I really need help with this....

[Mb]

Hello everyone:

I hope no one minds, but I am reposting the date from my husbands recent echo. Both Nancy and Ross were kind enough to reply, but I was hoping for even more input from some of you out there. I was hoping that those folks who had resideual heart issues, would have some idea of what all of the results mean. So, I am posting again. Again, to Nancy and Ross, thank you for always being here, with advice.

--------------------------------------------------------------------------------

Hello guys:

Here is my husbands most recent echo report. All input welcome.

Mitral Valve:
St. Jude valve in mitral positiion. Normally seated. Peak transmitral gradient is 12mmhg. Mean is 3mmHg. Mitral regurgitation by color and spectral Doppler. Degree is difficult to assess due to prosthesis shadowing. However, proximal flow convegence on the aneromedial side of the valve suggests a mild paravalular leak. There is focal thickening of the mitral chordae.

Left Atrium:
The LA is dilated.

Aortic Valve:
St. Jude v, in aortic position. Well seated. Peak AV gradient is 41mmHg, mean is 21mmHg. Evident of trace aortic insufficiency by color Dopplar. Also evidence of a miold posterior paravalvular leak unlike the normal jets by Doppler. Ascending aorta diameter above the sinotubular junction is 33mm.

The left ventriular cavity size is normal The left vent. systoclic function is within normal limits. Mild symmetric left vent. hypertrophy. EF of 73%

Tricuspid Valve:

There is color and spectral Doppler evident of severe tricuspid insufficiency with systolic flow reversal in the hepatic veins. There is incomplete TV closure. There is prominent right atrial dilitation. The superior/inferior RA dimension is 62mm. The medial-lateral right atrial dimension is 65mm.

Pulmonary valve:
Trace PV insufficnency. The RV systolic pressure estimated from the regurgitatnt tricuspid velocity (assuming a RA pressure of 10mmHg. The estimated RVS pressure is at least 44mmHg. This is likely to be an underestimate given the early truncation of TR velocities consistent with elevated RA v wave.

Right Ventricle
Moderately dilated. Mildly and diffusely hypokinetic consistent with increased afterload.

Interatrial Septum etc.
There is dialostolic flattening consisten with RA volume overload. There is paradoxical IVS motion consistent with a right ventricular volume overload. There is abnormal IVS motion consistent with prior surgery.

[bvdr]

How has it changed since the last echo?

It just doesn't seem like that good of report to me. It just seems like the heart is responding to stress since not only the left atrium is dilated but the right as well. The RVS (also sometimes referred to as the RVSP) is 44 and that is what the pressure in the pulmonary artery is as well since when the valve is open the pressure equalizes for a time. My echo from last week lists my RVS as 48.4. Both the 44, which your husband's report states might be underestimated, and my 48.4 both are pretty indicative of substantial pulmonary hypertension. Mine is based on an estimated right atrial pressure of 10mmHg also.

I'm not sure what to make of his mechanical valve reports either. I know my mitral is difficult for them to assess due to shadowing and "reflection" so that might be a common finding. I think most valves have some mild leaks too.

His Ejection fraction of 74% is good. Mine came back this time low and I'm going to have to discuss my whole report with my cardio. Have you and your husband discussed the findings with his cardio?

I have much to learn about correctly interpreting these reports but I would really be concerned about his pulmonary hypertension based on the little I do know. Please let me know what his cardio says, OK? I hope this report is actually a better one than his last one since the direction different values are heading is more telling than a single finding.

[hensylee]

I'd have posted, but I don't know about all of this. It's technical, but we do have technical studied members who will probably come along and help out.

[tobagotwo]

I am certainly not an expert, and you should only use anything I put here as thoughts to stimulate conversation with your cardiologist. With that in mind, here are some amateur thoughts...

- I suspect the 73% ejection fraction (EF) is on the high side, and caused by the hypertrophy and the fact that the left heart is doing most of the work for both sides. I would be leery of encroaching CHF over time.

