Leaking Mitral valve

Alan Crichton · 11th February 2007, 05:09

Thought my case history may interest the medically minded rebreather community. Anyway been diving for 14 years current age 54 male etc etc . In good health low cholesterol, BMI = 23 , always kept diving fit. I converted from OC after completing a Normoxic course ( He too expensive , bubbles too noisy ) 18 months ago. Thoroughly enjoyed it ! Dived every second weekend some technical some recreational. In Nov 2006 during the only OC dive for the year ( was accompaning an Australian visitor ) I started to cough after approximately 40 min. As I ascended I could feel fluid in my lungs and heard a gurgling sound on exhalation. At the 5m stop I even checked the fluid I was coughing up to see if it was froth or bloody - it was neither ! Anyway on the surface I had difficulty breathing but was Ok. I called the second dive and stayed on the boat as topman while the others dived. Felt better that evening and decided it must be that dirty OC gas ! Drained and cleaned the cylinder and decided no more OC for me. Did not think much more about it until the next dive day - after 40min on CCR I felt exactly the same - coughing up fluid , difficult to breath. Anyway this time on ascent felt much better ( pO2 v Conc ) ! Decided to do a second dive and repeated the whole thing same effect. By now I was convinced I had some kind of asthma or chest infection. Went to my local Dr who prescribed an antibiotic - note he was not a diving Dr. Felt better and planned the next dive series. This time a more technical dive. Our bottom time was 45min at 50m ! As I left the bottom could feel the same difficulty in breathing start and the desire to cough up the fluid. The TTS was over 80 min so I was anxious about the condition worsening anyway it did not - at the 6m I hung comfortably breathing almost pure oxygen on the loop - but still could hear my chest gurgling.

The next day I opted out and watched from the boat as the others explored a deep canyon of the coast. Decided "must see a diving Dr " - well you know how it is I began to feel better and before I knew it my mates were planning another dive day. Went along dived twice same thing ! Eventually my wife nagged me into making an appointment - we live a 2hr drive away from a hyperbaric centre. Saw the dive Dr and after about an hour of discussion about pulmonary edema etc he decided to check my chest. Almost immediately he asked " Has anyone ever told you you have a heart murmer ?" No was the answer - bear in mind I have an annual examination along with an ECG and this never came up. He promptly made an appointment for me with another diver who happend to be a cardiologist - that same afternoon. After much testing ultrasound and running on a treadmill the verdict was - a leaking Mitral valve. This caused 50% of the blood to shunt back towards the lungs resulting in the presentation of pulmonary edema - fluid on the lungs. No surgery is required at this stage but NO DIVING allowed. Still absolutely stunned gobsmacked and bummed as well as any other term you can think of. Not sure what the future managment of this will be but remain hopeful. Do not intend selling my CCR etc until I have a second opinion next week. Anyway the moral of the story is listen to you body and your wife - call DAN for advice as sson as something seems different - use an experienced diving Dr. Irrespective my love for the topography and creatures under the sea will remain.

dteubner · 11th February 2007, 05:35

What a bugger. Apart from investigating repair I have no advice to offer but here is a bit of an explaination.

Your mitral valve ususally closes when the left ventricle contracts so the left atrium and pulmonary veins are protected from the high pressures generated by the left ventricle. When your mitral valve leaks the pulmonary veins have to a much higher pressure than usual, and this can force fluid from the blood through the alveolar membrane into the alveoli - which is what pulmonary oedema is.

There are several things about (particularly CCR) diving which would make the problem worse.

Firstly whenever you enter the water some blood moves from the veins in your legs to veins in your abdomen and chest. This increases the return of blood to your heart, increasing the cardiac output and thus the pressure in the pulmonary circulation.

Secondly, breathing high oxygen partial pressures causes constriction of the arteries which increases the resistance against which the left heart pumps - again increasing the pressure in the left ventricle and therefore the pulmonary veins.

