Questions about my Echo

[jasond1979]

Hi I'm a 55 year old male that was diagnosed with a heart murmur a couple of years ago. Got it checked it seems that I have Aortic Valve Stenosis. According to my cardiologist he doesn't think I have a bicuspid valve but some kind of defect from birth. He also mentioned that the longer I wait to get the valve replaced the better and that as long as I don't have symptoms to let it ride. I've attached the last two echos and was wondering which reading is an indicator that valve replacement is imminent? I've heard that if the velocity gets larger than 4m/s or diameter smaller than .7cm I will probably get symptoms.

Just wanted to get some feedback from the community as to what you guys think and what you personally experienced.

Thanks,

Jason

Its weird up until a couple of years ago I thought I was totally healthy

M-Mode Data -······························--Indexed --· ·· IVSD 1.0 cm
LVPWD.8 cm ----------------- LVMI 94.5 g/m2 LVIDD (3.7-5.6) 5.7 cm
LVIDS (variable) 3.4 cm AO (2.0-3.7) 3.4 cm
LA (1.9-4.0) 3.6 cm ----------------- LAVI 18 ml/m2
Ejection fraction (>50%): 70 % EPSS.26 cm
DopplerData -·--· ·-··-· ··
AOV Max Vel 2.7 M/s ---------- AOV Max PG 31 mm/Hg ---------- AVA 1.2 cm2
---------- AOV Mn PG 21 mm/Hg
---------- MV E wave. 7 m/s
---------- MV A wave.6 m/s
---------- LVOT Velocity 1.0 M/sec
---------- PV velocity .7 msec


2015




LV Size: Normal
Septum: Normal
Wall Thickness: Normal LV Function: Normal . LA Size: Normal
AO Root:. Aortic root dimensions were normal.
RA Size: Normal
RV Size: Normal
AOV: calcified. Trivial AR
MV:. Mitral valve was normal for age.
TV:. Tricuspid valve was normal for age. Trivial TR.
PV:. Pulmonary valve was normal.
IVC: Collapse . IVC respiratory dynamics were normal.
Pericardia! Effusion:. Absent.
[h=1]Conclusion[/h]

1. Normal left ventricular size and systolic function with an ejection fraction of 70%
2. Mild aortic stenosis with a peak gradient of 31 mmHg and a valve area 1.2 cm2
3. Trace aortic insufficiency
4. Trace tricuspid regurgitation

2016

M-Mode Data -------------------·············-Indexed ------------------------------ IVSD 1.1 cm
LVPWD 1.1 cm ----------------- LVM I 117.7 g/m2
LVIDD (3.7-5.6) 5.7 cm
LVIDS (variable) 3.8 cm AO (2.0-3.7) 3.4 cm
LA (1.9-4.0) 3.9 cm ----------------- LAVI 25 ml/m2
Ejection fraction (>50%): 65 % EPSS.24 cm
DopplerData---------------------------------------------------------------------------
AOV Max Vel 3.1 M/s ---------- AOV Max PG 38 mm/Hg ---------- AVA.9 cm2
---------- AOV Mn PG 27 mm/Hg
---------- MV E wave.7 mis
---------- MV A wave.5 m/s
---------- LVOT Velocity. 7 M/sec ---------- LVOT diam 2.1 cm



LV Size: Normal
Septum: Normal
Wall Thickness: Normal LV Function: Normal . LA Size: Normal
AO Root:. Aortic root dimensions were normal.
RA Size: Normal
RV Size: Normal
AOV: calcified. Trivial AR
MV:. Mitra! valve was normal for age.
TV:. Tricuspid valve was normal for age. Trivial TR.
PV:. Pulmonary valve was normal.
IVC: Collapse . IVC respiratory dynamics were normal.
Pericardia! Effusion:. Absent.
[h=1]Conclusion[/h]

1. Normal left ventricular size and systolic function with an ejection fraction of 65%
2. Moderate aortic stenosis with a peak gradient of 38 mmHg and an estimated valve area 0.9 cm2
3. Trace aortic insufficiency
4. Trace tricuspid regurgitation
5. The aortic valve gradient is slightly higher than it was last year

 

[Paleowoman]

Hi Jason - I can't comment on the velocity. The pressure gradient is what alerted my cardiologist that the time was coming up for surgery - it was when my pressure gradient, which had been rising slowly and steadily, rose very steeply over the period of one year from 54mmHg to 68mmHg, peak gradient. My valve area at that time was 0.9 cm2, 0.7 cm2 is what I've heard is an indicator too. I never had any symptoms.

 

[jasond1979]

Ok will be on the look out for that too, never heard that pressure gradient was a big indicator. Where you symptom free when you had the valve replacement?

 

[Paleowoman]

Hi Jason - the pressure gradient is an indication of the stenosis (narrowing) of the valve. I was symptom free when I had valve replacement yes.

