Shortness of Breath and Coughing after AVR

My biggest problems 2 months post-op are shortness of breath, improving slightly if at all, and a constant dry cough.

In October, I was Dx with aortic stenosis/bicuspid valve.  I had slight shortness of breath then, not troublesome at all.  I was prescribed metroprolol.  Shortness of breath was much worse; soon I was in the ER, feeling that I couldn't breathe.  In March, I had AVR with a xenograft, no problems.  But two weeks later shortness of breath took me to ER again, after which my surgeon Dx orthostatic hypotension and metroprolol was discontinued.  Disturbing shortness of breath has continued, with a constant dry cough (no more fever, pain in left side and shoulder are infrequent now--I didn't hear Dressler's or pericarditis from my cardiologist at the time, but the symptoms matched.  I had a low grade fever, but it has ceased, and pain in left side and shoulder is rare now, so I'm thinking if I had Dressler's syndrome, it may be much improved or gone.  But the shortness of breath continues at an uncomfortable level.  

Now, 2 mo. post-surgery, I am taking half a tab a day of Atenol, doesn't make breathing or cough better or worse but brings my heart rate down about 10 points for several hours.  I sometimes think the breathing is improving, but other times I think I'm just coping better after looking up and experimenting with breathing tricks of resp. therapists.  Mild exertion will bring on shortness of breath almost immediately, lightheadedness or dizziness, and occasionally wobbly balance on my feet, and will not abate until I rest.  At this time, my resting heart rate is generally below 90 (down to  84-82-80) and, I think, still dropping.  My bp is a little higher than before surgery, not much, up from my usual 115-118/70 to about 130/75-80.  

One thing that concerns me a little is that my O2 saturation runs around 96-97 but has been as low as 91, and once went to 89.  In my pre-surgery life, I never saw it measure below 98%.  I know these are not terrible numbers, but I don't know why it is happening and I don't like the trend.

My cardiologist holds out the hope that shortness of breath will improve after the ventricle wall normalizes, but I'm not sure he's convinced of that when he says it.  What other explanation is there?  It's hanging around so long it's getting scary.

Thanks for anything you can suggest.  I find that information is my friend in this ordeal--the more I know, the less I worry, so please throw at me any and all thoughts you have about this picture.

Thank you very much.

[ireneo]

Have you had a chest x-ray or seen a pulmonologist?

[mrwjd]

Yes, thank you.  I am fortunate my cardiologist is extremely well qualified and also proactive with testing and the like--and not a risk-taker with my health.  He doesn't hesitate to send me down the hall for EKG or x-rays or blood work at any appointment, and will tell me whatever I ask--so it's good to know what to ask..  

Problem with the shortness of breath and cough is that I gather it can have one or more of several causes, some of which are benign and some of which are not.  Since I see me 24 hours a day and he sees me every 3 weeks or so, and these two symptoms vary quite a lot and persist and haven't cooperated by being at their worst for him, I'd like to learn more so I know what to ask and what data not to leave out when I see him.

It seems the most benign interpretation is that shortness of breath and cough will gradually disappear over the past year or so, as the left ventricle resumes its normal configuration, but I see people still suffering from it after 2, 3 or more years, and I'd like to have a handle on what that means.

At the moment, I'm not as concerned about Dressler's/pericarditis because the other two major indicators (temperature and left-chest-and-shoulder pain) are diminished or gone, which is a relief.  But that leaves these symptoms unexplained, and if I am looking at pericarditis despite normal temperature and infrequent shoulder pain, sources suggest it should be treated aggressively to minimize the chance of its becoming chronic.  So that's kind of at the forefront of my mind when I'm not breathing well, which is a fair portion of the time.

Thanks very much for replying.  It's encouraging to hear back, and know that questions are being read and people are concerned.

