Variability Of Echocardiograms

[Mike From Michigan]

Here is something I found to be a little disconcerting...

This past January I had a stress echo done with the following results:

Jan 2004
Mean pressure gradient: 50.5 mmHg (pre-test), 67.2 (post-test)
Peak Velocity: 4.2 m/s (pre-test), 4.8 m/s (post-test)
Valve area: 1.0 cm2
Ejection fraction: 55% (both pre/post test)

When my cardiologist reviewed the results he said that all of those measurement were just into the severe aortic stenosis stage and that it might be time to consider surgery, even though I went the full 15 minutes with no symptoms. However, he agreed that it would not hurt to get a 2nd opinion before I made my decision so I went to another cardiologist he recommended, working out of a different hospital, and I had another stress-echo. Here are those results:

April 2004:
Mean pressure gradient: 30 mmHg (pre-test), 58 (post-test)
Peak Velocity: 3.24 m/s (pre-test), 3.8 m/s (post-test)
Valve area: Not measured (Why, I don't know...)
Ejection fraction: 60%

Note that all of the 4/2004 measurements now fall into the "moderate stenosis" category. Now one of 2 things happened in those 3 months - either my condition improved (impossible, as far as I know) or there is a large degree of variability in this test. For example, the pressure gradient measurements varied by 40% between tests - not what I call an exact science!! What scares me is that they are basing their decisions on whether it is time for surgery or not based a lot on these numbers - give me a break! As an engineer I find such test variability as being unacceptable, especially since my life is on the line in a way. Both testing places insist their results are the true results of course, however my 1st cardiologist said that if there is any operator error (and there is plenty of room for that), it would show "better" numbers, as the April numbers. The primary reason would be because the person running the echo machine did not cut good sections he explained..

The other part of the 2 cardio Drs. decision on whether to recommend surgery is my symptoms. Well, truth be told I was mostly symptom free until I was told back in Feb. that "it might be time". Now with this test data confusion I have become somewhat stressed and feel some symptoms sometimes, directly correlated to how much stress I am under thinking about all of this. Somedays I have no symptoms at all (mainly when my mind is clear), other days, doing the same activities, I feel some slight chest pressure, even a little light-headedness if I am really stressed out about this.

What do you guys think of this? My main point is that I never knew that echocardiograms were subject to so much varability. With so much riding on those tests, that is not a comforting finding. I am now stuck in the gray area when I want this to be a "black/white" decision - to cut or not to cut, that is the question...

 

[Raverlaw]

Mike,

With numbers like those, it is probably time for a catheterization and angiography. My cardio told me that he had to do that, because he couldn't get accurate enough measurements from the echocardiogram.

In my case, the angiogram confirmed that my valve area was .62 cm2 and it was time to be replaced. He also found a coronary artery that was 30% occluded and I had that "fixed" while they were under the hood, as well.

Ask your cardio whether an angiogram would be warranted at this point. Better to be safe and catch your condition before permanent damage is done to the heart, in my humble opinion.

 

[JimL]

Frustrating, isn't it, Mike? I was so thrilled after surgery to have my ejection fraction almost at the top end. And then a year later another echo was taken and the ejection fraction had dropped -- which, I was told then, meant nothing, since the test isn't that accurate. Which means I was rejoicing a year earlier over nothing..

The various kinds of echos are easy and safe tests to do, so they are done first. But going inside the veins through an angiogram tells them more. However, that is as nothing compared to the detailed picture they actually get when they cut you open. I guess that's not very encouraging, just frustrating.

So talk to the various cardiologists, talk to a surgeon, but not everything will be cut and dried until surgery is done. I find it highly unusual that they didn't measure the valve area in the second test.

 

[Nancy]

Sometimes I wonder why ehoes are ever done and relied upon. They are so variable and dependent on the skill or lack of, of the tech doing them.

It's almost to the point that I think all should ask about credentials of the techs and how long they have been doing what they do.

I know this won't help you too much, but I have lost faith in the reliability of echoes.

The last one that Joe had, out of four heart valves (2 mechanicals) they could not visualize ANY of them. So it follows that the rest of the test was pure "you know what". I did get a copy of the results, and expressed my exasperation. I will make sure that next time, he doesn't get the same gal.

Some of the pressure measurements can vary greatly when compared with the results of other more defined tests.

In my own opinion, it is only done because it is non-invasive. But it's a guesstimate at best.

I'm not sure what the answer is. I only know that it is a problem which has to do with technician skill. It certainly isn't the patient's fault!

And they cost a pretty penny.

