Echocardiograms

[Konopka1955]

Hi Doctor,   I have a couple questions if you would be so kind as to answer.

1.  My doctor has told me that I will need mitral valve surgery when my left ventricle reaches 55 mm.  Right now I'm at 51 mm.  50 % leakage, prior MI, ICD inplant - EF 50%.  48 year old female.  

2.  I have no confidence in the echos for determining surgery 'time'.  Can you think of a test that is second best?  

3.  Do you know of a good book or two that I could read that would give me a good explanation - detailing 'how' the heart functions in regards to enlargements and alot of information on mitral valves and echos that would 'help' me to better understand the necessity of this test and surgery without symptoms?  Just reading the guidelines doesn't really explain enough - as how do you know if 55 mm is too large for that patient and surgery should be sooner - or 55 is 'fine' and 60 mm would be more of an appropriate time to have surgery.  I could go years on 55 mm.  

I hate living 6 mos echo to 6 mos echos always wondering if I'm going to have to have surgery.  Its like my life is on HOLD..  So I'm refusing future echos until such time as I feel symptoms.  

I would think that since there is not much difference between 55mm and 51mm 'why' are we waiting for 4 lousy points.  If its so important to catch it before it gets too large then why wait any longer.  

4.  Would 'delaying' surgery from 51 mm to 55mm make it more difficult to do a repair?  In other words does the size have any determining factor in whether the patient gets a repair vs. replacement?

Thanks
Konopka

[mari16]

i have mitral valve regurgitation diagnosed from an echocardiogram testing. my doctor wanted me to start on high blood pressure meds but i am fearful of this. also it is lisinopril and low dose and not sure if this is a beta blocker like i read about for the mitral valve regurgitation problem. i went for 2nd opinion but was the docs collegue so i don't see how he can make a decision if just reading same info as that doctor i first saw.I am scheduled for Mayo clinic soon and will ask that doctor about the heart meds & thyroid  meds & if I realy need to take  them. I heard that sometimes the meds can cause heart attacks too because of too low a bp going on then. I have no palpitations or anything and just get the extreme fatigue and tired feeling and somewhat lack of oxygen when laying down. This could be from my nasal congestion and sleep apnea and gerd i have going on also. I take pills for the gerd and use the nasal strips for sleeping now too. The nasal problem includes a nasal polup that has never been taken out or drained. They had done blood work and found low thyroid but when redoing the blood test they found it was ok...I did not start the sinthroid meds for this either as i do not have any symptoms for it except weight gain and tired feeling which could be from something else going on. The problem I am being seen for at Mayo Clinic is urethral blockage and incontinence and so hopefully they will find something to fix this problem. I have had two recent surgeries to try and get rid of the scar tissue and blockage with no results. I believe i may have beginning of kidney disease and get the left sided flank pain kidney colic also at times. I wake up at night frequently and have to urinate and small amounts...other times i have frequency with little urination or not frequency and backing up into bladder with swelling and edema in legs etc going on. The urethra gets blocked to point of needed catheter to drain the bladder and ill feelings from this blockage....My question is this....Could the blood pressure and its not always high be caused by the urethral blockage? Could the thyroid test be incorrect due to this serious medical condition going on? Once they repair the urethra blockage possibly with surgery will the blood pressure be normal and also the thyroid? How do they know the pituitary gland would not be the cause here or menopause that I recently went into? I have no menopause symptoms at this time and am not taking any supplements...Wouldn't hormone therapy for menopause help the blood pressure/thyroid problem also without heart or thyroid meds taken? Also could endometritis be the culprit here with the scar adhesions going on and the blockage? I had many gyn problems in the past and surgery to remove an ovary with large cyst and a small cyst on remaining ovary...And left with fibroids in the ueterus and swelling to a very uncomfortable level also here...i have read fibroids could cause this blockage and also other problems with hormonal levels flucuations etc etc....thank you. I also have a gallstone in gallbladder which one doc said he would remove then changed his mind. After surgery I got ill with pancreatitis and had the breathing problems shortly after this as well. The last surgery I had problems breathing right after surgery in the recovery room and they gave me oxygen so maybe is why my urology doc is hesitant to do surgery again to fix things here and is sending me to the Mayo Clinic. Thank you for any answers in this. Mary

[TL]

I was in your same situation about four years ago and decided to do some research on my own and concluded that it is better to error on the side of surgery.  I am glad I did.  I did not have any symptoms and my EF was about 55%.  My doctors were concerned however with the change in size.  After my surgery my doctors said that it was good that I got the surgery when I did.  If I would have waited it may have been to late.  I think you have a lot to lose by not having the surgery and a lot to gain by having it.  My EF went down to about 42% and then went back up over time.  If I would have waited longer it may have not come up and I may have gone into heart failure. Based on my experience, I would go immeditately to the Cleveland clinic and do whatever they recommend, your life may depend on it.

[Cleveland Clinic]

Konopka,

The main problem with Mitral Regurgitation is that there isn't a 100% way to evaluate the overall effects of the leak on the ventricle until there are concrete visual changes that indicate damage is ongoing (ie..LV dilitation, EF impairment) or changes in your overall functional capacity.

One reason for this is that the MR allows the ventricle to beat well because of the decreased resistance the ventricle pumps against as the blood flows both backward and forward.

We use changes in ejection fraction and dilitation as markers.

As far as your questions go:

1) again there are no perfect test.  I'm assuming you have at least moderatly severe MR. One option would be to do exercise echocardiography and look for dilitation, LV impariment, dilitation, or elevation of your pulmonary pressures during exercise. It would also give you more of a concrete baseline to follow over time.  TEE can also give a better idea of the severity and mechanisms of the MR.

2) The books I use are mainly written for cardiologist. A good web search for sites detailing valve repair, our web site, and some of the sites by valve manufacturers may be a start. Other medical text include Topol's text on cardiology or Ottos text on echocardiography. You might look in the library for a few ideas.  As the heart enlarges, the strutural ring that holds the mitral valve also becomes more dilated, making replacement or repair more difficult.

3) Don't place your life on hold. Live it up. That's the reason for the echos. Truly, if you have bad MR and want to go ahead and get the repair/replacement done so your not 'waiting around' your overall risk is exceedingly low if done at a center that does a high volume. For isolated replacement our mortality has been essential 0%. Other high volume centers may also approach this benchmark.  It may help to get a second opinion to confirm timing of the surgery, and help ease your mind. Refusing echos will impair your docs ability to catch subtle changes in your hearts function until it may already have permanant damage.

4) 4 lousy points represents structural changes in the heart. It really wouldn't be the actual size that made me determine timing, it would be more of a trend. Thus if you started a 45 and progressed to 51 over a short period then it might be time now.

5) Again, size has some impact as does the mechanism of MR and the strutcure of the valve and its apparatus, and the experience of the operator. Our e consult site allows you to submit your records for review. that might be a start.

I hope this is a start.

good luck