- The aortic pressures are higher than normal, which means that he effectively has mild aortic stenosis, although it is not due to the valve opening getting smaller. While pressures on installed valves do rise somewhat over time, the expected mean pressure gradient on an aortic SJM should be about 6.1 mmHG, vs. his 21mmHG mean gradient. This is not the valve's fault. This is probably because the left heart is enlarged and hyperdynamic from the extra load it is taking.

- The left ventricle is enlarged and pumping harder that it normally would, as it's doing both its own work and some of the leaky-valve right ventricle's work. I believe this is is causing the artificially high ejection fraction, and is also likely feeding into his pulmonary hypertension troubles.

- He doesn't appear to have any significant mitral stenosis

- Both the aortic and mitral valves mention paravalvular leaks. This would lead me to suspect that he may have myxomatous tissue, brought on either by a bicuspid valve syndrome, or deteriorating tissue from earlier endocaditis or radiation treatments. The failing of his tricuspid might also be consistent with this causation. Fortunately, the paravalvular leaks are mentioned as mild. A paravalvular leak would be cause by a surgeon's dropped stitch (very unlikely) or a tearing away of small parts of the scar tissue where the valve is attached. The scar tissue is what forms the seal around the edges of the valve. These leaks may remain insignificant for many years, though.

- His pulmonary valve seems to be working well under the circumstances.

- His tricuspid valve appears to be mostly nonfunctional, and is in at least a partially open state all of the time. This is causing problems with backflow, and is contributing to his pulmonary hypertension, atrial dilation, and his mildly enlarged right ventricle.

- His right ventricle dilation is mild, but the ventricle is also showing signs that it is not coping well with the flowback from the tricuspid valve. In simple terms, it is overloaded with blood, mostly because the tricuspid valve is not closing enough to help restrict the volume. It isn't able to pump efficiently because of this, and isn't contracting as much as it normally should.

- Both atriums are enlarged from the backpressure caused by the leaky valve, and the resultant inability for the right heart to effectively push blood.

All in all, not the report that I would want for my birthday. Please don't read more into this than is there, and don't be made overly unhappy by it. I remind you that I am not an expert, and this is only my set of suppositions, based on my potentially flawed understanding of the implications of the information on the report.

I hope your husband's situation can be aided through prescription medicines. If they are not helping him, do stay on top of the cardiologist, and see if he can shift to a different mix of drugs that can.

Best wishes,

[Mb]

Whew

Thank you for your input.

We saw his cardio last week, right after the echo was done, so we were not able to discuss this report face to face. The letter we received along with the copy of the report does not specifically discuss the itemized details of the report. When I first read the report, frankly I was taken aback, but wanted to compare this report, with the one done last year.

He needs a pacemaker, but the cardio does not feel it should be done now, as it will aggravate the tricuspid regurgitation.

The conclusion in the rport says that the comparison is limited by differences in hachime and color acquisition. The leak in the AV valve is suggested in the prior report, but the mitral leakage is new. His atria measures are larger now, than they were last year.

I did NOT know about the RVSP being indicative of PH, and was wondering about that, so you certainly cleared that up. This measurement was not taken last year.

The cardio did call me , but only really said that the echo indicated that he should be extremely diligent about his fluids, and that a three pound gain would now indicate increasing his lasix. He is sending the report to the surgeon who did the original valve replacements.

I am at a bit of a loss. I think I will e-mail his cardio and request he call, so I can discuss this with him.

The first surgery was done later than it should have been, four years ago today. This is not the result we had hoped for. My husband I think knows that his condition is not better, it is worse than even six months ago. Even three or four months post sugery we both knew there was a problem, which is when they did the echo that indicated the tricuspid regurgitation. I know his cardio is very concerned about a second surgery.

I truly appreciate all of your input. Thank you, thank you, thank you.

Marybeth

[Mb]

Betty:

Are tou taking meds for the PH?

Mb

[bvdr]

Betty:

Are tou taking meds for the PH?

