Mitral Valve regurgitation

[MDM01]

Dr. Fett,

I am new to this board but I would like some insight please. I was diagnosed with post partum cardiomyopathy on 10/31/05 three days after giving birth to my daughter. I had mitral valve repair surgery on 5/3/06 with some regurgitation after the ring. My EF has varied from 45% on onset to 25%. About a month ago my cardiologist said my regurgitation was severe again my EF was 25%. He felt I needed to have the valve replaced. I went to Houston where I had the original surgery and the cardiologist there said it was not that bad and my EF was 35% and that was pretty good. She recommended I increase the dosage on my Altace to twice a day (10mg each). I am also on Coreg 25mg 2x day and spiroactone 25mg day. I am worried about this. I do not want surgery but I want to do what's best. My worse syptom is fatigue. I can't seem to ever feel rested. I do have some shortness of breath but I take my Lasix whenever I notice weight gain and that helps. Should I stay this course of action?

[JAMESFETT]

Hmmmm--that's not easy to address. One reason it is not easy to decide is because I am not clear if your primary problem is mitral valve disease or your primary problem is PPCM, dilated cardiomyopathy. Usually, with PPCM, the enlarged left ventricle causes the mitral valve ring to stretch, leading to regurgitation. In most cases, that improves as the left ventricle returns towards normal in PPCM. In that situation the valve itself is normal, just a stretched ring, and it is very rare to ever require surgical correction. If, however, the valve leaflets are abnormal, and you have a form of mitral valve disease, that puts you into a different category. From what your Houston consultants are telling you, I am going to assume that you do indeed have PPCM and that you basically have normal mitral valve leaflets. If I am wrong about that please let me know. But if that is the situation, then, yes, you are on good treatment, and an EF of 35 percent is compatible with a very long life. Your Coreg is max dosage, and your Altace is more that I usually consider max (10 mg per day total), but I'm sure higher dosages than a total of 10 mg a day have been used safely. Can you tell me more about the valve leaflets? Also do you know from the echo the size of your left ventricle in terms of end-diastolic dimension (EDD) in centimeters? Best wishes, and I hope and pray for improvement.

JD

P.S. In your situation, there may still be questions about the current status of your left ventricle, in terms of what is going on there:
--is there any evidence by special staining of endomyocardial biopsy of active myocarditis, lymphocytic myocarditis, or inflammatory cardiomyopathy?
--is there evidence by PCR testing of biopsy for viral presence?
Cardiac magnetic resonance imaging with gadolinium enhancement is now available at many medical centers and that can help to know if there are areas of inflammatory process. If there are, that helps in knowing if and where endomyocardial biopsy could give useful findings. Blood tests of C-Reactive Protein (hsCRP) and B-type Natriuretic Peptide (BNP) are also biomarkers that can give a clue about inflammatory cardiomyopathy.

[MDM01]

Thank you so much. The last dated information I have dated 3/1 states I had LVEF 25% with global hypokinesis, left ventricular diastolic dimension of 5.3 (increased from 5.0 in August), severe mitral regurgitation, pulmanary artery pressure 60mmHg. This was from my local cardiologist who then recommended I go back to Houston. I have no idea what these terms mean. I also must mention I had an ICD implantation in September 06. Also the change to 35% happened within the course of 5 days is that normal?

[JAMESFETT]

Thanks for the follow-up info. The left ventricular (LV) dimension of 5.3 cms is enlarged, but not extreme, pretty average for PPCM. The global hypokinesis, that is general decreased motion of LV, is quite typical of PPCM. Are the readings of EF 25 and 35 from 2007? Yes, that could happen on readings 5 days apart, but if it did I would want to know about the quality of the test in each place, because one may be right and one may be wrong, although they may both be right if there has been some change of therapy or early in PPCM, one can see rapid improvement after diagnosis and start of treatment. When I know about who does echos and how well they do them, and in my own experience with well-qualified examiners, I find impressive consistency from test to test. Would you mind giving me the sequence of events with dates and EF from first to current, including time of mitral valve surgery and time of ICD implantation? Do you know what they actually did in the mitral valve surgery? Was it a simple reduction in size of ring, or was it a valve replacement?