[ireneo]

It sounds like you have a doctor that is taking an interest in your health and monitoring it closely. Sometimes a doctor will do a surgery, check you in two weeks and that's it, you're on your own. But it has only been 2 months and it's a major surgery. All I can say is keep your doctor posted and trust him to pick up on any problems. I wish I had the answers for you but I don't. I know it's frustrating to not breathe well and to feel off the norm. But hang in there. Hope there are better days ahead for you.

[Momto3]

Not sure about the shortness of breath, but is there any chance you are on a medication that could be causing the cough?  I think it's ACE inhibitors that are famous for producing a dry cough side effect.  I could be wrong on the type of medicine, but I am certain it is a cardiac medication.

[ireneo]

Yes, that's right. My Dad was put on them years ago and he couldn't stand the nagging cough. They changed his meds and he was fine.

[mrwjd]

Thanks very much.  That's something I hadn't thought of.  The shortness of breath was greatly aggravated by Beta blockers; I'll do some reading and see if they are similar or have similar side effects.

[mrwjd]

Wow!  Were you ever right!  I searched "ACE inhibitors side effects" and got pages of cites, including one titled "ACE inhibitors are nasty."  I was totally happy to see that I am not taking any of them, and I don't have the indications for which they are given (like high bp) so won't take them for the time being.  

Back to the drawing board.  

btw, Ireneo--I think you are right about follow-up.  I realized my surgeon's rule of thumb on follow-ups, unless there are surgical sequelae, is two, 1 week and 3 weeks after surgery.  I slipped in another at 2 weeks because I'd been in the ER with shortness of breath, and my 3-week appointment wasn't until 4 weeks because he would be out of town.  He's very charming during the appointments, and at the last one, he says, well, time to send you back to Dr. ---- (my cardiologist), kisses you on the cheek (only if you're female, I suppose), and that's the end of him.  

Can't blame him for moving on.  The fifth day, when I was leaving the hospital, his nurse-practitioner had a dickens of a time grabbing him for two minutes to look at me and sign the discharge.  That day, he had two scheduled open heart surgeries, and when I was leaving at almost 5:00, he had a heart coming in for transplant.  I heard later that he and his team got another heart later that night, sent a plane out from here for the second one, and didn't get out of OR until 6:00 a.m.  He has a great team, I think there were five Drs and med students plus nurses in the OR with me, but I'm still glad I was the first and not the fourth on my surgery day!  

I certainly wouldn't expect him to recognize me if he passed me on the street.
He is kind of the prototype surgeon, according to doctors I know--actually, more pleasant than many--happiest when he's got a scalpel in his hand and always eager to start cutting.  On the other hand, he has saved thousands of lives in forty years and just reached his 1,000th child (a couple of whom we know), so as far as I'm concerned, he could even be a jerk if he wanted to.  

My cardiologist is very nice and thorough and never seems in a hurry, although he's department head and must do a million things a day.  He'll happily tell me anything I ask, but doesn't give lectures about all the things that might happen and all the possible explanations of what is happening, and I like that kind of in-depth information.  So I try to learn what I can before going in, make a little list (try to keep it to 3 or 4 questions, but at my first appointment it was 15 and he didn't seem horrified).  I WOULD like a lecture, or at least a "laundry list" of possible reasons for shortness of breath and coughing, the only really troublesome symptoms right now, shortness of breath is really scary, so I'm trying to find out everything I can about them before my appointment in early June.

The cardiologist asked me last time, at two months, if I'm glad now that I had the surgery.  Kind of a no-brainer in my case, since I delayed as long as I could, and I think every doctor and med student who was in the OR stopped by my room to tell me that my valve was impressively NASTY.  Apparently I got the last possible mile out of it before the trade-in, which makes me happy because I don't ever have to wonder if I rushed into surgery--plus, except for this and some short-term stuff like low grade fever, everything so far has gone pretty much perfectly. I was interested, impressed even, that he (unlike any surgeon I've ever known, living or dead) actually inquired about how the patient is doing with all this other than physically.  

Anyway, have a good night, and if you think of anything else on this topic, please post it.  I'll be checking back.