Ejection Fraction, Mitral Valve Regurgitation, and Pregnancy

[ChristianH]

Background:  

My wife, who is 26 years old, was diagnosed with MVP at a very young age and has had severe mitral valve regurgitation for at least several years.  She is a already a CCF patient, and intends to have Dr. Cosgrove perform surgery at some point.  She sees our local cardiologist once a year and the CCF cardiologist once a year.  Her most recent examination at CCF (which included a stress echo) revealed a ejection fraction of 51%.  The size of her left ventricle is apparently still within normal limits, although it is borderline.  Her heart was deemed very strong, and we were told the time had not yet arrived for surgery (she is, and always has been, very active and completely asymptomatic).  Her "time" could be anywhere from two to twenty years.  She would like to have at least one child.  We were told if she was to get pregnant now, we'd have a 98% chance of a healthy mother and child, but may want to opt for a voluntary C-section to reduce the stress of delivery.  But we do not wish to have a child for at least 3-4 years due to career concerns.

Here's my questions:

1) Is a 51% ejection fraction cause for immediate concern?  My understanding is that 50-65% is considered "normal," but I was told by a physician at a holiday party (a nephrologist, who most likely was the wrong person to ask) that a person with severe regurgitation has an artificially *inflated* ejection fraction rather than a reduced one, and that hers was therefore below "normal."  Is that accurate?  Does ejection fraction only measure what is "ejected," or does it measure the end result of each heartbeat, i.e. the difference between what is "ejected" minus what ends up regurgitating back into the ventricle?

2)  How exactly could a pregnancy effect the heart of an individual with severe MVR?  Why would the effects occur?

3)  Is there any good news in all this?  We've done everything we can to educate ourselves and to find the best surgical team and facility in the world, but the long-term outlook is still fuzzy. Assuming a successful surgery (and possibly successful repeat surgeries down the road) is it possible, in your opinion, for an otherwise tremendously healthy woman to have a child and to live out a normal lifespan?  If any of the non-physician readers on the board have had mitral valve surgery at a young age, what have you been told with respect to long term prognoses?

E-mails are welcome.

Christian
***@****

[TONI191]

A related discussion, mitral valve regurgitation was started.

[cardiac sonographer]

your ejection fraction is within the normal limits.  60% and below starts to be a concern.

[michael e. lindenmeyer]

In the last two years, I developed a mitral regurgitation that
shows an echogram EF of 65%. My physician, an internist, tells
me that I may need mitral valve replacement in about a year. I am uncertain that he knows that much about it (he tells me that he can't read cat scans of the area surrounding my right clavicle that suddenly protruded without warning or pain.) and will be contacting a cardiologist.  Meanwhile, I would like to know whether 65% is considered a bad value. What are typical values
for EF for 'good' valves and deteriorating valves?

Thanks.

[debbie]

My Dad was at 18%. He had trouble breathing. Was to have a needle draw fluid out of his lung. Went into cardiac arrest. Should the hospital have waited?

[Sam]

I have a question-
My Mom has advanced COPD.  She is 71 years old, uses oxygen at night and as needed during the day.  She went into respiratory failure following a viral illness and consequently suffered an MI.
She was extubated after 3 days without complication.  Her echocardiogram showed a 20-30% EF.  She has never had any previous cardiac problems.  

1. Would she be a candidate for cardiac catheterization ?

2. What is her prognosis ?

3. Is it possible that she could recover to her post MI status ?

[holly]

Christian-
I am currently 29 years old and had been diagnosised with mvp when I was in elementary school.  I have been closely monitored by cardiologist especially since my reguritation went to moderate to severe.  I had my first baby when my regurgitation was moderate and my second baby when my regurg was severe.  I did very well carrying both of them; however, I did go into premature labor several times and was taken out of work about 3-4 months before I did deliver.  The truth is, during those nine months, I never felt better.  My cardiologist said it most have been the extra preload.  My delivery were uneventful and recovery was also uneventful.  However, since my two beautiful kids were born, I have become more symptomatic due to the stress on my valve due to the increase volume associated with pregnancy.  My cardiologist is now talking about a mitral valve replacement.  Yes, I am very anxious about this surgery and ironically I am a nurse (RN) that works in the medical intensive care unit.  I feel it is because I know too much!!  Oh well, best of luck to you and your wife.  If you have any questions please email me at ***@****

[Cleveland Clinic, MD]

Thanks for the comments.

[francesca]

Hi Christian,

The mitral regurg was not severe, but the stenosis was significant.and the aortic regurg was 3+.  The science of echocardiography was certainly not as advanced 20 years ago as it is today.  They didn't have doppler then. It is my understanding that you can withstand a large amount of regurg until the chambers become too dialated and lose contractility, Afib is also a huge problem. The increase in blood volume adds to the burden and the numbers do increase on the echo.  But following the pregnancy they go back pretty much to where they were prior. What does your cardiologist and/or ob say.  I was under the care of a high risk pregnancy specialist and was in each week and spend the last month prior to delivery in the hospital.  Again I do not have MVP so my case is different.  I am sure with the prevalence of MVP there is lots of studies out there and experience.

Best of Luck

[christian]

Francesca:

Was your regurgitation severe when you reared your children?  We're both a bit hesitant to go through a pregnancy with severe mitral regurgitation despite our doctor's assurances that she'd very probably be ok.  Since we don't want kids for several years anyway, we're in no hurry to make a decision.  But we're leaning towards having the surgery first.  If she gets a repair, we're in luck.  If not, we're stuck with a bioprosthesis and repeat surgery in 5-10 years.  But at least she'll presumably be able to have a child in either case.  

Thanks for your comments, and thanks to the CCF physician for answering my followup question.

Christian

[Cleveland Clinic, MD]

Thanks for your comments.

[francesca]

Dear Christian & Wife,
I was diagnosed with mitral stenosis, mitral regurgitation and aortic regurgitation also at the age of 26.  I went on to have two successful pregnancies (not without complications), my first at the age of 30 the second at 33.  I was carefullly followed by very nervous physicians.  I am now 45 and doing so so.  My disease is rheumatic in origin so it has a natural progression. I have never ever regretted my decision and if I could I would do it again.  But that is purely a personal decision.  Best of luck to you and if you have any questions ***@****

[Cleveland Clinic, MD]

It is slightly easier to pump blood when there is backflow across the mitral valve as well as forward flow across the aortic valve therefore the heart may be pumping "less strong" than it appears.  However, in someone with normal EF this is not really a concern.

[christian]

Could you (or someone) please explain why he's technically correct?  I'd really like to understand the specifics, but can't find an answer anywhere on the 'net.

Thank you,

Christian

[Cleveland Clinic, MD]

While your physician friend is technically correct there is probably no cause for alarm in your wife's situation.  The timing of surgery is as much an art as a science and it s better to wait as long as possible. I think in general the outlook for a young woman with MVP and regurgitation is very good and in gneneral not limited from pregnancy.  For women undergoing surgery the desire to bear children plays a role in choosing what type of valve to use but that is not currently an issue in your wife's case.