What is Aortic Stenosis
Aortic stenosis is the medical term used for a tight aortic valve. The aortic valve is the valve through which blood leaves the heart. A tight valve means greater stress on the heart and less blood to the body. The body needs blood to survive and the heart is responsible for pumping blood around the body. The main pumping chamber of the heart is called the left ventricle. Every time the left ventricle beats it pumps blood out to the body. To leave the heart though, the blood has to go through the aortic valve. The aortic valve is like a door that opens to allow blood to exit the heart and then closes to stop blood from leaking back in. In aortic stenosis the aortic valve is tight and cannot open properly. The tight valve means it’s harder for blood to leave the heart to reach the body where it is needed.
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The aortic valve opens well on this echocardiogram. In this video, you are looking directly at the valve.
The aortic valve opens well on this echocardiogram. In this view you are looking at the valve from the side and blood is flowing from the left ventricle through the valve (from left to right on the image) and into the aorta.
How Does Aortic Stenosis Affect the Heart?
Significant aortic stenosis is a stress on the heart and can lead to symptoms and heart failure and when severe enough can lead to death. As we said above, the aortic valve is like the door that blood has to go through to get to the body. Imagine that door hardly opened. The body would still need the same amount of blood but the heart would have to work much harder to pump the blood through a tight valve. The heart adapts to this over time and the heart muscle becomes thicker, much in the same way a bodybuilder gets bigger muscles as they life heavier and heavier weights. Unfortunately a thick heart muscle has negative consequences. The heart that used to be able to fill with blood now finds that more difficult because it is so thick. This leads to congestion, and congestive heart failure. The pressures generated by this thick heart are very high, as this is required to allow blood to leave the severely tight valve and reach the body. This may lead to passing out and potentially fatal heart rhythms. Also at some point, the heart will be required to generate such high pressures that it simply gets overwhelmed and fails. At this point the pumping function of the heart can seriously deteriorate and the heart becomes very weak.
What Happens to the Valve In Aortic Stenosis?
In most cases of aortic stenosis the valve becomes thick and full of calcium which can result in severely restricted valve opening. Decades ago rheumatic fever was the most common cause of aortic stenosis. Rheumatic fever is now rare in the Western world but aortic stenosis is becoming more and more common. This is because people are living longer and longer. Over time the aortic valve is subject to damage and degeneration, wear and tear, almost like joints are more likely to pose a problem in the elderly. This degeneration of the valve results in a process called calcification, which is basically build up of calcium. This calcium build up causes the valve to become less and less mobile, restricting the ability of the valve to open. In severe aortic stenosis, the valve leaflets hardly move and the valve becomes very tight.
When Aortic Stenosis Becomes Dangerous
Severe aortic stenosis is dangerous, particularly when symptoms develop. Mild aortic stenosis, or aortic sclerosis is not a problem. The heart usually handles moderate aortic stenosis well unless there are other heart problems going on. Problems typically develop when there is severe aortic stenosis however. Although in many people the heart can handle severe aortic stenosis well for a while, at some point the stress will become too much. When patients with severe aortic stenosis develop symptoms or show signs of heart weakness, it’s time to do something. This is because the combination of severe aortic stenosis and symptoms results in a significantly reduced life expectancy. At this point it’s clearly time to fix the valve. Once chest pain, passing out, or heart failure develop, patients with severe aortic stenosis are not likely to survive more than a few years unless the aortic stenosis is treated.
Signs and Symptoms of Aortic Stenosis
Symptoms of aortic stenosis include fatigue, shortness of breath, chest pain, feeling dizzy and passing out. It’s rare to develop signs and symptoms of aortic stenosis unless the degree of aortic stenosis is severe. Commonly patients may presents with fatigue, the tight valve means it’s difficult to pump the amount of blood the body needs. Fatigue may mean slowing down, reduced levels of activity, or just less energy. Tasks that patients used to do may be much harder. Shortness of breath is another common complaint from patients with severe aortic stenosis. This is a sign if congestive heart failure. There may be swelling also. The high pressures generated by the heart in response to the tight valve may lead to chest pain, particularly on activity. Some patients experience passing out spells; this may be due to dangerous heart rhythms.
Grading Severity of Aortic Stenosis
Grading the severity of aortic stenosis can be challenging and best results are seen from dedicated valve specialists.
Requires Expertise
Although there are criteria for diagnosing aortic stenosis its important to realize that decision making in patients with aortic stenosis is complex. The tests used are not an exact science. Often tests are not accurate and a number of factors need to be taken in to account to come to a conclusion. Many patients with severe disease are misclassified as being less than severe. In the same way some patients have their symptoms attributed to aortic stenosis when in fact the valve is not the issue.
Normal Aortic Valve
As we stated above, aortic stenosis is a tight aortic valve. Every time blood leaves the heart it needs to go through the aortic valve. A normal aortic valve that opens fully provides no obstruction and allows as much blood as needed to leave the heart. Imagine the normal aortic valve area to be as big as the clock face of a medium sized wristwatch. This can be from 3 to 4 cm2 in area.
Mild Aortic Stenosis
Aortic stenosis is tightening of the aortic valve and mild aortic stenosis is a mild tightening. As we said above the usual aortic valve area is like a medium sized wristwatch around 3-4 cm2 in area. Generally, in mild aortic stenosis, the tight valve remains greater than 1.5-2 cm2. Interestingly, this means the valve isn’t really considered to have mild tightening until it reaches less than half its normal size. Mild aortic stenosis is not of any real significance and does not place strain on the heart or the body. When pressure measurements are taken across the valve in mild aortic stenosis using Doppler ultrasound, a mean gradient of less than 20mmHg across the aortic valve should be measured. We are able to measure the pressure difference across the valve because as the valve begins to tighten, the blood spurts through the valve at faster and faster speeds, much like when you put your thumb over the end of a garden hose. Doppler ultrasound can measure this speed and convert it into a pressure drop across the valve, which we can use to define how severe the valve stenosis has become.
Moderate Aortic Stenosis
In moderate aortic stenosis, the valve continues to get tighter. Generally in moderate aortic stenosis the valve area is in the 1 – 1.5 cm2 range. Moderate aortic stenosis is not usually of any significance and does not cause symptoms alone. It is handled well by the body. When pressure measurements are taken across the valve in mild aortic stenosis, a mean gradient of greater than 20mmHg but less than 40mmHg across the aortic valve should be noted.
Severe Aortic Stenosis
In severe aortic stenosis the aortic valve starts to get severely tight. The area of the aortic valve in aortic stenosis is generally less than 1 cm2. This is considered to be a severe obstruction to blood flow leaving the heart and places the heart under strain. Surprisingly patients can handle severe aortic stenosis well and if they have no symptoms this can simply be watched, albeit closely. Once symptoms develop however, the valve needs to be fixed, and relatively quickly. When pressure measurements are taken across the valve in severe aortic stenosis a mean gradient of greater than 40mmHg across the aortic valve should be noted.
A 3D echocardiogram showing severe calcific aortic stenosis.
An echocardiogram showing critical aortic stenosis. Notice that the valve hardly opens.
Diagnosing Aortic Stenosis
Murmur – Patients with aortic stenosis will have a classic murmur when listened to with a stethoscope over the chest wall. It is a murmur that radiates up to the neck because that is the direction of the blood flowing through the valve as it enters the aorta through the diseased valve.
Pulses – Patients with aortic stenosis have a classic pulse waveform known as parvus et tardus. This means weak and late peaking. It is weak because it’s harder to pump as much blood through the diseased valve, and its late peaking because it takes longer to pump the blood through the tight valve.
