A-FIB, LVOT Obstruction due to SAM

[LacyMary]

I am grateful I was able to get thru. Thank You.

Had several Echo's in the past. All Normal except mild Mitral/Aortic Regurgitation and one time, showed, "positive stress echo for apical-septal ischemia".

Had new Echo 2 weeks after "1st attack of A-FIB" which Corvert IV,converted to NSR in 10 min. All Enzymes normal, in ER.

Glucose144, HCT was 55(H) Potassium 3.5(L), Chloride 112(H) Creatinine (L) RDW (L)

5 hours later, Troponim was 4.85 and CK-MB, elevated. These numbers came down hourly until discharged. They do not have a clue what caused the A-FIB or the rise in Troponin, CK-MB, 5 hours later. Cath only showed a 60% blockage and was stented.

Echo after this "heart Event" showed "30mmHg Dynamic LVOT OBstruction due to SAM". EF was 58%

Question: What exactly is a 30mmHg Dynamic LVOT due to SAM? Since other previous Echo's were normal, could there be a relation between this new Echo finding and the A-FIB attack, 2 weeks earlier?  I am looking for a reason for the A-FIB attack. Dehydrated?  (been on Avalide 150/12.5 for months) Plavix also, TopolXL and Crestor.

2.I had a heart cath last December. 2 stents placed in RCA due to "pressure readings" being 68. What does low pressure mean?

3. What are your thoughts on a Cardiac MRI showing things a Cath will not pick up?  Would this be good to clarify the last Echo findings and looking for the cause/damages from the A-FIB attack since there was a rise of Heart Enzymes 4 hours after the "heart Event".

Being CC is No. One for Cardiac Care, I look forward to your expertise reply. Thanks.

Lacy,55.

[CCF-M.D.-MJM]

Hi Lacy,

I am sorry to hear abour your recent health problems.

1. What exactly is a 30mmHg Dynamic LVOT due to SAM? Since other previous Echo's were normal, could there be a relation between this new Echo finding and the A-FIB attack, 2 weeks earlier? I am looking for a reason for the A-FIB attack. Dehydrated? (been on Avalide 150/12.5 for months) Plavix also, TopolXL and Crestor.

There are many causes of dynamic outflow tract obstruction.  What it means is the the anterior (front) leaflet of your mitral valve is partially obstructing the outflow tract of  your heart (the blood going into your systemic circulation). When we see this it is important to real out a disease called hypertrophic cardiomyopathy -- although it is caused by several other conditions.  People with SAM tend to have increased left ventricular pressures which translates into increased atrial pressures and therefore can lead to atrial fibrillation.  People with think heart muscle (hypertrophy) or hypertrophic cardiomyopathy sometimes don't tolerate A fib very well and occassionally have enzyme leaks (elevated troponin and CK MB).

At the Cleveland Clinic Dr. Lever and Dr. Thamalarison specialize in this disease.  If you are any where near Cleveland consider getting a second opinion from them (I don't mean to advertise but they are very good).  You will see their names mentioned on this forum occassionally.

2.I had a heart cath last December. 2 stents placed in RCA due to "pressure readings" being 68. What does low pressure mean?

I am not 100% sure what they are referring to.  It may be a pressure wire that measures the pressure proximal and distal to the obstruction to determine its clinical (physiologic) significance.


3. What are your thoughts on a Cardiac MRI showing things a Cath will not pick up? Would this be good to clarify the last Echo findings and looking for the cause/damages from the A-FIB attack since there was a rise of Heart Enzymes 4 hours after the "heart Event".

I do not think an MRI will clarify this question.  Consider getting a second opinion and look for someone that specialized in hypertrophic cardiomyopathy.

As an important side note, if we see some with a resting gradient and SAM we give an inhalant called amyl nitrite to reduce system pressure and look for an increase in the gradient.  In some patients the pressures do not change but others increase dramatically and may help identify people at more risk for symptoms and problems related to the obstruction.  Dehydration will likely increase the gradient as well.

I hope this helps.  Good luck.

[Momto3]

Hello!!

Just wanted to add my two cents about Dr. Thalmilarasan.  He is a fabulous and very caring physican!! I am not familiar with the other physician mentioned, but if he is anything like Dr. T...you can't go wrong.

Good luck and hope you are feelinb better!

