Valve pounding against sternum

[seth]

Since my Bentall procedure surgery in June 08 I've suffered from the constant pounding of the valve/heart against my sternum. This includes discomfort and frequent chest pain (usually occurring later in the afternoon and evening). You can hear the sound of the bone being struck by something hard, and if you put your hand on my chest you can feel it jumping with every beat. The vibrations also travel into both clavicle and my neck.

My surgeon, Dr. Cohen, said this condition sometimes occurs with thin patients. I complained to him about it on two occasions and he said the pounding would get better and I would get used to it. It hasn't, and I haven't. So I met with Dr. Abbas Ardehali at UCLA for a second opinion. The meeting was very brief, he said it was likely the problem may never improve and that there wasn't anything to be done surgically. He mentioned perhaps a different valve could have been used that might have been better for me, but said if he had done the surgery he'd probably have selected the same valve I now have because it's commonly used.

It's been over seven months since my surgery. Sometimes I feel like I'm going crazy. It's annoying, uncomfortable, and often like torture which I can't stop. It's a condition I deal with every second of my life since my heart rate is usually between 70-90 bpm. My general doctor put me on the psychiatric drug Zyprexa to help me deal with it. It was an off-label prescription that did help me be less aware of the problem, but it also made me less aware of other things too. I was sort of spaced-out and it made me tired so I reduced the dose to the lowest level. After taking the medication for about a month I realized it wasn't a solution and I went off it – which resulted in a bad reaction of extreme anxiety and panic attacks lasting for a month and a half. Now I'm afraid to take any other medications to "drug my way through" living with this condition.

I'm grateful that I survived the surgery and that a life threatening condition was treated. But another problem was created by the procedure and I'm being told to live with it. I'm 45 years old and hope to live many more years. What I need is a real solution to my situation.

Any input, experience or advice is welcomed.

________
My diagnosis: Aneurysm of the ascending aorta, and aneurysm of the sinus of Valsalva. Partially calcified bicuspid aortic valve. "Bentall procedure" surgery performed on 6-10-08 by Robbin G. Cohen, M.D. at USC University Hospital.

Composite Dacron graft replacement of the ascending aorta and aortic root, mechanical valve replacement of the aortic valve. St. Jude Medical Model Number 27CAVGJ-514-00

 

[sheridan07]

I'm sorry Seth and hope things get better for you. Welcome and I wish I had an answer but I don't. I'm sure some will have some kind of input.

 

[Ross]

Welcome aboard the insane asylum.

Seth I wish I had good news, but hence, I do not. Most people do get used to it and it eventually becomes a nonissue. Please don't take this the wrong way, but is it possible that your mind is so tuned into it that it may be amplifying how bad it is? Maybe a 3rd consult and some imaging tests are in order?

 

[Guest]

Maybe a 3rd consult and some imaging tests are in order?

My thoughts too, Seth I don't have any knowledge to appreciate what you are experiencing, but maybe locating the best surgeon out there for a 3rd opinion, and asking for imaging. The 64 slice CT comes to mind. We have a member, Duffman, who posted his scan on the forum and it outlined every detail of his aortic aneurysm and heart. I'm wandering also if scar tissue is causing some of your problem.

Duffman's Post-CT Image

I hope you are able to find some answers.

 

[Woodbutcher]

Hi Seth,
I had a Mechanical valve inplanted just six weeks ago. I can hear quite clearly the ticking in my chest and sometimes in my neck and or in my ears. It really depends on what I'm doing, how I'm sitting or lying. For some reason it's really loud if I'm stood infront of a mirror washing. I wouldn't say it felt as if it was banging the back of my sternum though, unless I take a deep breath, then it really seems to pound !
I've noticed more and more at odd times I'm not hearing it at all, but only until I think "I cant hear it" and it's back!
I've not thought about drugs to cope with it but it definately does drive me to distraction at times. Talking of which do you have any distractions to take your mind from the thumping ? I spend a lot of time playing my violin, that works for me every time (not sure about everyone else in my house!). Also walking the dog too, or going for a drive and singing my head off. If I just sit quietly the ticking is too much, which is a shame because I used to love sitting quietly...
I really do feel for you and hope you can find some way of dealing with it. For me it's definately not getting any quieter but my brain seems to be filtering it out more?
I've just this second noticed that if I put my head backwards my throat clanks ! You see, heightened awareness !?