Echocardiogram – This is the most important test in confirming the diagnosis and providing the critical information. The echocardiogram is the ultrasound scan test of the heart that gives us pictures of the valve and allows us to take measurements. This will show the tight valve and allow us to calculate a valve area based on pressure gradients through the valve. The echocardiogram also gives us information on the pumping function of the heart and the heart size. This test can also pick up other valve issues such as mitral regurgitation and tricuspid regurgitation. Patients may need a mitral valve repair or mitral valve replacement at the same time if they have a severely leaky mitral valve also.
Transesophageal Echocardiogram – This is an ultrasound scan of the heart, but in more detail, as the probe is passed in to the food pipe (esophagus) where it is close to the heart and can therefore give very clear pictures. This test is very useful in detailing structural heart disease. This allows us to see the valve in great detail and gives us information about other structures within the heart. Often when the normal echocardiogram findings are still unclear, the transesophageal echocardiogram can clarify the issue.
Heart Catheterization – In this test small tubes are passed up to the heart in order to gain information regarding heart pressures and also about the arteries that supply the heart with blood. In general most patients undergoing valve surgery will have a heart catheterization first to make sure no operation is required for the arteries either. Echocardiography is so good now that heart catheterization is rarely used to make a diagnosis of aortic stenosis, however in some complex cases, heart catheterization is used to confirm the diagnosis.
Treadmill Stress Testing – In some patients a treadmill exercise test is used to see the extent of symptoms or functional limitations caused by any aortic stenosis and potentially unmask symptoms patients didn’t know they had.
Stress Echocardiogram – In some cases the diagnosis of aortic stenosis is made difficult by either a weak heart pumping chamber or a small heart cavity. In these cases, standard testing may suggest a moderate tightening when in fact it is functionally severe. For this reason, in these patients, a chemical called dobutamine may be given to speed up the heart rate and the force of contraction, unmasking a severely tight valve of severe aortic stenosis. This is known as a dobutamine stress echocardiogram.
Medical Treatment of Aortic Stenosis
There is no medicine to treat significant aortic stenosis, it is a mechanical problem that requires a new valve to correct it. As things stand now, aortic stenosis is a problem of the valve itself and there is no medicine proven to prevent aortic stenosis or to reverse the valve tightening. For this reason valve replacement is the preferred treatment option. It’s important to make sure other cardiovascular risk factors are treated in patients with aortic stenosis for a number of reasons. Preventing the progression of other diseases such as artery diseases will improve outcomes. It’s also important to treat high blood pressures in this patient group.
When is it Time to Replace the Valve in Aortic Stenosis?
In general, in significant aortic stenosis, once symptoms develop or there is evidence of heart stress, its time to replace the valve. The answer is simple: in patients with severe aortic stenosis, once symptoms develop its time to replace the valve. Those symptoms were described a little earlier in this article. In patients with evidence of a weak heart due to the diseased aortic valve, the valve should be replaced even if there are no symptoms. In some cases, when the valve is very severely tight, a case can be made for replacing the valve even in the absence of symptoms.
Another time when the valve would be replaced before symptoms is when patients are undergoing cardiac surgery for some other reason and there is moderate or severe aortic stenosis. Although patients with severe aortic stenosis and no symptoms may be watched without valve replacement, it’s important to watch this group closely because if symptoms develop and they are not treated soon enough outcomes can be poor unless the aortic valve is replaced.
Why Don’t We Just Operate On Everyone With Aortic Stenosis?
In order for a treatment to be justifiable, the risk of the treatment has to be less than simply leaving the disease alone. This needs to take in to account both the short term and the long-term outcomes. In patients with less than severe aortic stenosis its very unlikely the condition will pose a risk. While it is obvious that patients with severe aortic stenosis and symptoms need to have their valve replaced, the situation is less clear in patients with aortic stenosis and no symptoms.
Let me walk you through some of the facts that help influence this decision. The chance of dying due to surgery for aortic valve replacement is around 2.5 %. This includes all patients, from the highest of the high risk to the lowest of the low risk. If we take a 70-year-old patient for example, with no other illness that is coming simply for what we would consider a low risk valve replacement, the chance of dying due to valve surgery is now less than 1%.
This is where it gets interesting. The risk of dying due to the severe aortic stenosis if we were to do nothing is around 0.5 – 1% per year. This approaches the risk of a low risk surgery and so in some circumstances it may be reasonable to consider valve surgery despite the lack of symptoms. On the other hand, in a high risk patient, where the risk of surgery is higher than the risk of simply watching the aortic stenosis, the risk of aortic valve replacement cannot be justified.
In centers of excellence, attention can be paid to risk factors in patients with no symptoms to see who is potentially in a higher risk group. These include patients with abnormal exercise tests, severely thick hearts, very calcified valves, and very tight valves. In patients with one or more of these risk factors it may be reasonable to perform aortic valve replacement in centers of excellence with known good outcomes.
Aortic Valve Replacement Surgery and TAVR procedure
Traditional Open Heart Surgery
Open heart surgery is the traditional method of replacing the aortic valve. The patient is put to sleep under anesthetic and the chest opened down the middle. This is called a sternotomy. Many of you may be familiar with the sternotomy scar that is the scar that runs down the middle of the top half of the chest. In this procedure the heart is placed on a heart lung bypass machine and the heart is stopped. The diseased aortic valve is then replaced with a new aortic valve. The heart is then restarted and the patient taken off the heart lung bypass machine. The in hospital stay will be in the region of a week. By this time most patients will be walking.
Mini Aortic Valve Surgery
This is still open-heart surgery however the incision made on the chest is much smaller than the traditional one. It is just a few inches long. The advantages to a mini approach are a much smaller scar and less trauma with faster healing times. Mini aortic valve replacement is generally the method of choice for the patients of established experts in valve surgery.
Transcatheter Aortic Valve Replacement (TAVR) – The New Revolution
TAVR also known as TAVI or transcatheter aortic valve replacement, is the revolutionary new method of replacing the aortic valve. With TAVR, the procedure is performed without having to place the patient on a heart lung machine. Most TAVR procedures are performed through small tubes that are inserted in to the arteries of the leg. The valve is passed up to the heart through these tubes and placed inside the diseased valve. The valve is then expanded in to place, crushing the old valve out the way and leaving the new valve functioning nicely. The TAVR procedure is outlined in detail in this linked article. In the few patients where TAVR cannot be performed through the arteries of the leg because they are too small or too diseased, then the TAVR is performed through a small incision on the chest wall. Incredibly, in expert centers, some TAVR patients are sent home in as little as 1-2 days after the procedure. Even more incredible is that we are beginning to perform TAVR procedures in patients without even having to put them to sleep.
Ensuring the Best Outcomes – Centers of Excellence
In patients with aortic stenosis, the key is to go to centers of excellence such as Princeton Baptist Medical Center where experts who live and breathe heart valve disease manage the condition. This ensures a number of things. First and foremost is a correct diagnosis and accurate assessment of the severity of the disease. Often this requires the expertise of dedicated imaging experts with expertise in advanced techniques such as cardiac CT scanning and 3D-echocardiography. Expert centers will have the entire range of treatment options available from standard, to mini, to TAVR, to ensure that the appropriate treatment is selected for each patient rather than simply a second best option because that’s all that is available at that place. This way low risk patients are ensured to remain at low risk and the highest risk patients that would have had no option previously are given good options. Expert centers ensure that experienced operators will perform procedures in top class facilities. Centers of excellence ensure no shortcuts are taken and that complication rates remain low. Heart surgery and procedures are a high stakes game. Even in the most routine of cases, unexpected things can happen and situations become critical. It simply makes sense to be in the right place with the right people in that event.