Connie

[LacyMary]

Thank You very much.  I suspected the A-FIB was secondary to 'something'.  The electrophysiologist doctor thought I had an MI but Cath doctor said no. Cath doctor called this an 'event'. I asked the Regular Cardiologist if I had Hyperthrophy Cardiomyopathy as my feet and lower legs are swollen and my upper abdomen is swollen and I am winded all the time.  He said NO, you do not have Cardiomyopathy or Congestive Heart Failure.
But, there is a nagging feeling in the back of my mind that I do!. Something is not right. I cannot get my pulse under 90 and it will shoot up in a matter of seconds to 130 for no reason and then I get weak and disoriented. I have printed this out for the Heart Center Doctors here. I need closure to all of this and yes, CC is on my insurance plan.

I am on Maxide now and NorpaceCR but not doing well on these.  

  Thank you very much, Doctor and Mom.

[LacyMary]

Dera CC Doctor, My husband just read your response and we  looked up Dr. Thamalarison on Search.  He is listed as an Echocardiographer doctor.  Are all Echo doctors specialty, Hypertrophic Cardiomyopathy or are their General Echo doctors and Specialized Echo Doctors? I am seeing an Echo doc but I do not think he knows all that much about this condition. In fact he is downplaying it. My swelling he said, is all cosmetic.

Is this conditon helped with surgery? I want it gone NOW! (-:  Thanks again.

Mom3, what did you see Dr. T for?  I l1ve about 1500 miles from Cleveland Clinic but willing to travel if I know I will get well. Thanks again, nice people.  God Bless.

[CCF-M.D.-MJM]

all echocardiography docs are next experts in HCM.

Remember, I want to make sure I didn't lead you to believe you have HCM, just that when we see SAM we make sure that isn't HCM.

Good luck.

[LacyMary]

Thank You again, Doctor.  We learned a lot tonight about my condition and found articles written by Dr. Lever and I see myself in these articles.  I also wondered why I am having more symptoms right after eating. Now I know why.  Now, we have to find the cause.  I will work on this tomorrow.

My best to you, doctor.

[LacyMary]

Thank You again, Doctor.  We learned a lot tonight about my condition and found articles written by Dr. Lever and I see myself in these articles.  I also wondered why I am having more symptoms right after eating. Now I know why.  Now, we have to find the cause.  I will work on this tomorrow.

My best to you, doctor.

[Momto3]

Hello,

I was referred to CC when I developed cardiomyopathy (EF 40%).  Because I have mitral regurgitation, the immediate thought was that the leaky valve was the culprit.  My EP is associated with another Cleveland hospital and is an expert in her field, but she said CC is the BEST place for a valve repair/replacement.  

After a thorough examination, Dr. Lauer (CC) scheduled me for a TEE. Anyway, Dr. Shiota and Dr. Thalmilarasan performed and monitored the TEE.  They were wonderful!!  Dr. T. is an expert echocardiographer and he was involved in reviewing my prior echo (I brought it with me) as well as the TEE.

Anyway, turned out that the cardiomyopathy was not a result of the leaky valve.  With this new information, my EP consulted with several echocardiographers (in Cleveland and around the country) and the consensus was that the CM was very possibly the result of my persistent pvcs. Because it is so rare, I posted a question to one of the doctors on this forum regarding any studies about cardiomyopathy and persistent pvcs.  

To make a very long story short, the forum doctor (based on what I wrote and the limited information he had) was very concerned and wanted to be sure I was not being misled.  He was worried that the valve was indeed the problem. So, I phoned my EP and explained the forum doctor's concerns. She explained why she felt my CM was NOT because of the valve, but rather b/c of the pvcs.   So, I decided to call Dr. T b/c he read the actual reports and performed the TEE.  He returned my call and very willingly, accepted my offer to phone my EP.  THEN, he called me back in the evening and discussed my doctor's evaluations, etc.  and confirmed that although it is RARE, it made a lot of sense and seemed quite reasonable. Turns out my EP was right b/c since my ablations in 2003, my EF has gone up at each exam and it is finally back to 60% and I'm feeling SO much better.  YEAH!

