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Forum Name: Valvular Heart Diseases

Question: Help to interpret echocardiogram


 lucky400 - Wed Feb 23, 2005 10:47 am

I have just recently had an echocardiogram and would like help understanding the results. The following is the information I received.
MMode/2D Measurements & Calculations
IVSd: 0.72 cm
LVIDd: 5.1 cm
LVIDs: 3.0 cm
LVPWd: 0.72 cm
Aoroot diam: 2.8 cm
LA dimension: 3.1 cm

Left Ventricle is normal in size EF is 60-65%. Doppler flow pattern suggest impaired left ventricular relaxation.
Right Ventricle is normal in size and function
Left and right Atria size is normal
Mitral Valve: Mild thickening of the mitral valve leaflets. Moderate mitral regurgitation.
Tricuspid Valve: Not well visualized, but is grossly normal. Moderate tricuspid reguritation. Right systolic ventricular pressue is estimated at 35-40 mmHg.
Aortic Valve: Focally thickened trileaflet aortic valve. A bicuspid aortic valve cannot be excluded. The aortic valve peak pressure gradient is 43 mm Hg. The aortic valve mean pressure gradient is 22 mm Hg. Mild to moderate valvular aortic stenosis. No aortic regurgitation is present.
Pulmonic Valve: Not well visualized.
Great Vessels: Aortic root size is normal
Pericardium/Pleural: The is no evidence of a pericardial effusion.

Comments: As compared to previous study aortic stenosis is worse.

I am a 55 year old female. Am I looking at possible surgery for the aortic valve or is that a long way off. Is the reguritation in the other valves a problem? I exercise on a treadmill 5 days a week for a 1/2 hour a day. I sometimes feel heavy pressure on my chest when I first start exercising but then it seems to go away. Also I get palpitations in the morning when I first wake up. I always exercise yet I have trouble climbing a large staircase - I feel pressure on my chest and sometimes short of breath when I reach the top. I thought with all my daily exercise climbing stairs wouldn't be difficult. Is this a sympton of the aortic stenosis? Thanks for your help.
 Dr. Yasser Mokhtar - Thu Feb 24, 2005 3:20 pm

User avatar Dear Lucky400,

Aortic stenosis has to be followed on regular basis to watch the progress and see if and when the patient will need surgery.

Your echo shows that the function of your heart has not been affected by the stenosed valve to the extent of having heart failure, you still have an excellent ejection fraction 60-65%.

Still, your left ventricle is becoming stiffer (this is what impaired left ventricular relaxation means) which means that the same amount of blood that the heart receives will make the pressure inside the left ventricle increases which means that there will be back up of blood to the lungs and this is manifested by shortness of breath.

The mitral regurgitation could be related to the thickening of the mitral valve itself.

However, you are having symptoms that can be related to aortic stenosis which are chest pain and shortness of breath.

Indications for surgery include:
1. Patients start to have symptoms such as diziness, losing consciousness, chest pain and shortness of breath.
2. Having a very narrow valve (the echo report never mentioned what is the area of the aortic valve).

At this point, my personal recommendation is to have a stress test with nuclear scan to make sure that the chest pain that you are having is not secondary to angina (coronary disease) and to have a coronary angiogram if it turns out to be due to it. And if bypass is incicated, then the valve replacement will be done at the same time. And if it was negative this most probably means that the symptoms are due to the aortic stenosis, so the next step will be an angiogram in preparation for surgery.

i think that you are headed towards surgery, and i would prefer sooner rather than later, so i think if your cardiologist is not conservative, he/she will most proabably recommend an angiogram and left heart catheterization and then head for surgery.

Keep me posted on how your appointment turns out.

Thank you very much for using our website http://doctorslounge.com and i hope that this information helped.

