Post Op Turbulence Normal?

[Alex]

I just got back from my cardiologist and am freaking out a bit.

In March of 2013 I had my second heart surgery which corrected my Ross Procedure. Both the aortic and Pulmonary valves were replaced.

I just came back from my cardiologist and he says that he hears turbulence in my valves but this is normal.... He says that when you have heart surgery most tissue valves will come with some turbulence...

What is everyones experience with this? Does everyone have turbulence after a heart valve replacement? This is freaking me out because I thought that valves were typically replaced by calcification but he is saying that if turbulence gets beyond an acceptable level, that may be a reason to have surgery as well....

 

[Paleowoman]

Hi Alex - my cardiologist has never said I have turbulence but I do have an extremely loud "flow" murmur. The echo technician who did an echo on me last week explained that my new valve is probably actually narrower than my previous bicuspid one because there is the ring into which the valve is sewn which takes up space which means that there will be some turbulence as the blood flows through the narrowed valve. The difference between a stenosed bicuspid valve and the narrow replacment valve is that the leaflets/cusps on the replacment valve work fine and are not stiff like a stenosed one. Still it means a very loud flow murmur, louder than my bicuspid one by all accounts. I've been assured this is all normal.

How is your pressure gradient and ejection fraction ?

 

[Alex]

Hi Alex - my cardiologist has never said I have turbulence but I do have an extremely loud "flow" murmur. The echo technician who did an echo on me last week explained that my new valve is probably actually narrower than my previous bicuspid one because there is the ring into which the valve is sewn which takes up space which means that there will be some turbulence as the blood flows through the narrowed valve. The difference between a stenosed bicuspid valve and the narrow replacment valve is that the leaflets/cusps on the replacment valve work fine and are not stiff like a stenosed one. Still it means a very loud flow murmur, louder than my bicuspid one by all accounts. I've been assured this is all normal.

How is your pressure gradient and ejection fraction ?

Is turbulence just another term used for murmur?

I am not sure about the gradient and ejection fraction; however, everything seems to be functioning well and everything is acceptable.

 

[Paleowoman]

Is turbulence just another term used for murmur?.

I'm not sure but I thought it was turbulence that usually caused the sound called murmurs (I'm not a doctor). On this medical website: http://www.nlm.nih.gov/medlineplus/e...cle/003266.htm it says:

"A heart murmur is a blowing, whooshing, or rasping sound heard during a heartbeat. The sound is caused by turbulent (rough) blood flow through the heart valves or near the heart."

Can you ask your cardiologist to clarify ?

 

[Alex]

I'm not sure but I thought it was turbulence that usually caused the sound called murmurs (I'm not a doctor). On this medical website: http://www.nlm.nih.gov/medlineplus/e...cle/003266.htm it says:

"A heart murmur is a blowing, whooshing, or rasping sound heard during a heartbeat. The sound is caused by turbulent (rough) blood flow through the heart valves or near the heart."

Can you ask your cardiologist to clarify ?

Yes, thank you for your response!

This has just been so stressful.... Here I thought if I get 2 tissue valves I will be back to normal without any problems until calcification begins... and that seems to not be the case. Not that he is saying anything is completely wrong, just that replacement valves are ofcourse not our natural valves so small issues like this arise.

 

[pellicle]

Hi there

Not that he is saying anything is completely wrong, just that replacement valves are ofcourse not our natural valves so small issues like this arise.

the thing is that with all the possibilities that face you (NB do nothing | replace valve with mechanical prosthetic | replace valve with tissue prosthetic) there are issues. The biggest issue involves staying with your natural valve (which has a problem). That choice usually has the worst outcome ... for all of us (well ok, most of us) the choice is always down to tissue vs mechanical. The summary is always (to quote from a journal article):

The advantage of a mechanical prosthesis is the excellent durability and low reoperative hazard

vs
no need for lifelong anticoagulation but brings with it a certain risk of reoperation during the patient’s life if they live long enough

General views are that if there is nothing strongly suggesting either way that the person perhaps least qualified to make the call is asked to decide ... that would be us (you or me).

There are plenty of people here who have gone through this (some even more than twice) so you are in good company to ask for opinions and start considering which way you will go.

No matter what prosthetic you decide upon if the surgeons say "its better to operate" know that all the types are much much better than not operating. Keep in mind that this surgery has the best history of outcomes of all surgical interventions.

