My echo report 2/04

[Marguerite53]

Hello. I am diagnosed with aortic stenosis, bicuspid aortic valve. My cardio thinks I have 1 -3 years wait for an AVR. Bob H (Tobagotwo) graciously offered to look over my echo numbers and comment. I welcome any and all such efforts, so please have at it!! Thanks! Marguerite

Clinical indication: Aortic stenosis with bicuspid aortic valve.

Comments: M mode, 2D, color flow Doppler echocardiogram images were obtained from standard views. Technical quality of images is fair except for poor endocardial resolution. The patient was in normal sinus rhythm during the study.

CHAMBERS: Global left ventricular systolic function is normal with estimated left ventricular ejection fraction of 60-65%. No segmental wall motion abnormalities were seen. There is diastolic filling pattern abnormality in the form of E to A reversal. No intracardiac thrombus or masses or obvious chamber dilation is seen.

VALVES: The mitral valve is morphologically normal without mitral valve prolapse or mitral stenosis and there is trivial mitral regurgitation. The aortic valve is possibly bicuspid and is heavily calcified with restriction in leaflet mobility. Peak velocity through the aortic valve was 3.6 meters per second with peak gradient 53, mean gradient 29 mmHg, with LVOT diameter provided at 2.5 cm which is probably an overestimate. LVOT velocity provided at 0.9 meter per second with LVOT/aortic valve velocity retio of 0.23. Calculated aortic valve area is about 1.2cm squared which I think is somewhat of an overestimate due to large LVOT diameter provided. The patient overall appears to have moderate aortic stenosis which appears to be practically unchanged as compared to previous report from September 2003. No aortic insufficiency is present. There is trace tricuspid regurgitation.

MISCELLANEOUS: There is no pericardial effusion. Mild concentric left ventricular hypertrophy is present.

Conclusion: 1. Normal left ventricular systolic function with normal chambers.
2. Possliby bicuspid aortic valve with moderate aortic stenosis
3. Mild left ventricular hypertrophy.

 

[Raverlaw]

Marguerite,

Your numbers are remarkably similar to mine, except that my estimated valve area by the echo was 1 cm2, and my pressure gradient was higher.

The angiogram I had three weeks later showed the true valve area to be .6 cm2 and a 100 mm/hg gradient. My EF was about the same as yours.

By all means, get your second opinion, and ask the cardio whether an angiogram is indicated at this time to get more precise numbers. If you're starting to feel symptomatic, it's time to get accurate measurements taken so you can get sound advice on whether to operate or wait.

Best wishes to you.

 

[tobagotwo]

Marge, to be sure you understand - I am not a doctor or an echocardiograph technician, certified or otherwise. All I can do is make some general comments based on what I have read and experienced, which may well be flawed. I'm not qualified to interpret your echo. So, please take my comments like a tea-leaf reading, rather than a factual report.

First, a good spot for information on atrial fibrillation (Afib): http://members.aol.com/mazern/afib101.htm

I had Afib fairly frequently before the surgery, and for one long night after the surgery. Afib is a common companion to aortic stenosis, and sometimes takes a while to get rid of after the procedure. For a few, it never really goes away, requiring implantation of antiarhythmia drugs, and/or a defibrillator, and/or the use of bloodthinners, notably Coumadin.

60-65% is a reasonable ejection fraction (how much of the blood in the heart chamber actually gets out into the body with each pump). That doesn't always correspond to a surgery date, though. Mine was measured at 65% just before I went in for the procedure with a .76 cm² valve. Your aortic valve opening is listed as probably overestimated at 1.2 cm², so it's closing in on that 1.0 cm² threshold. For comparison, 1.5 cm² is the low end of normal, although probably not normal for you. That does still put you in the moderate category.

The mean gradient of 29 mmHG (average pressure through the valve), is also in the moderate range. 50 mmHg is considered severe. The peak gradient, 53 mmHg, helps to show how much pressure it takes to open your calcified leaflets to start getting the blood through. If you look at your prior echo, see if these have risen, and by how much, and you can guess at your rate of progression.

Aortic Stenosis from calcification is progressive, and I have never heard of anything that stops that process. It starts out slowly, but speeds up as it goes along. It may take the valve opening much longer to get from 1.4cm² to 1.2cm² than it takes it to get from 1.2 cm² to 1.0 cm². Basically, the worse it gets, the faster is gets worse. Still, in worried human terms, it takes a long time.