Yasser Mokhtar, M.D.
 lucky400 - Thu Feb 24, 2005 4:16 pm

Dear Dr. Mokhtar,

Thank you so much for answering my post and helping me to understand my echo results. Your explanation is very helpful and I appreciate your prompt response. I'm grateful for your help and feel more prepared to see the cardiologist tomorrow, Friday 2/25.

This is my first time seeing a cardiologist and having some understanding before my visit should make the visit easier.

I also plan to get a second opinion after tomorrow's visit with a cardiologist from a large teaching hospital, University of PA.

I will let you know what the doctor I see tomorrow has to tell me and having your help is like having a second opinion already.

Thank you again.
 lucky400 - Fri Feb 25, 2005 2:38 pm

Dear Dr. Mokhtar,

I just met with the cardiologist. He has ordered a nuclear stress test. However, he did say that I am not sick enough for surgery yet. He said I will definitely have to have a valve replacement at some time but he would like to wait till it gets worse.

I am definitely seeing another cardiologist next week. I wonder why I would want to wait till I got sicker and less healthy to have that kind of surgery. If I need it and it's just a matter of when then why would I wait till I get older and less healthy. I really don't want any surgery but somehow that reasoning is not making sense to me.

I was wondering about your opinion. I know you have not examined me personally. The doctor did say my murmur is very loud and indicative of heart valve diesease but I am not bad enough for surgery.

Thanks for your help. I really appreciate it.

Barbara
 Dr. Yasser Mokhtar - Sat Feb 26, 2005 7:29 pm

User avatar Dear Barbara,

Thank you very much for the update.

The dilemma is to decide whether or not the symptoms are due to aortic stenosis. If the symptoms are due to aortic stenosis, then the next step in my opinion should be surgery.

Once symptoms start in aortic stenosis, the survival rate decreases. In elderly females, surgery outcomes are worse than others. You are right, if surgery is needed, i would advise to go ahead sooner rather than later when your heart is still strong and you are healthier.

Thank you very much for using our website http://doctorslounge.com and i hope that this information helped.

Yasser Mokhtar, M.D.
 lucky400 - Thu Mar 10, 2005 2:37 pm

Hi Dr. Mokhtar,

Thank you so much for all you sound advice. I have seen the cardiologist at Penn twice now and I am much happier with him than the first doc I saw. My doctor ordered another echo from Penn - he felt too much was missing from the first one. I got a more detailed report from the second echo. I wanted to go over a few things with you.

First this echo gave a aortic valve area where the first one did not. The valve area is 1.01 cm^2 (Peak grad = 45mmHg, Mean Grad = 26mmHg, LVOT dia+ 1.8cm, LVOT FVI =30 cm, Ao FVI = 75 cm) It states there is moderately decreased valve excursion during systole and it also says "There is moderate to severe aortic stenosis". The first echo said mild to moderate. What does decreased valve excursion mean?

This is what it said for the mitral valve:
The mitral valve is mildly thickened. There is moderate mitral regurgitation with multiple jets. The valve has mild myxomatous degeneration.
I don't know what the above means. Could you explain this and is this something I should be concerned about. Can this be fixed when I have the aortic valve replaced or doesn't it need to be fixed.?

Tricuspid valve:
The tricuspid valve is normal. There is moderate to severe tricuspid regurgitation which is centrally directed. There is moderate pulmonary hypertension (PASP=50mmHg, RAP=14mmHg).
Again, is this something to be concerned about and can I have this fixed at the same time as well or don't I need to fix this?

I am having a heart catherization at Penn on 3/21. My cardiologist says this will tell us more and he said to figure on surgery sooner rather than later.

In your opinion do you think I should curtail my exercise program - walking on treadmill for approx. 30 minutes a day - this is getting harder for me to do so I am going slower with no incline. I have stopped working in the weight room which I normally do 3 days a week.

Thank you for helping to explain all this to me.

Barb
 Dr. Yasser Mokhtar - Sat Mar 12, 2005 10:26 am

User avatar Dear Barbara,

Thank you very much for the update.