 

[dornole]

I found this paper helpful to understand somewhat of how they think about when to operate. It's old, and I'm sure the protocols are evolving, but it does show different factors they consider in their "flow chart" thought process.

https://www.ncbi.nlm.nih.gov/pubmed/15242302

 

[epstns]

Hi, Jason, and welcome to The Waiting Room - the virtual room where folks await their own turns at valve surgery. Your statistics are somewhat like mine were, although I didn't reach the "action" point until I was 63. The statistic that caught my eye in your sequential echo reports is the estimate of valve area. In 2015 yours was estimated at 1.2 cm2. In 2016 it was estimated at 0.9 cm2. This is a significant change, and many surgeons these days seem to push for surgery once the valve hits about 0.8 cm2. I think that's where mine was when it was replaced.

That said, I really wasn't symptomatic even when I had surgery. The human body is a miraculous machine, compensating for many of its own shortcomings. I had been a runner for over 30 years and was in pretty good shape for my age. We suspect that this conditioning is what enabled me to carry on in life without any apparent symptoms. My only "real" symptom was that of being tired a lot. The ultimate trigger for my surgery was that I declared that I was "tired of being tired." The rest is history.

 

[jasond1979]

Thanks for the feedback epstns, yes the valve area concerns me too! My cardiologist says be aware of any symptoms and report back. From what I can understand once you start having symptoms the end is near,and you should get it replaced.

jason

 

[jasond1979]

Duplicate Post

 

[epstns]

Jason - Don't go shopping for caskets yet! You may have mis-interpreted your doc's comment. The traditional wisdom is that once symptoms present, if no action is taken, then the likelihood is that the patient will die in something like 2 to 3 years. You still have time, just use it wisely ;-) . Odds are that you will want to meet with more than one surgeon before you choose your hospital, surgeon and valve type.

Also, what they mean by "symptoms" is what are commonly referred to as "Cardinal Symptoms." For aortic stenosis, these are SOB (shortness of breath), syncope (fainting) or angina (chest pain). If you develop any of these, your doc would want you to call their office soon - but if you have any of these symptoms to any extreme, a visit to the emergency room would be in order.

That said, I really had none of these symptoms. . . ever. I jogged and lifted weights right up to the week or two just before my surgery. I really stopped when I had the angiogram and needed time to heal. That was only a couple of weeks before surgery, so I just dialed it back then.

I suspect that my father died from untreated aortic stenosis. He had noticeable shortness of breath for several years prior to his death but his doctors attributed it to a lifetime of smoking. He was never treated for his breathing issues, and he died from sudden cardiac death at age 68. That was almost 30 years ago, though, and valve surgery was nowhere near as commonplace as it is now, and I'm sure that people were much more reluctant to opt for it. I think he just let the cards fall as they may. We are lucky to live in a world that offers us this lifesaving opportunity. Use it wisely, my friend.

 

[jasond1979]

Thanks epstns for your feedback. If you didn't have any symptoms why did you decide to undergo surgery? Where you afraid you might undergo a 'sudden' event that you wouldn't like. What was the main thing that prompted you to go for it, 'early'? Ok I read that you were tired a lot, did the surgery change that? I get tired at the end of the day, but nothing that seems out of the ordinary, I attribute that to my age, and sometimes not eating the best.

Jason

 

[ashadds]

Hi I'm a 55 year old male that was diagnosed with a heart murmur a couple of years ago. Got it checked it seems that I have Aortic Valve Stenosis. According to my cardiologist he doesn't think I have a bicuspid valve but some kind of defect from birth. He also mentioned that the longer I wait to get the valve replaced the better and that as long as I don't have symptoms to let it ride. I've attached the last two echos and was wondering which reading is an indicator that valve replacement is imminent? I've heard that if the velocity gets larger than 4m/s or diameter smaller than .7cm I will probably get symptoms.

Just wanted to get some feedback from the community as to what you guys think and what you personally experienced.

Thanks,

Jason

Its weird up until a couple of years ago I thought I was totally healthy

M-Mode Data -······························--Indexed --· ·· IVSD 1.0 cm
LVPWD.8 cm ----------------- LVMI 94.5 g/m2 LVIDD (3.7-5.6) 5.7 cm
LVIDS (variable) 3.4 cm AO (2.0-3.7) 3.4 cm
LA (1.9-4.0) 3.6 cm ----------------- LAVI 18 ml/m2
Ejection fraction (>50%): 70 % EPSS.26 cm
DopplerData -·--· ·-··-· ··
AOV Max Vel 2.7 M/s ---------- AOV Max PG 31 mm/Hg ---------- AVA 1.2 cm2
---------- AOV Mn PG 21 mm/Hg
---------- MV E wave. 7 m/s
---------- MV A wave.6 m/s
---------- LVOT Velocity 1.0 M/sec
---------- PV velocity .7 msec