 

[kfay]

Seth, Do you really think that it is your "valve pounding against your sternum"? I have a tissue valve and I feel my heart pounding much more but that is because I have been having rhythm issues since my surgery. I'm not saying that is the issue with you, but I can empathize with you. I am also thin. It really is disconcerting and I have all of the sympathy in the world for you. Even when I'm not having rhythm problems, I feel my heart beating much more forcefully than it had before.

Ross, No offense to you, but if I hear another person say that I am feeling this because I am more aware of my heart since my surgery, I am going to hit them. It just isn't true, at least for me. I have always been aware of every wayward beat of my heart and I have had many in my 45 years.

Seth, I really wish there was an answer. I feel exactly the same as you when you say that it solved on problem and created another. My local cardio even admitted to me that that was the case. It's easy to say just forget about it, but much harder to actually do that. I know that if I lie on my left, it is much more troublesome, so I try not to do that. I also find that if I get up and just walk around, it becomes less noticeable. Other than that, I don't have any answers for either of us. I think that you are right in realizing that you can't live your being drugged out. If I discover anything that helps, I'll be sure to share it with you.

Kim

 

[Bina]

Seth, welcome!
You are about 7 mths out and I can say that I had the same feelings....the pounding, the anxiety, etc.
I was freaking out constantly. I'm thin and very sensitive to everything.
My cardio told me to "just be grateful, and cope with it." (no help there).
But I have found that my Metoprolol dosing has alot of effect on controlling the pounding.
My GP agreed that I could now take a smaller dose 3 times a day and that has helped alot.
I have a BP monitor, so I took regular readings and reported back to him.
I take Metoprolol 25mg on waking up, 12.5mg at 5:00, and 12.5mg at 10:00 pm
Directly postop I took a higher dose.
How much are you taking? Do you check your BP?

 

[Duff Man]

when I look at my scans, i don't see how it would be possible for a valve to hit my sternum unless my heart were seriously deformed. I'm 250 lbs so perhaps you have a much closer sternum.

I have seen a post or two where people say they're convinced dacron conduit is noisier than their aorta was.


Here's a sagittal view

 

[Eva]

When I wake up during the night thirsty and feel so lazy to reach the glass of water and stay asleep, I wake up with a pounding heart...so my pounding is related to being dehydrated! Do you drink enough fluids? did you have new lab tests for electrolytes?! or even thyroid tests? Just my thoughts! Keep us posted.

 

[Eva]

I forgot to add the way you walk and sit may increase the pounding if you keep a hunched back...if so, try to always stand and sit with broad very straight shoulders.

 

[vprnet]

Dear Seth,

I'm 54 and had BAVR with a mechanical 27mm ON-X and Dacron conduit on Dec 19. I weigh 157lbs. Normally my weight is 165. I know exactly what you are speaking about because I brought up the same issue with my cardio last week. Here is what I noticed, when I take a deep breath, lets say above 75% of my lung capacity, I can distinctly hear and feel pounding on the breast bone develop from just above mid sternum to the collar bone. The cardio agreed and it is obvious to the touch.

What I was told is that there was a change in the anatomy and that will change over time. He also said the weight will start to come back as the mending subsides and that this will help. At the moment allot of calories are going to the healing process. The good news is he said its nothing to worry about, no damage is being done.

Have you tried to inhale and exhale slowly just to see if there is a point in your breathing range where the pounding diminishes? Have you gained back your normal weight?

