Speaking of ejection fraction

Posted by Tom on July 24, 1999 at 15:06:02
About 6 1/2 years ago, I underwent an AVR and received a St Jude mechanical valve. About a year ago, I contracted "shingles". Subsequent to apparently a full recovery, I underwent a battery of tests and it was discovered that I had a small growth on a parotid gland. Although it was anticipated that the growth was benign, it was recommended that it be removed. There was no indication that any of my symptoms, which included fatigue and what I perceived to be minor shortness of breath, were related to any one condition. I should mention that I had been an extremely active 51 yos male (golf& tennis) prior to the onset of the "shingles" and these other symptoms. The growth was removed about 3mos ago, and was in fact benign.
What causes concern is that prior to this operation, I needed "clearance" from my cardiologist. I was directed to undergo an "echo" exam. Several days later I met with the cardiologist at his office, where he gave me a cursory physical and then in my presence dictated a letter to the surgeon that was going to perform the "growth" operation. Included in the recommended protocol covered in the letter was the weaning time for coumadin, and the administration of antibiotics and heparin. In addition, he provided other information which included  BP: 130/70, EF: 45%, and mitral valve regurgitation.
Quite frankly I was stunned. I was surprised and dismayed by his mention of the EF and mitral valve regurgitation. It was the first I had learned of these conditions, although he has been monitoring the condition of my heart on about a yearly basis. I attempted to elicit answers to questions about whether these were new conditions and/or were a result of the AVR, and should I be concerned.  Although this cardiologist has an excellent professional reputation, he has the bedside manner of Attila the Hun. He curtly stated, " You don't want me to recommend heart surgery before you have a tumor removed, do you?", and then summarily dismissed me. Without exaggeration, this was the sum total of the answers to my questions. He didn't even recommend that I make an appointment to see him some time in the future.
(If someone ran a hardware store with this attitude, they'd be out of business.)
I have several questions:
Is the EF and mitral valve regurg. a usual result of the AVR, or would you guess this is a new condition?
I have asked my GP, who doesn't appear to know, but suggests that the measurement of the EF may not be precise. If that is the case, doesn't it beg the question, could it be 40%?  With regard to the mitral valve regurg., my GP suggests that it is probably minor, and nothing to worry about.
Finally, after over seven years with this cardiologist, I am at the end of my rope with the manner in which he treats me, and my understanding is others too. It seems rather silly to me that I am posting these questions here, when I think he should provide such answers. Instead of getting a straight answer from him, no matter what I ask, I am left with doubt and anxiety. I have mentioned this to my GP and have told him that I am ready to dump this guy. My GP discourages me from doing this because of the cardiologists standing reputation, as well as the fact that he has extensive understanding of my condition and history.  As much as I can appreciate these facts, how good can a physician be if patients leave feeling worse after seeing him than before, albeit psychologically? Should I dump this guy?
I am really "ripped". Thanks in advance for your answers, and providing a forum to vent.      


Posted by CCF CARDIO MD - CRC on July 26, 1999 at 09:19:33
Dear Tom,
Q: Is the EF and mitral valve regurg. a usual result of the AVR, or would you guess this is a new condition?
A: This is not usually a result of valve surgery.  Depending on the degree of mitral regurgitation would determine the treatment.  Mild or moderate regurg needs nothing done whereas severe regurg may require surgery.  The ejection fraction is only mildly decreased and should be followed but is not of major concern.
Q:I have asked my GP, who doesn't appear to know, but suggests that the measurement of the EF may not be precise. If that is the case, doesn't it beg the question, could it be 40%? With regard to the mitral valve regurg., my GP suggests that it is probably minor, and nothing to worry about.
A: While it's true that it is not percise it is within 5% either way so it's within a range of 40-50%.  By the way normal EF is 50 - 60% so yours could even be on the low side of normal.
As far as your cardiologist, I would vote with your feet.  A doctor's reputation dosen't matter if he can relate to his patients.  Another cardiologist can easily take over your care.  Best wishes and feel free to write back.
I hope you find this information useful.  Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies.  Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.  The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.

Posted by Tom on July 26, 1999 at 15:44:04
Thanks for the comments. In my rant I failed to mention another issue my cardiologist casually mentioned. I *guess* (as opposed to *know* because of the white coat syndrome he creates) he said the mechanical valve showed signs of calcification. I didn't know this was possible. I thought I had gotten rid of the calcification along with my bicuspid valve, and would avoid further calcification with a mechanical valve as opposed to some other "bioprosthetic?" valve. Might I have not understood him correctly? If I did understand, and it is calcifying, might this cause the apparently minor EF problem? If so, might it get worse?  