The basic adaptations of your heart to the stress and pressure from the valve show up mostly in the hypertrophies that develop, additional thickness in the chamber walls, and any chamber dilations. The other valves show the stress usually through concomitant trace regurgitations and even mild calcifications of their own. These are things that bear watching, as they are indicators of when damage may become permanent.

The report says your AS is "practically unchanged" from eight months ago, but it may have gone over an invisible line, beyond which it may start presenting you with symptoms. Or the symptoms may have been prompted by your recent heavy activity. Either way, once you become aware of them, you will notice them with greater frequency. It can become difficult to differentiate between the normal physical issues of middle age and symptoms of your valve. This can worry, panic, or just confuse you. I like to call that effect acute valvular hyperaesthesia.

The wild card is how much calcification is on your valve, and how inflexible it may be. You were having symptoms, which is also an indicator, although they were after prolonged physical stress. I had symptoms (unknowingly) for about a year before my surgery.

Your regular physician (PCP - Primary Care Physician?) still sounds pretty much on the money to me. A year should put you pretty close to surgery, assuming no new issues show up.

If you have no bad reaction to it, you might ask your PCP about taking an aspirin a day. Many take one, 81 mg aspirin in the morning. Due to recent posts about the efficacy of enteric coated aspirin, I have begun taking two, instead of one. Uncoated 81 mg aspirins should not have an efficacy issue, so one should do.

Remember: tea-leaf reading.

Best wishes,

 

[Marguerite53]

Thank you both. I completely understand that this is a forum of experienced people from many different walks of life, most of whom are not medical professionals in any way. I'm just so grateful to have the help in becoming more familiar with all the buzz words and measurements in a language I can relate to, and from people with such caring patience. Cardiologists are somewhat intimidating and I like to be ready and to ask meaningful questions. I can't know what to ask until I have a clearer understanding of what is important. You are all very helpful in this regard.
Marguerite

 

[Bryan B]

Cardiologists are somewhat intimidating and I like to be ready and to ask meaningful questions.

Hi Marg,

I agree that cardios can be intimidating or feel their patients don't need to understand their own condition. It's good to see that you're educating yourself, because afterall YOU are always going to be your own best advocate.

I had a Ross Procedure just to give my cardio a challenge (just kidding, but the look on his face when he listened to my heart after surgery was priceless).

 

[epstns]

Marg - You've received a lot of information her that is probably better and more useful than what most cardio's give patients. As long as you employ that "grain of salt" in interpreting the info, you'll do fine.

I think the one point that comes across clearly is that in almost every case, the onset of "clinically significant" symproms (my quotes) is the key. When you begin to show symptoms that you and your doctors view as serious enough, that's the time to proceed to the next step. As an example, I too have moderate aortic stenosis, with similar valve area, pressure gradient and ejection fraction. I'm 56 years old, yet I still jog 4 to 5 miles, 5 days a week and work out with moderate weights at the club. I've been doing this for many years -- which may contribute to my continuing ability to remain active and asymptomatic. (Being a smaller person may help, too.)

So, we're all different. Numbers are guideposts. Symptoms are the truest indicator of when it is time to proceed. Don't delay -- get that second opinion (or third, if you're not comfortable with just two). Your life depends upon it.

 

[tobagotwo]

It has been said several times that you want to avoid permanent damage to the heart. That is absolutely true. And you don't want to wait until the very last minute, as Bill and I discovered that our actual valve sizes were considerably smaller than estimated - and considerably less flexible.

However, you should bear in mind that most often, a basically healthy heart will shrink at least partially back to its original size after the burden has been lifted.

Here are some of my echo numbers, four years apart. The 2004 echo was three weeks before surgery:

................................................2000..........2004.........Normal
LV Diastolic Diameter.................3.5 cm.......5.7 cm......3.5 - 5.7 cm
LV Post Wall Thickness...............1.1 cm.......1.2 cm......0.5 - 1.1 cm
LV Intravent. Septal Thickness....1.1 cm........1.2 cm......0.5 - 1.1 cm
Left Atrial Diameter....................3.5 cm.......4.3 cm......1.0 - 4.0 cm
Aortic Valve opening..................1.1 cm²......0.96 cm²...1.5 - 2.6 cm²

Note that the valve opening was reestimated as .76 cm² during the cardiac catheterization, three weeks after the last (2004) echo.

This will give you something to compare to, although not enough to draw real conclusions. When I was calculated at a valve opening of 1.1 cm², it was still classified as moderate stenosis.

Note the enlargement in that time of the Left Ventricle Diastolic diameter - still "normal," but it moved the entire range. The left atrial diameter went right out of bounds. Both the LV and the LA were classified as mild hypertrophy.

