Sunday, February 21, 2016

Post-Op, Part 2



My post-op left ventricular indices are:


Left ventricular diastolic dimension: 57 mm
Left ventricular systolic dimension: 46 mm
Left ventricular ejection fraction: 48%


I'm very encouraged by the dramatic reduction in the diastolic dimension, immediately into the normal range. Normal for me is another matter, but my LV can't shrink overnight. This reduction must purely result from having a competent valve; that is, from no longer having at least half of my enormous stroke volume rushing back into my LV. 

As Dr. Chris Simpson predicted over in the discussion at Facebook, the initial effect is seen mostly in the diastolic dimension. My systolic dimension actually increased a little bit. Accordingly, my EF dropped from 60 to 48%*, but I'm not in the least bit worried that this might represent any significant irreversible contractile dysfunction, and like Dr. Simpson, I also think that it has no known prognostic significance. 

Loading conditions are everything here, and my LV has suddenly been dramatically under-filled.

My aortic regurgitation had been significant for more than 5 years, probably more than 10, prior to operation. It's going to take years for my LV to remodel, and the available data is clear: given my LV size, if pre-op LVEF was normal, it's normal during follow up (excluding a peri-operative myocardial infarction or some other catastrophe).

As my LV physically shrinks (LV mass declines), I'm sure that my ejection fraction, which is close to normal now, will once again end up in the normal range. My read of the literature suggests that most of the changes happen in the first six months, but my surgeon told me to expect continued remodelling over 2-3 years.

It will never be the heart that I would have had without aortic regurgitation, but the available follow up data strongly suggests that it should be a heart that will last me a long time into the future without any specific anticipated problems.

Here's an interesting question for my medical colleagues: if you were me, and you knew that your post-op EF was 0.48, would you take any medication for LV dysfunction to try to help my LV remodel over time?  A beta blocker, perhaps? An ACE-I? Both? None?

*measured several times using different methods and matching visual estimates as well.

3 comments:

  1. I wouldn't take anything unless the predicted course of positive remodeling doesn't materialize in, say, 6 months. If you start ACEi and BB now and see improvement, you won't have any way to tell whether it's due to the meds or would have happened anyway, and might feel compelled to take them in the long term, perhaps unnecessarily. The risk of not taking anything in the short term should be negligible.

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  2. I have decided to take both a beta blocker and an ACE-I. If my LV function is normal in 6 months, which I expect to be the case, I will then stop them. This is not an evidence based decision, but I think that the risks are extremely small, and there may be potential benefit.

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