I think I'm now asking you to speculate on my guess as to what I heard my cardiologist dictate in a letter to another doctor. Not to beat a dead horse, but I think I will vote with my feet.  However, it seems to me that doing so is exactly what he dares one to do. These are my words, but the sense that I get is..... if you don't like the way I "treat" you, you're more than welcome to go elsewhere. I have more patients than I need, it's your loss, not mine. (I've decided I'll take my chances.)
BTW, it isn't necessary for you to address this later issue any further. However, an answer to the the former would be greatly appreciated.
Thanks again for your valued comments.
Posted by CCF CARDIO MD - CRC on July 27, 1999 at 08:54:21
Mechanical valves don't usually calcify so I'm not sure entirely what your doctor meant.  When (if) you change doctors be sure to obtain copies of all your records and reports.  Best wishes.
I hope you find this information useful.  Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies.  Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.  The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.
Posted by Lori on July 27, 1999 at 15:27:18
Knowing that Doctors as well as patients are under a lot of stress these days with all that is going on in health care my question relates to relating to our cardiologists.
I had concerns which this forum addressed in a very kind, supportive way.  I wanted to discuss the suggestions given in this forum as well as other information I had uncovered with my cardiologist.  When I attempted to broach the subject he got very upset at me.  As a cardiologist yourself (though I know every dr/person is different and no one approach will work for all), what is the most benign way a patient can approach you and your collegues that will not make the doctor feel threatened and that will result in the patient not feeling he has been bludgeoned for asking a question?  As patients there is a lot we don't know about the body in general and we may misinterepret data when we attempt to research things ourselves however, no body knows our bodies better than we do.  Healthcare should be a partnership/symbiotic relationship between dr. and patient.  If you don't mind offering a few suggestions, what can we do to help the partnership along and to prevent having the experience described in the original message of this thread?

Posted by CCF CARDIO MD - CRC on July 28, 1999 at 10:48:35
You raise some interesting questions and some which I am sure many others will have comments on.  Let me say for myself I feel the doctor has the primary responsibility to make sure all of a patients questions and concerns have been addressed. Whether this is done all at once of by suggesting a follow-up visit or discussion with the nurse or PA is up to the doctor.  Also there is never cause for a doctor to be rude or to allow personal feeling to cloud clinical decisions.  As you point out, doctors are under tremendous pressure from insurance companies to see "routine" patients in very short periods of time but this does not excuse them from their primary responsibility to the patient.  
As for what the patient can do these would be my suggestions: 1) Try to learn as much as possible about your condition before visiting the doctor - be it from the reliable sources on the internet (for example Medhelp), medical books, or friends  Also be careful not to believe everything you read or hear. 2)Write down your questions and concerns in order of importance before you go to the doctor. Then pick the top 2 or 3 to discuss at the visit.  Even the most patient doctor may be a bit taxed with a dozen questions all at once.  Remember you can make return visits.  3) At the very start of the visit tell the doctor you have some speicific questions you would like answered. 4) Jot down some notes as he discusses the questions with you.  5) Be patient.  Remember that most medical issues are complex and there may not be a simple answer.  This is why medical training takes so long and the reason people consult doctors.  You are paying a physcian for their time and advice.  You don't necessarily need to know the minute details of the decision.  Sometimes just the explaination that their they feel this is the best course of treatment should be adequate.  This is where you need to have trust in your doctor's judgement and advice.  If you don't agree you can always ask him to send you for a second opinion, which most doctors are willing to do.  And finally remember that doctors are only human with all the faluts and weaknesses that come with that.  Doctors can have bad days and sometimes a smile and letting them know you appreciate them will go a long way.  Finally, as I have said before in this forum, if you are not getting answers from your doctor it's time to find a new doctors.
I hope you find this information useful.  Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies.  Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.  The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.
Posted by Lori on July 29, 1999 at 17:23:41
Thank you so much for your genuine, thoughtful and helpful response.  I appreciate it very much!  :)  (The best smile I can do in this venue) ;)

Posted by CCF CARDIO MD - CRC on July 30, 1999 at 09:54:27
Just some of my thoughts.  I would love to hear what ideas others have on this subject.
I hope you find this information useful.  Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies.  Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.  The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.