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What does my ECHO test report indicate?

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Posted on Wed, 18 Nov 2015
Question: I am a 72 year old female living in the UK. I was diagnosed with aortic stenosis three years ago. My first echo showed mild stenosis and second echo a year later was much the same. Now third echo 18 months later has shown a rapid decline. Looking on the internet this states it to have a poor prognosis which has really frightened me. Apart from getting tired more quickly and isolated chest pain I have no symptoms.
Peak Jet velocity m/sec 2.4 - now 3.6
Peak P Grad mmHg 23 - now 51
Mean P Grad mmHg 15 - now 25
Valve Area 1.5cm2 - now 0.9 cm2
Ejection Fraction 60
Left Venticle normal size and wall thickness with preserved systolic function
I am waiting to see a cardiologist under NHS service but wondered if you could give me some advice in the meantime.
doctor
Answered by Dr. Ilir Sharka (1 hour later)
Brief Answer:
I would explain as follows:

Detailed Answer:

Hello!

Welcome and thank you for asking on HCM!

Regarding your concern, I would like to explain that your clinical status is optimistic.

You don't have to be afraid, as your cardiac disease is thoroughly treatable.

As your echocardiographic parameters have changed, I would explain that a trans-valvular aortic mean pressure gradient of 25 mmHg and a valve area around 1 cm2 are compatible with a moderate aortic valve stenosis (but it is important to have an indexed valve area [valve area/body surface area]).

You have a left ventricle with normal structure and function and without any important clinical symptomatology (only isolated chest pain, tiredness, but no important heart failure, syncope and problematic angina).

Coming to this point, the best strategy to follow is a regular cardiac ultrasound scheduled check up (on a yearly fashion).

If the valve disease becomes clinically significant (overt chest angina, disabling dyspnea or syncope), the valve area progresses to lower values and the mean trans-aortic pressure gradient increases to equal or greater than 40 mmHg, a surgical correction of the stenotic valve should be considered (aortic valve replacement).

You should not be afraid of the aortic valve surgery, as it is actually a routine, and is frequently performed on always more elderly patients (80' 90').

If cardiac ischemia dominates the clinical scenario and there are strong suspicions of a concomitant coronary artery disease, then a coronary angiography should be anticipated and the valvular disorder management strategy re-reviewed.

There are also less invasive strategies for aortic valvular treatment, such as TAVI (transcatheter aortic valve implantation), if the risks of surgery are considerable.

At the end, as you see, You clinical conditions are quite favorable for a comfortable medical follow up and adequate treatment in a properly fashion.

Hope to have been helpful to you!

If you have further questions, please do not hesitate to ask me!

Kind regards,

Dr. Iliri



Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (1 hour later)
Thank you for your answer. What I am really concerned about is that with such a rapid progression in Jet velocity that the prognosis is not good even if one is basically asymptomatic. Can you please advise me on this.

Thank you
doctor
Answered by Dr. Ilir Sharka (9 minutes later)
Brief Answer:
My opinion as follows:

Detailed Answer:

Hello again,

I would like to explain that your echo parameters (aortic valve area, mean pressure gradient, etc.) are compatible with your actual clinical symptomatology. it is just a moderate aortic stenosis and it doesn't imply any adverse prognosis as you are just in time for a correct follow up medical evaluation and a properly timing of future surgical valvular correction.

For the moment it is necessary to be in close contact with your cardiologist periodically and check echocardiographically aortic valve and cardiac function (at least yearly).

Judging from the rate of progression, it will depend the decision to proceed to the most optimal strategy.

Greetings,

Dr. Iliri


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (4 days later)
I have been looking at your previous answer and note that you said my valve area was 1cm whereas it is 0.9 and thus I have been told this puts it into the severe category.

Also I have read many reports on the internet which say when you have a rapid progression of aortic jet velocity, in other words greater than 0.3 per year that the prognosis is very poor even if you have no symptoms.

This has frightened me very much. I am still waiting to see a cardiologist under the United Kingdom NHS system which could be some time yet.
doctor
Answered by Dr. Ilir Sharka (5 hours later)
Brief Answer:
No reason for being frightened.

Detailed Answer:

Hi, dear XXXXXXX

Regarding aortic valve stenosis grading, <1 cm2 is considered a general cut off for value severe patients, but the true results will depend on several factors, one of them being body surface area.

Other parameters as pressure gradient, ejection fraction, flow rate, etc should be considered when judging stenosis severity.

Severe aortic stenosis is unlikely if cardiac output is normal (transvalvular flow) and the mean pressure gradient is <40 mmHg.

In low body weight individuals a value of 1 cm2 may not be reliable, In such case and indexed aortic valve area of 0.6 cm2/m2 should be used instead.

From the other part, when judging stenosis progression rate, it should be carefully considered the accuracy or Doppler measurements and underlying planimetry and other hemodynamic parameters (blood pressure, possible difference of EF between measurements, etc., as potential assessment errors may occur.

