Echocardiogram Changes

I just received the results of my recent echocardiogram. From 2016 to 2017 everything was pretty much the same. Although I do not know hoe to read most of it I noted the following:

2016 left atrium normal in size; LA volume 39.8, volume index 25 ml/m2

Right atrium normal size, volume 46ml

2017 left atrium mildly dilated in size; volume index 37.1 ml/m2

Right atrrium normal size; volume 43 ml

2018 left atrium is severely dilated in size La volume (Biplane method) 89.0 ml LA volume 57.1 ml/m2

Right atrium is severely dilated in size volume index 50.9 ml/m2


Also from 2016 to now the mitral valve prolapse went from none to mild/moderate to mild valve regurgitation

I am seeing a cardiologist but would like your educated “first response” as to how serious this is.

I am a 69 year old female first diagnosed with a fib in a normal checkup and Holter monitor. No episodes requiring a trip to the ER, just persistent irregular beat. I am not on any heart medication but take Xarelto. Thank you for any opinions! Louise

You may want to read this
https://theskepticalcardiologist.com/echocardiograms-botched-misread-or-overutilized/
Something to consider along with all the other information used to understand what is going on.

Hoping for a poorly interpreted echo is a bit of a reach. The most important thing to be found in that report is your enlarged atria, and measuring atrial size isn't something a tech is going to mess up. The mitral valve probably hasn't changed much and shouldn't concern you.

You say you're not taking any medication other than Xarelto yet you have a persistent irregular heartbeat. How fast is your heart rate typically? Atrial enlargement is usually caused by a long-term, uncontrolled heart rate. That's why afib patients are often prescribed beta blockers -- to slow their heart rate. And yet you're in persistent afib but not taking anything to control the rate. That's a bit unusual. If your heart rate is often near or over 100, you need to visit your EP and get that dealt with. Enlarged atria will just make afib worse, and could lead to bigger problems.



Edited 1 time(s). Last edit at 12/03/2018 10:23PM by Carey.

What Carey said.

Thank you for responding. I’m not sure how I would determine if this was an incorrect reading.

Carey, my heart rate is usually in the 70s or 80s — 60s when I wake up. I was given Multaq for a brief time and that made it worse. And I also tried Metroplolol (sp), but that didn’t work well for me either.

Okay, it's good that your rate is usually well under 100. Did your cardiologist have anything to say about the report? Those aren't results that are going to endanger you, but they're not promising for your future with afib. You really don't want to be seeing your atria enlarging. Is your cardiologist an electrophysiologist? If not, I think it's time to find a new doctor.

I just got the results today and have not seen my cardiologist yet. I live in Santa Monica, CzA and haven’t seen an EP. my Drs are all at UCLA.

Okay, we'll see what your cardiologist has to say about the report, but in the meantime I think it would be a good idea to start looking for an EP. You have afib, and that's exactly an EP's field of expertise. Not so much a regular cardiologist.

Seems to me your atria enlarged a fair bit in a relative short time, Louise.
I was led to belief that with a HR you are mentioning that should not be the case?

In my case the enlarged left atria came back to almost normal within a year once the AF stopped (cardioverted)

I always thought conversion was for people who show up at the ER with a very elevated hr. Is that something that is done just for an irregular hr? I actually met with Dr. Natale in 2015 because people on this forum were suggesting an ablation. He did not recommend it or medication other than a blood thinner. He did not mention cardio conversion. Things have changed now so... I’ll gave to see what the cardiologist says. Another factor is that I’m on Medicare.

I had searched a few years ago and didn’t find an EP near me but just looked and Dr.Ajijola is at UCLA and it appears takes Medicare. I believe I will see if I can get an appointment with him and cancel the cardiologist. Thank you for the push.

On a separate note, can anyone tell me why my type is SO SMALL when I am posting on here? It’s larger after I post the message but while I’m typing it is teeny and I can’t seem to change it! Thx

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Louise
I always thought conversion was for people who show up at the ER with a very elevated hr. Is that something that is done just for an irregular hr? I actually met with Dr. Natale in 2015 because people on this forum were suggesting an ablation. He did not recommend it or medication other than a blood thinner.

Things have changed for you. Can you schedule another appointment with him? He accepts Medicare.

Possibly,Carey. I have to see when he is in La Jolla. I will try to see this EP first.

As of March, Natale was also inThousand Oaks <[www.afibbers.org]

On the text size, this is likely a "feature" of the Phorum software that is the platform here. To my knowledge, we don't really have a tech guy handling things like this. It possibly could be changed in the software settings, not by us the users.

Thank you for the info George. Thousand Oaks is much closer!

I will struggle along squinting until I can figure it out...

