Stenosis Pathology without Valve damage?

[tobagotwo]

"Riddle me this, Batman..." the Riddler.

My recent echo didn't quite come out the way it was originally casually explained to me.

In viewing the actual report, I noted that all of the expected measurements, mean and peak gradients, estimated aperture size, etc., were missing from the aortic valve section. As the main purpose was to check on the status of the new aortic valve, that was disconcerting.

Then I get a callback to the cardiologist's office, which turns out to be for some "further studies" with the echocardiograph.

Hmmm. The information that is on the report is that there is no insufficiency at the aortic valve, all of the other valves are functioning properly with trace insufficiencies. There is some concentric thickening of the left ventricle (LVH), pulmonary pressure is 39, and the velocity of flow through the aortic valve is 3.3 m/sec. Holter monitor came out clean.

Um, what was that flow again? 3.3 m/sec is on the level of moderate aortic stenosis....

Tech turns a 20-minute re-echo into fifty minutes of "We're going to figure this out, or at least get every drop of data possible."

I don't have the new report yet, but what I gleaned from the tech (who kindly showed me the tape) is that the new valve is fine, and is opening fully and operating properly. As are the other valves. No vegetation is present (no sign of infections), no visible obstructions. Normally, a high pulmonary pressure on an echo might be written off, as it's not infrequently off the mark.

But the pressure in the heart is high. At a flow of 3.3 m/s, my heart is still operating in stenosis pathology, like a runaway train.

One possibility is that it's (apparently) pushing twice the volume it should be pushing through the system. (Well, if there's no regurgitation, and it's going through a normal-sized aperture, it must be going through the system, right?) That also would mean it's likely the pulmonary pressure is up, as the blood has to make the circuit.

Okay, I guess, but why don't I have high blood pressure then? Averaging about 128/72, single high (from the last month) of 142/88.

Okay, logically, it could otherwise be a very short stroke (pump) at a more normal volume. But no mention of an unusual stroke in the original report, either.

It's not coarctation, and probably not a huge, ballooning aneurism, so what might be going on..?

Thoughts, anyone? Conjecture?

Thank you,

 

[Phyllis]

Bob, It is a riddle and I'm sure you have researched thoroughly yourself. The only thing I came up with is that a patient-prosthesis mismatch ( valve is too small relative to the patient's body surface area) causes immediate consequence of high transvalvular pressure. http://www.onevalveforlife.com/ovflcontenttmp.aspx?section=1&page=6
I trust that this is not the problem. Wishing you the best and anxious to hear when you get the new report.
Best Wishes,
Phyllis

 

[tobagotwo]

Fortunately, you are right. The valve is a #25, which would be well adequate for almost anyone, and it is opening fully.

The pressure issue is a building one, and wasn't there at the start (as you pointed out), which it would have been with a mismatch. In the prior echo, it was 2.6, now advanced to 3.3.

Thank you for following up Phyllis. I much appreciate it.

 

[Harrybaby666]

Hey Bob...

Hey Bob...

I don't know much about what's going on with the rest of your heart, however, I do know that I am surprised that the cardio didn't tell you that you have Pulmonary Hypertension...although your Pulmonary Artery Pressure is mild at 39 (mine was 43 when last checked), I am surprised that the cardio didn't tell you this..Mine made an all out point to tell me that I have PH. Hope in some small way this will help..Harrybaby666

 

[tobagotwo]

Probably because echo results for PH are frequently throwaway numbers, as the accuracy is very questionable, Harry.

If that 39 is correct, it is likely backend pressure from the overly vigorous pumping that my left heart is doing. After all, it's basically a closed system, so all that blood has to go somewhere. I guess that would be secondary PH?

That's it! I have the answer! Less blood, less pressure! Now, where did I leave those leeches?...

Best wishes,

 

[Harrybaby666]

Yes, Bob...

Yes, Bob...

Probably because echo results for PH are frequently throwaway numbers, as the accuracy is very questionable, Harry.

If that 39 is correct, it is likely backend pressure from the overly vigorous pumping that my left heart is doing. After all, it's basically a closed system, so all that blood has to go somewhere. I guess that would be secondary PH?

That's it! I have the answer! Less blood, less pressure! Now, where did I leave those leeches?...

Best wishes,

It would be Secondary Pulmonary Hypertension..because The PH itself is NOT the cause, but something that is gone wrong in your heart and/or lungs. Harrybaby

 

[Nancy]

Have you any symptoms due to the findings?

You are right about echoes not being a very valuable tool for PH, however, keep in mind that they can vary BOTH ways. So keeping an eye on that pressure is a very prudent idea.

Joe had PH for many years, and we were never told about the fact that it was showing up in his echoes. It wasn't until he developed severe PH, and almost died from it that anyone mentioned it, and it was an ER doctor, not his former card.

PH progresses without treatment. In the beginning, there are some simple meds that can be used.

Not saying you have it, mind you, just that it is a watch area, and should be a discussion point with your doctor.

