Valve Gradient

[brandyjob]

I've had my aortic valve replaced with a medtronic hall 22 in 2001.  Last year November, I had the medtronic valve replaced with a carbomedics valve and aortic root graft.  (my aortic root is very small).  Last week, my echo showed a mean gradient of 51 and a peak gradient of 82.  What are my options?  Is heart transplant the only option left?  I'm becoming symptomatic.

[brandyjob]

Thanks.  The valve is functioning fine and the graft does not appear to have a kink.  The gradient is up quite a bit since April.  My cardiologist believes I have a mis-match and she is exploring options at Mayo, Cleveland, and Toronto, where the most cutting edge replacements are being done.

[Cleveland Clinic]

In our institution we do perform third open heart redo operations, if this is indicated. What is the mechanism for the increase in gradient? Was the valve undersized ( valve-patient mismatch), or is the valve malfunctioning, or is there a growth around the insertion of the valve. And you have to remember that prosthetic valves show a phenomenon called pressure recovery, simply because of the non laminar flow around the 2 metallic leaflets, which cause a low pressure in front of the open orifice, and which causes an overestimation of the gradient (using continuous wave doppler) through the valve. This is very technical, but the actual numbers don't mean as much as an increase in the doppler gradients. If they are indeed increased, then it still may not be the valve itself: if undersized and in the setting of tachycardia or anemia your gradients will increase simply because of increased cardiac output.
In other words, this is a complicated matter, and requires a valve specialist to fully assess your functional class and symptoms, physical exam and results from the surface echocardiograms you have had in the past. We have several valve specialists in our institution because of the high volume of valve surgeries performed here. Only then can a cohesive plan be made, which may include re-do open heart surgery, escalation of medications or indeed initiation of heart transplant evaluation.