 

[Alex]

Hi there


the thing is that with all the possibilities that face you (NB do nothing | replace valve with mechanical prosthetic | replace valve with tissue prosthetic) there are issues. The biggest issue involves staying with your natural valve (which has a problem). That choice usually has the worst outcome ... for all of us (well ok, most of us) the choice is always down to tissue vs mechanical. The summary is always (to quote from a journal article):

vs
no need for lifelong anticoagulation but brings with it a certain risk of reoperation during the patient’s life if they live long enough

General views are that if there is nothing strongly suggesting either way that the person perhaps least qualified to make the call is asked to decide ... that would be us (you or me).

There are plenty of people here who have gone through this (some even more than twice) so you are in good company to ask for opinions and start considering which way you will go.

No matter what prosthetic you decide upon if the surgeons say "its better to operate" know that all the types are much much better than not operating. Keep in mind that this surgery has the best history of outcomes of all surgical interventions.

I think you may have misread my original post, I already have had surgery twice. Its just this is the first time I am hearing about 'turbulence.'

I have had murmurs before; however, never knew that turbulence and murmurs may be the same thing?

 

[pellicle]

I think you may have misread my original post, I already have had surgery twice. Its just this is the first time I am hearing about 'turbulence.'

you're right ... I did get my responce mixed up with reading another post (often have too many windows open) sorry about that. Probably I was thinking about this poster.

I hesitate to answer, as I'm not sure here, but I thought the turbulence with respect to your case was something other than a murmur. However the answer given by Paleogirl made me think twice. I was thinking of fluid dynamics (or more specifically hemodynamics) and contributed to irregular jets of blood on valve opening and closing. I've mainly read about this in context of mechanical valves.

May I ask, when you said in your post:

In March of 2013 I had my second heart surgery which corrected my Ross Procedure. Both the aortic and Pulmonary valves were replaced.

I assume this means that you have tissue prosthetics in both positions now ...

 

[pellicle]

http://circres.ahajournals.org/content/39/1/58.short

• ARTICLES

[h=1]Turbulent blood flow in the ascending aorta of humans with normal and diseased aortic valves.[/h]

• P D Stein and
• H N Sabbah

​

[h=2]Abstract[/h] Turbulent blood flow may contribute to a variety of pathophysiological effects. Because of its postulated importance, this study was undertaken to determine whether turbulent flow does in fact occur in the human body. In 15 persons (seven normal, seven aortic valvular disease, one prosthetic aortic valve), point velocity was measured in the ascending aorta with a hot-film anemometer probe. In one normal individual with a high cardiac output, turbulent flow occurred above the aortic valve during peak flow which corresponded to a peak Reynolds number of 10,000. In the other six normal subjects (peak Reynolds numbers of 5,700-8,900), flow was highly disturbed during peak ejection. Each of the subjects with aortic valvular disease and the subject with a prosthetic aortic valve showed turbulent flow during nearly the entire period of ejection, with Fourier components of velocity of significant magnitude up to 320 Hz (the maximum frequency we could evaluate with the equipment available). The turbulence energy density was higher in subjects with abnormal valves (3.2-14.6 ergs/cm3), than in normal subjects (0.6-2.9 ergs/cm3). In subjects with aortic stenosis, turbulence was observed throughout the ascending aorta and in the innominate artery. In others, the turbulence dissipated more proximally. The results of this study indicate that turbulent flow can occur in the ascending aorta of subjects with normal cardiac function; and it occurs consistently in the ascending aorta of individuals with abnormal aortic valves.

• Copyright © 1976 by American Heart Association

 

[pellicle]

also, let me know if you want a copy of this PDF

FLUID MECHANICS OF HEART VALVES

Abstract Valvular heart disease is a life-threatening disease that afflicts millions
of people worldwide and leads to approximately 250,000 valve repairs and/or
replacements each year. Malfunction of a native valve impairs its efficient fluid
mechanic/hemodynamic performance. Artificial heart valves have been used since
1960 to replace diseased native valves and have saved millions of lives. Unfortunately,
despite four decades of use, these devices are less than ideal and lead to many
complications. Many of these complications/problems are directly related to the fluid
mechanics associated with the various mechanical and bioprosthetic valve designs.
This review focuses on the state-of-the-art experimental and computational fluid mechanics
of native and prosthetic heart valves in current clinical use. The fluid dynamic
performance characteristics of caged-ball, tilting-disc, bileaflet mechanical valves and
porcine and pericardial stented and nonstented bioprostheic valves are reviewed. Other
issues related to heart valve performance, such as biomaterials, solid mechanics, tissue
mechanics, and durability, are not addressed in this review.