Decreased excursion means that the aortic valve is not moving enough. During systole (contraction of the heart), the aortic valve has to open all the way so that the blood in the left ventricle is pumped into the aorta easily, decreased excursion during systole means that it does not open all the way, and this is stenosis. This is just a complex way of saying that you have aortic stenosis and that the cause of this stenosis is the valve itself.

The grades of aortic stenosis according to the area of the valve are:
1. Mild: Valve area more than 1.5 cm2
2. Moderate: Valve area between 1.0 to 1.5 cm2.
3. Severe: Valve area less than 1.0 cm2
4. Critical: Valve area less than 0.75 cm2.

Yours is at the very end of moderate, approaching severe.

The heart has four chambers (2 left and 2 right) and each 2 are separated by a valve (door). There are times where the valves have to be closed and times where the valves have to be open. Mitral regurgitation means that the mitral valve is not closed when it is supposed to, allowing the blood to go from the left ventricle to the left atrium (in a direction in which the blood does not normally go) adding an extra burden on the heart).

In your case, this is caused by some kind of degeneration (myxomatous) of your mitral valve. There are cases where the mitral valve can be repaired without the need to replace it. The only person who can decide this is your doctor as he saw how the valve looked on the echo and if needed, to have a better view and make the best decision, sometimes, a transesophageal echocardiogram is done where the ultrasound (echo) probe is passed through your mouth to the esophagus (the swallowing tube) and the stomach immediately behind the heart which gives a far better view than the regular echo with the bones, muscles, fat and lungs intervening.

Needless to say that there is greater risk in replacing two valves more than in replacing one valve.

Regarding the pulmonary hypertension, in most cases, this is caused by other causes than causes in the right side of the heart itself. It is either caused by lungs problems or left side heart problems (which you have). When the cause is fixed, this should be normallized if it is still in the early stages and reversible.

The heart catheterization is definitely needed and let's wait for the results. Usually, a left heart catheterization is performed (with coronary angiogram if surgery is planned), but in your case, i am not sure whether or not you will have the coronary angiogram, but in stead of beating around the bush and have nuclear stress test and the like, i recommend going for the gold standard especially that you are having chest pain (so, i think that you will most probably have an angiogram with the left heart cath). Also, a right heart catheterization would not be a bad idea as well since you have pulmonary hypertension.

Regarding your exercise, i think it would be more cautious if you stopped exercising for now till everything is sorted out. However, if you want to continue, limit it to a minimum and be aware of the alarming syptoms such as chest pain, dizziness and near syncope. If you experience any of these symptoms, stop immediately.

Thank you very much for using our website http://doctorslounge.com and i hope that this information helped.

Yasser Mokhtar, M.D.
 lucky400 - Sat Mar 12, 2005 11:09 am

Dear Dr. Mokhtar,


Thank you so much for your very detailed explanation. It is so much easier to understand everything when you can actually read it and take your time to digest and think about everything that is said. When you visit the doctor explanations seem to go very fast and forgetting what is said is also a problem.

I wanted to let you know that I am having a dual catheterization as well as the angiogram part that you mentioned. My cardiologist said he would come and see me during the test as well, which I was very happy to hear.

You did not mention the tricuspid valve moderate to severe regurgitation. When I have the surgery do you think they will want to fix that as well?

Again I can't thank you enough for all the time and thoughtfulness you have put into your replys. I really appreciate it.

Sincerely,

Barb
 Dr. Yasser Mokhtar - Sat Mar 12, 2005 11:41 am

User avatar Dear Barbara,

Thank you very much for the update.

The tricuspid regurge follows the rule of pulmonary hypertension, it is usually reversible if the cause if fixed.

Tricuspid valve repair or replacement is very rarely indicated.

Thank you very much for using our website http://doctorslounge.com and i hope that this information helped.