My ejection fraction was measured at 77% three weeks before surgery (I had misquoted it at 65% in an earlier post).

This took four years to develop, with a 1.1 cm² opening to start. So, you can see that it is easy to fall into hurry-up-and-wait status.

One main difference for you is that you are showing symptoms. When I was first called by my PCP to set up the original echo, I came in to answer the phone from the back, where I had been busy handsplitting firewood with an eight-pound maul. That was when I was at 1.1 cm². I wasn't feeling any noticeable ill effects from the valve problem at all.

What I mean by all this is, you may be ready for replacement sooner than I was, going strictly by the numbers.

One suggestion might be to consider noting your symptoms when they occur. A simple listing of what you felt and a few words about what you were doing at the time might be helpful. Compare each echo to the prior reports to look for unhappy trends.

If your symptoms begin to deeply affect your ability to live normally, and your echos don't seem to validate that, ask for a stress echo, or an MRI (MRA, actually - Magnetic Resonance Angiogram) or a cardiac catheterization to bear out your symptoms.

But don't let that Acute Valvular Hyperesthesia get you so frazzled that you lose perspective. Stress brings on symptoms faster than physical activity sometimes. (You knew I'd get that AVH in there somehow, didn't you?)

You have time (months! a year! or more!) before you will go to surgery, and you shouldn't spend that time in the shadow of your stenosis. Be sure to enjoy this calm before the storm, and not wish it away, just to get past the surgery. Learn and prepare, but don't put your life on hold for this until you absolutely have to.

Best wishes,

 

[Marguerite53]

Thanks to all. Bob, all the comparisons got me wondering (even before your latest post) and so I looked through old insurance papers, found afew dates and am trying to recreate my history by having old cardio's fax me my echo reports. I did get one from 1998 and it is set up so differently, the measurements not in text, but all in a nice row! Of course many are termed abit differently, too (with diastole, systole), but I have been able to discern some items to compare. The true "reading" will come for me on monday when I ask the new cardio to ruminate over them. But, to keep this going -- here's afew more numbers.
LV Diastolic Diameter 1998 -- 51mm 2004 -- 2.5 cm (25mm, right?)
LV Ejection fraction 1998 -- .60 2004 -- 60-65%
Aortic Valve mean gradient 1998 -- 3mm 2004 -- 29mmHg
Aortic peak gradient 1998 -- 12 mm 2004 -- 53 mmHg
Aortic valve area 1998 -- 1.9cm sq. 2004 -- 1.2cm sq.
Other comments. 1998 -- borderline left ventricular hypertrophy vs. 2004 mild concentric left ventricular hypertrophy. 1998 fibrocalcific disease of the aortic valve vs. 2004 aortic valve is heavily calcified with restriction in leaflet mobility. 1998 no aortic insufficiency vs. hm, no mention 2004.


By the way, anyone know what this means?? "There is diastolic filling pattern abnormality in the form of E to A reversal" ??

Hm. Well, would love to ponder this further, but both my boys are home from college this weekend (the oldest won't be home for summer for the very first time and we thought his brother could train down from Seattle and we could be a 5-some for afew days, anyway. I have the most amazing kids, by the way) and I'm off to make crab melts. Mmmmmmmmmmmm Dungeness crab.
Marguerite

 

[tobagotwo]

No, that 2.5 would be in cm (51mm is .51cm). Still, those Left Ventricle Diastolic Diameters don't line up with what my reports show at all, do they? A quandary...

I checked both echo reports (they came from different facilities), and both list normal LVDDs as 3.5 - 5.7cm. However, it may be different for males, who do have slightly larger hearts. Or, perhaps it is associated with the "diastolic filling pattern abnormality" they refer to in the report. It can also be echo tech error or imaging problem. I just don't know. Is it possible that your heart is turned slightly on its axis, so that it presents sort of a side view to the sonograph (echo)?

The fact that your LVDD has grown significantly in size underlines the added stress on your heart required to pump blood through your stubborn valve. You might want to bring both reports with you, if you get to the point where your "numbers" aren't considered bad enough to take action, but your symptoms are becoming overwhelming to you.

You could show that, although you may still be within the limits of normal, the actual amount of change to your heart has been radical. That might help prompt action if you feel the time has come before the cardiologist is willing to listen.

Again, you're probably correctly designated as having moderate stenosis right now, and your PCP is likely right about having a good year left.

Enjoy your houseful of family. Pat's dad is 80 tomorrow, so her whole family will be here over the weekend. I pick up her sister at Newark airport in about four hours.

Best wishes,