Also, during the visit, I mentioned to my cardio that I could no longer hear the metallic ticking of my valve. Funny thing he told me he could here it the moment he entered into the room. He said that normally the mind will tune out background noise and that is just what happened. I stopped thinking about the ticking and now have to force myself to hear it. I'm not sure this will be the case for the physical impact you feel on the breastbone but I hope in time your body and mind will eventually adjust. I hope my will also because there is no question that I can feel this condition very pronounced when I exercise.


For what it is worth I also have my own theory. Because prior to surgery my BAV was extremely inefficient, the entire aortic system had to compensate by taking the large BP swings from my heart overcompensating with a huge push out on the systolic and then a big drop in the diastolic from the leakage back into the heart. My BP was 145/35 typically. Now the new valve is closing efficiently and when it does, my arterial system is still contracting such that the backpressure on the closed valve is greater than normal. Not to mention the LV in the heart is still larger than it needs to be. So what I think is happening is that when the valve closes, its like when you turn off a high pressure hose with a quick turnoff valve and the hose (in my case the Dacron) experiences a jerk in the body. In time I expect the LV in my heart to shrink, at lease my doctors believe it will, thereby reducing the size of the heart muscle in the cavity. Also the arterial system will eventually readjust to my wonderful new diastolic pressure of 70 rather than the 35 it dealt with for years. And the Dacron conduit will be absorbed by cell tissue giving it a bit of a cushion in the chest. But this will all take a year or more and I think will resolve the pounding I can feel.

Best wishes…. Vincent

Vincent (54)
BAVR with 27mm ON-X NYP Weill Cornell Dec 19, 2008.

PS. I am not a medical professional or a doctor. My comments in this forum are my own opinion and are not intended to be given as medical or professional advise or a recommendation of any valve choice. Decisions that affect your health and wellbeing are ultimately yours and your doctors. vprnet

 

[netmiff]

Tak to your cardio, maybe a beta-blocker would help, or even BP medication. I had AVR September 2007, and was immediately put on beta-blocker and BP medication, it is almost standard procedure here when the ventricle has increased muscle mass. I call it my "popeye" heart!!!! It is due to having to pump so hard against the small aortic opening in order to get a decent amount of blood to the rest of the body, and should "remodel" (that is the medical term, believe it or not) itself. I recently tried to come off the beta-blocker, by reducing the dosage by a quarter every 2 weeks. I had to finally revert to half the original amount, because at a quarter the original dose, I could feel the pounding in my neck and ears.

Oh, I am NOT thin !!!!!

Hope this helps, Seth, not that I am saying it is a solution to your particular problem, but something else to consider.

 

[Cooker]

The "real solution" will come with time …. After a period of time you will not even notice it …. I know that sounds like BS now but it will happen ….. I never heard mine tick, it was always a thump, thump , thump ….. it took a while but I don’t hear/feel it at all now ….. it takes some longer than others …. Hang tough…..

 

[Ross]

Ross, No offense to you, but if I hear another person say that I am feeling this because I am more aware of my heart since my surgery, I am going to hit them. It just isn't true, at least for me. I have always been aware of every wayward beat of my heart and I have had many in my 45 years.

Kim

Hon I know, it's just that some people do focus on it extremely and it's always nagging their souls. I'm not suggesting anything by it, just wondering if it's not part of the problem. That is why I said, please don't take this the wrong way. I know neither of you are nuts.

 

[seth]

Thank you to everyone who has taken time to post. Thanks for your support, opinions and insights. I really appreciate that each of you has read my post and offered help with my situation. Since humans are very subjective oriented beings, having the input of other people with similar experiences is a good thing.