I'm sure that's more than you wanted to know (LOL), but I wanted you to know just how nice he was.  No doubt, if I need further valve studies, I will not hesitate to schedule an appt. with Dr. T!!  He is so compassionate and friendly!  He told me to call ANYTIME if I had questions!! I can't say enought good things about his professionalism and very kind bedside manner.  Good luck!!  Feel better soon!!

connie

[LacyMary]

Thanks so much for this info. I am at a heart center in Texas but still have nagging doubts that I am not getting the best/testing/care. It is like I have to do my own research and present it and then they agree with me.  This should not happen.  What the CC doctor replied yesterday, was more info than I have received from the docs I am seeing.  The Elevated heart Enzymes were a concern as they normally raise with a heart Attack yet no heart attack was seen via a Cath. They did not have a clue. The CC doc explained that these enzymes can spill over during an A-FIB attack.  I have been blaming the use of Albuterol, the night before, on my Scary A-Fib attack but The CC doctor's reply made perfect sense that with Dynamic LVOT Obstruction, due to Systolic Anterior Motion,  A-FIB is a possiblity and Dr. Lever's article on the net also mentioned this. My poor hubby is beside himself that he is going to lose me. He called the Echo doctor and asked this question. I hate sharing all this with him as he is freaking out that he is going to lose me. We have an adopted 5 year old even though we are OLD!~!  (-:

I personally feel that my problems stemmed from elevated BP for a long time that no one would treat. It is was Labile...(good and bad)or some genetic condition. Dad died suddenly at the age of 39.

I am on Norpace that the EP doctor wants me on in case I have another A-Fib Attack and also back on TopolXL 50mg. Plus now separate Maxide and Avapro plus Plavix.  I feel I should be on a Blood thinner, i.e. Coumadin but this is contraindicated in people taking Palvix but..........

I asked for a TEE Echo but said I do not need this. I think I do.

My story is very long also and I apologize.  Dr. T sounds like a Gem with a capital G.

I read up on surgical options on the CC site. This may not be too far off.  

Thanks for listening and I wish you all the best. I am green with envy that you have DR. T. close to you. )-:  I may ask my Echo doc to call him.  If not, I will ask the EP doctor to call him.  Then follow it up with a box of Godiva Chocolates.

God Bless Us All.  

[Momto3]

You're welcome.  Boy, the heart centers in TX are supposed to be pretty good.  Too bad that you are not confident regarding the care and treatment you are receiving.  The forum doctors at the CC are great and we are so lucky to have the opportunity to ask questions of cardiologists from the #1 Heart Center in the county!  (Kudos to the CCF for achieving this ranking AGAIN!)

Frankly, I am kind of surprised that your doctor has not been able to explain the matter about the elevated enzymes.  Hmmmmm.....  

So sorry your hubby is feeling so bummed.  That's one of the great things about meeting others on the forum.  We understand each others' concerns and are here to support one another. If your husband is afraid of 'losing you' due to medical reasons, maybe it would help if he went to the next appointment with you.  My hubby went with me to a number of appoinments (including the CC) when things were getting serious....and he was also in the waiting room on a number of other occasions (I'm chicken!) He might be more comfortable if he could hear the doctor's responses and as well as ask his own questions.

You have an adopted 5 year old!!!  That is so cool!! We have 3 grown children, but I've (we've) contemplated adoption....at our OLD age....No such thing!!  Being parents automatically makes you young ; 0

Have you been treated for your elevated BP for a long time?  Is it under control?  I' very sorry to hear about your dad.  I'm sure that was a very difficult time.

Again, you are very welcome.  

Funny thing is, I just relocated to North Carolina, but if the need arises I will return to CC for valve concerns. I also plan to have my serial echos and other periodic exams in Cleveland.  Gives me a great reason to go "home."  LOL!!

Godiva Chocolates.......A FABULOUS idea!!
Have a great day!!  
connie

[LacyMary]

Good morning,  I am also Mom to 3.  Two grown, colleged and married.  Thank God!~!  (-:  

Yes, we adopted our lil Asian Doll when she was 2 months old. Talk about the LOVE and WARMTH she has given us is beyond words!
I just have to be around to help raise her. She is my life.  

Yes, there are Heart Centers in Texas but non compared to that of CC or John Hopkins which are the very top in Cardiac Care. These centers recruit the top dogs in the country.  No wonder everyone wants to go to these centers.

Hubby does go with me to most of my visits and he cannot comprehend what the Echo doc is telling him and neither can I. It is like this doc needs to go to Dale Carnegie to learn to communicate better. There was a Japanese Fellow in the room on one of my visits and I wanted to take this Fellow home with me. (-: He was precise, communicated well, had personality and we absolutley loved him but he was not the one who calls the shots.  )-:  I did ask where he would be practicing after he was finished and he said he was going back home.

He would be a great asset wherever he goes.  He knows his stuff!!

