Valves and Atrial Septal Aneurysm

[strawberry66]

Hi!  Some background:  about two years ago I had a lot of palpitations which I ignored.  Then a GI doctor told me I had an "extra beat." (English was not her first language).  She sent me to the cardio and the echo said I had a myxomatous mitral valve and mild aortic regurgitation.  Another echo six months later showed the same.  My cardio felt the aortic valve regurg was from a myxomatous process also.  My recent echo showed:  Normal mitral valve with trace regurg.  Mild aortic valve regurg.  Atrial Septal Aneurysm with no obvious shunting.  I don't see the cardio til December.

1.  How do I know which echo is correct regarding the mitral vavle?  Going from myxomatous to normal is unsetting; this is the valve which was most worrisome.  The nurse I spoke to said it was due to better technology and the way it was read (?).

2.  All the echos said the aortic valve is tricuspid and normal in shape.  If I don't have the myxomatous disease, are there other tests I should have to find out why it is leaking?  The only other issue in that area I have had is a PDA which was ligated and tied off 30 years ago.

3.The atrial septal aneurysm is a new finding.  It says it is bidirectional.  Given the aortic valve regurg, or even just because it is there, should I have any other tests to rule out a PFO or an ASD?  The tech did not have me strain while doing the echo.  I have read that the ASA is not a big deal but is sometimes related to strokes or tia's if there is a PFO also.  My cousin had an ASD.

Thanks for your help.

[strawberry66]

I don't know what happened to my comment.  It was just to say thank you for your thorough and kind answer.  I'm a 5'3" female so Marfans is doubtful.  My aortic root measurement is normal.  I recently found my records from my 1968 repair when I was 2.  The PDA was 8.0mm by 0.6 mm so it was short and fat.  Hopefully the AI is just an associated or resultant regurgitation and will stay mild.  Thanks!

[Cleveland Clinic]

1.  In the 80's and the 90's many patients were diagnosed with myxomatous mitral and aortic valves.  They had to be on antibiotic prophylaxis and were getting a lot of unnecessary work-ups.  Later, we learned that there was a lot of over-diagnosing going on and that many of those "myxomatous" valves were, in reality, normal variants.  With better echo technology and better defined diagnostic criteria we sometimes reverse the diagnosis of myxomatous valves.  Someone who is experienced in reading echos should probably look at yours.  There is nothing wrong with getting a second opinion.  You should first talk to your cadiologist and see what he thinks of the new echo findings.  The fact that you have trace or mild regurgitation is definitely good and there is nothing that needs to be done at this point.  Therefore, it's ok to wait until December.  

2.  The most common causes of aortic regurgitation are related either to the valve itself or to the aorta.  It sounds like the valve is normal, there is not history of endocarditis and you don't suffer from any connective tissue disorders.  One should definitely look at the aorta on the echocardiogram to make sure that it is normal in size.  Typically, we always want to rule out Marfan's disease and other connective tissue disorders if the aorta is not normal in size.  Having a PDA has been linked to aortic regurgitation.  This is probably just an association.  However, PDA closure has been reported in the past to cause mild aortic regurgitation.  The larger the PDA and the larger the shunt fraction before PDA closure the higher the risk of developing aortic regurgitation.  That may be the reason why you have aortic regurgitation now.  It is possible that you have had this for a long time and the fact that it has not progressed means that your prognosis is very good.    

3.  ASA means that you have some redundant tissue in the interatrial septum.  PFO's can be linked with that but as you said earlier are typically very benign and the association between PFO and stroke really isn't that well defined.  One out of every three individuals has a PFO.  If stokes were tightly linked to PFOs, we should see many more stokes given how prevent the PFO is.  Thankfully, we don't.  There really is not nothing to be done at this point, even in the setting of aortic regurgitation.  Obviously, if you did (God forbid) have a stroke in the past and there was no clear explanation as to why it happened, PFO would be the next thing to consider.  Since you have a very visible atrial septum that is aneurysmal and appears as a bidirectionally mobile structure, the likelihood that you have an atrial septal defect is very unlikely.  ASD means a partial or complete absence of the atrial septum.  The size of the defect may vary.  Yours is there and is actually quite redundant.  The fact that it moves in both directions makes me suspect less that there is a large defect in it.  The next time you have an echo have them do a bubble study.  There is nothing that needs to be done at this point.  Overall, I think you are in very good shape.  Don't let any of this get to you.