Moderate Aortic Regurgitation and Mitral Valve Prolapse

[mam123]

I'm a 34 year-old male 4th year med student. It's ironic that
I have poor access to healthcare! Anyway, I recently
had a physcial for military recomissioning as they
are paying for med school, and the EKG showed high voltages
in the V4-V6 leads. They made me get an echo just to rule
out pathology. I have been a distance runner for the past ten years with a best marathon time of 2:42 and mile of 4:40 just four years ago. I initially thought that I had some sort of athlete's heart EKG. The echo report was as follows:

ESTIMATED EF: Between 65 and 70% CALCULATED EF: 63%. The left atrium is of normal size. The right atrium is of normal size. Normal right ventricular size with normal systolic function and normal wall thickness. Normal left ventricular size with normal systolic function and mild hypertrophy. There is normal wall motion. The aortic valve is normal in appearance and in a bicuspid configuration. There is no aortic stenosis. There is moderate aortic insufficiency. The pressure half time of the AR jet is 363msec. The mitral valve is normal in appearance. The mitral valve demonstrates prolapse. There is no mitral stenosis. There is no mitral insufficiency. There is no tricuspid insufficiency. The aortic root appears normal.

They didn't tell me more, and I don't have an opportunity to follow up because my visit to that base was a one-time
event.  I am completely asymptomatic, very healthy, and two weeks ago, I ran a 20-mile training run at a 7:04 pace without problems; BP's 130's/70's. What does all this mean? Running? Meds? Surgery? Followups? Pognosis?

[Cleveland Clinic]

mam,

The criteria for LVH were determined for patients in an older population and are not neccessarily applicable to someone your age.

However, the echo results of aortic regurgiation and bicuspid aortic valve are abnormal.  You will need to start being followed by a cardiologist.  Nothing needs to neccessarily be done now given the normal size and fuction as well as your lack of symptoms on the echo. However, you should start to be seen by a cardiologist and have serial studies to follow your fucntion and size of the heart over time. If you develop changes or symtoms you will need valve repair or replacement.

Many people do fine for extended periods of time before requiring the above. People that do not have close followup and subsequently develop heart damage prior to surgery do not do as well.

Ask around the school for a good cardiologist and plug yourself in. Keep running and study hard.

good luck

[jdm]

Interesting question Doctor.  I lived my life very similar to yours in terms of health and aerobic activity level.  I ran a great deal and took up high altitude backbacking and mountain climbing.  About your age I noticed that my heart rate following exercise would not return to normal for long periods of time-directly related to the time and intensity of the exercise.  A vigorous hike of 3-6 hours at a rate in the 140s and higher would result in a resting pusle of 125 or more for hours.  

My rate would return to normal in such a situation in approx 8-12 hours.  My bp at your age was lower than yours and I had NO indication of problems on an exercise treadmill test at about age 35.  

The condition got progressively worse and led to severe anxiety reaction. I pretty much stopped vigorous aerobic activity about the age of 38 and gave up all my prior pursuits that required it.  

Now at age 54 I am diagnosed with mild aortic and pulmonary regurgitation. Your post is helpful to me in that it shows what they have been telling me - namely that my regurg could be a lifetime condition and that it may not worsen or need repair etc.  

However, the fact remains about the undiagnosed tach after exercise.  Eating and alcohol now cause it as well.  I am very sensitive to attenolol and get control with 1/4 of a 25 mg. tab 4x daily.  Then there are the antianxiety and antidepression medicines.  

Talk about poor health care.  Beginning in the late 80's my HMO docs told me consistently either that this was all in my head or was not a big deal.  Right, sitting in a chair relaxing with a hr of 125 three hours post exercise is no big deal.  

They never offered a EP study and have not said the words ablation to me.  I am firmly convinced it's just cost saving on their part.  All the HMO docs get profit share as I understand it.  

Here's my advice to you.  You're just about a doctor, I'm just a 54 year old with anxiety disorder and an MBA.  So let me say that I respect you for your achievement in education.  I suggest you take a tip from me drawn from my life experience. It might help you.  

You must get to the bottom of the problem.  You must know what is the cause.  Not knowing, in my case, WHY this is happening has crippled me psychologically.  You must not give up your aerobic pursuits.  If you're like me you need this outlet and joy.  Fight for it.  

Lastly beware of depression.  It runs in my family but has been enormously deepened by my loss of my aerobic pursuits.  ( plus, and not to suggest this is your situation ) my therapist believes that I was self treating my underlying familial depression for years with natural endorphins etc.  

I was 34 when all this hell started for me.  I hope this post will help you have a better outcome.  That's all.  Good luck young man.  JD

[Avel]

Hi,
In general I would encourage you to search the medical literature for papers on bicuspid aortic valves. Thanks to today's diagnostic capabilites, including the echo you had, early detection of bicuspid aortic disease (which includes more than just the aortic valve!) is possible and has lead to greater understanding and earlier treatment.
I want to mention one paper that gives a particularly good overview of this condition - the entire paper is available on the Internet at http://circ.ahajournals.org/cgi/content/full/106/8/900?eaf
I would also suggest the following locations for additional information
http://www.cedars-sinai.edu/bicuspid
http://www.cedars-sinia.edu/aorta
On these pages there is also an email option to request additional information, which might be particularly helpful to you since your access to health care is poor!
Best Wishes to you.