Hi Chuck,
Thank you for your response. It is helpful to me as it does confirm my research and my conclusion. Did anyone tell you that you had "high gradient AS?"
I believe I have low gradient AS. Therefore, my numbers are different.
I have noted that the criteria is met if symptoms are present. The sooner the better. My LV wall is getting thicker and my atrium is enlarged from A Fib.
What were your symptoms.
Thanks,
Nancy H.
Hi Nancy.
I did not wait for symptoms. When my aortic stenosis became severe, I was given a choice by my cardiologist to get surgery or wait for symptoms. After reading up on it, I decided to get my surgery and not wait for symptoms. BTW, although my cardiologist did not take a strong position and said it was totally up to me, my surgeon strongly agreed with my decision not to wait. There is a growing body of evidence that long term outcomes are much better if surgery is done prior to the onset of symptoms. One of the most predictive things in outcomes is whether surgery was done on time, or if irreversible damage occurs to the heart due to waiting too long. If one waits for symptoms, the risk of getting irreversible damage is increased. So, in my view, once a person is severe they should get their surgery and not wait. If they do wait for symptoms, my suggestion would be to get surgery as soon as possible after the onset of symptoms to minimize the risk of permanent damage.
Regarding your question about the gradient, yes, I had a high gradient across my aortic valve. What this means is that my mean pressure gradient was >40 mmHg. This is normal for a person who has severe AS and to be expected for me, since my AVA was severe at 0.89cm2. Another way to say this would be to say that these metrics were concordant for me and both indicated that I was severe. You have indicated that you have been diagnosed with severe AS and low gradient. This would mean that your metrics are discordant; your AVA is 0.84cm2 and your gradient would be expected to be >40mmHg, which is the threshold for severe. If your report indicates that you are low gradient, that would likely mean that your gradient is <40mmHg. Is that correct? Do you have your mean gradient value?
My first two echos were discordant, so I did read up on this at the time. In my first echo in 2019 my AVA came in at 1.0cm2 and my gradient was 22mmHg. One would have expected a gradient of about 38 to 40, given my 1.0cm2 AVA. A month later I had an echo at another clinic and my numbers were again discordant, but this time in the opposite direction. AVA was 1.4 cm2 and my mean gradient was 40mmHg. 40mmHg would be exactly what one would expect with an AVA of 1.0cm2, but not for 1.4cm2. In my next three echos all three of the metrics used to measure AS severity were concordant- they were in agreement as to severity. I believe that the first two echos got some things wrong. In follow ups with cardiologists, I have come to learn that depending on the method of measurement, it is common to underestimate pressure gradient. And there can be measurement error when determining the valve area. Even being off by 1 or 2mm when they measure your LVOT can cause a big error.
It can happen that a tech makes an error and this is why it is important to look at the trend of echos. Have your numbers always been discordant and are the values from your recent echo consistent with your trend? For example, if your previous AVA values were something like 1.3cm2 ; 1.2cm2; 1.0cm2; then your current value of 0.84cm2, I would say that your value is consistent with your trend and that would give greater confidence in the accuracy. On the other hand, if you had been seeing much higher numbers on your AVA, which were in agreement with your gradient, then suddenly the AVA drops in a way that is inconsistent with your trend, I might be more skeptical of the accuracy.
A few more questions:
Do you have any symptoms? What about upon exertion? For example, do you get out of breath easily when you go up a couple flights of stairs?
What is your ejection fraction?
If your numbers do not reflect your trend, you should probably get another echo to see if you are truly discordant.
You may want to read the following publication linked below. It discusses low gradient AS and the reasons for discordance, as well as some follow up testing which can be done to help determine true severity and timing of surgery.
"The management of this subset of patients is particularly challenging because the AVA-gradient discrepancy raises uncertainty about the actual stenosis severity and thus about the indication for aortic valve replacement (AVR) if the patient has symptoms and/or left ventricular (LV) systolic dysfunction."
"The finding of a LG AS at echocardiographic exam may be related to an error in the echocardiographic measurement of the AVA a or gradient."
https://academic.oup.com/eurheartj/article/37/34/2645/2469941
My LV wall is getting thicker and my atrium is enlarged from A Fib.
These would tend to be things which point towards getting surgery. BTW, atrium enlargement can also be due to AS and it could be due to both AS and afib.