Thirdly, particularly in some orientations (depending on CL position), you need to generate substantial negative pressures in the lungs to make gas flow in. By decreasing the pressure in the alveoli, you increase the gradient accross them again making the problem worse.

Regards,

Dave T

pattimegdiver · 11th February 2007, 07:46

I have been diving oc for 5yrs and ccr for 1.5 yrs, I also have a heart murmer and have mitral valve prolapse. Drs have told me that as long as the "leaking" is at the bottom and not from the top as the valve opens i will be okay. I have also seen Cardiologist's and done the stress test and so far I have not had any problems. Hope things work out for you and please let us know what develops with your condition.

mortenkjerulff · 11th February 2007, 07:56

Hi Alan.

Thanks for the very interesting information.
I hope you will be able to dive again.

Morten

saturation · 14th February 2007, 12:49

I concur fully. It may benefit to seek repair before the heart suffers injury from the leak since it could mean, at least, a return to recreational diving.

Quote: (Originally Posted by dteubner)

What a bugger. Apart from investigating repair I have no advice to offer but here is a bit of an explaination.

Your mitral valve ususally closes when the left ventricle contracts so the left atrium and pulmonary veins are protected from the high pressures generated by the left ventricle. When your mitral valve leaks the pulmonary veins have to a much higher pressure than usual, and this can force fluid from the blood through the alveolar membrane into the alveoli - which is what pulmonary oedema is.

There are several things about (particularly CCR) diving which would make the problem worse.

Firstly whenever you enter the water some blood moves from the veins in your legs to veins in your abdomen and chest. This increases the return of blood to your heart, increasing the cardiac output and thus the pressure in the pulmonary circulation.

Secondly, breathing high oxygen partial pressures causes constriction of the arteries which increases the resistance against which the left heart pumps - again increasing the pressure in the left ventricle and therefore the pulmonary veins.

Thirdly, particularly in some orientations (depending on CL position), you need to generate substantial negative pressures in the lungs to make gas flow in. By decreasing the pressure in the alveoli, you increase the gradient accross them again making the problem worse.

Regards,

Dave T

apitkin · 14th February 2007, 20:39

I presume your second opinion is from a cardiologist? If not, I strongly recommend you see one.

If you truly have 50% of blood leaking back across the valve (this is known as the regurgitant fraction), that indicates your problem is very significant, and eventually it will have a deleterious effect on the function of your heart. The heart is able to compensate most of the time, but under certain conditions (e.g. diving) it cannot and you get symptoms. As time goes by, those symptoms will appear more and more commonly.

Mitral valve repair is becoming increasingly sophisticated and safe, in the hands of an expert specialist surgeon (i.e. a cardiac surgeon who specialises in mitral valve repair). You can be cured, but it does involve a big operation.

Andy

Ben Field · 15th February 2007, 11:50

I just wanted to say- "crumbs" and Good luck, thanks for sharing this, goes to show that something small might indicate something more urgent.

I wish you all the best...

**Fun Under Pressure** · 16th February 2007, 13:25

Hi Al,

you must go too a cardiac surgeon. Because your leak can lead to a pulmonary hypertension. This can lead to many problems.

Good luck

Markku

Alan Crichton · 15th March 2007, 19:23

Just an update and a word of thanks to the divers who responded - your advice was greatly appreciated. I subsequently went to see 3 cardiac thoracic surgeons and 2 advised me to have a repair done. This was based on a regurgitant volume >50%. I am going in for OHS on Monday 19th and from the surgeons perspective I have a 99% chance of a repair - I really wanted to avoid a replacement - with the possibilty of diving again ! So I am already planning my recovery / recuperation period followed by some tests and if all is well my first post op dive in about Sept. So once again thanks for the support !

cjgbur · 22nd March 2007, 16:50

Greetings...

Reviewed your post. To really give any meaningful advice, I would need more information.

However, if you are developing pulmonary edema with diving, there is no doubt you should not dive for now. I am more concerned about long term consequences of "watching" the MR (mitral regurgitation).

