Moderately Severe MR

[kasthana]

I am 56 yr old female. I had a open mitral valvotomy done 20 years back. I have been on heart medication since with normal annual exams. My last exam reported MR. I have been asked to not exert, drink less than 1 litre of water a day with minimal salt and sugars besides medication, before a re-exam in 3 months. Is a surgery imminent? As I already had a valve repair, will it be replacement now? How successful is that and what are my chances of not needing surgery near term?

Last 2D Echo details
1. Mitral valve leaflet are thickened and mildly calcified with doming of AML and restricted movement of PML. Partial non-coaption of MV leaflets. Mean gradient across mitral valve 5mmHg
2. Moderately severe MR(eccentric jet directed medially) Moderate TR (PASP-37mmHg)
3. Mild thickening of aortic valve. No AS/AR. No PR
4. No LV regional wall motion abnormality. LVEF 60%
5. LA is dilated other cardiac chamber dimensions are normal
6. No intracardiac clot/pericardial effusion/vegetation

Other details
Aortic root diameter - 2.4cm
Aortic valve opening - 1.6m
Left Atrial dimension 4.1cm

Left Ventricle -
   ED dim:4.6 cm, ES dim 2.5 cm: ED IVS thickness 0.9 cm:
   ED PW thickness:0.9cm, ES IVS thicness:1.4cm, ES PW thickness: 1.4 cm
   LV ejection fraction : 60

Mitral
    E velocity - 153 cm/s , A vel - 125 cm/s, Max PG=9mm Hg,  Mean PG=5mmHg
    MR : moderately severe; stenosis : Nil
Aortic :
    Max vel =131 cm/s, AR: Nil,  No stenosis
Tricuspid
    Max vel -45 cm/s : TR moderate, PASP=37 mm hg, No stenosis
Pulmonary
    Max vel-80 m/sec, PR: nil, stenosis; Nil

Excepts from my earlier surgery note:
The mitral valve was severely stenosed with an orifice of about 7-8 mm in diameter. There was fibrous fusion of both the commissures and moderate involvement of the sub valvular apparatus. Post repair, mitral valve was tested by releasing the aortic cross clamp and tripping the aortic valve. The valve was found to be competent except for a trivial central leak.

[Lee Kirksey, MD]

I apologize for the delayed response. I had surgery two weeks ago and have been out of commission. To answer your question questions. It would be difficult to comment on your echo without having your previous echo to compare. Most important in any imaging test is the trend which occurs over time. The other important factor is your symptoms and the limitations imposed by your MR

Your doctors are waiting to see if your symptoms will improve with these restrictions, however, as you know, these restrictions over the long term may not allow you the best quality of life

When we evaluate who will require surgery, we also take into account a person's risk with operation. In the absence of coronear heart disease and lung disease, most peoples risk is reasonable.

I can best answer your question about imminence of surgery in that a lot will depend on the improvement of your symptoms and echo findins with your restrictions and your personal interest in being aggressive to improve your quality of life through repair of your surgery.

You are correct that a future procedure would probably be a replacement. Reoperation for replacement of the mitral valve in large volume centers have very good results and technology has made heart valve replacements very durable over time. We have an excellent surgeon, Clark Hargrove who is internationally known for his work with reoperative valvular disease

[kasthana]

Doctor, would appreciate your feedback on this situation. Request your advise