told me that I needed to have my mitral valve repaired within 8 months. I then went on to see a respected surgeon by the name of Dr. Tirone David in Toronto. He agreed that I should be operated on very soon. This surgeon has kept his own statistics over a 15 year period that show that people like myself enjoy a healthier life longer by having the surgery sooner. My surgeons words when I asked him about the conflicting diagnosis was that "they don't know" meaning that they(some cardiologists) do not have these statistics handy. I certainly wouldn't be one to suggest that you do need surgery and you are much younger than I am, I also am not sure how much worse my regurgitation was than yours . By the way I went on to have a successful operation and my valve repaired. The only thing I understand for sure is that you do not want to wait until your heart is damaged or enlarged and or develop shortness of breath. Like I wrote earlier I hope this message is of some use to you good luck and keep us posted on how you are doing...
JD

 

[barry70]

Thanks John. Well, the cardio I went to yesterday is a new cardio and she is much more in agreement (and I thought she was great). 1-3 years seems to be the best guess now for surgery, with more frequent echos going forward to make sure things stay under control. I'll keep updating on here. Thanks again for sharing your story.

 

[Karlynn]

Just be aware that many valvers have believed they were asymptomatic prior to surgery, only to find out after surgery that they really were experiencing symptoms. When the changes occur over time, the body can adjust to the symptoms and trick you into believing you are status quo. This is confusing to both doctor and patient. The doctors can often think that nothing needs to be done until symptoms appear. Some people have major symptoms years before surgery is warranted and some people have had no symptoms with a valve that was completely shot.

Bouncing off of Bob's comments on "normal". It's more important to compare your #'s from an echo when your MR is moderate, or mild to the echo which shows your MR as severe. Many people are sent to surgery with an MR of moderate/severe, or even a moderate. A severe MR is just that "severe", which would be causing the heart to work harder. It more than likely is having some kind of affect on the heart. The question is how much?

Have you consulted a surgeon? I don't recall if you mentioned that. If a surgeon says you are 1 to 3 years away from surgery, I would feel more comfortable with his/her assessment than a cardio, who can tend to be too conservative.

I'm certainly not trying to rush you into surgery. If you have previous echos to compare, this would be a better indication for you.

 

[Marty]

Early surgery best

Early surgery best

I have become convinced that early surgery is indicated for "severe" mitral regurgitation, particularly for a healthy young man with no other heart or health problems. The indicators traditionally were ejection fractions below 60% and left ventricular end systoltic diameters over 45 mm. The left atrium over 40 mm. was abnormal and perhaps a cause of atrial fibrillation.
My MVP was first diagnosed in 1961 but severe regurg not detected till 1997.
On Nov 15 1997 my EJ was 70%, my esd 31mm. On May15 1998 my EJ was 61% my esd 40mm. Soon after I began to notice some shortness of breath climbing stairs and would occasionally wake up at night gasping for breath(the medics know this symptom as paroxysmal nocturnal dyspnea).I listened to my own heart (which I had not done since medical school) and it sounded like a factory in there ( aptly called a "machinery" murmur). My cardiologist said I would probably go down hill slowly and would last quite a while .I was 72 then. I contacted the great Ed Lefrak chief heart surgeon at Inova and we set a date September 17 1998. When he got in and checked the valve it was shot ;flail torn leaflets and ruptured chordae. No repair possible. I got a St. Jude mechanical and its given me a wonderful second chance of 6+ years.I feel better now than I did in my 50's. I think my regurg and/or MVP was dragging me down and I just thought it was old age. Coumadin ? No fun but manageable.
My advice to you Barry-pick a good time in the not too distant future and they will repair the valve and you will be good as new. Young people with no other heart problems and in good general health do the best.

 

[RCB]

Strongly agree!

Strongly agree!

I couldn't agree more with what everyone has said so well. One thing that I would like to add is that mitral valve is more likily to cause more complication with A-fib after surgery, especially when your atria become enlarged. The longer you wait, the greater the enlargement, the higher the
change of A-fib. Good luck my friend- you will be fine