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AS, AR and MVR

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  • V vasuvius
    Thanks for the comments fromDr. Sorrell and others regarding MR in CABG pts. Now I have another problem. Saw this woman just this morning. 72 yr old,
    Message 1 of 7 , Apr 12, 2001
      Thanks for the comments fromDr. Sorrell and others
      regarding MR in CABG pts.

      Now I have another problem. Saw this woman just this
      morning.

      72 yr old, Mechanical MVR 8 yrs ago; Now with heart
      failure, not in pul edema but has significant
      exertional dyspnea and even orthopnea. Has h/o
      hypertension, now under control. Known to have some
      aortic valve disease. Has A fib, rate controlled. Echo
      shows normally functioning mitral prosthesis with a
      mean gradient of 6 mm Hg, 2+ AR, moderate AS (peak vel
      3.5, mean gradient 25, calculated valve area 1.2
      sqcm), LVH, EF:60%.

      Despite diuresis and hypertension control, norvasc,
      beta-blockers, etc, she is not doing well. A fighter
      and a woman with spirit.

      What do I do now?

      - She has 3-4 mild to moderate problems: mild MS
      (gradient across MVR), mild to mod AS, mild to mod AR,
      possible LV diastolic dysfunction. If one replaces
      aortic valve, she will still end up with a similar
      gradient across prosthetic ao valve and only
      accomplishment is elimination of AR.

      - Any advice on how I could handle this sick but
      charming patient?

      V Vasuvius

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    • David N. Abisalih
      First of all, how long has she been in afib? How large are her LA and RA--my point being it might be reasonable to try to achieve NSR. If not, is her afib
      Message 2 of 7 , Apr 12, 2001
        First of all, how long has she been in afib? How large are her LA and RA--my
        point being it might be reasonable to try to achieve NSR.

        If not, is her afib really rate controlled? In other words, is the HR
        response to exercise inappropriately fast, or too slow (pharmacologic
        chronotropic incompetence). If achieving NSR is not a reasonable goal, then
        maybe AV node ablation with permanent VVI-R pacing would be helpful to
        regularize the rhythm and provide near-physiologic HR response to exercise,
        which can be optimized--preferably with dual sensor technology.

        Does she have TR--have you been able to non-invasively quantitate RVSP. If
        not, perhaps a Rt. Heart Cath via Internal Jugular or Subclavian approach to
        assess filling pressures at rest and post-exercise.

        Lastly, could the AR be more than moderate--if the "jet" blends in with the
        mitral inflow it could be underestimated and aortic root angiography would
        help sort this out. By the way, is the LV dilated?
        ----------
        >From: V vasuvius <vvasuvius@...>
        >To: echocardiography@yahoogroups.com
        >Subject: [echocardiography] AS, AR and MVR
        >Date: Thu, Apr 12, 2001, 6:38 PM
        >

        >Thanks for the comments fromDr. Sorrell and others
        >regarding MR in CABG pts.
        >
        >Now I have another problem. Saw this woman just this
        >morning.
        >
        >72 yr old, Mechanical MVR 8 yrs ago; Now with heart
        >failure, not in pul edema but has significant
        >exertional dyspnea and even orthopnea. Has h/o
        >hypertension, now under control. Known to have some
        >aortic valve disease. Has A fib, rate controlled. Echo
        >shows normally functioning mitral prosthesis with a
        >mean gradient of 6 mm Hg, 2+ AR, moderate AS (peak vel
        >3.5, mean gradient 25, calculated valve area 1.2
        >sqcm), LVH, EF:60%.
        >
        >Despite diuresis and hypertension control, norvasc,
        >beta-blockers, etc, she is not doing well. A fighter
        >and a woman with spirit.
        >
        >What do I do now?
        >
        >- She has 3-4 mild to moderate problems: mild MS
        >(gradient across MVR), mild to mod AS, mild to mod AR,
        >possible LV diastolic dysfunction. If one replaces
        >aortic valve, she will still end up with a similar
        >gradient across prosthetic ao valve and only
        >accomplishment is elimination of AR.
        >
        >- Any advice on how I could handle this sick but
        >charming patient?
        >
        >V Vasuvius
        >
        >__________________________________________________
        >Do You Yahoo!?
        >Get email at your own domain with Yahoo! Mail.
        >http://personal.mail.yahoo.com/
        >
        >
        >
        >Your use of Yahoo! Groups is subject to http://docs.yahoo.com/info/terms/
        >
      • vuedoc@aol.com
        I agree with Dr. Abisalih- the patient s symptoms seem out of proportion to the degree of her echocardiographic findings, therefore either her valular lesions
        Message 3 of 7 , Apr 12, 2001
          I agree with Dr. Abisalih- the patient's symptoms seem out of proportion to
          the degree of her echocardiographic findings, therefore either her valular
          lesions and LV functon are worse than what they appear to be, or there is
          another etiology for her symptoms.  Assuming she is not tachycardic and the
          ventricular chamber size is normal, I doubt that replacing the aortic valve
          will help.