We have recently discovered, unfortunately primarily by accident and one dx at a time, that my husband has a bicuspid valve, moderate aortic stenosis, severe aortic regurgitation, and an aortic aneurysm. In the past 18 months he has developed or complained of fatigue, becoming weak kneed and either passing out or feeling as if it is about to happen, shortness of breath, chest, shoulder and arm pain, and persistent nausea (esp when under stress). We have long asked if there is any reason to be concerned about his heart as he has suffered from ED for at least the past 10 years. I would appreciate any comments you may have regarding treatment or questions we should be asking the cardiologist.
Do you have any specifics of the echo reports. How large is the aorta? How is the pumping function of the heart? If the regurgitation is severe and he has symptoms that can be attributed to this such as fatigue he likely warrants consideration of aortic valve replacement, and depending on the size of the aorta he may need aortic root replacement. See the article on this site about bicuspid aortic valve and the other article about aortic aneurysm.
Yes. I have both the first echo done a little more than a year ago and the most recent echo. Both have number references. “There is mild aortic root dilation. Sinus of Valsalva: 4.2cm. Ascending aorta 3.6cm.” I need a little guidance on what numbers or abbreviations answer your questions. It lists 2D/M Mode Measurements. AoR Diam MM is 4.2 now (was 3.6). The peak transaortic gradient was 43.0 mmHg (24 last yr). Also states trace tricuspid regurgitation on this year’s but last year’s clearly states existence of bicuspid valve.
Portsmouth Cardiology Queen Alexandra Hospital Southwick Hill Road Portsmouth, Hampshire PO6 3LY
Secretary: 02392286000 ext 4659 / 4611 [email protected]
Consulting rooms and correspondence:
Spire Portsmouth Hospital Bartons Road Havant, Hampshire PO9 5NP
Secretary: Alison Moore Tel: 023 9236 5010 Fax: 023 9200 3932
[email protected]
Dr Alex Hobson MBBS BSc MD MRCP Consultant Cardiologist
Dr G W Parry
DVLA
Drivers Medical Group Swansea SA99 1DG
Dear Dr Parry
M36629714 – Mr Mohamed El Kilany (24/12/1965), 118 Fareham Road, Gosport, PO13 0AQ
22/11/2018
Many thanks for asking us to perform an echocardiogram on this gentleman in whom you are considering his fitness to hold a Group 2 driving licence. I note that he has a history of atrial fibrillation and hypertensive heart disease.
The echocardiogram shows normal left ventricular size and function. There is no significant valvular abnormality. The right heart appears normal. There is, however, severe left ventricular hypertrophy and this appears particularly severe in the intraventricular septum where it measures 2.3cm.
There is therefore evidence of severe left ventricular hypertrophy. This could all be due to hypertensive heart disease but may also represent previously diagnosed hypertrophic cardiomyopathy and I would suggest further evaluation is performed.
Kind regards
Yours sincerely
Alex Hobson
Dr Alex Hobson Consultant Cardiologist
cc Mr M El Kilany Dr M Yeandle, GP
Dear Mr El Kilany, your heart scan has shown severe thickening of the heart muscle (left ventricular hypertrophy). This has been noted previously but is more pronounced now. This could all be related to uncontrolled high blood pressure but also raises the possibility of an inherited (genetic) condition and I would suggest that further evaluation is performed. If you are happy to be seen please liaise with your GP who can organise an appointment. Yours sincerely, Dr A Hobson
We have now had our appt with local cardiologist who presented himself as the head of the echo dept where my husband’s echocardiagram was done. He then stated that he does not pay any attn to the tech’s findings. In his opinion, there is nothing more than a leaky valve that should be followed with an annual echo. He explained away every concern/symptom of concern and took him off his BP meds. We were stunned. He did agree to do a treadmill test but nothing more.
Sounds like good news. I often see people previously diagnosed with aortic stenosis that turn out to nor have significant disease. You should ask the cardiologist to be specific with regard to why the result has changed to ensure it can be explained.
Portsmouth Cardiology Queen Alexandra Hospital Southwick Hill Road Portsmouth, Hampshire PO6 3LY
Secretary: 02392286000 ext 4659 / 4611 [email protected]
Consulting rooms and correspondence:
Spire Portsmouth Hospital Bartons Road Havant, Hampshire PO9 5NP
Secretary: Alison Moore Tel: 023 9236 5010 Fax: 023 9200 3932
[email protected]
Dr Alex Hobson MBBS BSc MD MRCP Consultant Cardiologist
M36629714 – Mr Mohamed El Kilany (24/12/1965), 118 Fareham Road, Gosport, PO13 0AQ
22/11/2018
Many thanks for asking us to perform an echocardiogram on this gentleman in whom you are considering his fitness to hold a Group 2 driving licence. I note that he has a history of atrial fibrillation and hypertensive heart disease.
The echocardiogram shows normal left ventricular size and function. There is no significant valvular abnormality. The right heart appears normal. There is, however, severe left ventricular hypertrophy and this appears particularly severe in the intraventricular septum where it measures 2.3cm.
There is therefore evidence of severe left ventricular hypertrophy. This could all be due to hypertensive heart disease but may also represent previously diagnosed hypertrophic cardiomyopathy and I would suggest further evaluation is performed.
Kind regards
Yours sincerely
Alex Hobson
Dr Alex Hobson Consultant Cardiologist
cc Mr M El Kilany Dr M Yeandle, GP
Dear Mr El Kilany, your heart scan has shown severe thickening of the heart muscle (left ventricular hypertrophy). This has been noted previously but is more pronounced now. This could all be related to uncontrolled high blood pressure but also raises the possibility of an inherited (genetic) condition and I would suggest that further evaluation is performed. If you are happy to be seen please liaise with your GP who can organise an appointment. Yours sincerely, Dr A Hobson
Hi my boy 3 months old has been diagnosed with mild aortic stenosis . Per echogram he had a trileaflet aortic valve but it is a bit stiff due to slight thickening of commissures. I understand that congenital aortic stenosis is commonly due to bicuspid but not in my Son case. Per your expertise, is there a possibility that this thickening can resolve by itself as his heart grows ? Also what’s the future outlook going to be like , could the condition remain static or worsen? His current gradient is 18. What’s the stenosis gradient range for mild, moderate and severe for babies? Thanks so much , appreciate your response . Worried mummy here.
Hi Elaine, i’ll have a pediatric cardiologist answer your question in the next few days.
Thanks alot Doctor. Did you hear back from the pediatric cardiologist?
Keen to hear his/ her response. Thanks!
Ill have someone check on that.
thanks so much!
Hi Doctor, we came back from my baby’s cardio visit last week and apparently he has a bicuspid aorta valve with raphe – fusion of the right and left cusp. Gradient is 17.0. His cardio mentioned that its around same gradient as our last review 3 months ago. My baby doesn’t have any other heart conditions stated besides bicuspid and mild aortic stenosis. Next review would be in 9 months time. He mentioned that he is not forseeing this to change that much probably in years to come. May we seek your opinion on this too? Also wonder what’s the future like for my baby, he can lead a normal active life like any other child? He said gradient level for mild is like 5 to 40, 40 to 80 for moderate and beyond that is severe? Much thanks!
Can you provide more specific echo report details, was that a mean or a peak gradient?
I not very sure if there’s a mean or peak gradient, below are the details of the echo.
