moderately severe mitral regurgitation

[bings]

I am a 49 year old female with moderately severe mitral regurgitation 3+.   There is also mild tricuspid regurgitation present grade 1+.  I had rheumatic fever at the age of 5.    The mitral valve leaflets appear thickened but open well.    A somewhat eccentric posterolaterally directed jet of mitral regurgitation.   No cardiomyopathic process is evident.  The mitral annuylus is not dialated.    There is trace pulmonic valvular regurgitation present. The left atrium is mildly dialated. LVEF is 60-65%  E/E ratio 7.6
M.Mode/2D measurements and Calculations              
RVDd 1.5 cm     LVIDd 5.4cm     FS 38%
IVSd 1.0 cm     LVIDs 3.3cm     EDV (teich) 141 ml
IVSs 1.6 cm     LVPWd 1.0cm     ESV (teich) 45 ml
                LVPWs 1.6cm     EF (teich) 68%
EDV (cubed) 157 ml
ESV (cubed) 37 ml
EF (cubed)77%
SV (teich) 96 ml     Ao root diam   2.8 cm   asc Aorta 2.9 cm
SV (cubed) 120 ml    Ao Root area   6.o cm2
                     ACS 2.0cm
                     LA dimension 4.4 cm

LVOTdiam 2.1
LVOT area 3.4cm2

Doppler measurments and calculations
MV Emax vel  98cm/sec
MV A max vel  69cm/sec
MV V2 max 130cm/sec
MV max PG  6.7mmHG
MV dec time 0.18 sec
AOV2 max 162 cm/sec
Ao max PG 11mgHG

MR max vel 562 cm/sec  MR PISA 3.5 cm2          
MR max PG 126 mmHG     MR flow rate 127cm3/sec
                       MR ERO 0.23cm2
                       MR PISA radius 0.74cm
PA V2 max 84 cm/sec  
PA max PG 2.8mmHg    RAP systole 10 mmHg
I have SOB and definate heart fluttering and palpitations. IS it too soon for surgery? What should I be doing for this?

[renee in chicago]

Hi- My partner and I are meeting with a heart surgeon on Monday to schedule surgery to repair her mitral valve and an ascending aortic aneurysm with a dissection.  She already has an artificial aortic valve and because of the difficulties she has had with spontaneous bleeding of the subdural they don't want her to be on anymore coumadin so he doesn't want to replace her mitral valve.  If she wasn't having problems with spontaneous bleeding he has stated that he would replace the mitral valve. She is only 40 and has Marfan's syndrome, so he isn't recommending a biosynthetic replacement.

As someone that has gone through heart surgery more than once, are there any questions that you would recommend that we ask the surgeon?  Do you have any personal advice for her as she is very hesitant and scared to have a second operation?  Her last operation was twelve years ago and her recovery was difficult.  I appreciate any input, words of wisdom or advice you have to offer.

Thanks,
Renee

[DottyCece]

Hi

It is hard to say when surgery is best.  They use specifice criteria.  If you are symptomatic..with peripheral edema etc it may be time.

I have just had my mitral valve replaced for the second time in 11 months.  When I originally presented, I was in Atrial Fib, uncontrolled.  They will probably want to know about your palpitations.  That can indicate geater irritation etc in the LA.  I didn't see a RA dimension but the 4. something is not too bad.  If you have surgery, inquire about the maze procedure.  I had a modified one last time and this time I had the pulmonary vein isolation approach.  I am now on my intrinsic rhythm with pacer backup only and seem to be coping well with it.   To not be pacer dependent was alway a goal I had but they were not optimistic because of my biatrial enlargement and scarring that was already there.  

I also had a ring placed on my TV valve this time and ablations in the right atrium for the atrial flutter. I have been plagued with the futter and periodic atrial fib(cardioverted 7 times in less than a year) So far all is going well just have to mend and get my strength etc back.  I ended up with a whole groups of new Doctors, surgeons and cardiologists.  It worked out wel but I had to be the advocate for myself.  It is unfortunate but I am sure there are many people who would not have known what to do and how to navigate the complex health care system we currently have.

[Cleveland Clinic]

bings,

thanks for the post. It really is impossible to distill the raw numbers from your echo into recommendations about valve surgery, as looking at the numbers is like looking at a paint by the numbers painting.  You really need to look at the painintg to understand the big picture.  More importantly you need to look at the patient.

Your EF and pulmonary pressures are normal, as are the dimensions on your echo.  However you are having symptoms which could easily be the regurgitation.  I would think you have a couple of options.  

You could follow serially your echo, looking for signs of damage or progression of the regurgitation over time while trying to maximize your medical therapy with vasodilator therapy (eg ACE inhibitors). There is nothing wrong with this approach.

Another option would be to try a stress echo to examine the contribution of your MR while active, which could be much worse.

The main issue is the mechanism of the regurgitation and the type of repair or replacement of the valve that might be needed. An isolated mitral repair in the hands of a skilled surgeon has little long term risk.

Either route, I would make sure I had the procedure in a facility that does a large number of procedures a year.  If there is any concern, there is nothing wrong with seeking a second opinion.

good luck