Things happen quickly. Two friends with afib have recommended an EP in Santa Monica, He is in a boutique office so I wrongly assumed they didn’t take Medicare. This is a wonderful Christmas present because he is a few blocks from my home. My appt is Jan 4 so I will definitely get your opinions about recommendations at that time. Thank you so much for responding so quickly. This forum has been serving me for many years and it is so nice in this anger filled world to feel the kindness and caring of so many people. I wish everyone happy healthy holidays! Louise

Louise, they did not cardiovert me when i went to ER. They kept me in for 5 days and just gave me drugs and monitoring.
A few weeks after discharge (still in AF) i saw a cardiologist and asked him for a cardioversion. He reluctantly agreed and said that it probably won't work. It did - for 1 hr. I was in permanent AF for a good 4 months prior to first cardioversion.
I asked him for another one and it happened 4/5 weeks down the track. This one lasted for 3 years.
Recently i had a 5 week episode of AF and this time converted with Flec.

Good info, Joe. Thank you!

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Louise
Things happen quickly. Two friends with afib have recommended an EP in Santa Monica,

Be careful of recommendations. Most people don't really know what makes a competent ablationist, and that includes most doctors. If getting to Thousand Oaks is possible for you, then I think you'd be making a mistake to choose any other EP no matter how good.

Carey, I’m not even CLOSE to getting an ablation. I just meant two friends liked this EP. I’m going in because of this latest echocardiogram and would rather an EP look at it than a regular Cardiologist. I will see what he recommends and go from there. If I get to a place where I am considering it I would certainly want to see Dr. Natale.

Okay, that's great then! I guess I misunderstood and thought you were considering an ablation with him. But if he comes with recommendations from people you trust and you're just looking for a good clinical EP, then by all means go see him. I think it's a good idea to have an established relationship with a local EP you like if you ever do pursue a procedure elsewhere.

Hi Louise,
I'm an echo tech. What sticks out for me, besides what the others mentioned as a cause for your growing atria, is that you have mitral prolapse and your valve regurgitation has also grown. Your mitral valve may be complicating the picture. Like the chicken and the egg, it's hard to know whether the atria grow from the a-fib and then the valve leaks or your prolapse is worse and the valve leaks and then you get a-fib. It will be interesting to sort out which is primary. The fact that the regurge was quoted to go back from moderate to mild, I would have to see with my own eyes. Sometimes the jet squirts back into the atrium and it's hard to quantitate. Also, if your images are tough there can be discrepancy in measurements, but as someone else noted, it's the upward trend that's concerning. I'm glad you're seeing a specialist. As someone stated above, your atria can shrink if the issues affecting them are addressed.
Wishing you the best!

Libby, thank you so much for your input. I cannot get an appt until Jan 4 but I am anxious to see what can be done. I am hoping the EP does another echo to confirm the results. Louise

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Louise
I always thought conversion was for people who show up at the ER with a very elevated hr. Is that something that is done just for an irregular hr? I actually met with Dr. Natale in 2015 because people on this forum were suggesting an ablation. He did not recommend it or medication other than a blood thinner. He did not mention cardio conversion. Things have changed now so... I’ll gave to see what the cardiologist says. Another factor is that I’m on Medicare.

Cardioversion is used more broadly than you described it. It is common way to get people out of AFIB, back into NSR. It is one of the 1st treatments given for AFIB, before it becomes too chronic a condition.
It does not always last although, as people can revert back to AFIB later on. Dr Natale, probably thought your regular Cardiologist had already tried this or discussed it.

No cardiologist has ever suggested this. That’s one reason I’m going to an EP. I’m thinking after all this time maybe it should have been tried. If this EP suggests it I wil do it. From what I’ve read, although there is no guaranty, the risks are low and not much recovery time.

Anti-Fib said;

Cardioversion is used more broadly than you described it. It is common way to get people out of AFIB, back into NSR. It is one of the 1st treatments given for AFIB, before it becomes too chronic a condition.


I don't know where you get that Cardioversion is one of the first treatments given for AF, I have had episodes of AFoff and on for about 20 years, never, never has any doctor or Ep suggested Cardioversion. I have always converted on my own, the first MD wanted me to take a beta blocker (that was a big mistake), I found a EP and got off the beta blocker (it gave me a lst degree heart block) and I had to have a pace maker implanted. After that I took Propafenone which I still take a small amount at night.

If Louise is in permanent AF then that is a different story, then yes a Cardioversion should be tried.

Liz

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Elizabeth
I don't know where you get that Cardioversion is one of the first treatments given for AF, I have had episodes of AFoff and on for about 20 years, never, never has any doctor or Ep suggested Cardioversion.