Under Semilunar Valve – Aortic valve – fusion of rt and left coronary cusp with mildly thickened commisures.
Under Doppler/Colour Flow studies it states:
Mild turbulence across the aortic valve. No aortic regurgitation.
Doppler interrogation m/s – AAo 2.1(17.0 mmHg), DAo 1.0 (3.8 mmHg), MPA 0.9 (3.6 mmHg).
Under Mmode(mm) it states:
Aorta (mm) Left aortic arch, no CoA, no PDA Asc Aorta 11.2
The rest are normal.
Diagnosis it states: Bicuspid aortic valve. Mild aortic stenosis.
My baby is 6 months old. My husband and I went for echo as well and we have the normal trileaflet aortic valve – all ok for us.
Thanks so much doctor!
For mild aortic stenosis the key will be follow up, the mild aortic stenosis itself is not dangerous, its a biscuspid valve however and surveillance echocardiography will be required. I suggest good follow up with a pediatric cardiologist.
Hi Elaine
I was born with a bicuspid valve – at the time it was a “heart murmur”. The valve analysis was done in my 40s, because by then they had more tests to find out what it was that caused such a racket in my chest. At that time, I was told I should do a follow-up every six months. I thought that was ridiculous, and said to the doctor – “I run 60+ km a week – if there’s something going wrong, I would have problems doing that, I think”. He agreed and put my follow-up at two years. Now I am on an annual measurement, and am losing about 0.1cm squared of aortic area/year. I still have 3cm squared of valve area. At 58, my cardiologist says I am one of his healthiest patients. For sure do all the follow-up necessary, but encourage your child to make healthy choices to ensure a long life and don’t panic! 😀
I had an echo over the summer, my aortic valve area was calculated at 1.6cm. My GP thought it was more stenotic, so he referred to another cardiologist. New echo few weeks ago, it came back at 1.25. The new cardiologist felt that was not accurate either. He reviewed my results with 2 structural heart specialists. After crunching the numbers they came up with 1.07 cm. They are on the fence about surgery now, my heart function is still good. We decided to wait as I am only mildly symptomatic. I am following up with echos 3-4 times a year, next being a TEE. Does this sound a reasonable approach? In my opinion that’s a huge difference in numbers. What is it that makes this so difficult to calculate?
I cant comment truly accurately without seeing the images. I personally perform the analysis of our centers echocardiograms for this reason, there is a disturbing amount of variability seen when attention to detail isn’t paid. If you don’t have any symptoms whatsoever it doesn’t really matter technically. In this case i suggest a TEE with potential 3D and multi-planar reconstruction for direct aortic valve planimetry.
Thank you very much for your comments. I know this place has the ability to do the TEE you recommend as I saw an example of it when I was there. My main complaint is fatigue. My whOle life I have been an insomniac who functions very well on little sleep. Lately I require 8-10 hours of sleep and still have little energy. Things I could do a year ago have become more difficult and I can feel a change in the way my heart handles stress.. it pumps much harder. Although, I certainly do not feel near death. March is TEE and I will ask about your recommendation.
With a bicuspid aorta is valvuloplasty an option some times? TAVR was discussed with me, so I assume they feel replacement is needed when it’s time. I am young, doesn’t a valve replacement reduce life expectancy? It only lasts so long, and can only be done so many times? Obviously, I understand the purpose is to extend my life, but curious.
In pediatric patients valvuloplasty is an option. In adults i would only use it if the situation was truly emergent, and with that i would be gentle. The problem is that the bicuspid valve is more prone to tear and therefore significant leak. As for TAVR, I’ve done many in bicuspid valves, the key is to select the correct ones to do. Unless there are extenuating circumstances, i would say that if otherwise healthy and young a surgical valve replacement is the standard of care as things stand.
Thanks again. It gives me a better understanding. I am not very healthy, including other congenital heart defects in which the repairs are holding up amazingly well by some small miracle. It was expected I would need more surgery years ago. That must be why TAVR is being considered.
I am researching types of surgery and valves in preparation for my follow up appointment after my TEE. I feel like I would push for an open heart. Do you have a preference for type of valve in this situation? I am thinking tissue because with a mechanical valve if it fails it would need to be retrieved open heart and I may not be healthy enough at that point. If it is determined that I am not a candidate and TAVR is my only option, do you have a preferred valve in a bicuspid aorta? I am noticing a lack of support in my decision to hold off on surgery, most importantly from my husband, primary care physician and the doctor I work for. Those who know me, know that when given the option due to my fear of surgery I will walk out of my appointment 100% of the time saying, I just dodged a bullet. In your article it says when symptomatic it’s times for surgery. Technically my valve is still in moderate range. I think I understand correctly when the cardiologist says it’s because I have another stenotic valve, it’s doesn’t require surgery but it’s contributing to my symptoms. While I am aware something is wrong I don’t feel sick enough for surgery. While I feel extremely confident in my cardiologists, I am overwhelmed with anxiety. I have lost 25 pounds in less than 2 months. I have been instructed to eat at least small amounts every 3 hours. I feel like this is normal to have anxiety considering but wondered your opinion on if cardiac patients should have anxiety treated. What you are doing for patients through this website is remarkable!!
Your situation is complex and i feel it would be irresponsible to advise you on specifics unless i was familiar with all aspects of your case and evaluated you in person. Just so i understand a little more and can maybe shed a little more light on the situation, do you have details of your echo report.