 

[bvdr]

My cardiologist also has said how much guestimate goes into every echo interpretation. My echoes have varied with valve sizes, degrees of stenosis, degrees of regurgitation and amount of pulmonary hypertension as well. My last echo showed the left atrium reducing in size but that the left ventricle was now enlarged.....but no problem....."it is too early to start worrying about that".

I'm sure your symptoms are real. Even if they are brought on by stress. I also think that sometimes when you find out that there really is something going on then you become more aware of subtle things that you before simply overlooked.

 

[Mary]

Echos vacuum (suck)

Echos vacuum (suck)

Mike,
I know exactly what you mean. I had an echo March 1 that showed valve area of .7 Cardiologist said he didn't believe it, that my pressure gradient wasn't that bad (40). I changed cardiologists, because the first one was moving anyway.New guy also had an echo done. The second echo was done at the same facility. The results were exactly the same (.7)
It was about that time that I joined the forum, because I was going a little nuts.
Second cardiologist performed an angiogram, angioplast, and something else. He measured pressure above and below the valve. He came up with 1.1
Now, I'm on a four month schedule of return visits, but I don't know what test they'll use. I do know there's no reason to use the stupid echo. And like Nancy says, at $1700 a pop, it's an expensive proposition. I did say no to a TEE, so I'm sure they'll be after me to do it when I go back.
Mary

 

[Bryan B]

I agree that echos are variable and are only one tool for cardiologists and surgeons to use. But I have to say, when echos first came out they probably saved me from having to have a cath every other year. I was born with a moderate VSD and was followed by the military. I had caths at age 2,10, and 18. I'm willing to bet that if the echo technology had not come along in my early teens there would have been a couple more caths between the age of 10 and 18.

When I had endocarditis the echo caught the vegetation growing on my aortic valve.

When I had my followup echo after the endocarditis it caught the increased regurg from my aortic valve.

OK, echos are not a presice way to test and are subject to operator variances, but I personally am glad they are around. The pictures taken using the 3D doppler echo for my followup after endocarditis were incredible. Hopefully as technology advances the echo test will become more accurate.

I would also think that any "stress" test using any test instuments or equipment would be more difficult to duplicate. My biggest surprise with your different numbers is the fact that the measurement of the valve opening was missing on your 2nd test. Isn't that one of the main measurements used when deciding when it's time to replace the valve? I would think that at 1cm, that opening is getting pretty small.

 

[tobagotwo]

I don't understand why they would use a stress echo as a baseline. It's not accurately repeatable. A standard echocardiogram, on a table with no stress but the fear of bad results is much more accurate and repeatable. They are not perfect, but ECGs are generally far better than the results you are showing above.

I had two about six weeks apart, shortly before surgery, that were nearly identical. The only notable difference was that the second didn't show all kinds of bad electrical activity, because my company, who had been doing layoffs, had decided to keep me, and I was no longer worried sick about losing both my benefits and my income.

Trying to use a stress echo as a base is like trying to measure all tornadoes based on two samples taken by two different people from two different twisters. It doesn't work: the targets keep moving, and they were never really the same to begin with.

These guys should chuck their treadmills and other gymnasium foofaw and do a real baseline echo. To my uneducated view, they're wasting your money, your time, and your concern. Also, have it done at a different facility, by a different technician than the last one. They should take their time and be thorough. I have a deep chest, and the ECGs I had took about an hour and a half each, and left a considerable pattern of invisible bruises on my chest.

As far as the symptoms, it's hard to be accurate about your own symptoms. The only one I could really be sure of was the angina. Mine felt like that tight, top-of-the-lungs feeling you get when you breathe too much cold air too fast (it was August). That, and when my heart was doing those Gene Krupa-Ginger Baker drum-offs at night. And it is absolutely true that stress will affect any symptons you do have negatively.

It sounds like you're hovering around critical, but not quite there yet. And critical isn't necessarily the end point. A decision has to be made then as to whether there is danger of permanent damage to your heart, or imminent danger of losing you to afib or thrombosis (clot/stroke/heat attack).

Differences between the ECG and the cardiac catheterization results: In the ECGs, my valve opening was just under 1.0 cm². In the final catheterization, it shows as .76 cm². I'm not sure which was more accurate. The ECG tech said she believed I had a very calcified tricuspid valve. The cath cardio was 99% sure it was bicuspid. The ECG tech was right. The ECG also felt it should be done as soon as possible. The cath cardio checked off "elective" on the cath results form. The valve was so calcified and concreted in place, that the surgeon later said he didn't know how I was getting blood through it at all. Score two for the ECG tech. Pressures were very similar for the two methods, although catheterization is usually expected to be more accurate. Go figure. And the cath cardio is highly experienced and respected.