JD

[MDM01]

Here's the info from my cardiologist notes:
11/05 LVEF 45%. Mild mitral regurgitation. Left Vent end diastolic diameter of 5.4cm.
3/06 LEVF 50%. Severe mitral regurgitation. Left Ventricalar end diastolic diameter 5.7cm.
Mitral valve repair with#25 St Jude mitral ring on 5/3/06.
Echo on 8/06 shows left ventricular diastolic dimenion 5.0 cm. Mild to moderate mitral regurgitation.
Medtronic ICD impantation 9/22/06.
Echo 3/1/07 LVEF in the range of 25% left ventricular diastolic dimension 5.4. Severe mitral regurgitation.

Unfortunetely I dont have the information from the echo that was done in Houston which again was 5 days later than the one on 3/1/07.

[JAMESFETT]

Here is what I think you need and deserve to know:

1. What happened to your mitral valve function between diagnosis of PPCM and 3 or 4 months later. And why? On 11-1-2005, all of your findings were compatible with PPCM, with an EF of 45 percent and an EDD of 5.4, and only "mild mitral regurgitation." On 3-2006, although your EF went up to 50 percent, an expected finding in the course of treated PPCM, your EDD increased and you then had "severe mitral valve regurgitation," both surprising findings. Why did those "surprises" come about? Was it because of some abnormality of the mitral valve itself, or something such as a ruptured papillary muscle that anchors a normally-functioning mitral valve?

2. Did your mitral valve or endomyocardial tissue at the time of placement of St. Jude mitral ring on 5-3--2006, show any abnormal pathology? I assume they had tissue from that procedure and subjected it to pathological examination. Again, I am looking for some evidence that you had an abnormal mitral valve, and not just a stretching of the mitral valve ring as one sees in PPCM, and for which surgery is probably never indicated. Did you have that surgical procedure at the same place in Houston that you are now consulting?

3. Was your ICD placed on 9-26-2006 because of decrease in EF to 25 percent, or because you had experienced a dangerous heart arrhythmia?

4. How severe really is your mitral regurgitation at this time and is your current EF really 35 percent, or is it 25 percent?

Answers to those questions should help you to know what is the best course for you. If you have additional information about those questions, and if I could be of any help, please let me know.

JD

[MDM01]

Thank you for the feedback. I obviously have some questions to ask. I did see the same consultants in Houston that performed the surgery. I am just very concerned that I don't know what is causing the problem and I feel basically the same as before. The only time I really felt bad was the onset when I was verty short of breath. I am pretty non symptomatic with the exception of fatigue. This worries me. And the medicine really wears me down.

[JAMESFETT]

Your Altace (ramipril) would perhaps do you as much good at 5 mg 2x/day (total 10 mg) as would 10 mg 2x/day (total 20 mg) without side effects, if fatigue is a side-effect?

You will want to be sure your renal function (creatinine) is normal, particularly as you are on spironolactone, a potassium-sparing diruetic, and you want to be sure your potassium level is neither too high (sometimes found with spironolactone) nor too low, both of which could have side-effect of fatigue.

Your pulmonary artery pressure of 60 mmHg may be a bit concerning; I suppose that verifies rather severe mitral regurgitation?

JD

[JAMESFETT]

I have been thinking quite a lot about your information. Do you think you could obtain an operative report from the 5-03-06 surgery, and a tissue/pathology report, if there was any tissue? I believe that would be the most helpful in clarifying.

JD

[MDM01]

How would I go about obtaining that information? Would my cardiologist have it, or do I have to contact the hospital directly?

[JAMESFETT]

I'm sure your cardiologist also has a report from the hospital, so either place should be a source of that info. You can ask that a copy be sent to you, or if you like you can sign a release of info and request they send me a copy (operative report from 3 May 2006, along with pathology report); if needed, I will furnish you with my medical address. Just remember, it is information about you, and therefore it is info that you merit having. I would guess there would be no hesitation to meet your request.

JD

[MDM01]

I would very much like to have them send it to you. What is the address I should use, please?

[JAMESFETT]

James D. Fett, MD
Peripartum Cardiomyopathy Research Project
611 Sumner Ave.
Aberdeen, WA 98520-3343