Yasser Mokhtar, M.D.
 lucky400 - Tue Mar 22, 2005 10:33 am

Dear Dr. Mokhtar,

I had the catheterization yesterday and am feeling fine. I think I got some good news from the test. I was hoping you would help me to understand the report I got back.

Hemodynamic Data: Heart Rate (bpm): 60 Hgb (g/dl):11.5 Assumed 02 consumption (ml/min):175

Baseline (PRE)
Pressure (Mean) mmHg 02 SAT % Calculated Values Baseline
Ao 122/ 70 (90) 97.2 Cardiac Index (L/min/m2) 2.6
LV 134/ 8
PCW (7) v= 8 Aortic Gradient (mean nm Hg): 10
PA 25/ 10 (15) 68.2
RV 25/ 4 Aortic Valve Area (cm2): 1.7
RA (4) Pulm Blood Flow (L/min): 3.9
PRE
Cardiac Output (L/min): 3.9 Method Fick
PVR (Wood units): 2.1

Complications: None

Clincial Summary
55 year old female with hypertension, hyperlipidemia, exertional chest discomfort and a bicuspid aortic valve with moderate to severe aortic stenosis by echocardiography (1.0 cm^2) referred to diagnostic cardiac catheterization.

Diagnostic Summary
1. Hemodynamics (see above) were significant for an LVEDP of 8mmHg. There was a peak trans-aortic pressure gradient of 12mmHg and a mean gradient of 10 mmHg. The calculated aortic valve area using the Gorlin formula was 1.7 cm^2.

2. Coronary angiography revealed luminal irregularities in a right dominant system.
a. LM: Luminal irregularties
b. LAD: Luminal irregularties
c. LCx: Luminal irregularties
d. RCA: Luminal irregularties

3. Left ventriculogram in the RAO projection revealed normal systolic function, ejection fraction of 74% and 1+ mitral regurgitation.

4. Aortography in the LAO n revealed a mildly enlarged ascending aorta and arch. The ascending aorta measured 3.9 cm in its widest diameter. There was no aortic regurgitation.

Final catheterization diagnoses:

1. Aortic Stenosis
2. Ascending Aortic Aneurysm
3. Diffuse Non-Critical Coronary Disease

The doctor in the cath lab said that the valve area is probably somewhere in between the catheterization reading and the echo reading.

Could you explain what hemodynamics means and what luminal irregularties are? Also I would love to hear your opinion on whether I should be still considering valve replacement. The docs in the cath lab would not give an opinion. Also they said my pulmonary pressure was not nearly as high as it was in the echo, it was 50 in the echo. Could that go down because I have not been exercising for the last 2 weeks? Also my ejection fraction went from 60-65% in the echo to 74% in the cath report. Is that increase dangerous? I am only 4'11" and should my small stature be considered when trying to find a baseline for the aneurysm and my ejection fraction?

Thank you so much for all your help.

Sincerely,

Barb
 Dr. Yasser Mokhtar - Wed May 18, 2005 6:07 pm

User avatar Dear Barbara,

Thank you very much for the update.

If your doctor thinks that it is still not the right time for surgery, then i would recommend following your doctor's recommendations.

Hemodynamics are mainly the pressures in the heart and great vessels and the relationship between these pressures and the size of the valves, heart chambers and great vessels.

Luminal refers to the lumen of the artery itself and irrgularity refers to the fact that there isn't any localized blockage in any of the arteries. This means that there is no danger of sudden blockage. So, if you were going to have an aortic valve replacement, there is no need to perform a coronary bypass surgery at the same time.

i don't there is anything to worry about regarding this increase in the ejection fraction and i think it is just the way it was measured.

Pressures on the echo are estimates, but with the cath it is actual measurements, so i would go with the cath measurement rather than the echo.

It is not uncommon to have dilated aorta with aortic stenosis, a condition known as post stenotic dilatation.

Thank you very much for using our website http://doctorslounge.com and i hope that this information helped.

Yasser Mokhtar, M.D.

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