          In my experience, whenever a patient with A-fib is "not doing well",
          restoration and maintenance of NSR can work wonders.  Even with proper rate
          control, if she has LVH and moderate AR, she probably has impaired LV
          relaxation along with a rapidly rising LV chamber pressure during diastole,
          making atrial "kick" all the more important.  

          I agree with determining pulmonary artery pressures, although a mean
          trans-mitral gradient of  6 mmHg shouldn't cause pulmonary hypertension.  
          Could there be co-existing primary pulmonary disease?

          How about ischemic heart disease?  She was probably cathed before her MVR,
          but a lot could happen in 8 years.  A dobutamine stress echocardiogram will
          give you lots of answers: evidence of myocardial ischemia along with dynamic
          hemodynamic data regarding the valves and LV systolic and diastolic function.

          Bradley J. Artel, M.D., F.A.C.C.
          New York, NY
        • V vasuvius
          Dear Dr. Abisalih, -A fib is chronic; As I said, rate is well-controlled. under these conditions, any form of pacing is unlikely to be beneficial. - She does
          Message 4 of 7 , Apr 13, 2001
            Dear Dr. Abisalih,

            -A fib is chronic; As I said, rate is well-controlled.
            under these conditions, any form of pacing is unlikely
            to be beneficial.

            - She does have moderate pulm hypertension PASP 55-60
            mm Hg. TR is only mild.

            - AR is 2+ based on comprehensive assessment of AR;
            Aortic angiography is a crude stone-age technique for
            assessing AR. No comparison to a comprehensive echo.

            - LV is not dilated.

            - RH cath is unlikely to contribute. We know that she
            is in heart failure.

            - She has no lung disease; no significant CAD (cor
            angio)