2015




LV Size: Normal
Septum: Normal
Wall Thickness: Normal LV Function: Normal . LA Size: Normal
AO Root:. Aortic root dimensions were normal.
RA Size: Normal
RV Size: Normal
AOV: calcified. Trivial AR
MV:. Mitral valve was normal for age.
TV:. Tricuspid valve was normal for age. Trivial TR.
PV:. Pulmonary valve was normal.
IVC: Collapse . IVC respiratory dynamics were normal.
Pericardia! Effusion:. Absent.
[h=1]Conclusion[/h]

1. Normal left ventricular size and systolic function with an ejection fraction of 70%
2. Mild aortic stenosis with a peak gradient of 31 mmHg and a valve area 1.2 cm2
3. Trace aortic insufficiency
4. Trace tricuspid regurgitation

2016

M-Mode Data -------------------·············-Indexed ------------------------------ IVSD 1.1 cm
LVPWD 1.1 cm ----------------- LVM I 117.7 g/m2
LVIDD (3.7-5.6) 5.7 cm
LVIDS (variable) 3.8 cm AO (2.0-3.7) 3.4 cm
LA (1.9-4.0) 3.9 cm ----------------- LAVI 25 ml/m2
Ejection fraction (>50%): 65 % EPSS.24 cm
DopplerData---------------------------------------------------------------------------
AOV Max Vel 3.1 M/s ---------- AOV Max PG 38 mm/Hg ---------- AVA.9 cm2
---------- AOV Mn PG 27 mm/Hg
---------- MV E wave.7 mis
---------- MV A wave.5 m/s
---------- LVOT Velocity. 7 M/sec ---------- LVOT diam 2.1 cm



LV Size: Normal
Septum: Normal
Wall Thickness: Normal LV Function: Normal . LA Size: Normal
AO Root:. Aortic root dimensions were normal.
RA Size: Normal
RV Size: Normal
AOV: calcified. Trivial AR
MV:. Mitra! valve was normal for age.
TV:. Tricuspid valve was normal for age. Trivial TR.
PV:. Pulmonary valve was normal.
IVC: Collapse . IVC respiratory dynamics were normal.
Pericardia! Effusion:. Absent.
[h=1]Conclusion[/h]

1. Normal left ventricular size and systolic function with an ejection fraction of 65%
2. Moderate aortic stenosis with a peak gradient of 38 mmHg and an estimated valve area 0.9 cm2
3. Trace aortic insufficiency
4. Trace tricuspid regurgitation
5. The aortic valve gradient is slightly higher than it was last year

I have a higher gradient but seemingly a larger valve area...my PG is 50mmHg(fluctuating) but my mean gradients are in the 30s .... my valve area is more than 1 cm2....its still in the moderate category

 

[epstns]

Jason - I knew that sometime in the very near future (back then) my valve would get to the "critical" size where it would be risky not to have it replaced. By most standards, I should have needed surgery a year or three before I actually went, but I was able to compensate so well that my cardio and I waited it out. Our logic was that at my age, the longer I could wait for replacement, the greater would be my chances to do well with a tissue valve and having surgery only once. Had I opted for earlier surgery, I would have wanted/needed to have a mechanical valve to reduce the likelihood of repeat surgery. By the time I finally had the valve replaced at age 63, all of the major clinics I polled (University of Chicago, Northwestern, Cleveland Clinic) would have recommended tissue for me. But don't read my timing as "early" by any means. Some surgeons would have operated much sooner. We called my timing "almost late."

did I have any other symptoms? I really didn't think so, but I may have simply adjusted my lifestyle to avoid them. I still jogged, but at a slower pace. My wife said that before surgery my skin was almost gray, while afterward my normal color returned. People actually asked me if I had been out in the sun (February in Chicago?), as I looked to "pink." Prior to surgery, I wasn't just tired at the end of the day. . . I was exhausted. In the evening, if I stopped moving, I could immediately fall asleep. On weekends, I slept my normal nightly sleep as well as taking a mid-afternoon nap for an hour or two. I just couldn't catch up.

As far as changes after surgery, let's skip the first 6 months or so. I had many post-op complications - some were normal cardiac surgery issues, others were related to co-morbid conditions. Once I got past the initial 6 months, during which I finally completed cardiac rehab, I was doing great. Even now, 6 years later (which means that I am 6 years older at 69 now), I feel better than I did in the months just prior to surgery. It really is like getting a new lease on life.

