Severity of stenosis

[Paleowoman]

Rephrasing my previous question, if a person has a aortic valve area of 0.8 cm2 how would that be classified ? I thought that under 1 cm2 was classified as "severe" and under 0.6 cm2 as "critical" yet the radiologist who measured my aortic valve area on MRI wrote "no sigificant stenosis" at 0.8 cm2.

 

[FredW]

Hi Ann,

Based on my research in the past year, you are correct in understanding that a valve area under 1.0 cm2 is classified as severe. However, I suspect you already know that there are other variables they also used to classify stenosis. (http://www.echopedia.org/wiki/Classification_of_valve_stenosis_and_regurgitation)

I also found in my experience and research that there is a lot of room for variable results in all the tests: normal echo, TEE, Cath, and MRI. I never got a clear consistent answer as to how docs classify stenosis and what criteria they used to get one into surgery. I find it amazing that the criteria even varies depending on the country one is in and maybe even health insurance and facility.

Before my surgery, an echo test showed my valve area at .8, a Cath test said 1.4, a TEE said .9 - 1.1 and the surgeon who replaced it said 1.1. It was not any of these test results, nor my symptoms that caused my cardiologist to put me into surgery. It was during a normal checkup and a stress test where the EKG results showed heart rhythm so wacky it had him so concerned he won't let me even go home to prepare for surgery.

I'm not sure how one deals with the inconsistencies of tests results other than asking questions. I did a fairly good job of asking questions, but the answers were still inconsistent and I was never fully comfortable with the results and conclusions. The real question I wanted answered is: can you fix my problem is before it kills me?

I relate to your frustration with having to trust others to determine what course of action is appropriate for you. It's not their life, but yours that impacted.

I wish you the best and recommend you ask questions until you are satisfied.

 

[Paleowoman]

Hi Fred - yes it is frustrating. I had one echo in May saying valve area is 1cm2, two weeks later another echo with a different technician on a different machine said 0.8cm2, TEE says valve small and gives a 3D orthogonal dimension which makes no sense to me at all, and the MRI gives 0.8cm2 and says "no signficant stenosis" ! My pressure gradient is in the moderate stenosis category, so is peak gradient. The valve is not degenerating, but is "very small" and "small" by descriptions from a cardiologist and cardiac surgeon. They will fix the problem before it kills me, I'm sure of that from the way it's being monitored, so I'm not worried just curious. Thanks for that link to echopedia !

 

[epstns]

Anne - I'm certainly not a doctor, therefore not an "expert" - just another experienced patient. Is it possible that the use of those dimensions as delimiters for stages of stenosis are only applied to "native" valves, and that the presence of your prosthetic valve requires use of other statistics for staging? For many of us, our prosthetic valves are not quite as large as our native valves were, but they are (usually, hopefully) fully adequate for sufficient blood supply. I'm not sure, for example, what the expected AVA is for my 23mm Edwards valve, but I would bet that it is smaller than a normal, healthy aortic valve in a similarly sized patient. IIRC, at one of my echo's they sized it at 1.X mm, which surprised me, but my cardio said that was as expected.

Maybe worth an email to Edwards Lifesciences?

 

[jwinter]

Anne, I have a chart I found on the net that I took a snapshot of and saved it on my desktop. I named it with my numbers to refer to when people are comparing. I don't remember seeing my velocity number and not sure where it comes into play. I am sure someone here probably has your answer and I am betting it is a combination of readings,

Your numbers look like they are in the more severe range to me but I am no doctor. Keep on it!

I truly understand your concerns so keep on asking those questions of your specialist.

 

[Paleowoman]

Hi Steve - I wondered if the statistics were different for prosthetic valves, I've searched and searched and just found similar figures for aortic valve area to native valves, though of course that smaller porsthetic valves are inhenerntly stenotic, especially the 19 and 21 mm ones, and they do say it's importatnt that the valve chosen is not too stenotic. I've found that when it comes of patient prosthesis mismatch that in patients under the age of 65-70 that 19 and 21mm valves are best avoided. And that root enlargment is done to put in a bigger valve, but that with elderly patients, ie late 70s and 80s that their hearts can cope with 19 and 21mm valves - presumably because they are not so active. But I was 60 when I had AVR, not late 70's !