            V. Vasuvius


            --- "David N. Abisalih" <drdna@...>
            wrote:
            > First of all, how long has she been in afib? How
            > large are her LA and RA--my
            > point being it might be reasonable to try to achieve
            > NSR.
            >
            > If not, is her afib really rate controlled? In other
            > words, is the HR
            > response to exercise inappropriately fast, or too
            > slow (pharmacologic
            > chronotropic incompetence). If achieving NSR is not
            > a reasonable goal, then
            > maybe AV node ablation with permanent VVI-R pacing
            > would be helpful to
            > regularize the rhythm and provide near-physiologic
            > HR response to exercise,
            > which can be optimized--preferably with dual sensor
            > technology.
            >
            > Does she have TR--have you been able to
            > non-invasively quantitate RVSP. If
            > not, perhaps a Rt. Heart Cath via Internal Jugular
            > or Subclavian approach to
            > assess filling pressures at rest and post-exercise.
            >
            > Lastly, could the AR be more than moderate--if the
            > "jet" blends in with the
            > mitral inflow it could be underestimated and aortic
            > root angiography would
            > help sort this out. By the way, is the LV dilated?
            > ----------
            > >From: V vasuvius <vvasuvius@...>
            > >To: echocardiography@yahoogroups.com
            > >Subject: [echocardiography] AS, AR and MVR
            > >Date: Thu, Apr 12, 2001, 6:38 PM
            > >
            >
            > >Thanks for the comments fromDr. Sorrell and others
            > >regarding MR in CABG pts.
            > >
            > >Now I have another problem. Saw this woman just
            > this
            > >morning.
            > >
            > >72 yr old, Mechanical MVR 8 yrs ago; Now with heart
            > >failure, not in pul edema but has significant
            > >exertional dyspnea and even orthopnea. Has h/o
            > >hypertension, now under control. Known to have some
            > >aortic valve disease. Has A fib, rate controlled.
            > Echo
            > >shows normally functioning mitral prosthesis with a
            > >mean gradient of 6 mm Hg, 2+ AR, moderate AS (peak
            > vel
            > >3.5, mean gradient 25, calculated valve area 1.2
            > >sqcm), LVH, EF:60%.
            > >
            > >Despite diuresis and hypertension control, norvasc,
            > >beta-blockers, etc, she is not doing well. A
            > fighter
            > >and a woman with spirit.
            > >
            > >What do I do now?
            > >
            > >- She has 3-4 mild to moderate problems: mild MS
            > >(gradient across MVR), mild to mod AS, mild to mod
            > AR,
            > >possible LV diastolic dysfunction. If one replaces
            > >aortic valve, she will still end up with a similar
            > >gradient across prosthetic ao valve and only
            > >accomplishment is elimination of AR.
            > >
            > >- Any advice on how I could handle this sick but
            > >charming patient?
            > >
            > >V Vasuvius
            > >
            > >__________________________________________________
            > >Do You Yahoo!?
            > >Get email at your own domain with Yahoo! Mail.
            > >http://personal.mail.yahoo.com/
            > >
            > >
            > >
            > >Your use of Yahoo! Groups is subject to
            > http://docs.yahoo.com/info/terms/
            > >
            >
            >
            >
            > Your use of Yahoo! Groups is subject to
            > http://docs.yahoo.com/info/terms/
            >
            >


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          • Dr. Pedro GutiĆ©rrez-Fajardo
            ... De: V vasuvius [mailto:vvasuvius@yahoo.com] Enviado el: Jueves, 12 de Abril de 2001 04:39 p.m. Para: echocardiography@yahoogroups.com Asunto:
            Message 5 of 7 , Apr 14, 2001
              -----Mensaje original-----
              De: V vasuvius [mailto:vvasuvius@...]
              Enviado el: Jueves, 12 de Abril de 2001 04:39 p.m.
              Para: echocardiography@yahoogroups.com
              Asunto: [echocardiography] AS, AR and MVR

              Thanks for the comments fromDr. Sorrell and others
              regarding MR in CABG pts.

              Now I have another problem. Saw this woman just this
              morning.

              72 yr old, Mechanical MVR 8 yrs ago; Now with heart
              failure, not in pul edema but has significant
              exertional dyspnea and even orthopnea. Has h/o
              hypertension, now under control. Known to have some
              aortic valve disease. Has A fib, rate controlled. Echo
              shows normally functioning mitral prosthesis with a
              mean gradient of 6 mm Hg, 2+ AR, moderate AS (peak vel
              3.5, mean gradient 25, calculated valve area 1.2
              sqcm), LVH, EF:60%.

              Despite diuresis and hypertension control, norvasc,
              beta-blockers, etc, she is not doing well. A fighter
              and a woman with spirit.

              What do I do now?

              - She has 3-4 mild to moderate problems: mild MS
              (gradient across MVR), mild to mod AS, mild to mod AR,
              possible LV diastolic dysfunction. If one replaces
              aortic valve, she will still end up with a similar
              gradient across prosthetic ao valve and only
              accomplishment is elimination of AR.

              - Any advice on how I could handle this sick but
              charming patient?

              V Vasuvius
              It is a very interesting case. Did you already look for pulmonary embolism?
              You only mentioned left heart data but it could be interesting how right
              ventricle is (normal, dilated, hypokinetic) how is pulmonary artery pressure
              (normal or elevated). In some old-patients with high risk factors for
              pulmonary embolism could be ignored and we try to find left heart problems
              but the problem in fact is on the right heart due to acute overload pressure
              Pedro Gutierrez-Fajardo MD
              Monterrey, Mexico
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            • Satoshi NAKATANI
              What about a possibility of post surgical constrictive pericarditis ? ... Satoshi Nakatani, MD, PhD, FACC Cardiology Division National Cardiovascular Center
              Message 6 of 7 , Apr 17, 2001
                What about a possibility of post surgical constrictive pericarditis ?