Was the TEE painful?  I asked for this but the Cardio said No. Another Cardio in the same group said I need this.  The EP doctor wants me on a holter monitor one week after being on the Norpace. (one week is up) The Cardio doc said I do not need this. And, these docs are all in the same practice.  It is like the left hand does not know what the right hand is doing. )-:

I LOVE North Carolina. Great place to retire. Texas is too Hot!

You mentioned your EF is 40.  Do you have a lot of symptoms?  My EF was 62 last Echo and I do have symptoms.  Breathlesness and fatique and after eating, I get severe arrthmias but they are still in NSR.  No A-FIB, thank God..

Primary Internist doc called today and will do blood work tomorrow. He wants to check Glucose and do Complete Thyroid studies on me and RA tests. Been on Armour Thyroid for years. Heart Doc only did a TSH and not complete studies and did not follow up on elevated sugar, low potassium, seen in the ER room.

God Bless You and I wish you all the best.

[Momto3]

Hello again : 0

How cool!! Another "mom to 3."  The older two are graduated from college and WORKING!! HOORAY!! Our youngest is a senior in college! One more year of tuition : )

If you don't mind, could you share some of your adoption story with me?  You can email me at ***@**** (if it's OK).  The house is just feeling TOO empty.  We were therapeutic foster parents for 10 years, and really miss having children around the house...  We're also considering getting back into foster care.  We would have to start over and go through a new licensing process, but that's OK.  You mentioned your "Asian" baby...did you go through a foreign adoption process?  My sister-in-law's sister adopted two baby girls from China...They are SOOOO adorable!!!  Just want to hug 'em and take 'em home : )

Too bad you could not get affiliated with the "fellow."  The mixed messages you are getting from your doctors must be causing you so much confusion.  Sorry to hear about all that...No wonder you are frustrated.  My cousin is a surgeon and he said more doctors should take classes on dealing with people....Like the Dale Carnegie course you mentioned.  Seems like a good idea for some of the more clinical physicians.  There is a LOT to be said for knowing the book stuff, but dealing with people takes a different kind of knowledge and certainly some understanding.

The TEE was not painful.  I have nearly no recollection of the procedure itself, which was just fine with me!!  I was taken into a procedure room and given an IV for the sedative and pain medicine (versed and demerol).  They hooked me up to the monitors and sprayed my throat with some gross stuff (maybe something like novocaine).  I also had to gargle with some REALLY gross stuff (kerosene, maybe.....lol).  The gargle stuff was the worst part and definitely not something that I would worry about if I had to have it repeated.  Once my throat was prepared for the scope, I had to lie on my left side.  I remeber asking the nurse when I would start to feel drousy......um.....then I was sitting up, pathes off, and feeling pretty good.  The only problem I had was that the demerol cause some nausea.  The nurse suggested fentynl for any future procedures.  I took her advice and had NO problems....If you end up having a TEE, you might ask your doctor (or the doctor/nurse who are performing the test) about fentynl instead of demerol.  Apparently, quite a few people get nauseous from the demerol.

So far, North Carolina is really nice.  My husband used to travel quite a bit to Temple, TX (outside Austin) and I had the chance to go a few times.  It was very nice, but you are right....HOT!  I enjoy the change of seasons, so I'm hoping this will work out.  In Ohio, we were accustomed to big snowstorms, dumping up to 24" of snow in a given storm.  It will be nice NOT to shovel : )

For years my echos indicated a normal EF. I did have significant shortness of breath in 2000, but still normal EF.  After months of SOB, it finally seemed to resolve (stress, anxiety??).  Then, in December 2002, my serial echo revealed an EF of 40% and I was caught totally off guard!!  One thing I did notice was swollen ankles, and I had NEVER had that before.  I did have very frequent, consistent pvcs and that was exhausting.  No A-Fib here either....I agree, thank God!! Now, with my EF back to normal, no swelling, NSR, I feel SOOO much better.  

Good luck with the upcoming blood work.  

Thanks for sharing your story.  

Connie

[LacyMary]

I will e-mail you privately.  I have to run to the store in a sec and get more Omega Fish for my diet.  My ankles look like elephants and the Cardio says, "cosmetic reasons".  Well, I know better. It has something to do with this LVOT stuff they have seen on the last Echo. I was not born yesterday. (-:

Ok...I will share the adoption story.  It was beautiful and teary. Better than all the tea in Asia!  (-:  

Lacy