@WendyBG …been thinking about you and wondering. Any verdict on your valve replacement?
@VeeEnn I have a transesophageal ultrasound scheduled on Wednesday, July 10. This will give a more accurate assessment of the valve’s condition since the probe will be only an inch away from the valve. The previous external ultrasound that detected the valve stenosis has lots of physical structures in the way and uses an equation to calculate the flow and size of the valve.
Meanwhile, the cardiologist put me on a med to slow my heart rate. The purpose is to enable the blood to fully enter the left ventricle during the resting (diastolic) phase since the side of the ventricle is stiff and the exit valve is restricted. I got a Fitbit-type fitness watch to monitor my pulse rate while working out. Keeping the pulse rate under 120 at all times.
Thanks for asking. 
Wendy
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Ah…Zone 2 training!!! It’s amazing what you can accomplish with extended periods at a lower heart rate. Perfect for listening to podcasts if you have a treadmill or other piece of equipment handy that allows for complete control of intensity.
Getting the teaser email for this Peter Attia podcast is what tempted me to take out a subscription (initially intended to do just one month then cancel) and how come I got the heads-up to follow up on the allegedly “mildly elevated LDL-C”…
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I just put this out there Wendy, because it’s everso easy to feel restricted when you’re advised to keep your heart rate below an arbitrary number you associate with being “too easy”. Back when I had my spinning classes I found that folk loved intervals and groaned at the idea of a lower intensity “endurance class” as a waste of workout time. Until about 40 minutes in and 10 more to go of a class with no planned recovery.
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I’m guessing you have Aortic Valve Stenosis. Have you talked to your cardiologist to find out if you are a candidate for the minimally invasive procedure for this called a TAVR? It’s a widely performed and well researched procedure that is pretty common today. You avoid having your sternum split and the recovery is much quicker and less painful as they approach from your femoral artery with catheters. Interestingly the Yale literature says more are being done using this minimally invasive route than the open hearth approach. Hope you are a candidate for the TAVR vs the open heart AVR. Just curious…doc
Transcatheter Aortic Valve Replacement (TAVR) (clevelandclinic.org)
Transcatheter aortic valve replacement (TAVR) - Mayo Clinic
edit: 8 Things to Know About TAVR, a Less Invasive Way to Replace an Aortic Valve > News > Yale Medicine
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Yes on both counts.
An external echocardiogram detected severe aortic valve stenosis and Grade I diastolic dysfunction after my primary care heard a heart murmur.
I want TAVR. Thanks for the links – I already read them as soon as my aortic valve stenosis was diagnosed over a month ago. This is 2024 – why would anyone want an old-fashioned sternum-splitting surgery when TAVR is available?
I have discussed TAVR with my cardiologist. He’s on board with TAVR. The purpose of the transesophageal ultrasound in 2 days is to accurately image the valve.
The question is when to do TAVR. I would like this ASAP. My cardiologist seems to prefer medical management of the condition since he expects me to live at least 15 years longer and is concerned that the expected replacement (in 10 years or so) would restrict blood flow. The medical device companies are working on improved valve mountings with this issue in mind.
I’m age 70. Will I live another 10 years? On one hand, I exercise hard 5 days a week (not counting walking 7 days a week) and my cardiologist was astonished to see the video of me doing a handstand. (How many of your 70-year-old patients can still do a handstand?) On the other hand, I’m a cancer survivor (10 years so far) and both my parents died around age 70.
I appreciate your input. I don’t want my heart failure to progress any further.
Wendy
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Wow, a handstand! That’s impressive.
Very glad you are a candidate for TAVR. Does your cardiologist do TAVR? If he doesn’t, then he would have to send you to another cardiologist - invasive cardiologist - and he might be concerned about losing you as a patient. Unfortunately that is common. My next door neighbor is going through a similar situation with her cardiologist regarding a different diagnosis/procedure. Her cardiologist doesn’t do the procedure and he wants to send her to another city 6 hours away for the procedure which I questioned because we have excellent cardiologists here in the city that do this common procedure she needs.
You sound like you are in good health. Seek information which you are already doing. You might get a second opinion from an invasive cardiologist. I don’t understand why your doctor would wait and risk ongoing irreversible damage to your heart but I am not a cardiologist. I don’t know how severe your stenosis is either. That is another guiding factor. Blessings…doc (retired)
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Very common reason that patients are not referred to alternate invasive specialists (cardiologist) in the United States. I brought this up in a different thread with you that A-fib patients are not referred sufficiently early for intervention.
Thank you for your comments and insights.
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I’m not sure I understand the difference between an ‘invasive cardiologist’ and a ‘cardiologist’. Can someone put the differentiation at a simple 10 year old vocabulary level?
JimA
In the 1980s up until 1990 cardiology was a subspecialty of internal medicine. Any cardiologist could endeavor to be trained in invasive cardiology, but since then invasive cardiology is a fellowship program required afterward. Currently an invasive cardiology fellowship program will be offered primarily to trainees who have completed a fellowship program in general cardiology.
Generally, TAVR programs require more training and many invasive cardiologist don’t have the training to do them. Eventually there will be a separate subspecialty in cardiac structural intervention.
