Sensitivity of TEE to assess Heart Valves

[kayl]

This is my third post concerning my Rheumatic Heart disease.  In short, I've had three heart surgeries on my mitral valve. Commissurotomy, mitral valve repair, and replacement.  I have a-fib, and had an AV node ablation and am pacemaker dependent since 1999.  In 2003, an echo showed increasing heart pressures, which were recently confirmed by a Right Heart Cath in December.  The Cardiologist felt that the aortic and tricuspid valves needed to be taken care of.  I had a TEE to gather more information.  The good news was that the valves were felt to be okay, in fact the mitral valve is better than it was when new in 1990.  I have a few lingering doubts.  I have not heard my mitral valve click in over a year.  The doctor who was to perform the heart cath thought I had a pig valve, (I have a mechanical St. Jude valve).  I am worried about the mitral valve because of the apparent difficulty the surgeon had in replacing the valve.  The operative note stated that "the valve was excised including the chorda tendinae down to the tip of the papillary muscles.  Posterior leaflet was left in partially and the minor chorda up against the ventricular wall were left in place.  Also I left a markedly scarred and matted papillary muscle and chorda in the posterior medial commissure area attached to the posterior leaflet.  This was stuck to the ventricular wall and would have been hazardous to try to excise."  The Transesophageal echo was done while I was on my back because of left arm pain.  How accurate is a TEE in assessing heart valves?  Can increased pressures be from other than valves?

[Cleveland Clinic]

kayl,

thanks for the post.

Rheumatic heart disease can cause scaring of the entire apparatus of the valve. This includes the leaflets, the cords of the valve, and the muscles surrounding the valve.

Don't focus as much on whats left of the valve and what it took to get the old valve out.  Focus more on how they are working now.  TEE really is the gold standard to assess the function of prosthetic valves, especially when the trans thoracic images are not optimal.  However, pressures measured by echocardiography can sometimes be misleading, because they are based on flow and not actual pressures. Direct hemodynamic measurement with catheterization can substantiate these measurements when there are doubts.

Im not sure where the pressures you mentioned are elevated and can not comment specifically if they are related to the valve. If they are elevated in your lungs, ie pulmonary hypertension, then there are potentially some other causes of this besides valve itself that should be evaluated.

hope this is a start

[Rick9897]

It has always been my understanding that the TEE is the most accurate as long as the person doing it is an expert.  The probe is placed in the esophagus and stomach very close to the heart.  You don't have the bones and muscles etc in the way.  Your pressures could be up for other reasons.  Do you have any lung diseases?  How old are you>   At the time you had your mitral valve repaired/replaced, did you have a repair of your tricuspid at the same time? And, did you have a maze procedure in your atrium to treat the atrial fib?  You should feel reassured with the TEE that your mitral valve is working well.  I have an artificial mitral valve well (carbomedics) and I can hear it most of the time.  There are times when I don't notice it all.  I too have a pacemaker but I have adamantly refused an AV nodal ablation.  That is way too permanent for me.  With the pacemaker though, I can feel mode switches and I can feel a very heavy pounding heart sensation.  My pacemake will sometimes pace other muscles within me..which is a very bizarre feeling.

[kayl]

No, the tricuspid valve was not replaced or repaired.  I am concerned with not hearing the clicking of the prosthetic valve because the sound was loud until about a year ago.  My husband could hear the click also.  It was very comforting.  I guess I am worrying needlessly.  I don't have lung disease, but one of the pressures which was increased is the pulmonary artery pressure.  Anyway, thanks for your response.

[Rick9897]

I am not an expert (just had lots of experiences) but I would think one wouldn't wait for left ventricular enlargement to determine when surgery would be indicated.  It would seem to me that surgical outcomes would be best with normal ventricles etc.  My philosophy is to do it before one develops high markers for risk.  Decrease in EF etc. can't be a good thing.  I never had a TEE before my valve replacement.  They estimated the mitral regur at moderate to severe per transthoracic ECHO.  But, since surgery I have had two transthoracic ECHOs and one TEE.  I will have another TEE next week.  The TEE is by far a better diagnostic tool to evaluate valvular problems.

[Momto3]

What a great question for us "valvers".  An annual echo a few years back suggested it was "time" for surgery, so a TEE was scheduled to get a closer look.  I was a wreck!! Luckily, the TEE revealed moderate MR (2-3+), normal LV function and no LV enlargement (4.3cm). I was not a candidate for surgery. Needless to say, I was very happy!!  

It is my understanding that the TEE is considered the "gold" standard for valvular evaluation, but normally an echo can get the job done.

[TL]

I would definitely go to the Cleveland clinic for an evaluation.  I was basically in your same condition a few years ago with no symptoms but opted for the surgery.  My EF initially went down from 55 to 43 after the surgery. This is not uncommon because the EF can be artifically high before the surgery because the heart is only pumping the blood back to the atrium instead of through the body.  My EF eventually came back up to low end of normal (50+) after the surgery, but I would not have wanted to wait any longer.  I think any indication that the heart is starting to weaken is a sign that surgery should be considered.

[kayl]

It is good to see that there are so many others who are confused about valve issues.  (The best time to try to post now is between 8:30 and 9:00.) Good luck, I'd like to read the answer to your proposed question. Rick, good luck with your TEE also.  I hope your valve is ticking along properly.