Considering your almost mild symptomatic clinical status and moderate aortic stenosis (mean pressure gradient only 25 mmHg), there is not identified any obvious discrepancy between clinical and echocardiographic evaluation.

If a discrepancy would exist, a stress echo would be useful in quantifying valve stenosis severity and other prognostic variables.

In mildly symptomatic moderate aortic stenosis the risk of sudden serious complications is not significant, and no indication for surgical valve replacement is consistent, unless serious coronary artery co-morbidity exists.

You should not be frightened as you actually have no indications for surgical treatment, and the only consideration for the moment is a careful medical follow up (physical exam and echo).

Hope to have been helpful to you!

Wishing you a pleasant weekend,

Kind regards,

Dr. Iliri

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (17 minutes later)
Then why on the internet does it say on many study papers that a rapid progression in aortic jet velocity of greater 0.3 in one year - even if the patient is asymptomic - is a prognosis for a very poor outcome and most of these patients, ie 60% are dead within one year. Mine went from 2.4 to 3.6 in 18 months.

I am not sure what you mean by body weight but I am 5"6" tall with a weight of 85klms.
doctor
Answered by Dr. Ilir Sharka (3 hours later)
Brief Answer:
You are not an increased risk if properly followed by your doctor.

Detailed Answer:

Dear XXXXXXX

What I was trying to explain you is that when concluding about a severe aortic stenosis (symptomatic or no), it is important to combine several variables:

- an aortic jet velocity >4 m/s;
- valve area <1 cm2 (when aortic valve area is divided by body surface area, thus calculating the indexed valve area the cut off is <0.6 cm2/m2)
- mean transaortic gradient>40 mmHg

While you have:

- aortic jet velocity 3.6 m/s
- mean gradient 25 mmHg
- aortic valve area 0.9 cm2, where it is not clear if it is indexed to body surface area (BSA) or not.

An aortic valve stenosis with normal LV EF would hardly be severe if the mean gradient is <40 mmHg, as it is your case.

If you could upload both of your echo reports, I could give my direct professional opinion.

Regarding aortic stenosis progression, it is usually 01 -03 cm2/year and pressure gradient 10 -15 mmHg/year, and a more rapid rate of aortic stenosis occurs in elderly patient with concomitant renal disease, hypercalcemia, diabetes, dyslipidemia, smoking, etc.

A more rapid aortic stenosis progression indicates greater risks, but it is the stenosis severity and not the rate of progression which determines the final short and long term prognosis.

if you are asymptomatic and with that degree of stenosis a six month echo follow up, and especially a stress echo would be helpful to keep the valvular disease under control and avoid potential complications by timely deciding the adequate surgical correction.

I hope to have been clear and explained your uncertainties.

Best wishes,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (1 hour later)
I still don't truly understand. How do I upload echos as do not know how to attach them to this answer. Perhaps you could advise me how to do this.

Bearing in mind in 18 months my stenosis has gone from mild/moderate to moderate on doppler echo, would you expect it to continue to progress at this rate.

I thank you for your patience
doctor
Answered by Dr. Ilir Sharka (19 minutes later)
Brief Answer:
You are welcome.

Detailed Answer:

Dear XXXXXXX

There must be an option: upload reports (you have to look on the viewing internet page, when you write the follow up question). Or you can use the link below:

http://doctor.healthcaremagic.com/Funnel?page=askDoctorDirectly&docId=69765

to directly ask me by attaching also your echo reports.

Regarding stenosis progression rate, the only way to clarify this issue is by continuing echo follow ups and comparing aortic valve area change over time (thus concluding for an average area change).

Regards,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (7 minutes later)
I will try to send the echos on the address you have given me. Perhaps you could let me know if you get them. At my age I am not that good with computers.

In case I do not hear further from you, in conclusion, are you saying that I need not be too worried at this point in time.

Many thanks for all your kind help.

XXXX
doctor
Answered by Dr. Ilir Sharka (11 minutes later)
Brief Answer:
Feel free to ask me at any time.

Detailed Answer:

Hi,

I think it's not too complicated to upload the reports.

You have to look for a dedicated link for uploading reports on the screen you write your follow up question.

Whenever you could upload your reports, I would be at your disposal to review them.

By using the above mentioned link you can reach me directly at any time.

My actual advice is to continue keeping close contacts with your attending cardiologist and perform repeated cardiac echos.

At this time point this is the only necessary strategy.

That's my opinion.

Best wishes,

Dr. Iliri


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (11 hours later)
Dr Sharka

I have no idea if you received my echos or were able to read them but I could not reach you on the link you sent me. So I have renewed my account to continue to talk to you.

Perhaps you could let me know if you received the echos and were able to gather any information from them.
XXXX
doctor
Answered by Dr. Ilir Sharka (2 hours later)
Brief Answer:
It is important a carefully scheduled medical follow up.