Your personal experience notwithstanding, Anti-fib is right that cardioversion is a first-line treatment. That doesn't mean every single afib patient will be cardioverted. It's unlikely to be successful with persistent afib so it's less often used for such patients. Not sure why you think it should be tried only if she's persistent. It's much more often successful with paroxysmal patients.

To give you an idea how common it is, I've had somewhere in the neighborhood of 20 cardioversions, and that's no record. I've met people who've had dozens.

Carey, since I’ve not been in mar since 2013 (or before), it sounds like I should have cardiovereion but it probably won’t work...

Hard for me to believe that cardioversion is the first line of defense in AF, my mother was in permanent AF, never a mention of cardioversion. I would like to see how many people on this board were cardioverted when they first got AF? The. next time I see my EP I will ask him if that is a first line of defense for AF. Hey George were you cardioverted when you first went into AF, I know you were in AF for more than a couple of months so I would think that would be a different story. But, it is being said on here that cardioversion is the first line of defense for AF, I have been coming to this board for many years never heard that, don't believe Hans ever said that.

Paroxysmal patients convert on their own so why would they want to be cardioverted?

With 20 cardioversions isn't that rather hard on the heart, apparently it doesn't work, just short term.



Edited 1 time(s). Last edit at 12/08/2018 04:46PM by Elizabeth.

mar should have been nsr a

After a certain age many cardiologists don't bring up cardioversion.

I am 69; is that too old? I am, other than afib, in excellent shape/health and very active. Louise

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Louise
I am 69; is that too old? I am, other than afib, in excellent shape/health and very active. Louise

Certainly not.

One issue, as you appear to have been in afib for some time, is keeping you in NSR after a cardioversion.

George

Yes, George, from what I’m reading here it doesn’t sound like the odds are in my favor.

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Elizabeth
But, it is being said on here that cardioversion is the first line of defense for AF, I have been coming to this board for many years never heard that, don't believe Hans ever said that.

It is among ER docs and many cardiologists. EPs perhaps not so much. They may be willing to try chemical cardioversion with anti-arrythmics. Depends on whom you meet. Always ask.

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Elizabeth
Paroxysmal patients convert on their own so why would they want to be cardioverted?

They shouldn’t, in my opinion. If the AF is burdensome I’d recommend rate control (beta blocker) until the episode ends.

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Elizabeth
With 20 cardioversions isn't that rather hard on the heart, apparently it doesn't work, just short term.

Any cardioversion is hard on the heart. It stuns and inflames the atria. That’s the reason you’re going to be likely anticoagulated for at least 30 days following an electric cardioversion.

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Elizabeth
Paroxysmal patients convert on their own so why would they want to be cardioverted?

I would guess that you've never experienced afib in its full glory.

Dr John Day recommends cardioversion if you've been in AFib for 24hrs because that might be the time where stroke becomes a risk

[drjohnday.com]

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Louise
I am 69; is that too old? I am, other than afib, in excellent shape/health and very active. Louise

Not at all. There is no age limit.

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Elizabeth
Anti-Fib said;

Cardioversion is used more broadly than you described it. It is common way to get people out of AFIB, back into NSR. It is one of the 1st treatments given for AFIB, before it becomes too chronic a condition.


I don't know where you get that Cardioversion is one of the first treatments given for AF, I have had episodes of AFoff and on for about 20 years, never, never has any doctor or Ep suggested Cardioversion. I have always converted on my own, the first MD wanted me to take a beta blocker (that was a big mistake), I found a EP and got off the beta blocker (it gave me a lst degree heart block) and I had to have a pace maker implanted. After that I took Propafenone which I still take a small amount at night.

If Louise is in permanent AF then that is a different story, then yes a Cardioversion should be tried.

Liz

Yes Liz I agree with you that people like yourself that convert back on their own within several days or so should not be Cardioverted. There are many like myself, that after about 48 hours are unlikely to spontaneously convert, so in our cases we must chose between being Cardioverted or accepting an increasingly likelyhood of Permanent AFIB, or proceeding to a Procedure like Ablation. Maybe I missed something, but I can't tell exactly how much AFIB Louise has, or how to classify it, but I assumed since a trip was made all the way to Austin for Ablation consideration, that she was not spontaneously converting on her own.

If a patient doesn't convert on their own, Cardioversion is often tried before a Dr. will commence other treatments. These include Anti-Arrythmic Drugs, Ablation, or a decision to accept Permanent AFIB. Electrocardioversion is seen as a relatively safe way to get a patient back into NSR, and to try to avoid the other options I mentioned, all of which have risks and negative effects. Also the more symptomatic a patient is, the more likely that Cardioversion will be used to alleviate the discomfort and restore NSR.

