Stress echo and mild left ventricular hypertrophy

[Paleowoman]

I had the stress echocardiogram yesterday which my cardiologist referred me for due to the mild left ventricular hypertrophy that I developed following aortic valve replacement. The cardiologist who did the stress echo, Dr Ranjan Sharma, is considered a "national and international expert in complex echocardiography" and "recognised expert of stress echocardiography". So I guess I was in expert hands. I received a copy of his report to my cardiologist by email yesterday evening. He confirmed that I have mild left ventricular hypertrophy which he wrote: "is very typical for someone who has had a 19 mm aortic valve prosthesis." Has anyone else come across that ? I had absolutely no hypertrophy prior to surgery nor at the 4 days post op baseline - it only appeared from six weeks onwards. Now I am 2 years 4 months post op.

My pressure gradient across the prosthetic aortic valve, at rest before the treadmill, was 42mmHg peak and 20mmHg mean. Post exercise it was 46mmHg peak and 24mmHg mean. The "absolute" valve area size was 1.2 cm sq.

I had no trouble with the stress echo, in fact I enjoyed it as I love walking uphill. My heart rate went from 72 to 165 which was 100% maximum predicted target heart rate. I could have gone on longer and harder but Dr Sharma didn't need me to to be able to see the effect of exercise on my heart and the valve. He said the valve was working perfectly and looked very good.

I'll be seeing my cardiologist next week to discuss this but I wonder has anyone any thoughts about mild left ventricular hypertrophy being typical for someone who has a 19 mm aortic valve prosthesis ?

 

[Midpack]

In my experience (coming from my talks with cardiologists along many years), nothing labeled as "mild" in an echo report should be a cause of worry. My bet is that your cardiologist will not give it any importance.

 

[Paleowoman]

Yes, the cardiologist who did the stress echo said everything was very good. I'm just puzzled as to why mild left ventricular hypertrophy could be "typical" for someone with a 19mm valve as I've never come across this with anyone on the forum.

 

[ottagal]

Hi Paleogirl, Sounds like you did very well on the stress echo which is great! I don't have an answer about the mild ventricular hypertrophy. However, my pressure gradients since surgery have been on the high end of normal. Both my peak is 50 and mean is 25. My cardiologist doesn't seem concerned as long as I am continuing to be physically active. When I did my stress echo, I felt the same as you! I could have gone longer and quite enjoyed it.
Good luck and do let us know what your cardiologist says. I agree with Midpack that anything 'mild' doesn't get much air time.

 

[cldlhd]

I don't have any personal experience as my valve was repaired but is 19mm considered to be a relatively small valve, especially for someone who is physically active? If so could the work of pumping the blood through the smaller valve be causing it? Just throwing it out there because you pointed out how he said multiple times "for a 19mm valve".

 

[Paleowoman]

Hi Ottagal - I'm glad to know that someone else with a 19mm valve has high pressure gradients to but that your cardiologist isn't concerned. I've read that these valves are inhenerntly stenotic but presumably it's not the same as a native valve that is stenotic as everything looked good with the stress test.

Hi Cidhld - yes I think the 19mm is the smallest valve (though presumably children must get smaller ones), but 19mm is the smallest of the Edwards Lifesciences ones. They choose the valve when you're in surgery based on the size of the annulus. I wondered if there was a "patient-prosthesis mismatch" but that wasn't mentioned.

 

[ottagal]

Hi Ottagal - I'm glad to know that someone else with a 19mm valve has high pressure gradients to but that your cardiologist isn't concerned. I

Just wanted to correct that I have a 21mm Edwards Perimount Valve which is stented (I think this make is one generation older than the type you have). From what I read, because it is a stented valve, it can result in higher pressure gradients (in my case). That's what I was led to believe, but I guess time will tell if that is the case.

 

[Paleowoman]

Hi Ottagal - the 19mm Magna Ease Edwards Perimount Valve I have is also stented. I suppose that's why the pressure gradient is higher ?

 

[cldlhd]

I'm no expert, as I'm sure you've ascertained from my posts, but I imagine being active and having you're left ventricle move all that blood thru a smaller valve could cause it to grow larger.

 

[scott.eitman]

I have the hypertrophy as well. I believe my valve is 23mm.

 

[Paleowoman]

I'm no expert, as I'm sure you've ascertained from my posts, but I imagine being active and having you're left ventricle move all that blood thru a smaller valve could cause it to grow larger.

Yes that's what I've been thinking all along, but that would mean surely "patient-prosthesis mismatch" and no one has suggested that. However, the first echo when the hypertrophy showed up was at six weeks post-op when I wasn't active at all. Oh well....bit annoying that I should have this, albeit very mildly, post surgery, when the whole purpose of having surgery is to avoid that sort of thing in the first place !

 

[Paleowoman]

I have the hypertrophy as well. I believe my valve is 23mm.

What does your cardiologist say about your hypertrophy ? Do you know the cause ?

 

[MethodAir]

The pressure needed to push through a smaller idea makes sense. I wouldn't be concerned. Anyone who does heavy compound weight exercises (squats, deadlifts), with valsalva will have some lvh. It's a normal training adaptation.

 

[cldlhd]

The pressure needed to push through a smaller idea makes sense. I wouldn't be concerned. Anyone who does heavy compound weight exercises (squats, deadlifts), with valsalva will have some lvh. It's a normal training adaptation.

Makes sense as the heart is a muscle. When my murmur was first detected by a GP back when I was approximately 20 he wrote it off as "athletes heart" as I was working out a lot then.

 

[Paleowoman]

Saw my cardiologist today about that stress echo. Because the pressure gradient has risen again and because the ejection fraction has suddenly dropped a lot he has decided that I should have a repeat echo in six months' time, and then maybe an MRI depending on the result of that echo to see if there is thickening of the ventricle. I'm okay with that as the important thing is obviously to keep an eye on things.

I don't do valsalva because the kind of weight lifting I do is SuperSlow (10 sec lift, 10 sec lower) so you breathe freely or pant throughout. Plus the hypertrophy first appeared at six weeks post op well before I was back exercising. I think it's to do with the small size of the valve, maybe a degree of "patient prosthesis mismatch".

 

[MethodAir]

Saw my cardiologist today about that stress echo. Because the pressure gradient has risen again and because the ejection fraction has suddenly dropped a lot he has decided that I should have a repeat echo in six months' time, and then maybe an MRI depending on the result of that echo to see if there is thickening of the ventricle. I'm okay with that as the important thing is obviously to keep an eye on things.

I don't do valsalva because the kind of weight lifting I do is SuperSlow (10 sec lift, 10 sec lower) so you breathe freely or pant throughout. Plus the hypertrophy first appeared at six weeks post op well before I was back exercising. I think it's to do with the small size of the valve, maybe a degree of "patient prosthesis mismatch".

What were your echo heart wall thickness measurements, Anne?

 

[Paleowoman]

What were your echo heart wall thickness measurements, Anne?

It says on the report "maximal end-diastolic wall thickness of 1.1 cm" It's "mild".