Changes in valve(s) function as heart disease progresses

[LMD__0]

  Dear Sir or Madam,
  I appreciate that this forum is available. I don't think my doctor would have the time to answer  my questions. My doctor is very good, I just think the answer would be rather involved.
  I had rheumatic fever at ages 17, 19 and possible a second time at 19. As a result I ended up developing mitral stenosis and regurgitation. In 1983 (I was 23) I mitral commisurotomy and valvuloplasty. I had a carpentier ring put in. I was only on coumidin for 3 months. Since that time I have had numerous cardiac caths, echos etc. Over the years I have different heart valves change in their functioning. I have had tricuspid regurgitation and then on my next echo it is gone. At one point the tricuspid regurgitation was not there and my mitral valve broke open a little in my sleep. As a result I suddenly had severe tricuspid regurgitation. Then months later that went a way. The amount of regurgitation and stenosis in the mitral valve has changed over the years. Sometimes it is as little as 1.21 cm sq and at other times it is 1.5 cm sq. These changes in the mitral valve area and the functioning of the tricuspid valve have been changing one direction or the other for years.
  In 1995 my mitral valve area on both echocardiogram, to include Doppler and cardiac catheterization indicated the mitral valve area to be 1.21 cm sq and I had mild mitral regurgitation. Now in February I started experiencing an increase in ectopic beats. I have experienced exctopic beats for years. But by March 1 the ectopic beats had increased to the point that I ended up in an ER two nights in a row. I was experiencing what was diagnosed as PAC's, and I was feeling 1-5 of them every 60 seconds. I am now on an cardiac even monitor and lanoxin. I take lasix and potassium and aspirin as well. In February I was told that I had an aortic ejection murmur that the doctors had not heard before. This was confirmed via asculation by another cardiologist. But apparently nothing idicated this murmur on the echo.  What causes a murmur if there is no damage? How can a valve be affected one month and months later not be affected? My current cardiologist is concerned that I may be developing an arrythmia or atrial fibrillation, are these common results of the damage of rheumatic fever? I am only 37 now and it has been mentioned several times that my mitral valve needs to be replaced. The left side of my heart is straight also. If the mitral valve is failing will replacement keep the aortic valve from failing and will my left atria which is 56 mm return to its normal healthy size. Is it common for the other valves to fail as a result mitral valve failure. My cholesterol is fine and I have no symptoms of CAD. I experience the ectopic and irregular beats while at rest as well as during activity.
  I realize this letter is rather lengthy, and I hope I have not abused the privalege of writing in this forum. I am very concerned and have been told that after the mitral valve is replaced this time I would be a candidate for a heart transplant next time. Do they perform heart transplants for failed heart valves, I was told that this was not the case, and I am very concerned.
  Thank you so much for offering this forum and being willing to answer peoples questions. And thank for you time and compassion in advance.
  Sincerely,
  LMD
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Dear LMD:
An echocardiogram is a very useful test to diagnose valve problems.  However, it is in large part interpreted based on visual estimates; therefore, a little bit of variability from echo to echo can be due to the technique used and the particular interpreter.  You mention valve areas calculated to two decimal points, but the technology is not currently powerful enough to give this degree of precision.  Another factor that can limit reproducibility of echos is the different conditions under which they are performed.  The types of medicines, the blood pressure, and the heart rate are a few of the factors that can influence the amount of leakiness (regurgitation) or tightness (stenosis) that a valve shows.  Cardiac catheterization data shares these limitations.
Not every murmur that is heard corresponds to a serious valvular abnormality.  Sometimes if a valve is thickened or calcified, it produces enough turbulence of blood flow to cause a murmur, but not enough to cause a significant stenosis.  Problems of the mitral valve can lead to problems with the tricuspid valve and to the heart function overall.  Moreover, rheumatic heart disease can affect multiple valves to different degrees.
Rheumatic mitral valve disease often does lead to heart rate problems (arrhythmias) such as atrial fibrillation.  Replacement of the valve sometimes cures the atrial arrhythmias, and often will at least make them easier to treat.  With time after mitral valve replacement, the left atrium can remodel and decrease in size.  In people with advanced heart failure secondary to valve problems, heart transplant is definitely an option, but this is a complex issue, as far as determining the appropriate patient and the appropriate timing.
Information provided in this forum is of a general nature.  Specific diagnoses and treatments can only be made by your doctor.  If you would like to see a cardiologist who specializes in valve diseases and valve surgery (including heart transplantation), please call 1-800-CCF-CARE for an appointment at desk F15.