ECHO COMPLETE
Component Results
LV Septal Thickness 1.40 cm cm
LVED Diameter 3.42 cm cm
LVES Diameter 2.21 cm cm
LVOT Diameter 1.72 cm cm
LV Posterior Wall Thickness 1.08 cm cm
LV Isovolumic Relaxation Time 87.66 ms ms
LVOT PWD Velocity (peak) 96.0 cm/s cm/s
LVOT PWD Velocity (mean) 73.0 cm/s cm/s
LVOT PWD VTI 21.5 cm cm
LA Diameter 3.68 cm cm
Mean Gradient 14.12 mmHg mmHg
AV CWD Velocity (Peak) 252.76 cm/s cm/s
AV CWD Velocity (Mean) 174.33 cm/s cm/s
AV CWD VTI 50.27 cm cm
MV Peak A Velocity 84.0 cm/s cm/s
Deceleration Time – MV 222.00 ms ms
MV Peak E Velocity 65.0 cm/s cm/s
PV CWD Velocity (peak) 227.09 cm/s cm/s
PV CWD Velocity (mean) 156.26 cm/s cm/s
Velocity Time Integral – PV 43.25 cm cm
Peak Gradient – TR 31.16 mmHg mmHg
Peak Velocity – TR 279.12 cm/s cm/s
Aortic Diameter (mid tubular) 3.00 cm cm
Aortic Diameter (sinus of Valsalva) 2.84 cm cm
Heart Rate 80 bpm bpm
RV Peak Systolic Pressure 39.2 mmHg mmHg
LA Systolic Volume 31 mL mL
LVED Diameter BSA Index 1.8 cm/m2 cm/m2
LVED Diameter Height Index 2.3 cm/m cm/m
LVES Diameter BSA Index 1.2 cm/m2 cm/m2
LVES Diameter Height Index 1.5 cm/m cm/m
LVOT Area (calculated) 2.32 cm2 cm2
LVOT Stroke Volume 49.93 cc cc
LVOT SV BSA Index 26.01 mL/m2 mL/m2
LVOT SV Height Index 33.3 mL/m mL/m
LVOT Cardiac Output 3.99 L/min L/min
LVOT Cardiac Index 2.08 L/min/m2 L/min/m2
LVOT Stroke Rate (peak) 222.9 mL/s mL/s
LVOT Stroke Rate (mean) 169.5 mL/s mL/s
LV ASE Mass 138.2 gm gm
LV ASE Mass BSA Index 72.0 gm/m2 gm/m2
LV ASE Mass Height Index 92.2 gm/m gm/m
LV ASE Mass Height 2.7 Index 46.4 gm/m2.7 gm/m2.7
LA Diameter BSA Index 1.9 cm/m2 cm/m2
LA Diameter Height Index 2.5 cm/m cm/m
LA Systolic Vol BSA Index 16.1 mL/m2 mL/m2
LA Systolic Vol Height Index 20.7 mL/m mL/m
RA Volume 38 mL mL
RA Volume BSA Index 19.8 mL/m2 mL/m2
RA Volume Height Index 25.4 mL/m mL/m
LVOT + AV Gradient (peak) 25.6 mmHg mmHg
LVOT + AV Gradient (mean) 12.2 mmHg mmHg
AV Gradient (peak) 21.9 mmHg mmHg
AV Gradient (mean) 10.0 mmHg mmHg
LVOT/AV Velocity Ratio 0.38
AV Area (LVOT SV Mtd) 0.99 cm2 cm2
AV Area (LVOT SR Mtd) 0.88 cm2 cm2
RVOT + PV Gradient (peak) 20.6 mmHg mmHg
RVOT + PV Gradient (mean) 9.8 mmHg mmHg
PV Area (LVOT SV Mtd) 1.15 cm2 cm2
PV Area (LVOT SV) BSA Index 0.60 cm2/m cm2/m
RA Pressure Estimate 8 mmHg mmHg
PA Systolic Pressure Estimate 18.5 mmHg mmHg
RR Interval 750.00 ms ms
E/A ratio 0.77
LVED Volume 79.0 mL mL
LVES Volume 25.0 mL mL
LVED Volume BSA Index 41.1 mL/m2 mL/m2
LVED Volume Height Index 52.7 mL/m mL/m
LVES Volume BSA Index 13.0 mL/m2 mL/m2
LVES Volume Height Index 16.7 mL/m mL/m
LVEF (Volume) 68 % %
LV Stroke Volume 54.0 mL mL
LV SV BSA Index 28.1 mL/m2 mL/m2
LV SV Height Index 36.0 mL/m mL/m
LV Cardiac Output 4.32 L/min L/min
LV CO BSA Index 2.25 L/min/m2 L/min/m2
LV SV – LVOT SV Diff 4.07 mL mL
Mitral Annular Ea Velocity 5.0 cm/s cm/s
Mitral Annular E/Ea Vel Ratio 13.00
Echo RV Stroke Work Index Estimate 876.4 mmHg•mL/m2 mmHg•mL/m2
AV Area (LV SV Mtd) 1.07 cm2 cm2
AV Area (LV SV) BSA Index 0.56 cm2/m2 cm2/m2
MR Regurgitant Volume (LV SV Mtd) 4.1 mL mL
MR Regurgitant Fraction (LV SV Mtd) 0.08
PV Area (LV SV Mtd) 1.25 cm2 cm2
PV Area (LV SV) BSA Index 0.65 cm2/m2 cm2/m2
Pulmonary Vascular Resistance Estimate 7.2 mmHg mmHg
LVED Volume BSA Index 41 ml/m2 ml/m2
LVES Volume BSA Index 13 ml/m2 ml/m2
LV Systolic Volume Index 13.0 mL/m2 mL/m2
LV Diastolic Volume Index 41.1 mL/m2 mL/m2
General Information
Resulted:
11/18/2016 11:39 AM
My previous echo also indicated early aneurysm as well as moderate/severe pulmonary hypertension. This one does not, thankfully. Results are so different. In the back of my mind I wonder it’s possible to have that much progression the aortic stenosis in that short of time or if the previous results were truly wrong. Curious to see what the TEE will show. Thank you
I feel the need to explain that as a very young adult that my lack of knowledge on my condition nearly cost me my life. My cardiologist was a family friend and he was not forthcoming about my condition or how severe it was, he didnt want me to worry. When I developed severe chest pains and a weight sensation on my chest I was told by the ER doctor that women my age don’t have heart attacks and he referred to me as hypochondriac and told me to cancel cardiology appointments so as not to waste anyone else’s time. I did. It delayed treatment for weeks in a severely stenotic valve. Several weeks later when I ended up in the cath lab I was told that due to a scheduling error I would need to reschedule. Fortunately, there was a cardiologist there charting and he stopped me from leaving. He ended up doing my test and procedure. He revealed to me later that he could see just by looking at me that I was critically ill and would not have survived another week. So this time around I want to be as educated as I can be, although I don’t forsee a similar situation coming up.
It makes sense to be educated and i think you are smart to do so. Your situation is complex and while i want to be able to provide as much information as possible i need to be sure not to do you a disservice by providing specific recommendation in the absence of a detailed knowledge of your case that would include full evaluation. I think the best first step is to see your specialist again and seek an in depth explanation regarding treatment plan, and if you cant get that or do not feel reassured then seek a second opinion by someone that can evaluate you and spend the time required to ensure you are confident in the treatment plan. With regard to your echo, i would need to see the pictures to comment. The velocities across the valve do not suggest severe aortic stenosis or even moderate aortic stenosis, they do not correlate with the given valve area.
I completely understand your limitations as far as advice goes. I sincerely appreciate your comments and time. You are right, he mentioned that the gradient was lower than would be expected. While I was told the valve surgeons were confident in their calculations in the valve area, they couldn’t offer an explanation as to why the low Gradient. I can say with certainty this doctor will give me the time I need. If I were about 8 states closer I would gladly seek an opinion at your center. Thanks again.
Oddly enough, I had the same experience. My cardiologist said there was nothing wrong with my heart and 10 days later I nearly died of cardiac tamponade – a liter of liquid was crushing my heart. Now I check and cross check all the time. We have to!
My husband has a very tight aortic valve and an EF of now 15%. The EF dropped in the last couple weeks from 35 to 15 – no explanation. He’s been in hospital (hospital of University of Pennsylvania) for 8 days now. He had a cardioversion, and right heart cath. He was scheduled yesterday for an angiogram, but they didn’t do it. He has labored breathing, and is on oxygen. I’m afraid he’s dying. Can anything be done? Where are centers of excellence? Is University of Penn one of them for this problem?
It’s difficult to comment without knowing the complexities of the case, but ask the drs if the aortic stenosis is driving the decompensation and if so whether there is a role for balloon aortic valvuloplasty.
Hello Dr. Ahmed,
I am a 72 yo woman with severe AVS. I cannot live the life I did a year ago. Fatigue, shortness of breath, occasional Angina, pain in left arm and shoulder blade, pain on the left side of my neck. I never used to Jan but I do more now and my resting heart rate during sleep went from about 75 to the high 60s. I have cut out the activites I love (hiking and dancing) so no longer have the 1 or 2 days in bed to recoup. Still, I can’t do the work I should (self employed artist) and production has suffered. Sometimes I just feel like I can’t focus, make decisions. I’m optimistic that all will turn out well, but would like your opinion on how to proceed.
An agiogram 2 weeks ago showed I have no blockage.
Dominant right coronary artery: Minor proximal 30% plaquing was seen. Wide patency normal.
Severe AOrtic Valve Stenosos with estimated AVA 0.74 CM2 (0.74 CM2/M2) Trileaflet Valve.
Normal LVEF of 65%
I got a copy of the full report if you need any other information.