When I'm totally absorbed in some activity, and not having chest pain, I'm not aware of the problem; so to some degree there is a mind over matter component. I've been on the beta-blocker Metoprolol since the surgery, they later increased the dose to 100mg daily. I am not on BP medication. I check my BP on a regular basis and it's always good. The "clicking" or "ticking" sound of the valve is not a problem (yes I can hear it but it's pretty quiet). I do not mean that the valve itself is hitting the sternum. But if I held up a blanket to your arm and socked you with my fist – you wouldn't say you were hit by a blanket. I think the pain and discomfort I experience is probably due to accumulated physical irritation inside my chest. I'm 5'9" and weigh between 145-150 lbs which is my normal weight. I think what my surgeon meant by saying "this sometimes happens with thin patients" is it can happen when there is a small chest cavity.

A CT scan done post-surgery showed the valve is very close to the bone. The vibrations can clearly be felt by someone touching my chest and collar bones. If I blow all the air I possibly can out of my lungs, the pounding/vibration diminishes almost entirely. Otherwise the pounding/vibration is always there. If I take a deep breath in, the pounding/vibration becomes even more pronounced. Obviously the more space my lungs occupy, the closer my heart/valve is pressed against my sternum. Any physical activity makes it worse. My surgeon said the heart is normally protected by a fluid-filled sack but mine was cut into and destroyed during the surgery and that the formation of scar tissue would lessen the impact and improve the problem over time. But the problem has never improved, so perhaps scare tissue never formed to provide protection.

My GP, who's been practicing for 30 years, said he's never seen anyone with my problem. My cardiologist said he'd never encountered such a thing before and called my condition "bizarre"; he immediately got on the phone with my surgeon. Ultimately he said he'd have to defer to whatever my surgeon's opinion was, but supported my getting the second opinion. Unfortunately I don't think the surgeon who gave me the second opinion gave very careful consideration. He asked me what what my surgeon's response was to my condition... I made the mistake of telling him... and he said he agreed with my surgeon. The only thing he had to contribute was to say that my heart is pumping vigorously, and probably more efficiently, and producing the knocking against the sternum. No doctor ever told me that the bicuspid valve was ineffective, the surgeon said he replaced it because when they opened me up it was partly calcified and in his terminology "looked nasty". I don't know if the heart was over-developed or needs to remodel itself. I do know in seven & a half months and it hasn't improved.

I'm currently looking for a doctor for a third opinion. I live in Southern California and am open to any recommendations.
Thanks, Seth

 

[Ross]

I can't name any off hand, but you've got many all around you. Somebody here will speak up. I'd certainly look into a 3rd consult, probably with the most experienced surgeon I could find.

 

[kfay]

I can't name any off hand, but you've got many all around you. Somebody here will speak up. I'd certainly look into a 3rd consult, probably with the most experienced surgeon I could find.

Ross, the only one I can remember someone post about was Harleygirl's surgeon, Dr. Sharo Raissi. He is the director of Thoracic surgery at Cedars. She really thought highly of him. Seth, if I were you, I would seek out both a new cardiologist as well as a consult with a different surgeon. It may be that a change of meds might help in making your heart not beat so forcefully. Good luck to you, I know how something like that can drive you crazy.

Kim

 

[Guest]

Harleygirl's surgeon, Dr. Sharo Raissi. He is the director of Thoracic surgery at Cedars. She really thought highly of him. Seth, if I were you, I would seek out both a new cardiologist as well as a consult with a different surgeon. It may be that a change of meds might help in making your heart not beat so forcefully. Good luck to you, I know how something like that can drive you crazy.

Kim

My first thought was Harleygirl and Dr. Raissi too. A new cardiologist is also a good idea. Maybe Raissi's office can recommend one for you or Cedar's doctor referral service.

 

[Duff Man]

+1 Sharo Raissi. I think he only does tissue valves, but you might need a tissue valve from what I read. Not that you necessarily need another valve replacement. I loved your analogy of the blanket punch.

 

[Bina]

Seth, Metoprolol is a beta blocker form of blood pressure med, which is why those who take it need to keep track of their BP. It is quite good at slowing down the force and rate of the heart. Even if your BP is fine, many times a slight increase of the med can get your heart down to a reasonable rate that won't feel so forceful.
And being only 7 months out means that your heart is still recovering.....give it some time.