 

[epstns]

Alex - I'm also not sure if your cardio is saying that he has detected turbulence in the flow or a murmur, or even if a murmur heard may actually be turbulence. That part I cannot answer.

I can answer that I have a tissue valve, and it has a noticeable murmur. I have been told that many tissue prosthetic valves exhibit varying degrees of murmurs, and that this type of murmur is benign. It is more due to the turbulence caused by the structure of and around the valve and does not mean that there is any impairment of the valve's function. Also, the present murmur sounds quite different than the murmur produced by my former valve, which was bicuspid with severe stenosis.

 

[cldlhd]

http://circres.ahajournals.org/content/39/1/58.short

• ARTICLES

[h=1]Turbulent blood flow in the ascending aorta of humans with normal and diseased aortic valves.[/h]

• P D Stein[/URL] and
• H N Sabbah[/URL]

​

[h=2]Abstract[/h] Turbulent blood flow may contribute to a variety of pathophysiological effects. Because of its postulated importance, this study was undertaken to determine whether turbulent flow does in fact occur in the human body. In 15 persons (seven normal, seven aortic valvular disease, one prosthetic aortic valve), point velocity was measured in the ascending aorta with a hot-film anemometer probe. In one normal individual with a high cardiac output, turbulent flow occurred above the aortic valve during peak flow which corresponded to a peak Reynolds number of 10,000. In the other six normal subjects (peak Reynolds numbers of 5,700-8,900), flow was highly disturbed during peak ejection. Each of the subjects with aortic valvular disease and the subject with a prosthetic aortic valve showed turbulent flow during nearly the entire period of ejection, with Fourier components of velocity of significant magnitude up to 320 Hz (the maximum frequency we could evaluate with the equipment available). The turbulence energy density was higher in subjects with abnormal valves (3.2-14.6 ergs/cm3), than in normal subjects (0.6-2.9 ergs/cm3). In subjects with aortic stenosis, turbulence was observed throughout the ascending aorta and in the innominate artery. In others, the turbulence dissipated more proximally. The results of this study indicate that turbulent flow can occur in the ascending aorta of subjects with normal cardiac function; and it occurs consistently in the ascending aorta of individuals with abnormal aortic valves.

• Copyright © 1976 by American Heart Association

Thanks for the links,I'm a sucker for these kinds if things-anything mechanical , maybe it's the German in me.When I was told I had minimal leakage in my valve but it was high velocity in nature it got me wondering about wear and tear in the leaflets over time. One look at the grand canyon will show the power moving fluid can have over time.
I'm not sure about a murmur being related to turbulence though as it seems the one study shows a lot of people with normal cardiac function have turbulence but I doubt they all have murmurs. For what it's worth I was always told I had a murmur but since my repair they say it's gone,valve certainly feels different to me, and according to my post op TEE there's no leakage,although I personally imagine there's always some.

 

[Paleowoman]

I can answer that I have a tissue valve, and it has a noticeable murmur. I have been told that many tissue prosthetic valves exhibit varying degrees of murmurs, and that this type of murmur is benign. It is more due to the turbulence caused by the structure of and around the valve and does not mean that there is any impairment of the valve's function. Also, the present murmur sounds quite different than the murmur produced by my former valve, which was bicuspid with severe stenosis.

That's what I tried to explain above. My new murmur has even been described by an A&E (ER in the US) consultant as "stonking" loud which is Brit English colloquial for extremely loud. It can really confuse doctors who aren't cardiologists. When I was a patient in an exam for doctors moving higher up to specialist level last year, five out of seven doctors thought my murmur was pathological and to do with my mitral valve as it was so loud and "all over the pericardium" - only two doctors got it right, that it was a "normal flow murmur from bioprosthetic aortic valve".

 

[Alex]

Alex - I'm also not sure if your cardio is saying that he has detected turbulence in the flow or a murmur, or even if a murmur heard may actually be turbulence. That part I cannot answer.

I can answer that I have a tissue valve, and it has a noticeable murmur. I have been told that many tissue prosthetic valves exhibit varying degrees of murmurs, and that this type of murmur is benign. It is more due to the turbulence caused by the structure of and around the valve and does not mean that there is any impairment of the valve's function. Also, the present murmur sounds quite different than the murmur produced by my former valve, which was bicuspid with severe stenosis.

It seems like maybe this is the same case here. My cardiologist made it seem like my valves were functioning just fine (pulmonary valve actually looked better this year than last year). He just said that with valve replacements in general, the valves are not our natural valves so, as a result, many people experience turbulence in bloodflow (because the valve is not the same exact size and blood cells may collide, bounce off walls, etc..)