                >
                > 72 yr old, Mechanical MVR 8 yrs ago; Now with heart
                > failure, not in pul edema but has significant
                > exertional dyspnea and even orthopnea. Has h/o
                > hypertension, now under control. Known to have some
                > aortic valve disease. Has A fib, rate controlled. Echo
                > shows normally functioning mitral prosthesis with a
                > mean gradient of 6 mm Hg, 2+ AR, moderate AS (peak vel
                > 3.5, mean gradient 25, calculated valve area 1.2
                > sqcm), LVH, EF:60%.
                >
                > Despite diuresis and hypertension control, norvasc,
                > beta-blockers, etc, she is not doing well. A fighter
                > and a woman with spirit.
                >
                > What do I do now?
                >
                > - She has 3-4 mild to moderate problems: mild MS
                > (gradient across MVR), mild to mod AS, mild to mod AR,
                > possible LV diastolic dysfunction. If one replaces
                > aortic valve, she will still end up with a similar
                > gradient across prosthetic ao valve and only
                > accomplishment is elimination of AR.
                >
                > - Any advice on how I could handle this sick but
                > charming patient?

                Satoshi Nakatani, MD, PhD, FACC
                Cardiology Division
                National Cardiovascular Center
                5-7-1 Fujishiro-dai
                Suita, Osaka 565-8565
                Japan
                Phone: 81-6-6833-5012
                Fax: 81-6-6872-7486
                E-mail: nakatas@...
              • Andrew Mitchell
                The other thing to consider is trying to restore and maintain sinus rhythm, that may require endocardial cardioversion +/- amiodarone. Andy Mitchell ... From:
                Message 7 of 7 , Apr 19, 2001
                  The other thing to consider is trying to restore and maintain sinus rhythm,
                  that may require endocardial cardioversion +/- amiodarone.

                  Andy Mitchell


                  -----Original Message-----
                  From: Satoshi NAKATANI [mailto:nakatas@...]
                  Sent: 18 April 2001 01:59
                  To: echocardiography@yahoogroups.com
                  Subject: Re[2]: [echocardiography] AS, AR and MVR

                  What about a possibility of post surgical constrictive pericarditis ?


                  >
                  > 72 yr old, Mechanical MVR 8 yrs ago; Now with heart
                  > failure, not in pul edema but has significant
                  > exertional dyspnea and even orthopnea. Has h/o
                  > hypertension, now under control. Known to have some
                  > aortic valve disease. Has A fib, rate controlled. Echo
                  > shows normally functioning mitral prosthesis with a
                  > mean gradient of 6 mm Hg, 2+ AR, moderate AS (peak vel
                  > 3.5, mean gradient 25, calculated valve area 1.2
                  > sqcm), LVH, EF:60%.
                  >
                  > Despite diuresis and hypertension control, norvasc,
                  > beta-blockers, etc, she is not doing well. A fighter
                  > and a woman with spirit.
                  >
                  > What do I do now?
                  >
                  > - She has 3-4 mild to moderate problems: mild MS
                  > (gradient across MVR), mild to mod AS, mild to mod AR,
                  > possible LV diastolic dysfunction. If one replaces
                  > aortic valve, she will still end up with a similar
                  > gradient across prosthetic ao valve and only
                  > accomplishment is elimination of AR.
                  >
                  > - Any advice on how I could handle this sick but
                  > charming patient?

                  Satoshi Nakatani, MD, PhD, FACC
                  Cardiology Division
                  National Cardiovascular Center
                  5-7-1 Fujishiro-dai
                  Suita, Osaka 565-8565
                  Japan
                  Phone: 81-6-6833-5012
                  Fax: 81-6-6872-7486
                  E-mail: nakatas@...




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