I am otherwise pretty fit- slim, no diabetes. HBP, and cholesterol ranges from 185- 205. My ” good” cholesterol is always great. I eat a very healthy diet, drink lots of water, coffee and a glass of wine daily. Though 5 years ago an endocardiogram indicated I might have Barrett’s syndrome. I retested two years later and it showed it had not gotten worse. I was proscribrd Dexilant for two years then got off that with no trouble. I take Detrol LA for “unstable bladder” and .5 mg Xanax at night. Also two grains Naturethroid for many years.
I might be accepted into a phase 3 trial for the Edwards TAVR where 50% will get that 50% will get the SAVR. I live in Honolulu one of the cities where the trial is being held for low risk people with severe aortic valve stenosis. They were both pluses and minuses for SAVR and TAVR and if you think one would be better for me than another I would like to know.
I’m wondering if anything unanticipated might happen were I to get the TAVR, would the team at the Queens Hospital here, be an excellent place to have it done… or, should I be researching hospitals on the mainland where they specialize in heart surgery, and do many every day?
I met a cardiac surgeon who recommended the Trial. He thought I would be a good candidate but I have an appointment in two weeks with the Dr who actually will make the decision if I will be accepted in the trial. I think he has done 400-500 TAVR procedures. Would that give him enough experience in your opinion?
Any comments you may have for suggestions would be greatly appreciated as I am uncertain. I have a friend who has been doing research online and thinks getting into the trial ASAP would be best. The cardiac surgeon said that I should have something done soon… in fact he said I could get up in the morning, go to brush my teeth, and have a heart attack. He didn’t seem like a person who would exaggerate.
Thank you for your time and consideration regarding my situation. I am very grateful.
Carol
Hi Carol,
https://myheart.net/articles/tavr-transcatheter-aortic-valve-replacement/ That is a post about the TAVR procedure.
What is clear here is that you have severe aortic stenosis and symptoms and require some form of intervention on the valve.
Its important to realize that technology has outpaced evidence at this point which makes it almost impossible to give a ‘right answer.’ Lets look at both sides of the argument. Historically, you are 72 and considered a ‘low risk candidate’ if otherwise healthy. Usually there would have been no question and you would undergo surgery. Lets look at the surgical option. Its known to be safe in general and the long term results excellent in the right hands. We have decades of experience with this and can talk confidently about the results in the long term. Of course there is the small upfront risk of surgery, that in most low risk cases far exceeds 95% success. TAVR came along about a decade ago, we found that we had an incredible option for patients that were inoperable. We then advanced that to patients at high risk and also intermediate risk. These moves were backed by evidence from good quality trials. Whereas everyone of us felt good about the high risk trials, some had reservations about intermediate risk, but in general we offer TAVR to intermediate risk. We have performed hundreds of TAVR in out institution and thousands of surgeries with excellent outcomes, and can therefore speak from good experience. The truth about low risk is that we simply don’t know whether TAVR vs. SAVR is better in the long term for these patients. We won’t know for a while and the only way to know is to complete the trial and follow people long term. Potential advantages of TAVR include faster recovery time, less invasive, shorter hospital stay, and low procedural risk. Potential disadvantages include the unknown about the long term outcomes of TAVR in the low risk populations. Advantages of SAVR are that the long term outcomes are well established, and disadvantage is of course that it is more invasive. In our center we perform minimally invasive AVR as opposed to sternotomy in this population which shortens recovery and avoids cracking the chest. Its therefore essentially up to you in that you must weigh the risks and benefits and proceed in the manner you are most comfortable with. Currently both Medtronic and Edwards are offering low risk trials with their TAVR valves.
Finally, i think most situations of severe aortic stenosis with symptoms are an urgency and not an emergency, if you aren’t having passing out/chest pains with every exertion/being hospitalized etc, then saying you may have a heart attack while brushing your teeth is clearly over dramatic, although you do need to fix the problem in the near future to minimize your risk.
Hope that was helpful, do read the TAVR post to understand the procedure better. https://myheart.net/articles/tavr-transcatheter-aortic-valve-replacement/
Given the large amount of people we have been able to help here, we are starting a twitter to help keep heart patients up to date with advances and relevant information. Mine can be followed at @MustafaAhmedMD
My 90 year old father just had a heart cath and pacemaker implanted. He has been diagnosed for some time with aortic stenosis and had the accompanying murmur.
The cath showed his aortic valve was .58 cm which is well below the 1 cm “severe” rating. He is not symtatic of aortic stenosis except for low energy, no swelling or shortness of breath.
His pulse had been 48-51 which is the reason for the pacemaker. The cardio Dr said he is a TAVR candidate due to age and fragile condition. He also said the aortic valve was critical.
My question is given his age, is the TAVR something that we should consider or hold off until he exhibits other symptoms. We are hopeful he will show improvement due to the pacemaker, but it was just implanted today.
Read the following article about TAVR, I think you’ll find it useful https://myheart.net/articles/tavr-transcatheter-aortic-valve-replacement/
I have performed hundreds of TAVR procedures and seen them remarkably change the life of patients. The key is careful patient selection and an experienced team. In the right hands, patients often go home within 48 hours. We perform the procedure without even having to put patients under general anesthesia. The age of 90 itself is not a contraindication and at this age the TAVR is the only sensible way to go. If he has severe symptomatic aortic stenosis, (even with fatigue as the symptom) and is felt to be a decent candidate by an experienced heart team then it would be a reasonable step.
If you are interested in cutting edge information and therapy for heart disease then follow my twitter at @MustafaAhmedMD
If you are interested in cutting edge information and therapy for heart disease then follow my twitter at @MustafaAhmedMD
have echo showing with trileaflet aortic valve moderate to severe aortic stenosis Ao velocity 4.3 m/s peak gradient 75 mmHg mean gradient 48 mmHg AVarea -1.1cm2 mild aortic insulliciency. Scheduled for next echo sept last one in march. Is this normal procedure for my readings ? Have calcification on Aortic valve with peak velocity 4.3 m/s mean velocity 3.3 m/s ivot peak velocity 141 cm lvot peak gradient 7.9 mmHg Have a lot of anxiety with worry about this, Please advise……Thank You
If the velocity is 4.3 and the mean gradient 48, your aortic stenosis is severe, not moderate to severe. If there are symptoms, this should be discussed and consideration to fixing the valve be given. If there are no symptoms whatsoever and other associated assessment is low risk then periodic assessment with echocardiography and monitoring for symptoms is advised.
If you are interested in information and therapy for heart disease then feel free to follow my twitter at @MustafaAhmedMD
Is there a difference in blood flow between a size 17mm mechanical aortic valve and the 19mm mechanical valve? If not then why would one be recommended over the other? Thanks
In general the largest valve that can be used for any given situation is used. 17 is small and should generally be avoided in an adult population, 19 is small too. In our center we enlarge the aortic root as necessary to ensure appropriate valves can be used. The smaller the valve, the higher the gradient and likelihood of residual stenosis.
If you are interested in information and therapy for heart disease then feel free to follow my twitter at @MustafaAhmedMD
I am a congenital heart disease patient. I have learned more about my conditions by reading your articles as well as the questions and replies on here. So, thank you for your efforts.
This post has sparked a question for me. My next surgery will be an aortic valve replacement. I am a female in my 40s, my AVA at last echo was .97, my jet velocity 3.4. I am 4’11” 125lbs. It was explained to me that my pressures are lower than expected with the given valve area because my heart is small, therefore they believe my aortic valve started out smaller than the average persons. I don’t know if that makes sense.