If you want to read about PH, here's an article.

http://www.emedicine.com/radio/topic583.htm

 

[Karen]

Harry and Nancy, more on pulmonary hypertension

Harry and Nancy, more on pulmonary hypertension

In the report of my last echo, there was mention of mild pulmonary hypertension based on the tricuspid regurgitation (RA pressure of 38mmHG) and atrial pressure of 5mmHG. I did a bit of research at the time, and wasn't very happy with what I could learn about pulmonary hypertension. Namely, that it's progressive, not curable, and the life expectancy numbers given are rather daunting. Even in that article that Nancy referred to (in this thread). Somehow, I convinced myself that this is probably common among valvers and not as serious as it appeared from what I gleaned in my reading initially. Is that true?! It makes sense to me that Secondary Pulmonary Hypertension is NOT as serious a situation as PPH. But what IS the prognosis and the expected rate of progression to a critical stage with Secondary PH? How do you distinguish the symptoms from PH from the normal pathology of the valve situation? My cardio made no specific mention of these numbers in my report, so I counted it as not being too significant. What effect does medication have on PH? Is it simply to address the symptoms, or does it slow the progression of the PH?

Bob, 'hope you get satisfactory answers soon to the riddle...

Karen

 

[Debrinha GT]

Stupid question

Stupid question

Why would a surgeon put the wrong size of valve in the first place? Now that I come to think of it, I remember that when I asked my cardio what went wrong with my valve only five years after I'd had my first surgery, she said that I was growing and developing too quickly and when they did the operation, the surgeon didn't even know if I would make it. I was only fourteen when I asked the question, but now I wonder what she really meant!!????
Bob, I hope you get the answer to your question and that everything turns out ok for you in the end.

Débora

 

[Nancy]

When Joe started treatment two and a half years ago, his pressures were in the mid seventies. It was thought that he had secondary PH, but as it turned out after all the testing, it was determined to be primary. He was put on an oral medication Tracleer. His last cath showed pressures in the low 40s. So Tracleer was a miracle drug for him

In the past several years there have been great strides in the treatment of PH. If it is treated successfully, by a specialist, it is considered a chronic illness rather than a terminal illness.

Years ago, there was nothing viable for treatment of PH, so it was a terminal illness. That is not the case now.

Some of the other meds that are used in addition to Tracleer are Flolan, which is an IV med, distributed from a cassette and uses a central line for the vehicle, Remodulin which is a continuous injection subQ which also comes in a cassette, like insulin. Viagra is being used for some (not the dosage used for ED). Some get relief with heart meds that are pretty common. Those with sleep apnea use a c-pap machine. There are also several others and some in clinical trials too.

Joe's cardiologist has said that usually they do not start heavy duty treatment with folks in the mild category.

But it is important to keep a good eye on it, and not rely on your doctor to tell you about it. Too many people have either had it ignored until it became critical, or have been misdiagnosed. There are doctors who do not specialize in PH who do not know that there are treatments available for it, and thus may not want to press the issue with their patients. It is also a rare disease, but on this site there are several with PH. Most doctors will never treat a patient with PH in their entire career.

Seconadry PH usually goes away when the underlying problem is corrected.

Here's the address for the PHA website main page.

http://www.phassociation.org/

 

[bvdr]

Bob, when is your follow-up appointment? Things have gone so well for you I hope it all continues. Pulmonary hypertension can easily exist without systemic hypertension. I'll have to think about this but I don't think I have any answer for you. I associate pulmonary hypertension though much more with mitral problems, which if I remember right, they are watching yours for possible problems. What was the measurement of your mitral valve opening?

Something doesn't seem to gel, does it?

 

[tobagotwo]

Yer darn tootin' it doesn't add up right.

Basically, I'm neither forgetting about the pulmonary number, nor embracing it at this point. What is arresting my attention is that 3.3 m/s flood through a perfectly-opening aortic valve, and the fact that it has increased over the last year. It should be around 1.6 or so. I feel like it's beating the tar out of my new valve.

My primary suspicion is that if the left-side mystery is cleared up, the right-side (pulmonary) number will evaporate. As there is no off-kilter right-side data, it just doesn't seem to follow that the high pulmonary pressure is the driver here. I certainly hope it's not.

I don't have an aperture size for the mitral valve, but the report from 5/27 says the following: "The mitral, tricuspid, and pulmonic valves were normal in appearance and open without restriction."

The inflow numbers are here: mitral 0.9/0.6 m/sec; tricuspid 0.6 m/sec; pulmonic valve peak velocity 1.0 m/sec. "Assuming a jugular venous pressure of 10 mmHg, the right ventricular systolic pressure is 39 mmHg."

No right atrial or ventricular enlargement noted on the report, although left atrial enlargement is still present (but reduced from 4.9 cm pre-AVR to to 4.4 cm now). RV and LV function normal. Aortic root is normal (and well within normal size). Mild LVH. EF is 65%.

LV end diastolic diameter went from 5.7 cm at AVR time to 4.4 cm currently. LV end systolic diameter went from 3.4 cm to 2.5 cm. Good remodelling. Posterior wall thickness and intraventricular wall thickness stayed at 1.2 (1.1 is top of normal range).