 

[jasond1979]

Hi Steve,
Yea my Cardiologist says the same thing, the longer you wait the better that technology gets. I can't get a straight answer as to what the most critical measurement is Pressure, Velocity, or Valve area? Seems like the main thing is symptoms, although my cardiologist did mention that valve area isn't an exact calculation on a echo. One thing he did mention is that once velocity gets over 4M/S that's a sign

 

[Bonbet]

Hi Jason, you sound like you are moderate and asymptomatic. The valve area is important but also in the context of your velocity and mean gradient. Look at the ACA/Acc guidelines for a comprehensive analysis (but easily understandable) of the categories mild-moderate-severe-critical both with symptoms and without -and when surgery is indicated. I was hovering at borderline /severe for a couple of years and my cardio and surgeon were ready to operate. They advocated doing while I was still pretty healthy as the risk of sudden death was equal to the mortality risk of surgery - or 1% per year. I was asymptomatic - unless you considered that my daily workouts were not as good as they used to be - but compared with most women my age they looked pretty darn good. I'm 64.
I procrastinated, mostly because I knew that I did not have Left Ventricular Hypertrophy. When you start to develop LVH then your heart is working too hard to compensate and just like any other muscle it enlarges. But it also creates the risk that the heart muscle will have trouble "remodeling" after the surgery. LVH was my deal killer. I just got back from Mayo and my AVA is .92, mean gradient 45, max velocity 4.5 and I have LVH. So I am scheduled for surgery May 24th. I am an advocate of always seeking a second, or even third opinion. I did so for years while in the waiting room. That was until I found a cardio and surgeon who were smart and respectful and extremely competent. Good luck on your journey, Bonbet.

 

[ashadds]

I have asymptomatic moderate stenosis ! I have mild/ borderline LVH 1.1cm . All my doctors advocate waiting as my EF is 65% and I am fully asymptomatic. My valve is opening fine and post surgical risks outweigh the risks of me not being operated ! Surgery is not an issue with the risk being very low for me as I am very young and the risk is less than 1% for me. but I am not ready for blood thinners or the risk of endocarditis ! its easy to go to surgery when your very old > 50 years like your age group because potentially a tissue valve could last a long time ! Once there are even trace symptoms , I would have to strongly consider a mechanical valve due to my age ! I know this group is a blessing for people like me

 

[Bonbet]

ashadds, Thanks for your message. Does your last post mean you have mild/borderline LVH and an AVA of 1.1cm? (I was confused because it says "LVH 1.1cm) Anyway you wondered how long I was in-waiting, It has been about 16 years since I discovered the murmur. I ignored it for 12 of those years with infrequent checks. Probably around 2012 was when my AVA got to 1.3cm or 1.4ish. but it varied depending who did the echo/calculations. So it has been about 4 or 5 years moving from moderate to severe. When I visited Mayo in 2013 the doc said I was borderline mod/servere and would most likely need surgery in 1-3 years. It pretty much hovered there for almost 4 years, last July the numbers weren't that scary, it had been 9 months since my last echo. This echo in March was definitive. It isn't just my AVA, but all my numbers have worsened. I concur with the recommendation of my surgeon and cardio and will get a mechanical valve, even though I am "old". I posted on that choice in a previous thread a few weeks ago, you may be interested in reading that. Bonbet

 

[Paleowoman]

Iits easy to go to surgery when your very old > 50 years like your age group...

> 50 "very old" ! Just remember that you siad that when you're 51 ashadds LOL I know what you're trying to say though

 

[ashadds]

> 50 "very old" ! Just remember that you siad that when you're 51 ashadds LOL I know what you're trying to say though

lol I am 26 , practically like a baby in this group ! Born with congenital stenosis !

Bonbet glad to hear , my LVPW thickness is 1.1 cm which is the upper limit of normal borderline LVH ! all my parameters have moved from mild/moderate to moderate over the past 5 years ! They were stable at mild/moderate for 15 years maybe because I was a child with no LVH!

 

[Paleowoman]

lol I am 26 , practically like a baby in this group ! Born with congenital stenosis !

My bicuspid aortic valve was discovered when I was 25. But of course I was born with it......but in the 'olden days' they didn't pick these things up so easily as they do nowadays ! And there was no internet then so no contact with others with BAV. I lasted till I was 60 when I needed AVR. I hope you are able to keep moderate for several more years !

 

[jasond1979]

that I did not have Left Ventricular Hypertrophy. When you start to develop LVH then your heart is working too hard to compensate and just like any other muscle it enlarges. But it also creates the risk that the heart muscle will have trouble "remodeling" after the surgery. LVH was my deal killer. I just got back from Mayo and my AVA is .92, mean gradient 45, max velocity 4.5 and I have LVH. So I am scheduled for surgery May 24th. I am an advocate of always seeking a second, or even third opinion. I did so for years while in the waiting room. That was until I found a cardio and surgeon who were smart and respectful and extremely competent. Good luck on your journey, Bonbet.

Hi Bonbet thanks for sharing your experience. My cardiologist also said that once your max velocity gets over 4.0m/s then they get concerned. Interesting you really weren't experiencing any symptoms? Just curious is your BMI under 25?

Jason