The only mentions from the in-procedure TEE are that nothing was leaking, so I have no bases for comparison there.

Good luck with this. It's frustrating at times. With your training and understanding, make them hold to a repeatable standard, so you can understand and track the results, and so any changes to the ECG over time can be meaningful to you.

Best wishes,

 

[Mike From Michigan]

2nd Opinion Doctors

2nd Opinion Doctors

After I posted the original message yesterday, I tried to contact my 2nd opinion cardio but he was unavailable. Even though I'm told he is highly respected in his field, his bedside manner was poor in my opinion. When I had an appt. with him to discuss the 2nd stress echo test results he seemed hurried and annoyed at my questions, did not want to give specific test results (such as pressure gradients), preferring instead to say simply "Mike, it's time for surgery". He also kept pressing me to admit I was having symptoms, even though I am not sure. He was the same way in my first meeting with him before the stress-echo - he is not the caring and understanding 2nd opinion Dr. I was hoping for to provide me with a clear understanding of my condition. My primary cardiologist is quite the opposite, always willing to answer every question I have - so he is the one who I am sticking with, although when I have the AVR it will most likely be at the hospital where the 2nd opinion Dr. works out of (they are rated #1 in Michigan for heart procedures). My primary cardio also recommended this hospital.

I am just wondering if the 2nd opinion Dr. took a hardline "It's time for surgery" stance due to possible litigation concerns. That way, if I should keel over dead of heart failure tomorrow he will be on record as having recommended surgery, so no one (i.e., attorney) could point a finger at him. There would be much more risk from a malpractice standpoint if he said surgery could wait - after all he was the 2nd opinion guy whose only purpose for me was to say yeah or nay regarding the need for surgery. If that is the case, that is too bad that malpractice concerns figure that much into a Doctors diagnosis. Yet in this litigious society we live in, I am not surprised. Then again I have always been very cynical...

 

[Mike From Michigan]

ECG vs. Cath. Tests

ECG vs. Cath. Tests

I spoke with my primary cardiologist and a cardio technician and they both believe that the cath, test is more accurate than an ECG, one reason being that there is much less room for interpretive error in taking the measurements. Of course ECGs are used more because they are non-invasive. My primary cardio said I should just ignore the 2nd stress-echo tests and get a cath. test done to really see what my condition is, although he maintains that a well skilled ECG tech. (like his) can get results in line with the cath. results. The problem is that an ECG test is only as reliable as the tech doing the various scans and measurements. I remember about 12 years ago I had a new Dr. who sent me to an offsite lab for an ECG and the test results came back as normal - no more bicuspid aortic valve or aortic stenosis, even though all previous tests taken showed that I had that condition!! Needless to say, those test results were also thrown out...

The next step for me is to talk with a surgeon, so that is where I am headed tomorrow. From there I'm sure the cath. test will soon follow. Hopefully I will soon get the clear picture I need - I am mentally ready for the AVR if the test results say it is time...

 

[tobagotwo]

The catheterization is a good next step.

Good luck in your quest for results.

 

[ALCapshaw2]

Hello Mike,

Sorry you are having such a time with your testing / results.

There IS an intermediate alternative which I am surprised your Cardiologist has not suggested, namely a TransEsophageal Echogram (TEE) where they place a transducer down your esophagus (right behind your heart) which yields better pictures than are possible from a chest echo. My (second opinion) Cardiologist PERSONALLY did a TEE when I was told I needed AVR and felt that I could get some more time (optimistically 3 to 5 years) out of my existing valve with a change in my medications. One year later, I was becoming more symptomatic and this time a second echo and cath both confirmed that it was time to replace my aortic valve. I was told that a valve area of 0.8 cm sq or less is generally accepted as an indicator that surgery is warranted.

You should also be aware that MANY of us found that our valves were in WORSE condition than our test results indicated. You should also ask your cardiologist if there is ANY sign of Wall Thickening or Heart Enlargement. If either of these conditions continue for too much time, PERMANENT DAMAGE can be done to the heart muscles so EARLIER is BETTER once valve disease is diagnoses. Also note that this damage can occur WITHOUT SYMPTOMS so don't go by the "I don't FEEL BAD, why should I have surgery" philosophy.

Food for thought.

'AL' (grew up in Michigan)

(Are you going to Beaumont Hospital?)

 

[Mike From Michigan]

The TEE and me...

The TEE and me...

Al, yes at this point I will have the AVR at Beaumont (Royal Oak), although my only interface with them so far has been the 2nd opinion cardiologist that did not impress me. Hopefully the surgeon will be better...

