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Forum Name: Valvular Heart Diseases

Question: Mitral Valve with Vegetation Indicated What to do?


 wizbanger - Sat Nov 21, 2009 7:11 pm

Thank You for taking time to consider my question.

Back in Jan 09 one of our family members had surgery to repair her mitral valve.
Her orginal valve was sucessfully repaired and and all was reported normal after her surgery

However, in April this women started having trouble at time focusing her eyes which would be a transient problem lasting less then an hour.

Various MRI were performed but all returned negative. She went to various Doctors but other then the MRI no one could say what was at work with her eye focusing issue. I pushed that they could be TIA's but we live out of State and no one seemed to honor my logic.

This went on through-out the summer of 2009 perhaps once or twice a month with her eyes.

Then in Oct 09 she suffered a minor stroke but serious enough to have her hospitalized for a week and a half. She is making a good recovery.

This time in the hopital they finally ran a TEE. This echo was fairly unremarkable till the section that dealt with the Mitral valve. Here it was noted vegetation was found on and around the mitral valve (to me this was a key finding). No sizing data was presented re: the vegetation on the final report and which to date I have had no luck trying to get the Doctors to re-evaluate the digital data to provide sizing data. Hence I have no way to say how large an area was being reported. I feel this was another key marker missed.

All cultures taken indicated a negative culture for infections as I am told. Nor did this women have any signs of an infection (i.e. fever, joint pains etc. etc. prior to her stroke and there after).

Current treatment consisted of long term warfin as well as 80mg of Liptor and I am still trying to get her recent Lipid panel results, prior to her stroke her Lipid panel did not require the use of statins. I have no real objections with Lipitor just general curiosity as to why such a dosage and what does her current lipid panel have to say.

The only feed back that thus far that makes sense to me is that her Cardiologist feels the clot came from her heart and seems to me why his choice of blood thinners as opposed to others.

Now my questions - after doing a little research at the American College of Cardiology specifically http://content.onlinejacc.org/cgi/reprint/52/13/e1.pdf using the search criteria culture negative (pages e8, e71-78). I am left with the impression that the recommendation (minus the sizing data re: vegetation I can’t get) is to treat with antibiotics if less the 1 CM. If larger then surgery seems to be called for.

Is there any other condition that would show vegetation on the Mitral valve other then infections with a culture negative repotr?. Perhaps from the original mitral valve surgery itself? Although all testing at the time of surgery indicated - successful repair. If it would help I can say what was exactly done to the mitral valve to effect the repair but this is getting lenghty enough.

My fear is that there is perhaps a sub-clinical bacteria, microplasam pathogen slowly at work on the valve resulting in the finding of vegetation.

This women is 72 and further reading seems to indicate not all with heart valve infections (in the elderly) present with fever and/or other symptoms.

So my two questions are what other then infections could show on the TEE as vegetation and would you take the treatment plan thus far of blood thinners and Lipitor as the correct treatment regiment in light of the ACC recommendations to treat with antibiotics.

Since her stroke and new meds – I can’t be sure but she may have had a TIA (numbness in her foot that lasted a half hour). My fear is it might not be just blood clotting but infected tissue that is breaking away.

Your thoughts would be greatly appreciated to know if I am tilting at windmills.
Sincerly, Wizbanger
 John Kenyon, CNA - Sat Nov 28, 2009 10:18 pm

User avatar Hello -- You've certainly done your homework. If this is, in fact, vegetative growth then either antibiotics and/or surgery are appropriate. However, it appears as though it is being treated as non-infectious. There are other vegetative growths that don't respond to regular antibiotics, but they do respond to appropriate medications (anti-fungals for example). What I'm really wondering, since this was uncovered via echocardiogram and stroke is consistent with a diseased mitral valve, is whether or not this is truly vegetative growth. It's been my experience that sometimes this is a pretty equivocal finding visually on echo vs. myxotomous growth (a sort of tumor, actually, myxoma) which sometimes can look exactly like vegetation or even a large clot. If the problem were treated with medication appropriate to either fungal or bacterial infection (or both if enough doubt exists) and it responded, that would pretty much be that. If it were unresponsive it would almost have to be, by default, a myxoma. Of course this can be determined more quickly by angiographic visualization in the cath lab, and sometimes a myxoma can even be romoved via this process.

You could be right about small bits of the growth breaking off, and sometimes both clot material and vegetative material have been found in thrombi removed from a patient. Whole clot is more common by far, of course, but either is possible and the real issue is that whichever form of growth is on there, it favors formation of clots. The first stroke already happened, and warfarin is likely to prevent additional ones, but is a mixed blessing when it has to be used. If the problem could be resolved without indefinite use of warfarin it would be a lot better for the patient. Of course in cases where there's no other option it can be a lifesaver. However, if there's some disease on the valve and it was already repaired once, something is not right and it is likely to continue to grow or recur if not treated appropriately for whatever type of growth it is. To simply circumvent a cerebral event with symptomatic treatment seems odd to me.

The patient could easily not present with fever or other typical symptoms of infection with a subacute endocartitis (which is characteristic of "subacute" infections) and if it were a fungal growth this also would likely not cause fever. Myxoma would grow merrily with no fever ever.

The question remains: Why is this not being actively pursued beyond simply recognizing there is something growing on an already problematic valve? I have no idea, but were it me or my family member I would be strongly considering or advocating a second opinion. This isn't something normally just worked around. It can and should be corrected; if not, there should be a sound explanation. Obviously none has been advanced thus far. A second opinion should be considered, and if the patient lives near you there is a wealth of talent in the area in the cardiology field nearby.

I hope this is helpful. Good luck to you. Please follow up with us here as needed.
 wizbanger - Sun Nov 29, 2009 8:17 am

Thank you very much for your response. This is further affirmation to me that a chance for the vegetation to be resolved is being missed before more damage is done.

If not addressed correctly, I fear additional strokes and or eventual mitral valve replacement will occur.

Plus, I too would hope that if the vegetation is resolved then perhaps the use of warafin could be discontinued or at least changed to a less problematic blood thinner (i.e Plavix or perhaps one of the newer ones coming online).

Since the surgery on the mitral valve occurred fairly recently (Jan 09) I feel it is not impossible that a myxoma growth could be involved but my guess would be somewhat low in comparison to the infections mentioned. Perhaps as you point out an angiographic visualization in the cath lab will be performed.

Lupus could also be a factor but there is no reason I would say to suspect she has this condition.

Hence, I agree fungal and/or bacteria are the most likely causes (it would seem) and the chance for a cure will only occur if the correct diagnosis is made and treated with the appropriate medication.

My next step will be to find a seasoned cardiologist that is current with the literature re: vegetation, wants to provide great patient care and who will work with an infection disease specialist to help nail down the correct diagnosis and treatment plan.

Thank you so much for your input, good wishes and helping confirm that there are reasons to get a second opinion.
Sincerely
Wizbanger.

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