You need to ask your cardiologist several questions:
1) Left ventricular function: is it normal?
2) Estimated pulmonary artery pressures (should have been calculated from your echocardiogram)
3) Left atrail size, again from the echo.

Early repair if anatomically possible would be a good option. You can fix it before it effects the the heart irreversabily and you hopefully can avoid valve replacement surgery and the need for long term anticoagulation.

Best of luck,
CJG

11th February 2007, 05:09	#1 (permalink)
Alan Crichton New Member Current Rebreather/s: Inspiration Classic Other Rebreather/s: Join Date: Mar 2006 Location: Richards Bay South Africa Posts: 38	Leaking Mitral valve Thought my case history may interest the medically minded rebreather community. Anyway been diving for 14 years current age 54 male etc etc . In good health low cholesterol, BMI = 23 , always kept diving fit. I converted from OC after completing a Normoxic course ( He too expensive , bubbles too noisy ) 18 months ago. Thoroughly enjoyed it ! Dived every second weekend some technical some recreational. In Nov 2006 during the only OC dive for the year ( was accompaning an Australian visitor ) I started to cough after approximately 40 min. As I ascended I could feel fluid in my lungs and heard a gurgling sound on exhalation. At the 5m stop I even checked the fluid I was coughing up to see if it was froth or bloody - it was neither ! Anyway on the surface I had difficulty breathing but was Ok. I called the second dive and stayed on the boat as topman while the others dived. Felt better that evening and decided it must be that dirty OC gas ! Drained and cleaned the cylinder and decided no more OC for me. Did not think much more about it until the next dive day - after 40min on CCR I felt exactly the same - coughing up fluid , difficult to breath. Anyway this time on ascent felt much better ( pO2 v Conc ) ! Decided to do a second dive and repeated the whole thing same effect. By now I was convinced I had some kind of asthma or chest infection. Went to my local Dr who prescribed an antibiotic - note he was not a diving Dr. Felt better and planned the next dive series. This time a more technical dive. Our bottom time was 45min at 50m ! As I left the bottom could feel the same difficulty in breathing start and the desire to cough up the fluid. The TTS was over 80 min so I was anxious about the condition worsening anyway it did not - at the 6m I hung comfortably breathing almost pure oxygen on the loop - but still could hear my chest gurgling. The next day I opted out and watched from the boat as the others explored a deep canyon of the coast. Decided "must see a diving Dr " - well you know how it is I began to feel better and before I knew it my mates were planning another dive day. Went along dived twice same thing ! Eventually my wife nagged me into making an appointment - we live a 2hr drive away from a hyperbaric centre. Saw the dive Dr and after about an hour of discussion about pulmonary edema etc he decided to check my chest. Almost immediately he asked " Has anyone ever told you you have a heart murmer ?" No was the answer - bear in mind I have an annual examination along with an ECG and this never came up. He promptly made an appointment for me with another diver who happend to be a cardiologist - that same afternoon. After much testing ultrasound and running on a treadmill the verdict was - a leaking Mitral valve. This caused 50% of the blood to shunt back towards the lungs resulting in the presentation of pulmonary edema - fluid on the lungs. No surgery is required at this stage but NO DIVING allowed. Still absolutely stunned gobsmacked and bummed as well as any other term you can think of. Not sure what the future managment of this will be but remain hopeful. Do not intend selling my CCR etc until I have a second opinion next week. Anyway the moral of the story is listen to you body and your wife - call DAN for advice as sson as something seems different - use an experienced diving Dr. Irrespective my love for the topography and creatures under the sea will remain. __________________ *Al from the Bay* *The best dive is the next dive !*
(Offline)

