A First Visit With The Surgeon

When I last saw my cardiologist in August 2008 for my yearly echo, I learned that my aortic stenosis had progressed from mild to moderate during the past year after having remained about the same since first diagnosed in 2004. The difference in valve area was a loss of between .4 and .7 cm2 between June 2007 and August 2008. I was asymptomatic (I thought, in denial,) with only the typical getting winded easily complaint that many of us with valve disease experience. My cardiologist left me with the advice to return to see him in a year, but cautioned me that if I developed any dyspnea, syncope, near syncope or chest discomfort I should immediately seek medical attention.

When I got copies of my echocardiograms from 2007 and 2008, and looked at the numbers I realized that if the rate of progression of the stenosis continued unabated, I would quickly fall into the severe stenosis category. I could develop severe symptoms at any time. Not content to wait for the onset of severe category symptoms, I resolved to talk to a surgeon. My primary question would be about the timing of surgery: should I wait for the onset of severe category symptoms? I am fortunate to live near a major heart center, the University Of Pennsylvania Hospital. An acquaintance who had AVR had given me the name of his surgeon several years ago. My own research confirmed that this surgeon Dr. Joseph Bavaria, is a well known and highly respected practitioner, so I made an appointment to see him. Yesterday ( November 20) I finally met with Dr. Bavaria. I gave him copies of my echos. I was highly impressed with his “take charge” approach to my situation. He reassured me from the start: “We’ve got a handle on your situation,” and answered my primary question before I even had a chance to ask him: “We KNOW when to pull the trigger,” he said - and he actually used those words. Who in the waiting room doesn’t want to hear that? What a big relief already. He explained that although my “numbers” where technically still only in the “moderate” range, because I’m a “big guy” (I’m 6’5” and weigh 228) my stenosis could already be effectively severe. I had not encountered the whole body area factor in my own research. He did some valve area calculations with his nurse practitioner that I did not understand. The bottom line is that, with the recent quick rate of progression of the stenosis, it may be time for surgery already, especially if there is any coronary artery blockage requiring grafts. That would be a sure “trip,” meaning surgery immediately, he explained. He suspects that the valve is bicuspid, contrary to previous echos, and there is the possibility of an aortic aneurism. He ordered a series of tests: echo; CT Angio chest; chest X-rays; blood work including Coumadin and Heparin related tests; EKG, etc., and set a follow up for one month, so I’ll see him again in late December. I had the echo right after my visit with Dr. Bavaria. Echo techs aren’t supposed to tell you anything, but I did watch the screen and he was quite conversational. We both saw some sort of mass on one of my aortic valve leaflets. “Could that be calcium?” I asked. “Could be,” he responded. Seems like I did all this not a moment too soon!

So, for those in the waiting room, take note the stark difference in the two approaches here. My cardiologist advised me to come back in a year unless I developed severe symptoms. The surgeon is much more proactive, ordering additional tests and considering the possibility of surgery in the short term. It almost seems to me like once a cardiologist finds moderate or progressive stenosis, he ought to consider his job done and refer the patient to a surgeon. For those “in the waiting room,” the advice of Al Capshaw and others is spot on, it seems to me. Only a surgeon can cure valve disease. If you want to know when to “pull the trigger,” see a surgeon.