I seem to remember that fellow member Seaton has a very small aortic valve area, native valve, but that for some reason it doesn't mean it's severe ?

Hi jwinter - I shall carry on asking questions, most definitley, I shall have to ask more pointed questions of the cardiac surgeon when I next see him.

 

[mom2angel]

Sounds like you've received some very good answers from some members. I second the advice of asking questions until you are satisfied. Also, if you are concerned, make sure you tell the Dr. all your symptoms, if you are symptomatic. Sometimes I think they put more emphasis on if you are symptomatic or not.
I am kind of in the same boat. I've been symptomatic lately. I'm good at downplaying my symptoms to the Dr., but this year I will tell him how tired I have been, etc. I hope you get some answers soon.

 

[Paleowoman]

I have some vague symptoms, palpitations, especially when I’ve just had a meal and climb the stairs, or when I get up at night, weird. And more tired. My cardiologist knows. Hope you find answers too mom2angel.

 

[ottagal]

Anne, I think I mentioned to you that my cardiologist does not even measure the diameter of my bio-prosthetic valve. He told me that with the 'aortic size' for a bio-prosthetic valve isn't as important a measurement as pressure gradients, ejection fraction, ventricle and patient symptoms. He also said 'in his words that measurements are unreliable'. I know every cardiologist thinks differently and has different protocols for following patients . He is also the director of the Echocardiogram program. The reason I know this is I question him every time I receive an echo and it doesn't measure the AVA. I am not sure if this helps or confuses you more. This is just my own personal experience.

I am sure you have seen this before. This shows the "normal" measurements for various bioprosthetic valves.
http://www.echopedia.org/wiki/Normal...alve_protheses

Hope this is of help.

 

[Paleowoman]

Anne, I think I mentioned to you that my cardiologist does not even measure the diameter of my bio-prosthetic valve. He told me that with the 'aortic size' for a bio-prosthetic valve isn't as important a measurement as pressure gradients, ejection fraction, ventricle and patient symptoms. He also said 'in his words that measurements are unreliable'..

I don't remember you saying that Ottagal but that is most interesting, thank you, becasue at the hospital where I used to get my regular echocardiograms done they did not mesure the valve area. One time a new sonographer did record it and the chief sonographer corrected the report with these words: "Prosthetic aortic valve area calculations have been removed from report as it is computer generated and not applicable to any prosthetic valve replacements”. But the cardiologist who now does my echos, he's an UK national expert in echocardiography, told me he could measure it becuase he has an "App" that enabled him to do so.

I was actually a bit puzzled that the Royal Brompton echo measured the valve area to be honest (that guy made it even smaller) but the measurement on MRI was planimetry which means, from what I can discover, that it was actually measured as they can get a good still image of the valve. These tests beg so many questions !

I have that chart for the measurements of normal bioprosthetic valves. I have to find out if mine is in the supra-annular position or regular postion - none of the reports nor the Operation Notes says so. Another question for me to ask.

 

[ottagal]

I have that chart for the measurements of normal bioprosthetic valves. I have to find out if mine is in the supra-annular position or regular postion - none of the reports nor the Operation Notes says so. Another question for me to ask.

Yes, it seems one answer always leads to another question! LOL. Why not contact Edwards Lifesciences to find out whether its supra-annular or regular position. It may be a more direct route.

Good luck with everything!

 

[Paleowoman]

Hi Seaton - Thanks for your post ! And explaining what I couldn't get my head around ! I can't say I've ever had my AVA "indexed", it's always been either "calculated" or "absolute". But I see your unindexed has been different on differnt echos too - it's very confusing isn't it.

All the very best at your stress test and check-up today.

PS: just found a llnk which explain about the different methods of calculating aortic valve area: http://research.omicsgroup.org/index...ea_calculation

And a link about indexing the AVA: http://heart.bmj.com/content/100/1/28 Indexing mine would give an AVA of 0.6cm2/m2 or 0.5cm2/m2 so I don't think I'll go there !