The Gordian complicator in this scenario is that most of the things that would create that kind of pressure in the heart should also raise or lower my blood pressure - noticeably. Yet, it's absolutely humdrum, boringly normal...

Blockage? But where? Did he leave a surgical glove in the aorta? Or his watch?

How can the goezoutta have high pressure, the goezinta also have high pressure, but the middle (measured by BP) not? It's basically a closed system. Doesn't that violate fluid dynamics somehow?

Hmmmph...

 

[T-Money]

Hi Bob.
Sorry I don't know any more about this stuff to make a contribution. I'm new to the game so I have a lot more to learn before I can work on the level that you guys do. I hope you find your answer quickly. You're a great person that is always so responsive to other people's post. Surely karma is on your side on this one. Best of luck.

 

[tobagotwo]

This, from the link you provided, Nancy. eMedicine, Pulmonary Hypertension by Davinder Jassal, MD, FRCPC. Seems the most likely causation for possible PH:

Pulmonary venous hypertension is the most common form of pulmonary hypertension and usually due to left-sided heart disease. Pulmonary hypertension develops as a result of the obstruction of blood flow downstream from the pulmonary vein. Causes of pulmonary venous hypertension from distal to proximal of the pulmonary vasculature include coarctation of the aorta, aortic stenosis, aortic regurgitation, hypertrophic cardiomyopathy, constrictive pericarditis, restrictive cardiomyopathy, dilated cardiomyopathy, mitral stenosis, mitral regurgitation, and left atrial myxoma.

I didn't seem to be able to glean from the article whether this is also progressive (like PPH), as the article turns to PPH, and any further mentions of this are associated only with CHF, which isn't appropriate to my situation. At least, not yet...

Sheesh.

 

[tobagotwo]

Uh-oh... not the K word!

Until I ran into Ross, I thought my wife and I had the most cantankerous karmas in the world. Together, though, we mostly cancel each other's out.

I may have been Vlad the Impaler in some previous life, but Ross was surely Ghengis Khan...

Thank you for the kind thoughts.


Best wishes,

 

[tobagotwo]

Well, Harry, Nancy, and Betty...

I would have to very reluctantly agree that I probably have some form of pulmonary hypertension, most likely a secondary PVH from the valve issues. I say reluctantly because the PH sites aren't very pleasant reading, as Karen noted.

One site does say that removing the cause can slow or even stop that form of the disease. In that way, secondary pulmonary hypertension is different from primary PH, in which controlling the symptoms and progression are the focus. The questions then remain what the cause is, whether that cause is reversible, and whether the progression will abate.

The reading I have done about this, while paltry, doesn't indicate anything about affecting the left heart. Only the right heart. I am hoping that whatever is fueling the 3.3 m/sec pump on my left side is the key to this, and not a byproduct of it, or that at least there is some defined source that is treatable.

As far as symptoms, I can't tell right now which responses are real and which are imagined, so I'm not yet a valid source. You know how that is. The rush of information impairs your judgement.

Thank you all for pushing the issue. I have freshly candled ears, and am ready to listen.

Best wishes,

 

[Mary]

Thank you all for pushing the issue. I have freshly candled ears, and am ready to listen.
Best wishes,

You know my advice. Don't go crossing bridges until you reach them. It could be a long week at this rate!

 

[Phyllis]

Hope you get some answers soon, Bob. Don't let your imagination carry you away to dark places- Mary gives good advice! Hey, maybe somethings wrong with their echo machine- strangers things have happened.

 

[Nancy]

When Joe's PH was severe, he had bi-atrial enlargement. Don't know if it was from the PH or not, since he has so many other issues, but both sides were involved at that time.

More recent echoes show his left atrium as dilated, and the right of normal size.

He has right-sided heart failure.

Peculiar-- and I know that many cardiologists looked at his right and left heart caths for a long time, last time he was in the hospital a couple of months ago.

Their final conclusion was that he had restrictive/constrictive heart disease. Perhaps more constrictive than restrictive, and primary suspicion is that it is from scar tissue. He has had a single amyloidoma removed from his lung, years ago, so there was suspicion of amyloidosis, although at the present time, that doesn't appear to be the case.

Don't know where I'm going with this, just throwing out a few things that have been peculiar with Joe's situation.

 

[Debrinha GT]

Although it isn't easy..

Although it isn't easy..

Hi Bob, don't jump into any conclusions until you get a more definite answer. The doctor might want to run some more tests on you before he can tell you for sure what's going on. The thing about the machine not having worked properly might also have been an issue. Don't know if you read my thread about an EKG I did less than a month ago and well, as I had suspected, the worrying result was all wrong in the first place. Don't go by any symptoms you might be experiencing now because at this stage, it's quite likely your brain may start playing tricks on you, but on the other hand, don't underestimate them either. You've been such a nice friend to all of us here on the site that I'm sure, you WILL be ok in the end. I'll say a special prayer for you from now on. Take care!
Débora