I will also ask about the TEE test, thanks. Was that test very uncomfortable or very tolerable? Bad sore throat afterwards? I read up on it and they said you cannot drive for 24 hours after the procedure, must be from the IV drugs...

 

[Nancy]

TEE is an excellent test. Joe's had several. The secret to a good TEE, is to make sure you have a very experienced doctor doing it. When Joe had an experienced doctor, he had minimal discomfort. A little soreness in his throat. They spray your throat with numbing medication, and then put you into a semi-conscious state.

When he had a neophyte, he had a terrible time. The doc didn't spray his throat enough with the numbing stuff, and I'm not even sure that they gave him any kind of relaxation medication. This is a man who NEVER complains about anything medical, but he did complain about that one. In addition, his throat was all scratched up because the guy forced the transducer down his throat.

So, for your own comfort ask for an EXPERIENCED doctor to do the procedure and you will have a much, much easier time of it. NO interns here, please.

 

[Raverlaw]

Mike,

I agree that a cath and a consultation with a surgeon are in order. Surgeons generally are more disposed to surgery now (before damage occurs) than most cardios are. A TEE might be beneficial, but you should probably just go for the cath. I can't speak to the comfort of the TEE procedure, because my only one was during the surgery when I was unconscious.

My echo showed an approximate 1.0 cm opening with some calcification; my angiogram showed a .62 cm opening with calcified bi-cuspid AV; the surgeon told me afterwards that the valve was barely operable, much worse than he would have thought from either the echo or the angio films, and that, in his opinion, I was extremely LUCKY to have made it that far without a major stroke or death.

My point is that all measurement procedures are inexact and you could be a lot worse off than you think. Surgery will fix you; if you know you will ultimately have to have surgery in the next 5 years, why not have it now, while you are younger and healthier? I wish I had, if only because I feel so much better now.

 

[tobagotwo]

Bill makes an excellent point. My surgeon also stated that my valve was so completely calcified and stiff as to be basically unusable. "I actually don't know how you were getting any blood through it at all."

The valve opening is not the whole story, although it's the primary indicator they use. The valve gets completely glued and immovable at some point. Not necessarily closed up, but certainly completely broken.

My symptoms didn't feel that bad, including the angina, which I could easily ignore. At the top of the stairs, I wouldn't even be winded, and people who came up behind me would be. But my heart was definitely suffering, even though I usually couldn't feel it.

The cath isn't perfect either, but at the least, it should yield a result that the cardios can agree on.

 

[Rich]

Hi Mike,
Sorry you are having all these problems.
I can tell you from experience a cath is the only reliable tool that really showed my problem.
You are definitely going to the right hospital. I just read in our local paper that Troy Beaumont now has a heart center and will be doing surgeries there also.
Mine was done at Royal Oak and went very well. They have done more heart surgeries than any other hospital including the Cleveland Clinic.
When you break it down into valve surgeries, by-pass surgeries, etc I don't know what the stats are.
I hope your'e happy and confident in both the cardio and the surgeon.
If you need a recomendation for either one let me know.
The absolute best surgeons around here are Southeast Michigan Cardiac Surgeons, better known as the Basset team.
They are on Big Beaver just west of Crooks.
Like I mentioned before if you need any help I'm right around the corner.

Rich

 

[surfsparky]

G'day Mike,
Sorry to hear you are going through all this.
I had a cath done and a TEE (called a TOE down under), and they were both accurate tests. I don't even remember the TEE, although the cardiologist that performed it said that he had quite a conversation with me about it afterwards...not that I can recall! I experienced no sore throat either. They performed my TEE to analyse the severity of the leak and to see if I would be a candidiate for the Ross Procedure (Aortic and Pulmonary sizing need to be within certain limits).
All the best and follow your instincts,
Chris

 

[ALCapshaw2]

I had a slightly sore throat for maybe a day after my TEE. They can put you in a deep semi-conscious state with VERSED which also has an short term amnesia effect (probably why they don't want you driving for a day).

Do a SEARCH for TEE (and possibly my name) and you should be able to locate my description of the procedure. I forgot which forum it was posted under. Gotta get up early tomorrow so I'm off to bed.

'AL Capshaw'

 

[ericaj]

know how you feel

know how you feel

You know, I don't know exact measurements just what my cardio told me but he said that my echo this past march was improved over my echo a year ago march but yet my symptoms have worsened and this week especially I feel miserable. If my family dr. does call me this afternoon I think I will ask her about that. It is frustrating and a pain to feel so yucky and constantly feel like I am bothering these drs. Cross your fingers for me that my dr calls me back so I don't have to feel miserable all week. Sorry I know this wasnt any help, I just know where you are coming from with your uneasiness about test varations and problems.

take care,

Erica