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Today, there are cardiologists who perform invasive procedures and then some who don’t. The ones who don’t won’t do heart caths, EPS (mapping the conduction pathways in the heart and then doing ablations to fix the abnormal rhythm) or any procedure like this TAVR. They just see you in clinic and order EKG’s, ultrasounds and stress tests along with treating your heart disease/hypertension with the proper medications. They may also do critical care medicine and take care of you in the CCU (place where you go with severe heart disease or heart attack). To be an invasive cardiologist requires extra training and certification at an accredited program. I hope this is a little more clear Jim…doc
edit: invasive cardiologists are first board certified cardiologist and then get more training/accreditation to do special procedures
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Thanks. I’ve never seen the term before. In 2001 when I had my heart attack, the cardiologist who put in the stent is the same guy I’ve been seeing for some 23 years. I hope he knows what he’s doing! 
JimA
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This entire thread is an excellent read.
Is it fair to say “invasive” is another word for surgeon? The problem in this context is the surgery is less invasive.
Is it fair to say with changes in how to approach surgery to work with billing invasive is used because minor surgery is more valuable but harder to bill for as surgery compared to major surgery? That comparison is full of dynamics.
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Jim
heart caths and stents fall into the invasive category. I’m sure he was well qualified…doc
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Yes, the TAVR is less invasive than an Aortic Valve Replacement done by a cardiothoracic surgeon. The TAVR approach is where the cardiologist utilizes an artery like the femoral and places a valve using catheters while the AVR is done by cutting your chest open, going on bypass and sewing a valve in under direct vision or repairing the valve. The open heart approach has the longer recovery with more pain if that helps in the explanation…doc
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@JimA759s …just to clarify, although I’m sure some cardiologists just see you in clinic and order EKGs and stress tests and whatnot, a heck of a lot of them actually think and diagnose…treating and managing their patients’ conditions appropriately (not all of which require surgery). US healthcare tends to be quite procedure heavy…with greater reimbursement for the technical/surgical than the cognitive, leading to high cost but oftentimes without the improvement in outcome you’d expect.
This isn’t confined to cardiology. My husband, by specialty training is a gastroenterologist. His sub speciality is hepatology (fellowship in diseases of the liver and pancreas to be specific) His sub, sub specialty is transplant hepatology. No, he does not perform liver transplants…the route to that part of the transplant team is via the surgical training route. Two distinctly different career paths with the either/or decision taken decades ago.
What has blurred the distinction a bit between the physician vs surgeon route is basically the advances in both technology…enabling less invasive approaches conditions that previously required surgery (your TAVR, stent placement etc)…and more advanced diagnostics and pharmacology that can enable non surgical treatment for what was originally the province of the surgeon.
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In addition to our respective career choices/approaches dh’s and my own experiences may give you a bit more insight…or confusion. One reason that Wendy’s cardiac issues have been on my mind is because dh and I have both had our follow up appointments for our different cardiology issues with the same intervention cardiologist recently. Same cardiologist but two different conditions with dramatically different initial treatments and subsequent management.
Just over 5 years ago my husband had an emergency bio-Bentall procedure. Google will help you with a description but, in a nutshell, he’d had an unknown/undiagnosed/asymptomatic aortopathy that manifest itself as a sudden onset aortic incompetence (exact opposite of Wendy’s stenosis)…incredibly fortuitously just a few days before, and picked up on our annual physicals, else I’d be a widow now. This successful procedure was performed by a cardio thoracic surgeon and who, as part of a large multidisciplinary unit at the University Hospital here in Denver, specialized in aortopathies/aortic valve replacement. Absolutely no alternative to open heart surgery. Six monthly follow up with the intervention cardiologist on the team (CT angiogram making it now a non invasive follow up…if you don’t count the radiation) Everything perfect…until this most recent when a very early HALT was detected (again, Google will do a better job for you than I could for description)
This leaflet thickening apparently looked more like a small thrombus than actual valve degeneration so attempted reversal with anticoagulant therapy has been the treatment over the past 3 months. Monday is the day we will find out if it’s been successful. If not…the valve can now be replaced by a TAVR approach performed by the intervention cardiologist.
Now with me, two years ago I discovered that previous reassurances that my mildly elevated LDL-C was not a problem were dead wrong. Immediately on finding out the degree of my CAD, my husband arranged for me to see “his” intervention cardiologist…assuming I’d need a stent or two…or three etc, and this would be the guy. No. Apparently, the last decade or so has seen a reduction in stent placement in asymptomatic CAD in addition to the introduction of new medications (PCSK9 inhibitors among others) that are capable of, not only halting the disease process in its tracks but actually reversing the process with aggressive lipid lowering.
So, for one intervention cardiologist, advances in technology (TAVR) giveth at the same time as pharmaceutical advances (PCSK9 inhibitors) taketh away.
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@WendyBG …you mentioned taking meds to slow your heart rate. Are you taking beta blockers or something like diltiazem (a calcium channel blocker) Only asking because there’s more than a good chance that these will affect your heart rate response to exercise. If you’re new to using a continuous read HRM device, you might not have a feel for the perceived exertion that would go with the response you see on your fitbit. Generally speaking you’ll see a more sluggish response with beta blockers especially during warm up and a steady state reading that’s a bit lower than the 120 bpm maximum at the appropriate intensity …i.e. you might need to mentally revise that 120 downwards a bit to avoid working harder than you should be.
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@VeeEnn I am taking metoprolol ER which is a beta blocker. The pill is 25 mg but I break it in half so I’m taking 12.5 mg per day.
The effect has been what the cardiologist is aiming for – heart rate under 100 most of the time and under 120 during maximum exercise (which means belly dancing in Zumba and big moves with weights in my fitness class). I haven’t felt short of breath and blood O2 is consistently > 95%.
Wendy
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A near homeopathic dose! My husband is on 50 mg, I think. His use is to keep his B.P. artificially low to protect his valve. It’s never been high but runs at around 115/70 or below these days.
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