Mb

No, not yet. I'm getting ready to call my cardiologist about my report as well. It had not been read yet when I saw him a couple of weeks ago. I went to the hospital and got a copy so we have not discussed any of this yet. Maybe it is an error...I hope so anyhow. I'll let you know.

[Michaelena]

Marybeth,

I have read your posts. I was very symptomatic prior to my surgery. One of the surgeons I consulted I was able to get a copy of his report to my pcp. With regards to my liver, it was enlarged, palpating three to four fingerbreadths below the right costal margin and is very pulsatile. The doctors were very concerned about eventual cardiac induced chirosis of the liver. Extremities reveal +2-pitting edema. I was always fatigued. My quality of life was not very good, it was getting to the point I was not able to work.
My right atrium was so enlarged, they were concerned with irreparable damage.

I wish there was a standard for echo's, I tried to compare your husband's to my but it was not easy. Pressures for women vs men may be different, I don't know.

Staying on Lasix long term was not an option for me. 3 out of 4 cardiologist recommended surgery in the near future, as did the surgeons, I consulted with 3.

The decision was when to have the surgery done, who was going to do it, I knew it had to be done, I could not go on feeling as bad as I did.

Eight weeks post op - after cardiac rehab, I feel great. Best decision I ever made. I am on less meds now than before surgery. I am still in a-fib.

You and your husband will be in my prayers.
If I can help further, please let me know. I will check the web site and my email daily.
Michaelena

[Mb]

Dear Michaelena:

I was hoping you would answer/reply.

Wayne is symptomatic. He has taken lasix for years, and is now up to 120mg a day, and a couple of times a week, he swallows done an extra 60 mg. His liver is enlarged, and has been for at least three years or so. I do not think he really has any issues with it yet, as his labs seem to come out ok, and he is stable. He is very, very fatigued. Gets up in the morning fatigued. But, neither of us want him to have a second surgery, until he absolutely has to. I have checked this echo against his one from last year, and his right atrium measurement was 53 and is now 65. New mitral valve regurg., hypokentic right ventricle, etc., lots of new things. I am concerned. He did have a very small stroke in January, and a TIA in January....on coumaden. I think I am going to speak with another Dr. I know, and then call or e-mail his cardio, who is always very good about getting back to me. I wish we had this info when we saw him, as my questions could be answered then. Thank you again, all of you, for the input. Hte echo was not really what I expected. - Marybeth

[Michaelena]

Dear Marybeth,

I understand your concern regarding a 2nd surgery. I was amazed to read your husband is taking twice the amount of Lasix that was prescribed for me. If I did not have the surgery, I do believe that my Lasix would have also been increased, that is what one cardiologist had in mind when he told me that I could go for about 3 to 5 year before having surgery.

What is good is that his liver enzymes are not high, mine were starting to get out of whack, that was one of the reasons for having the surgery sooner than later. I can't compare right atrium size because on all of the reports I have says "gigantic", my surgeon said that I had the largest right atrium he has seen in 8,000 surgeries.

None of the doctors I saw made the decision for me. I had to weigh the risks against what I hoped would be a positive outcome. It's not easy, from your post it sounds like your husband has other health issues which complicates and does'nt make your decision any easier.

I would just keep talking to the doctors, utilize their expertise to help make any decision. I also did alot of praying.

My prayers are with you and your husband.

Michaelena

[BAV Pt's daughter]

Betty:

Are tou taking meds for the PH?

Mb


Isn't it freaky: Viagra is now used sometimes as a treatment option for PH. Not what I would have expected.

[Mb]

Hello to all:

When my husband was immeidaely post-op, he was on 20 mg. of lasix. He has been titrated up to the 120 mg as he has retained more fluid. I think his last change (except this most recent change, to add 60 mg when he was up 3 lbs.) was about a year ago.

I found interesting what you said about the 3-5 years. I had read that somewhere about a year ago....that a person could "tolerate" tricuspid regurgitation about three years. It is now four years for him.

