Totally OT: My heart in detail

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A couple of months ago, a heath care provider detected a heart murmur and informed me that it could be benign or serious. I followed up with an echocardiogram, a transesophageal echocardiogram (TEE) and a CT scan with contrast. There is now enough data to understand that the situation is serious.

In a nutshell, I have severe aortic valve stenosis (narrowing). My entire blood supply is pumping through an aperture of only 1 square cm, which is 1/4 the normal size. My aortic valve is bicuspid (two leaflets instead of the normal tricuspid) and is severely calcified and stiff. In addition, my ascending aorta has a moderate aneurysm. On the good side, everything else is OK, including my heart, coronary and pulmonary arteries, etc.

The question is what to do about this.

There is a minimally-invasive technique called TAVR (Transcatheter aortic valve replacement) which feeds a device like a large stent with an animal valve in the middle up through the arteries and into the aortic valve. It’s like pushing on a very large string. The new valve nests into the existing valve. The chest isn’t opened and recovery time is short. Results are good for 97% of the patients.

The problem is that the good results are obtained with normal tricuspid valves. If you try to push a stent into a bicuspid valve, especially if it is stiff with calcification, the circular stent won’t fit well and blood will leak around the outside of the valve stent. Studies show that this is correlated with higher mortality.

The very nice CT technician let me look at the scans. These included 2 regular X-ray type images and also scans with and without contrast. The images can be scrolled up and down the body. I noticed a bright white spot right in the middle of my heart in the image without contrast. This opacity was as white as a bone. It looked to be about an inch across. I’m sure that this was the calcification on my aortic valve. The TEE already found that the valve is stiff. Now I saw why. It isn’t just a little calcified, it’s calcified enough to be radio-opaque.

My bicuspid valve has two leaflets out of 3 fused together. I don’t think it would be possible, let alone easy, to push a new circular heart valve into a stiff, narrow slit and expect it to fill the space evenly. At least two research articles state that TAVR is contraindicated in this case.

With TAVR excluded, the valve replacement has to be done by open heart surgery. On the positive side, this will enable the surgeon to cut out the bad valve and replace it with a larger size valve compared with TAVR. I don’t know yet whether my cardiologist and the surgeon will decide to replace the aneurysm in the aorta, which is a much larger surgery than simple valve replacement.

On the minus side, the hospital stay is long and recovery takes months.

I have a consult with the surgeon on September 3.

I will keep you’all posted on development.

For those who want to see the details I have copied the CT and TEE results below.

This is probably way too much information.
Wendy

CT ANGIO CHEST W CONTRAST
Collected on August 21, 2024 1:30 PM

Impression
Moderate aneurysmal dilatation of the ascending thoracic aorta, measuring up to 4.6 cm.
Narrative
EXAM: CTA CHEST W CONTRAST EXAM DATE: 8/21/2024 01:30 PM.

CLINICAL HISTORY: Dilated ascending aorta. She has functional calcified bicuspid aortic valve with severe aortic stenosis and eccentric aortic regurgitation (TEE) and dilated ascending aorta at 4.4 to 4.5 cm. She has been mildly symptomatic. ICD-10-CM - I71.21 Aneurysm of ascending aorta, without rupture (HCC). ICD-10-CM I35.9 - Nonrheumatic aortic valve disorder, nonspecified.

COMPARISON: XR CHEST 1 VIEW 03/25/2015 4:11 PM.

TECHNIQUE: Prior to and following intravenous administration of Omnipaque 350, 100 mL, multiplanar 3D/MIP reconstruction of the thoracic aorta was performed.

In accordance with CT protocol optimization, one or more of the following dose reduction techniques were utilized for this exam: automated exposure control, adjustment of mA and/or KV based on patient size, or use of iterative reconstructive technique.

FINDINGS:
Vascular Structures: Moderate aneurysmal dilatation of the ascending thoracic aorta measuring 4.6 cm. No dissection or flow-limiting stenosis. Major branches are unremarkable with normal anatomy. Pulmonary arteries are unremarkable. Minimal air within the main pulmonary trunk, likely result of intravenous injection. Accessory right renal artery. Visualized abdominal arteries are otherwise unremarkable. Aortic valve calcifications, poorly assessed given motion artifact.

Measurements obtained in the double oblique plane.

The sinuses of Valsalva measure 3.4 cm at the left coronary cusp, 3.2 cm at the right coronary cusp, and 3.1 cm at the noncoronary cusp.

The sinotubular junction measures 3.9 x 3.4 cm (measurements may be inaccurate secondary to motion).

The proximal ascending thoracic aorta measures 4.5 x 4.6 cm.
The distal ascending thoracic aorta measures 3.6 x 3.5 cm.
The aortic arch measures 2.6 x 2.5 cm.
The proximal descending thoracic aorta measures 2.1 x 2.0 cm.
The distal descending thoracic aorta measures 1.9 x 1.7 cm.
Lungs/Pleura: No consolidation, nodules, or edema. No effusions or pneumothorax.
Mediastinum: Normal. No cardiac enlargement or adenopathy.
Upper Abdomen: Unremarkable.
Other: None.