11th February 2007, 05:35	#2 (permalink)
dteubner Pedant Current Rebreather/s: Sport Kiss Classic Kiss Other Rebreather/s: Join Date: Mar 2005 Location: Adelaide, Australia Posts: 217	Re: Leaking Mitral valve What a bugger. Apart from investigating repair I have no advice to offer but here is a bit of an explaination. Your mitral valve ususally closes when the left ventricle contracts so the left atrium and pulmonary veins are protected from the high pressures generated by the left ventricle. When your mitral valve leaks the pulmonary veins have to a much higher pressure than usual, and this can force fluid from the blood through the alveolar membrane into the alveoli - which is what pulmonary oedema is. There are several things about (particularly CCR) diving which would make the problem worse. Firstly whenever you enter the water some blood moves from the veins in your legs to veins in your abdomen and chest. This increases the return of blood to your heart, increasing the cardiac output and thus the pressure in the pulmonary circulation. Secondly, breathing high oxygen partial pressures causes constriction of the arteries which increases the resistance against which the left heart pumps - again increasing the pressure in the left ventricle and therefore the pulmonary veins. Thirdly, particularly in some orientations (depending on CL position), you need to generate substantial negative pressures in the lungs to make gas flow in. By decreasing the pressure in the alveoli, you increase the gradient accross them again making the problem worse. Regards, Dave T
(Online)

11th February 2007, 07:46	#3 (permalink)
pattimegdiver #1 COPIS Mini Meg Girl Current Rebreather/s: Megalodon Sport Kiss Other Rebreather/s: Join Date: Nov 2005 Location: Portland Oregon Posts: 307	Re: Leaking Mitral valve I have been diving oc for 5yrs and ccr for 1.5 yrs, I also have a heart murmer and have mitral valve prolapse. Drs have told me that as long as the "leaking" is at the bottom and not from the top as the valve opens i will be okay. I have also seen Cardiologist's and done the stress test and so far I have not had any problems. Hope things work out for you and please let us know what develops with your condition. __________________ Patti Meg Diver Remember that great love and great achievements involve great risk Last edited by pattimegdiver : 11th February 2007 at 08:45.
(Offline)

11th February 2007, 07:56	#4 (permalink)
mortenkjerulff Customise Me! Current Rebreather/s: Megalodon Other Rebreather/s: Not Bought Yet Join Date: Mar 2005 Location: Denmark Posts: 143	Re: Leaking Mitral valve Hi Alan. Thanks for the very interesting information. I hope you will be able to dive again. Morten
(Offline)

14th February 2007, 12:49	#5 (permalink)
saturation New Member Current Rebreather/s: Not Bought Yet Other Rebreather/s: Not Bought Yet Join Date: Sep 2005 Location: Philadelphia, PA, USA Posts: 53	Re: Leaking Mitral valve I concur fully. It may benefit to seek repair before the heart suffers injury from the leak since it could mean, at least, a return to recreational diving. Quote: (Originally Posted by dteubner) What a bugger. Apart from investigating repair I have no advice to offer but here is a bit of an explaination. Your mitral valve ususally closes when the left ventricle contracts so the left atrium and pulmonary veins are protected from the high pressures generated by the left ventricle. When your mitral valve leaks the pulmonary veins have to a much higher pressure than usual, and this can force fluid from the blood through the alveolar membrane into the alveoli - which is what pulmonary oedema is. There are several things about (particularly CCR) diving which would make the problem worse. Firstly whenever you enter the water some blood moves from the veins in your legs to veins in your abdomen and chest. This increases the return of blood to your heart, increasing the cardiac output and thus the pressure in the pulmonary circulation. Secondly, breathing high oxygen partial pressures causes constriction of the arteries which increases the resistance against which the left heart pumps - again increasing the pressure in the left ventricle and therefore the pulmonary veins. Thirdly, particularly in some orientations (depending on CL position), you need to generate substantial negative pressures in the lungs to make gas flow in. By decreasing the pressure in the alveoli, you increase the gradient accross them again making the problem worse. Regards, Dave T __________________ Safe Diving and Best Wishes, I.G. Saturation, MD { Comments are informational only and not meant to be medical advice applicable to a particular case. Consult your physician when considering information posted here }
(Offline)