Because of health issues, previous surgeries and more surgeries likely in the future, they feel TAVR should be done when I become symptomatic. From reading the the TAVR article and posts, it seems valve in valve, valve in valve in valve are a possibility.
My question is will a small heart and small valve necessarily limit me to a smaller first valve, reducing the likelihood of a second and third procedure to replace the prosthetic valve when it fails? Would a root enlargement be a possibility in such a case?
Could an increased heart rate indicate progressed aortic stenosis? My average was 80-85, it’s now 90-95. My stenosis is severe, I am due in January for echo and check up. I feel ok with the exception of occasional dizziness. I am considering skipping or postponing this year. My employer has changed medical policies. For the same ridiculous high price I have significantly less coverage. It is making affording health care a luxury that’s out of my reach.
If you have truly severe aortic stenosis and symptoms, even occasional you need the valve replacing or your change of poor outcome is significant.
you can follow my twitter at @MustafaAhmedMD
Oh. ? . I saw my cardiologist and reported my dizzy episodes. Sometimes I don’t even known I am dizzy and stand up to walk and fall down. I’m 47. He wants me to wait as long as I can, says to increase water intake to increase blood volume to increase blood flow to my brain. It’s all about controlling symptoms for as long as I can. This did concern me, as I have done plenty of research and it seems the longer you wait the higher the mortality rate is at 1 year. Maybe I should consider another opinion….
Two weeks ago my Son had the artery procedure to find out if there were any blockages due to the fact that he has to have a heart valve replaced…the procedure went great no blocks.
Today was his follow-up appt. and he was told that the valve has critically narrowed but not severe? To me critical means dangerous!?
It is inevitable that he must have heart surgery but the problem is that although the cardiologist has referred him to a heart surgeon my Son has to wait 2wks. for the insurance company to approve it.
I am stressing and worried that waiting 2 more weeks is dangerous! If in 2wks the valve has become critically narrowed I am so afraid waiting another 2wks. is not good!
Even though I have accepted the fact that he has to have heart surgery I am now emotional about the waiting on approval from insurance.
Any information you can give to reassure me would be greatly appreciated.
It depends on stability, the word critical if used correctly would imply unstable symptoms such as active heart failure, shock, or severe symptoms that typically would require hospitalization. I suspect they are just referring to severe aortic stenosis. If the need to fix the valve has been determined then although there may be a relative urgency, it is not an emergency and a brief waiting period isn’t expected to be of concern. Call the physician and ask if this is simply an urgency or an emergency.
you can follow my twitter at @MustafaAhmedMD
I am a 32 year old female, recently diagnosed with moderate aortic stenosis and a “likely functionally bicuspid aortic valve” per echo. Several months ago, I began noticing decreased endurance and increased chest tightness during my runs. I have also noticed a decreased energy level and feeling slightly short of breath after walking upstairs and even with some regular household chores (mopping, vacuuming, mowing, etc.). I have not had a PCP for quite a few years, so I finally made an appointment with a new PCP. My doctor noted a “quiet murmur” during exam and recommended an echo. Echo results are as follows:
Aortic Valve Summary: A bicuspid morphology cannot be excluded. There is moderate stenosis. There is trivial regurgitation.
(Addendum: Aortic valve likely functionally bicuspid)
Aortic Valve:
Annulus diameter, S 2.4cm
Peak velocity, S 2.7m/sec
Mean velocity, S 1.91 m/sec
VTI, S 56.1 cm
Mean gradient, S 16 mm Hg
Peak gradient, S 30 mm Hg
VTI ratio, LVOT/AV 0.39
Valve are, VTI 1.0 cm2
Valve area/bsa, VTI 0.63 cm2/m2
Velocity ratio, peak, LVOT/AV 0.42
Valve area, peak velocity 1.1 cm2
Valve area/bsa, peak vel. 0.7 cm2/m2
Velocity ratio, mean, LVOT/AV 0.37
Aortic regurg deceleration 390.17 cm/s2
Aortic regurg deceleration time 1091 ms
Aortic regurg pressure half-time 316 ms
Left Ventricle Summary: The cavity size is normal. Wall thickness is normal. Systolic function is normal. Estimated ejection fraction is 55-60%. Wall motion is normal; there are no regional wall motion abnormalities. Wall motion score: 1.00. Left ventricular diastolic function parameters are normal.
Left Ventricle:
Wall mass 110 g
Mass/height 65.88 g/m
Fx area change, A4C 47%
Fx shortening 29%
Mid-wall fx shortening 15%
End-diastolic volume 78 ml
End-diastolic volume/bsa 51 ml/m2
End-systolic volume 29 ml
End-systolic volume/bsa 19 ml/m2
Ejection fraction 57%
Stroke volume, 2D 50 ml
Stroke volume/bsa, 2D 23 ml/m2
Cardiac output, 2D 4 L/min
Cardiac index, 2D 2.6 L/min-m2
End-diastolic volume 1-p A2C 61 ml
End-systolic volume 1-p A2C 23 ml
Stroke volume, 1-p A2C 39 ml
Stroke volume/bsa 1-p A2C 24.8 ml/m2
Cardiac output 1-p A2C 3 L/min
Cardiac index 1-p A2C 1.9 L/min-m2
End-diastolic volume 1-p A4C 74 ml
End-systolic volume 1-p A4C 30 ml
Stroke volume, 1-p A4C 44 ml
Stroke volume/bsa 1-p A4C 29 ml/m2
Cardiac output 1-p A4C 3.8 L/min
Cardiac index 1-p A4C 2.4 L/min-m2
End-diastolic volume 2-p 68 ml
End-systolic volume 2-p 27 ml
Stroke volume, 2-p 41 ml
Stroke volume/bsa 2-p 26.3 ml/m2
Cardiac output 2-p 3.3 L/min
Cardiac index 2-p 2.1 L/min-m2
LVOT:
ID 1.8 cm
Peak velocity, S 1.15 m/sec
Mean velocity, S 0.71 m/sec
VTI, S 21.9 cm
Peak gradient, S 5 mm Hg
Mean gradient, S 2 mm Hg
SV, LVOT DP 55 ml
Cardiac output, LVOT DP 4.3 L/min
Cardiac index, LVOT DP 2.8 L/(min-m2)
Stroke index, LVOT DP 36 ml/m2
Based on the reading I have done, it is my understanding that moderate stenosis does not typically cause symptoms. Based on my echo results, is it possible that my symptoms of decreased endurance, fatigue, & occasional shortness of breath could be related to my aortic stenosis? I am awaiting an appointment with a cardiologist in January, however am just anxious for further information/answers. Thank you for your time.
Its unlikely that the moderate degree of aortic stenosis as suggested by those numbers can lead to symptoms. I personally am very particular about echo performed for valve disease as it is possible echo can underestimate or overestimate disease if not performed meticulously. In your case some form of exercise testing may be warranted to further investigate the response of the heart and the valve to exercise.
you can follow my twitter at @MustafaAhmedMD
I have had 5 echos in 14 months. 1st showed AVA of 1.6, 2nd 3 months later AVA 1.07. 3rd TEE 4 months later 1.06, 4th TTE 9 months later and last week AVA .96. I also had follow up with cardiologist, based on that and symptoms of severe dizziness that causes falls, I am 47 he referred me to a surgeon.