ECHO TRANSESOPHAGEAL (TEE)
7/10/2024
Results
• Moderately to severely calcified functional bicuspid aortic valve with restricted cusp motion. Moderate to severe aortic stenosis with mean pressure gradient of 44 mmHg and a calculated valve area of 1.09 cm². Mild to moderate eccentric aortic insufficiency.
• Normal left ventricular size, wall motion and systolic function with an estimated LVEF of 65%.
• Mild mitral regurgitation. Mild tricuspid regurgitation.
• No PFO or intra-atrial shunting by color Doppler or saline contrast bubble study.
• No spontaneous contrast or thrombus seen in the left atrial appendage.
• Dilated sinus of Valsalva and ascending aorta.

Vitals BP Systolic
Your value is 122

Vitals BP Diastolic
Your value is 71

Vitals Heart Rate Rest
Your value is 73

LVOT diameter (Left ventricular outflow tract)
Your value is 2.20 cm

Stroke Volume
Your value is 125 ml

AV peak vel
Your value is 437 cm/s

AV VTI
Your value is 115 cm

AV DVI
Your value is 0.2654

AV peak gradient
Your value is 76 mmHg

AV mean gradient
Your value is 44 mmHg

AV Mean Velocity
Your value is 314 cm/s

Aortic Valve Area by Continuity VTI
Your value is 1.0908 cm2

LVOT peak vel
Your value is 116 cm/s

LVOT peak VTI
Your value is 33 cm

AV LVOT Peak Gradient
Your value is 5 mmHg

AV LVOT Mean Gradient
Your value is 3 mmHg

LVOT Mean Velocity
Your value is 82.7 cm/s

Vitals Height
Your value is 160.0

Vitals Weight
Your value is 70.00

LVEF-TTE TRANSTHORACIC ECHO
Your value is 65 %

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Fascinating.

May your consultations lead to an optimum plan, a successful surgery, and full recovery!

d fb

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I had open heart surgery as well to repair a Mitral valve. Fortunately the sternum was kept intact, with just a 3-4" incision between two ribs to allow access to the heart. I’m hoping something similar can be done to you. It’s still not a fun recovery but it is easier.

I was given a choice, if repair was not possible, to go with a pig valve or a mechanical valve. I opted mechanical (though, fortunately, mine was repaired). Which type are you going to go with?

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I can’t use mechanical since it needs daily anticoagulant. As a breast cancer survivor I expect to need surgery in the future. Nix the anticoagulant.
Wendy

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I’ve been wanting to ask but afraid to pester for fear of jinxing you. Bummer…but not the worst news in the world. If you need replacement of the ascending aorta also, the procedure is likely to be a bio-Bentall like my husband, if you can bring yourself to check up on it (dh hasn’t even looked at the various educational sites showing it and even bellyaches the the cardiologist shows him his CT angiogram every time!)

There’s an irony in that, if it is a bio-Bentall you need, it’ll be for the reverse of dh’s…aortic (valve) incompetence secondary to a rapidly increasing aortic aneurysm.

Can’t finish without an anecdote. On our trip back to England last summer, we had a get together with cronies from the the old days…a fellow “fellow” from husband’s hepatology fellowship days and his wife. We hadn’t seen them for about a decade so, whilst we were catching up on Life events and illness and whatnot, it turned out the Gray (our friend) had done part of his residency with Prof Hugh Bentall…who pioneered quite a lot of cardiology surgical procedures. On balance, husband decided he would rather have had that association with the name rather than the one he has.

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Actually, you might still need anticoagulation immediately after the surgery (assuming dh’s experience to be typical…which it appears to be according to Google)

After the first 3 months, that stopped but reintroduced when what we expected to be his last CTangiogram showed a clot on one leaflet of the valve. That’s due to end in a couple of months time.

Big advantage too…he doesn’t click. That can be quite disconcerting with mechanical valves.

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Please keep us posted, Wendy.
Sending best wishes and karma.
You have earned every bit.

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I have been impressed over the years with your willingness to share your health issues and your research into both them and their treatments. All our healthcare decisions are a bit of a gamble, but I know that when the time comes you will make the best decision based on both your doctors’ advice and your understanding. I am also sure you will have all of our best wishes.

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This needed more than a rec on my part. Wendy, I am so grateful for all that you have shared. I am sure it’s not always easy to do so, but it is so helpful for all of us to hear.

Blessings.

IP

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For some reason, it feels appropriate to chime in after months of inactivity to say “nice stroke volume!” I’ve acquired a cardiologist in the past year and have a full set of stats as well.

I hope it all works out for you. Your devotion to fitness should serve you well.

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Just reading that made my heart hurt. Both of them.

Qazulight

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