Hi All
Currently "modertate AVS "1 cm" 9 months ago and was 1cm 18 montha ago, but am wondering what was the trigger to decide to have surgery.
Functioning ok, although fitness level and exercise tolerance are pretty poor now (from what they used to be). Was doing moving the yard (1.5 acres) and house cleanups, and struggling a bit now. No pain or anything like that, but cant do yard work for 5-6 hrs straight like i used to. Also getting quite tired as well. After a rest, though, seem to recover ok. Cant jog anymore though, although a risk walk does not present issues.
I dont want to get to the point where surgery is imminent or needs to be rushed, but last checkup - 9mths ago, was good (had echo and stress echo).
Hi Michael,
When you indicate 9 months ago your AVS was "1 cm", I am going to assume that you mean 1cm2 (1 square centimeter), as the area of your aortic valve. If not could you please clarify what that stands for?
Assuming you mean cm2, in your last echo 9 months ago, you were right on the border of moderate/severe, based on that metric, as severe is considered < 1cm2. There are other measurements to help determine severity: peak jet velocity, aortic pressure gradient and sometimes the dimensionless index (DI). I would be curious to know if your other metrics agree with your valve area in terms of severity.
Here are my thoughts:
-Being right on the border of severe I would not be going 9 months between echos at this point. Conditions can move slowly and then suddenly progress rapidly. I am surprised that your cardiologist is not having a look at you with an echo every 6 months and that previously, 9 months ago, you indicated that your cardiologist was not concerned about your condition. When my AVS was first discovered I was also measured at 1cm2 and they saw me every 6 months and I was told that they could give me an echo every 4 months if I wanted.
-What you describe sounds like symptoms upon exertion. My cardiologist had indicated to me that once I get to that point, symtoms upon exertion, it would be time for surgery. There is a video with surgeons Lars Svensson and Doug Johnson of the Cleveland Clinic out there disussing the optimum time, and Johnson also suggests that this would likely be the time to take surgical action.
-I would be curious to know if your other metrics agree with severity as suggested by your valve area, or if perhaps one or more of them indicates that you crossed the line into severe at your most recent echo 9 months ago. Aortic valve area is calculated using the continuity equation and can be significantly off if your LVOT measurement is off by only 1mm. So, it does make me wonder if you are truly at 1cm2, especially since your echo also calculated your valve at 1cm2 18 months ago and 9 months ago you spoke about symptoms upon exertions. Did your stenosis really not progress at all in those 9 months, or was the measurement off a little? There are good reasons why they look at more than one metric to determine severity. Also, 9 months ago you expressed this same symptom upon exertion, and it sounds like you have not had an echo since. Hopefully you will be getting a follow up echo very soon to see if you have crossed the line yet. Personally, my valve area seemed the least reliable compared to pressure gradient, peak jet velocity and dimensionless index, the three of which were in agreement with one another at most echos. Valve area measurements for me were 1.0cm2 then 1.4cm2, then 1.1cm2, then 1.1cm2 then finally .87cm2- basically all over the map and highly suggestive that the first one was significanly off, especially when one graphs out the progression of the other 3 metrics. My other metrics showed gradual progression during this 19-month period and generally agreed with one another. At the time I received surgery all 4 metrics agreed that I was severe and yet I had no symptoms.
-9 months ago you expressed some misgivings about your cardiologist- he did not want to discuss things with you much and was not concerned even though your valve was right on the border of severe and you had symptoms upon exertion. I sure hope that you got a second opinion. My concern is that, based on your description of him, he might be the type to hold onto patients too long before he refers them to a surgeon for opinion- there are some who are notorious for this.
Assuming your valve measurement is accurate, and in that you were right on the border of severe and had symptoms upon exertion 9 months ago, I would not be surprised if your next echo shows that you are now severe, and as I indicated above, you might have been severe 9 months ago, with a slight measurement error in calculating valve area. In the world of aortic valve surgery, you are still young. You should recover just fine from surgery as long as you don’t wait until the point at which irreversible damage has happened. The best advice I can give is that if you don’t have an echo scheduled, get one scheduled and if you are still with that same cardiologist get a second opinion and make sure that you explain that you are experiencing a loss of energy upon exertion.
Best of luck and please keep us posted.