Detailed Answer:
Hi again XXXXXXX

You have uploaded only one of your ECHOs; I could only partially review the echo report, as the imagine resolution is not sufficient for reading clearly all the written phrases.

Nevertheless, it seems the same information you have provided me at the beginning of our thread.

So, I insist again for a careful medical follow up by repeated cardiac ultrasounds in order to be always prepared for a timely surgical valvular correction.

Hoping you are having a pleasant weekend.

Regards,

Dr. Iliri

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (2 hours later)
Dear Dr Sharka

I didn't think that possibly you could read the echo. Not sure why there was only one.

However Based on what I have told you do you think there is any urgency in this situation or is it safe to await for a cardiology appointment in due course.

Are you still of the opinion that I have moderate stenosis and that yearly echos would be sufficient.

XXXX
doctor
Answered by Dr. Ilir Sharka (33 minutes later)
Brief Answer:
No urgency for the moment.

Detailed Answer:

Dear XXXXXXX

As you are only mildly symptomatic, and considering your ECHO parameters as a whole, I would conclude that you actually show a moderate hemodynamic aortic stenosis.

I would not rely only on aortic valve area (as we are not sure if it is indexed to body surface area or not, or Doppler techniques are properly applied) when judging your valvular dysfunction severity.

So, my opinion is: there isn't any urgency for the moment. Just follow your scheduled medical check ups and be in close contact with your cardiologist for keeping the clinical conditions under control.

I am at your disposal whenever you will need.

Best wishes,

Dr. Iliri

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (10 minutes later)
Dr Sharka

At the beginning of our conversation you said I needn't follow up echos annually.

Are you saying you have now changed your opinion regarding this.

XXXX
doctor
Answered by Dr. Ilir Sharka (10 minutes later)
Brief Answer:
Cardiac ultrasound is the best approach for you.

Detailed Answer: XXXXXXX

At the beginning of our conversation my opinion has been given as follows:

"Coming to this point, the best strategy to follow is a regular cardiac ultrasound scheduled check up (on a yearly fashion)."

You may check all our thread and find the above quote.

As you will see, my opinion HAS NOT changed regarding this topic.

Periodically scheduled echo follow ups are the best approach in addressing properly cardiac valvular dysfunctions.

Please try to review carefully all our discussion.

Regards,

Dr. Iliri

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (2 hours later)
Dr XXXXXXX

As A final question, can you tell me the relevance of the Peak P Gradient as this value is the only one that has not really been mentioned.

Thank you for all your help

XXXX
doctor
Answered by Dr. Ilir Sharka (3 hours later)
Brief Answer:
Explanation as follows:

Detailed Answer:
XXXXXXX

Generally, it is preferred the mean pressure gradient when grading the severity of aortic stenosis.

Nevertheless, the maximal trans-aortic velocity (and hence the maximal pressure gradient) may be utilized by incorporating in a ratio noted as aortic valve velocity ratio.

A ratio of less than 0.25 denotes a severe aortic stenosis.

Regards,

Dr. Iliri

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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What does my ECHO test report indicate?

Brief Answer: I would explain as follows: Detailed Answer: Hello! Welcome and thank you for asking on HCM! Regarding your concern, I would like to explain that your clinical status is optimistic. You don't have to be afraid, as your cardiac disease is thoroughly treatable. As your echocardiographic parameters have changed, I would explain that a trans-valvular aortic mean pressure gradient of 25 mmHg and a valve area around 1 cm2 are compatible with a moderate aortic valve stenosis (but it is important to have an indexed valve area [valve area/body surface area]). You have a left ventricle with normal structure and function and without any important clinical symptomatology (only isolated chest pain, tiredness, but no important heart failure, syncope and problematic angina). Coming to this point, the best strategy to follow is a regular cardiac ultrasound scheduled check up (on a yearly fashion). If the valve disease becomes clinically significant (overt chest angina, disabling dyspnea or syncope), the valve area progresses to lower values and the mean trans-aortic pressure gradient increases to equal or greater than 40 mmHg, a surgical correction of the stenotic valve should be considered (aortic valve replacement). You should not be afraid of the aortic valve surgery, as it is actually a routine, and is frequently performed on always more elderly patients (80' 90'). If cardiac ischemia dominates the clinical scenario and there are strong suspicions of a concomitant coronary artery disease, then a coronary angiography should be anticipated and the valvular disorder management strategy re-reviewed. There are also less invasive strategies for aortic valvular treatment, such as TAVI (transcatheter aortic valve implantation), if the risks of surgery are considerable. At the end, as you see, You clinical conditions are quite favorable for a comfortable medical follow up and adequate treatment in a properly fashion. Hope to have been helpful to you! If you have further questions, please do not hesitate to ask me! Kind regards, Dr. Iliri