There is no way in the world he could take Viagra. I am still unclear as to whether he has PH or not, based on the report. Can anyone figure that out definitely from the report above?

Thank you so much for the info.

marybeth

[BAV Pt's daughter]

There is no way in the world he could take Viagra.
I just found it pretty amazing when I learned of that. (When I had a FEMALE patient ordered to take it on a scheduled basis as an inpatient. Just a sidenote, anyway. :)

[Nancy]

Yes, that is true about Viagra being used to treat PH in some patients, even women. Remember this was first brought on the market to dilate blood vessels, and the side effect which led to its spectacular use for ED was just a phenomena a sort of off-label use for Viagra. Now, that's all everyone thinks about, but it is valuable for other things as well.

The dosages used for PH are quite different than those used for PH.

There are many other medications used for PH. Some of then are calcium channel blockers, Remodulin, Flolan, and Tracleer and now Viagra. Joe also takes Imdur for dilation of blood vessels.

[Mb]

Yes, that is true about Viagra being used to treat PH in some patients, even women. Remember this was first brought on the market to dilate blood vessels, and the side effect which led to its spectacular use for ED was just a phenomena a sort of off-label use for Viagra. Now, that's all everyone thinks about, but it is valuable for other things as well.

The dosages used for PH are quite different than those used for PH.

There are many other medications used for PH. Some of then are calcium channel blockers, Remodulin, Flolan, and Tracleer and now Viagra. Joe also takes Imdur for dilation of blood vessels.


Nancy:

I am unclear on wheter Wayne has PH or not. Does the measurement of his right ventricualar systolic pressure indicate that he has PH?
Marybeth

[Nancy]

A Pulmonary Artery Pressure (systolic) of 40-55mm hg is considered mild PH. You mentioned, however, that the report said the pressure of 44 was a possible underestimation.

Echoes are not that good at measurements for PH. The right heart cath is the gold standard test.

[Mb]

yES, THE REPORT DID SAY THAT IS WAS PROBABLY AN UNDER ESTIMATE.,

Should I ask for the right heart cath? Actually I did e-mial the cardio on Friday morning, and hopefully he will call in the next couple of days.

At our January visit, he had said that if he were to have PH, "that wouldn't be good." So I am surprised he himself does not want to investigate this further.

I will post anything, when I hear from his cardio. If I don't hear by Tuesday, another e-mail he will get! - Marybeth

[Nancy]

I'm glad you are going to pursue it. It would certainly be a good idea to ask about a right heart cath, since the echo said it could be an underestimation. I think it's very important to know what the correct pressures are, if not, then how can anyone asses what's going on with Wayne?

If your cardiologist balks, then ask if Wayne should see a PH specialist.

If he does have PH, then waiting around for it to get worse is not a good thing. There are meds that can help him, even in the early stages. It need not be the extra heavy-duty ones.

Joe's old card fooled around while Joe's MEAN pressure got to 75. Severe MEAN pressure starts at 45. So at that pint, Joe's days were numbered, and I'm sure his declining health is in some part attributible to not paying attention to his PH when it was mild to moderate. I think a lot of damage was done to his heart and to his lungs. Severe SYSTOLIC pressure starts at 75. The specialist that gave Joe Tracleer and rearranged all of his other medications added years to his life, and his pressure is now in the mild range.

Think of all the damage ordinary high blood pressure does to all organs in the body, then think of high pressures within the lungs which are so delicate, and one can certainly see how bad damage could occur and spill over into the heart.

Has a visit with a surgeon been discussed at all?

[bvdr]

Marybeth, I think the word I meant to use to describe an RSVP of 44 was "significant" rather than "substantial" because as Nancy mentioned it would fall into the "mild" area. I think I wanted to just let you know that it wasn't an insignificant finding.

As for my last echo, my cardiologist did call me and he is pulling the last three echoes and reviewing them and said he will call me back and discuss what to do. I'll be watching how Wayne's cardiologist handles this.