Anti-Fib,

I did not go to Austin, I went to La Jolla, CA from Santa Monica. The visit was prompted by many people here, mostly Shannon, who thought if I was going to see an EP, I should see Natale. At that time given my history he did not recommend an ablation; and actually asked me why I was there ( which made me slightly embarrassed that I wasted his time)

I was diagnosed during a routine physical and subsequent 24 hour Holter in 2010. Without going into all the details, I was put first on Warfarin and Metroprolol, then Pradaxa and Multaq. The metroprolol and Multaq seemed to make the irregular heartbeat worse. Dr. Natale only recommended Xarelto or Equious (sp) and I’ve been on Xarelto since, except for one year when I only took Cardiokinase. I am back on Xarelto now; which I think is best given my recent echocardiogram.

I didn’t pursue an EP before because of Natale’s Lack of concern about my condition and am doing so now also because of the echo. I will see an EP on January 4 and find out if a conversion is recommended or possibly medication to stop the cause of right and left atrial inflation can be reversed.

I haven’t been more aggressive in the past because of seemingly no “acceleration,” if that is the right term, of my afib. I have had the irregular heartbeat non-stop but it has never interfered with my lifestyle except for my fear of high aerobic excercise. I’ve been a pet sitter for 11 years so I walk a lot of dogs daily and boarded several at a time for nine years, so I keep relatively active.

In retrospect maybe conversion long ago would have put me in nsr, but no one including Natale recommended it.

Thank you all who have responded. I so appreciate those who are so much more knowledgeable than I am! Louise

If I understand your summary correctly, your afib did progress from what it was in 2010. You say your heartbeat is irregular non-stop, which sounds like you're now in persistent afib. Natale would have a very different opinion about that than he did almost 9 years ago. Although a cardioversion might be worth a try if you start another antiarrhythmic drug first, it has a low likelihood of success. I think you might have over-interpreted the advice you got from Natale years ago and should consider seeing him again. You have a very different situation on your hands than you did then.

Are you still taking metoprolol?

Thank you, Carey. I saw Natale in 2015. Since then I have had an echo every year with “no change.” This is the first year with a change and is why I am seeing an EP. I will start there and if medication and/or conversion don’t work and an ablation is recommended I would go see Natale. No to the metroprolol — my heart went crazy on it.

Well, whenever you saw him I'm sure you weren't in persistent afib at the time but it sounds like you are now, and you need to do something about that. What's your typical heart rate on a day to day basis? If it's near or over 100, you really need to get on a rate limiting drug of some type. Letting your heart buzz along in tachycardia for a long time will cause atrial enlargement and can can eventually caused overall heart enlargement and heart failure.

I’m not sure what persistent or permanent afib is. I have not been in NSR since I was diagnosed in 2010. Natale knew this. That’s why , when I hear these nightmare episodes people here describe I thought an irregular heart rate is not the same. My heart rate during the day can be in the 90s, usually if I’m feeling anxious, but is usually in the 70s to 80s. It is in the 60s when I remember to take it before I get up in the morning.

Since this conversation started with my recent echo, should I expect this EP to do their own? Should I ask for one? Thank you. Louise

Persistent is afib lasting more than seven days. Permanent afib is persistent afib that you don't intend to try to stop.

With a rate well under 100 you can live with afib forever by just remaining on an anticoagulant. That would be permanent afib, and many people make that choice when they're not highly symptomatic, as you apparently aren't. I would expect that's why Natale didn't recommend ablation. The atrial enlargement isn't harmful or dangerous in and of itself. That's only a concern for people who intend to try and stop their afib with ablation or drugs. Only enlargement of the ventricles would be a concern, but I gather the echo didn't find overall enlargement, so that's good.

I doubt that an EP is going to repeat an echo if one's been done recently. Just make sure he receives a copy of it. There's no reason to ask for another one. However, I wouldn't be surprised if he wants a stress test and he might combine that with another echo.

Thank you, Carey

I saw Dr. Doshi at that Pacific Heart Institute today. Because I have been in afib for so long and it doesn’t really effect my lifestyle, I am not a candidate for cardioversion or ablation. I am on a monitor for a week, and it sounds like I will get a Watchman implant. It won’t put me in NSR but I won’t have to take a blood thinner, which is my goal.

Hmmm, I thought I posted this earlier but I saw Dr. Doshi at Pacific Heart Institute in Santa Monica today. I am not a good candidate for conversion or ablation since I have been in afib for so long and it doesn’t really effect my lifestyle. I most likely am getting a Watchmsn. I am on a monitor for a week.



Edited 1 time(s). Last edit at 01/06/2019 06:00PM by Louise.

Sorry about duplicate messages. When I discovered my mistake I tried to delete the second one, but didn’t know how.

Can anyone who has had a Watchman implanted please share your experience with the procedure and results? Dr. Doshi said it was a 30 minute easy procedure with essentially no recovery time. Thank you very much. Louise