The surgeon of my choice was at another hospital. He asked me to go to the hospital yesterday morning for a TEE. He wanted his own images and a closer look at another valve to make it didn’t require surgery as well. When I arrived, I was admitted, worked up for surgery, chest xray, PFT, blood, EKG. I was told surgery would be Tues or Weds. My poor husband had an anxiety attack. I was also supposed to get an angiogram. After the TEE I ended up being discharged as AVA came up as 1.2cm. Do these things happen often? I am not even sure how I am supposed to know which hospitals calculations are correct.
I am so relieved to be home . I don’t need to see the surgeon again for 2 years. I am just not sure how I am supposed to feel confident in this. Any thoughts?
Thanks for this resource and the excellent article on stenosis. I am a 50 year old man diagnosed with severe stenosis (1.1 valve area, 50mm/hg velocity). My question is about exercise. My excellent cardiologist has cleared me for basically all exercise (I don’t do competitive weightlifting or anything), noting that my heart has not undergone thickening or developed any aneurysms or other abnormalities from my stenosis and I feel fine. The official word is that people with severe stenosis should avoid strenuous exercise, but there don’t appear to be any studies indicating a higher mortality or a cause for such mortality among this population in the case of strenuous exercise. Just wondering if there’s something I or my cardiologist hasn’t considered here? I’d hate to give up my workouts.
Oh — one other odd thing that I’ve asked several cardiologists about without an answer. While I can strenuously bike, rock-climb, swim, and perform calisthenics/stretching with no problem, getting my heart rate up to 150 or so, if I jog at even a very slow pace for more than a few minutes, I experience painful chest tightness and nausea/headache, even with a heart rate below 110. Nobody seems to be able to explain this. Had my arteries checked via MRI — no blockages.
Any thoughts?
I would need to know a lot more and see the valve images to comment. I do not tell my severe AS patients to do strenuous exercise, i typically tell them to do activity as tolerated however i will almost always perform a supervised exercise treadmill test in that instance to give reassurance and guidance while monitoring response, close follow up is key as is symptoms counseling, if your peak gradient is 50 and your area 1.1 then the stenosis may well be only moderate or high moderate in nature.
you can follow my twitter at @MustafaAhmedMD
Dear Dr. Ahmed:
I have never experienced a physician so willing and able to counsel patients re heart valve problems. I am 76 and had the TAVR procedure at PennMed about 10 weeks ago. The surgery was uneventful but I experienced no immediate sense of improvement. However, I felt generally “better” after the surgery. Since then I have not had broad symptom relief. However,
now I experience new symptoms: increased shortness of breath, low energy, poor stamina, and significant increase in need to sleep (I sleep up to 20 hours a day whereas before the surgery I’d be lucky to sleep 2 hours per day). I am desperate to find something to do to improve my symptoms. I am unable to find an appropriate PT in or around Princeton. Can you opine in general about my condition and specifically about physical rehabilitation that I might need.
I have never experienced a physician so willing and able to counsel patients re heart valve problems.
Dear Dr. Ahmed:
I am 76 and had the TAVR procedure at PennMed about 10 weeks ago. The surgery was uneventful but I experienced no immediate sense of improvement. However, I felt generally “better” after the surgery. Since then I have not had broad symptom relief. However, now I experience new symptoms: increased shortness of breath, low energy, poor stamina, and significant increase in need to sleep (I sleep up to 20 hours a day whereas before the surgery I’d be lucky to sleep 2 hours per day). I am desperate to find something to do to improve my symptoms. I am unable to find an appropriate PT in or around Princeton. Can you opine in general about my condition and specifically about physical rehabilitation that I might need.
I have never experienced a physician so willing and able to counsel patients re heart valve problems.
First thing would be to check the heart and valve functioning. It needs to be ensured the valve is functioning well and there is no significant tightening or leak. Then if symptoms persist a broader net cast by a general medicine physician regarding possible other causes. Thereafter the focus needs to be on rehabilitation. Your symptoms are not normal after TAVR and need attention.
Dear Dr Ahmed
On 5/9/18 I had a regular Eco for my calcified Arotic Valve, the reading was 1.3cm2 as it was for the last several years.
On the 6/13/18 my doctor preformed an angio based on a nuclear test done in his office 10 days earlier that caused him to check the condition of my stent.he went ahead and checked my Arotic Valve,the reading came at .82cm2. it was calculated by reference to Grossman 4th ed p. 158. As a result I have few questions
A.Is this an accurate way to calculate?
B. If the Eco is so wrong what do I need to do in order to follow up monitoring my valve
I’m 71 years old and I have no symptoms I’m just so worried.
Thank you very much for taking the time.
Best Regards
Yoram Pelman
The best way to assess an aortic valve is
1) meticulous attention to detail
2) use of multiple methods on echo including gradients, areas and calculations
3) if still ambiguity then use of alternate methods such as tee or other
seek clarification as it can not have gone from 1.3 to 0.8 in 1 month.
you can follow our twitter at @MustafaAhmedMD
Please recommend “centers of excellence” for aortic valve replacement in the Chicago metro area.
A woman 75 old, with aortic valve regurgitation (PHT = 274) and moderate stenosis (AV = 1.34 cm2, Gmean = 44 mmHg and Velocitymax = 4.19 m/s ).
– LV dimension end-diastole = 67 mm
– EF = 39 %
– SIV = 12 mm
– PP = 10 mm
Please, can you tell me if she needs urgent operation or follow up ?
Many thanks Doctor.
Thats a large heart size, what did the evaluating cardiologist say? If severe regurgitation consideration of operation may be advised depending on the circumstance.
you can follow our twitter at @MustafaAhmedMD
I am Still waiting for your response Doctor
Many thanks Dr for your reply, But the X-ray did`not chow a large size of left ventricular (no cardiomegaly ) ?
My Father, 67 years old, has done away with aortic value replacement in April 2018.His peak gradient in echo presurgery was 89 mmhg. Now after surgery he was pretty ok. Echo during discharge showed peak gradient of 50 mmhg and 4 months after surgery, peak gradient reduced to 37mmhg.
3 weeks back he was feeling angina in the chest portion.We went to the doctor for an echo , peak gradient now has become 216mmg.Every body were in a shock. there were no signs of clots. St johns pig value 21 MM was put.Doctor told us that he will put for heparin dose of 3 days to see what is happening.
2 days after the heparin dose in hospital, peak gradient reduced to 168mmhg.AFternoon he took another to recheck the gradient it further came down 135 mmhg . He told to continue the medication for 3 more days. Now we are in a confusion. myfather is 172.5 cms of height and around 75 kgs. is the value size small. He was put St. Jude ‘s value. Secondly can he escape from Value redo surgery.
Has a TEE been done?
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Hello, I’m a father of new born boy, today he has 2 months and 13 days old, he is 58 cm and 5.5 kg.
We made an Echocardiogram one month ago and it shows as main results Aortic Area was 0.19 cm2 ; speed of blood flow 5 m/s and average gradiant of 65 mm hg.
Yesterday we made a 2nd Echo and we found that Aortic area is 0.3-0.4 cm2 (means increased) ; speed of blood flow is about 5,3 m/s and average gradiant of 53 mm hg.
IS teh increase of the Aortic Area a sign that it’s better to not do any surgey now and wait to see the evolution os status by time better?
Is the Aortic Surface by itself a reliable input to say that status isn’t severe aortic stenosis ?
How much the normal Aortic Area should be for a normal baby similar to my boy (Body Surface of 0,309 m2) ??
Please your help and advice for a worried father. Thank you in advance.
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Oddly enough, I had the same experience. My cardiologist said there was nothing wrong with my heart and 10 days later I nearly died of cardiac tamponade – a liter of liquid was crushing my heart. Now I check and cross check all the time. We have to!
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