ejection rate expectation following surgery

My 69 year old husband had surgery for a mitral valve repair and aortic valve replaced with an On-X valve on July 29, 2009. His ejection rate is 25% and the cardiologist wants him seen by as specialist to consider a biventricular pacemaker with defibrillator. He had indicated that he has left ventricular cardiomyopathy that might be a separate condition and not secondary to the valve issues. He also has left bundle branch block. My husband had surgical complications as well as anemia and is an asthmatic and so I am concerned regarding invasive procedures. Our GP has just put him on some supplements (d-ribose, magnesium, Co-Q 10, L-carnitine) as the cardiologist doesn't "deal with those sorts of things" and didn't know about them to even discuss their value. He is on Coreg, Lisinopril, Coumadin, 81 mg aspirin and Advair along with fish oil, vitamin D. My husband is slowly recovering his functional skills though, as expected, fatigue and shortness of breath with a certain level of exertion persist. I should add that in Oct. of 2008 this man worked 3 1/2 -4 hours lifting and splitting wood so that the functional impact of all of this has been astounding. I guess my questions would be: 1. What would be the expected time for recovery to see the full impact of internal healing? 2. How long before the impact of the supplements should be apparent? 3. How long has this device been used and what is the complications/issues with it? We are meeting with the specialist on Tues. and want to be prepared. Also if there are recommended readings or sites about this device, it would be appreciated. Thank you, Jane

[kenkeith]

I take the same medication your husband is taking, and I had a low EF (13-19%) 5 years ago and currently it is normal at 59%.  The low EF can be attributed to an enlarged left ventricle, and the medication helped reduce the heart's workload and the there was a reversal to the remodeling of the LV to a normal size.  It took about a year and shown on a subsequent echocardiogram.  An enlarged LV can also cause arrhythmias, but I never had a pacemaker.  There are other medical problems and that may or may not be an issue.  

[Janerww]

Thank you for your prompt response and encouraging words. Funny, it is like you anticipated my thoughts ..........I woke up thinking and wondering about heart remodeling post surgery ....... have only found one article to date on it. Could you tell me how long it took for those rates to climb? He has been on Coreg for about 10 months, Lisinopril (previously Benazepril) just recently. We have asked for another echocardiogram to measure ejection rate. We knew that there was interrater reliability issue with this test, but were shocked to learn that when the doctor reads these, he does so by visually estimating the action of the heart! My husband wants to wait for several months to see the effectiveness of the supplements. Fortunately we will be meeting soon with our GP, who is wonderful about putting everything in perspective.

[kenkeith]

Yes, all dimensions are estimates, and there is probably a marginal error of about 5%. There is another test that can be done that helps evaluate the heart's functionality and that is fractional shortening.

If you have your echo report, it will show left vetricular end diastolic dimension (filling capacity)  and left ventricular end systolic dimension (after pumping size).  The calculation is made by obtaining the difference of the two parameters and dividing left ventricular end diastolic dimension and that would be the fractional shortening.  Above 30% is considered normal, and 26 to 30% represents a mild decrease in the EF.

Your doctor may be observing the heart wall movement.  If there is some damage to the heart wall, it can be seen as an impairment to wall movement and a decrease in EF.

[Janerww]

Thank you for explaining how the ejection rate is determined by echo ...... both my husband and I found your explanation clear and concise. I have been trying to immerse myself in reading about reverse remodeling and the biventricular pacer. My husband had complications with his valve surgery and I guess I am so reluctant for him to have another body invasion. On the other hand, the understated message from the cardio about a pacer with a defribillator gives me pause as I have read that people with his ejection rate are at risk for sudden death. Hopefully the next echo will show an increase in his rate. Any thoughts about sites/articles to read on this? Your help is very much appreciated.