14th February 2007, 20:39	#6 (permalink)
apitkin New Member Current Rebreather/s: Prism Topaz Other Rebreather/s: Join Date: Feb 2005 Location: Cloud Cuckoo Land Posts: 102	Re: Leaking Mitral valve I presume your second opinion is from a cardiologist? If not, I strongly recommend you see one. If you truly have 50% of blood leaking back across the valve (this is known as the regurgitant fraction), that indicates your problem is very significant, and eventually it will have a deleterious effect on the function of your heart. The heart is able to compensate most of the time, but under certain conditions (e.g. diving) it cannot and you get symptoms. As time goes by, those symptoms will appear more and more commonly. Mitral valve repair is becoming increasingly sophisticated and safe, in the hands of an expert specialist surgeon (i.e. a cardiac surgeon who specialises in mitral valve repair). You can be cured, but it does involve a big operation. Andy
(Offline)

15th February 2007, 11:50	#7 (permalink)
Ben Field CK+Shearwater Current Rebreather/s: Classic Kiss Other Rebreather/s: Sport Kiss Join Date: Aug 2005 Location: London, England Posts: 1,621	Re: Leaking Mitral valve I just wanted to say- "crumbs" and Good luck, thanks for sharing this, goes to show that something small might indicate something more urgent. I wish you all the best... __________________ Know your PPO2, Pre-breath, Use checklists, Validate cells at 6mtrs, Use pure O2 at or near surface, Use a BOV, Don't dive Solo, Change Slime and Cells as recommended by Manufacturer and RTFM! Beware Fridge Suck! www.hugsac.org.uk
(Offline)

16th February 2007, 13:25	#8 (permalink)
Fun Under Pressure Supporting Member Current Rebreather/s: Megalodon Other Rebreather/s: Inspiration Classic Join Date: Nov 2006 Location: Germany Posts: 696	Re: Leaking Mitral valve Hi Al, you must go too a cardiac surgeon. Because your leak can lead to a pulmonary hypertension. This can lead to many problems. Good luck Markku
(Offline)

15th March 2007, 19:23	#9 (permalink)
Alan Crichton New Member Current Rebreather/s: Inspiration Classic Other Rebreather/s: Join Date: Mar 2006 Location: Richards Bay South Africa Posts: 38	Re: Leaking Mitral valve Just an update and a word of thanks to the divers who responded - your advice was greatly appreciated. I subsequently went to see 3 cardiac thoracic surgeons and 2 advised me to have a repair done. This was based on a regurgitant volume >50%. I am going in for OHS on Monday 19th and from the surgeons perspective I have a 99% chance of a repair - I really wanted to avoid a replacement - with the possibilty of diving again ! So I am already planning my recovery / recuperation period followed by some tests and if all is well my first post op dive in about Sept. So once again thanks for the support ! __________________ *Al from the Bay* *The best dive is the next dive !*
(Offline)

22nd March 2007, 16:50	#10 (permalink)
cjgbur New Member Current Rebreather/s: Not Bought Yet Other Rebreather/s: Not Bought Yet Join Date: Mar 2007 Location: Toledo Ohio Posts: 3	Re: Leaking Mitral valve Greetings... Reviewed your post. To really give any meaningful advice, I would need more information. However, if you are developing pulmonary edema with diving, there is no doubt you should not dive for now. I am more concerned about long term consequences of "watching" the MR (mitral regurgitation). You need to ask your cardiologist several questions: 1) Left ventricular function: is it normal? 2) Estimated pulmonary artery pressures (should have been calculated from your echocardiogram) 3) Left atrail size, again from the echo. Early repair if anatomically possible would be a good option. You can fix it before it effects the the heart irreversabily and you hopefully can avoid valve replacement surgery and the need for long term anticoagulation. Best of luck, CJG __________________ *Charles J Gbur Jr, MD, FACC, FSCAI, DMO* SSI AOWI
(Offline)

Thread Tools
Show Printable Version Email this Page
Display Modes
Linear Mode Switch to Hybrid Mode Switch to Threaded Mode