Questions about Mitral Valve with Regurg

[bzmed]

Hi,  I am a 45 year old female with bileaflet mitral valve prolapse with regurg. and mild left atrium enlargement.

My cardiologist recently performed an echocardiogram with the following findings:

Aortic Valve: Structure - Mild Focal Thickening

Mitral Valve:  Bileaflet Prolapse, Regurgitation - Moderate

Est EF 62%
LA Vol Index - 33.1

Under "Additional Findings" it states:

Bileaflet Mitral Valve Prolapse with eccentric regurgitation jet
Unable to quantitate severity of mitral regurgitation

Then under "Conclusions" it states:

Bileaflet Mitral Valve Prolapse with Myxomatous Mitral Valve and Moderate Mitral Regurgitation
Left Atrial Enlargement

I also noticed my Aortic Root is noted as 3.5 cm (they reference a range of 2.1 to 3.7 as normal)


Then a follow-up TEE with the following findings:

visual est ef: 55% to 60%

Mildly myxomatous mitral valve with bileaflet prolapse and mild-to-moderate MR
Mild left atrial enlargement

A few questions:

Why would they not be able to tell more specifically about the level of regurgitation?

Would the fact that the left atrium is enlarged be more indicative of moderate regurgitation or just long-term regurgitation?

I have a family history of aortic aneurism (my great-grandfather and he looked Marfan-ish).  Should I be concerned about the size of the aortic root or is it more usual for people to be at the upper end?

What is "mild focal thickening" of the structure of the aortic valve?

Currently I am taking a beta blocker and an ace inhibitor.  Do they both seem necessary at this point?

Is it more likely than not that the regurg is progressive?

Thank you for any information you can provide.

[EchoTech]

The repair of mitral vavles, with just repairing one leaf in specific, is usually good if it involves the anterior mitral leaflet.  The anterior leaflet, all things considereed, is easier to repair than the posterior leaflet.  It is not uncommon to fix both leaflets though.  If the time comes to it, there are surgeons who specialize in fixing mitral valves, and many cardiologists know who is good in that sub-specialty.
  You are right that there can be some enlargement in the left atrium, and it can hold that size for years and years.  There are cases where it doesn't do that and it grows, but no one can tell which group will grow and which will stay the same.  This is the reason for follow up visits.
  Being 45, you will heal quicker than most if you have to have it.  The younger you are the quicker you heal.
  The only thing that you can do not to real exacerbate the situation is do heavy load bearing exercises like lifting a maximal amount of weight. They would also probably suggest no contact sports/ highly exertional competitive sports.   I would discuss with your doctor as to what sort of activites that they would rather you do/not do.

Thank you for the thank you.

Good night and good luck.

[bzmed]

Thank you for the additional info.  I was hoping there were some indicators that could give a clue as to the progression - such as (just made up examples) bileaflet progresses in 90% of the cases they see or once you have some enlargement of the atrium then they know it is progressive, etc.  But it doesn't sound like that is the case.

I am one of those that would rather know the gorey details vs. finding out by accident.

I have read that bileaflet repairs are not as successful as when it only involves one leaflet.  So if there is anything I can do to not encourage progression I would like to know and be able to do.

I hope the rheumatologist will be able to help as many members of my family have symptoms of a connective tissue disorder and it would be nice to have it resolved for my children and future generations.  Also, if I have to have a repair I know that my healing time may be extended if I do have connective tissue disorder.  (I know from past experience that I heal more slowly.)

Thank you again for taking the time to write.  I greatly appreciate the info.

[EchoTech]

If the mitral regurgitation (MR) follows the side of the atrium instead of squirting back straight into the atrium, it can be difficult to properly assess how much regurgitation there is.  Mild focal thickening on the aortic leaflets can be a normal age related change in an echo.  At this point, there is nothing to worry about the aortic valve.  As far as the MR is concerned, do follow up with the cardiologist  when they suggest to.  If you get to feeling short of breath or feeling tired all the time, then call him and get yourself an appointment.  As far as the stability of the MR and it progressing vs. not progressing, nobody knows.  The docs can't predict the future.  If you are lucky, it will keep the way it is for the rest of your life without and side effects.  Worse case scenario would be open heart surgery to do a mitral valve repair/ replacement, but that is off in the future, and like I said before, no one can predict if it will progress that far.  Overall, I would put more emphasis on the TEE report concerning the MR because it is a better test, since they take the pictures only a inch or two from the heart when you swallow the probe.  The rheumatologist may be able to help see if you have Marfan's but you would be in the right age group for things to be progressing along in terms of aortic dilatation ( I lean heavily towards you probably not having it), but the doctor should be able to give you a definitive yes/no answer.

Good night and good luck

[bzmed]

Thank you for your reply.  

The dr did not comment on the mild focal thickening in the TEE.  I didn't know as much about my great-grandfather (he died the year I was born) before my appointment with the cardiologist but now have photos and more history that I can give my dr the next time I go in.  I also have an appointment with a rheumatologist soon to be evaluated for connective tissue disorders since I have some additional symptoms.

According to my cardiologist, the ACE inhibitor is so the heart doesn't work as hard and the beta blocker is to reduce palpitations (I think?) and I had a really significant "honk" when I went in to see him initially.  Also I had some ankle swelling (that I had not noticed before) which seemed to concern him.  (I was already on spironolactone for another issue.)

I was confused when the report said "unable to quantitate severity of mitral regurgitation" and then it said "moderate" and then TEE said "mild to moderate" and then I see a lot of other people reporting a number.  

I really appreciate that you all take the time to support this forum.  Thank you, thank you.

[Forum-M.D.-bkj]

bz,

thanks for the post.

Why would they not be able to tell more specifically about the level of regurgitation?

Echo is a noninvasive modality where you examine the heart from the outside. There are specific criteria to quantify regurgitation, however it is generally seen in a range. It sounds like they did quantify it as mild to moderate.

Would the fact that the left atrium is enlarged be more indicative of moderate regurgitation or just long-term regurgitation?

Atrial enlargement can be indicative of either. It can also cause regurgitation to be underestimated.

I have a family history of aortic aneurism (my great-grandfather and he looked Marfan-ish). Should I be concerned about the size of the aortic root or is it more usual for people to be at the upper end?

Marfan is a clinical diagnosis based on multiple findings and family history. Aortic dilatation does not in itself give a diagnosis (which you are not in the range). I would discuss this finding with your cardiologist in the context of your full history and physical.

What is 'mild focal thickening' of the structure of the aortic valve?

I would have to see the pictures to know. It again could be a nonspecific finding. I would want to know if it was seen or commented on the TEE.  

Currently I am taking a beta blocker and an ace inhibitor. Do they both seem necessary at this point?

I'm not sure why you are on them as they can be prescribed for a large number of conditions. It's impossible for me to make recommendations about appropriateness of medical regimens without fully reviewing your hitory.

Is it more likely than not that the regurg is progressive?

It can be in some. i would tend to repeat an echo in a few years or sooner if you noticed a change in symptoms.

Thank you for any information you can provide.


good luck