Heart Murmur information

[Guest koopster]

Hello all,

I have a heart murmur that's due to moderate tricuspid valve regurgitation. I did not have to request a waiver to get my class I FAA flight physical. It's an asymptomatic condition that does not require treatment.

Is that condition waiverable to be a pilot? Is a waiver even needed?

Thanks.

Alex

[Guest koopster]

Hello again,

I just found this at

https://usmilitary.about.com/library/milinf...ly/blcardio.htm

"History of valvular heart disease to include pulmonic, mitral, and tricuspid valvular regurgitation greater than mild, aortic regurgitation greater than trace, and any degree of valvular stenosis. Mitral valve prolapse (MYP) and bicuspid aortic valve are also medically disqualifying."

I was diagnosed with mild to moderate tricuspid valve regurgitation so I should be ok.

FlightDoc: can you confirm?

Thanks.

Alex

[Guest Flight Doc]

Mild (OK) versus moderate (no-go) tricuspid regurgitation makes all the difference in the world.

Hope that it doesn't seem too loud to the flight doc....

[Guest koopster]

FlightDoc:

Yeah, I just realized that AFI calls for mild regurgitation at the most.

First echo done in 1999 revealed mild to moderate tricuspic regurgitation.

Just got echo results from yeserday. The doc classified it as "at least mild" tricuspid regurgitation (I did inform him of the AF regs).

The doc also said that the murmur is very "innocent". He stated that the regurg. is not detectable without an echo (a doctor would not be able to suspect the regurgitation without the echo).

Of course, I put the "mild to moderate" and the "at least mild" findings on all my Air National Guard applications.

What do you think is going to happen?

Will they have me do an echo for sure?

Is mild to moderate DQ?

My prognosis was pronounced as excellent with no physical restrictions...are waivers commonly approved?

I am in need of good news.

Thanks FlightDoc.

Alex

[Guest Pete2037]

Koopster,

I was just disqualified for my flight slot with a bicuspid aortic valve with mild regurgitation. I can't get a waiver if it's over trace regurgitation. Anyway I went to mayo clinic and they determined that I have trace regurgition. They have the abilitly to measure the volume and the air force doesn't. However the AF doctors won't change their minds so I'm in the middle of fighting this thing with the help of a General. You will have to get an echo done if you get selected. It's part of you MSF physical which will be done at Brooks AFB. There is no way around it. Every pilot has this done and I didn't know that I had this thing until I went there. It also doesn't matter what a civilian doctor says. They won't care. Anyway best of luck to you man.

Pete

[Guest koopster]

Pete,

I believe you were DQ'ed by two findings. First the bicuspid aortic valve is ground for DQ. And like you said, the mild regurg. is the second.

Why won't the AF docs let you apply for an Exception To Policy waiver?

Did the Mayo Clinic also confirm the bicuspid aortic valve? If yeah, technically, you're DQ'ed. If no, you could find a way to challenge their "mild" qualification for the aortic regurg. and reverse the finding to "trace". What process is in place to challenge/appeal the AF's findings?

Sorry to hear about the ordeal. On my end, I just pray that the AF echo is miscalibrated that day. I am borderline DQ with my regurg.

Alex

[Guest Pete2037]

Koopster,

I do have a bicuspid aortic valve there is no doubt about that from either source. However, if I have trace regurgation the I am DQ'd with the option for a waiver. The doctors and Brooks said that the waiver would not be a difficult thing to get. Right now they say I have mild and that is DQ'd without option to waiver. I can go for an ETP and will but the General that runs the Air Guard in my state is trying to get it back without having to go through the ETP process. I'm not really sure what he plans on doing but it's pretty much in his hands. I'll do whatever I have to do. The big thing right now is that Mayo says I have very low trace regurgation and that is what I have to fight with.

Pete

[Guest koopster]

FlightDoc:

Could you please answer my follow-up question that was posted after your original reply?

Thanks a bunch.

Alex

[Guest Flight Doc]

This is an iffy one, too. Anything more that minimal regurgitation would probably require ACS workup for waiver consideration.

https://quicksand.brooks.af.mil/web/af/afc/...20Disorders.htm

[Guest afrotccadet]

I'm getting a physical from a doctor soon. Is having a very slight heart murmur a detriment to my hopes for a pilot career in the AF? Any information on this would be helpful, thanks

[pcola]

That would depend on what is causing the murmur and on how slight it is. If the murmer is greater than mild, or if it is caused by a mitral valve prolapse or a bicuspid aortic valve, then you will not be flying class 1 qualified.

[Guest navobd]

Most murmurs turn out to be nothing. You'll have to get an echocaridogram to determine whether or not your murmur is an issue. I've got one and didn't know it until I was in high school.

Turned out to be nothing serious and I am FC1 qualified.

[Guest upthopeful]

flight docs: two brief questions

1. I have a heart murmur- I got through my DoDMERB and PPQ, but now I've got to get the IFC-1 and MFS clearance this summer. Should I be especially concerned? Is there anything I can prepare for going into Brooks? I've read A7.17.1.6 (history of valvular heart disease) and will send it to the cariologist to check, but is there anything else? Would quitting running reduce the regurgitation?

2. I just fractured my collarbone. No displacement, and the fracture is hairline- all the x-rays are documented. Am I pushing my luck with the heart murmur and the fracture? Anything to look out for or documents to prepare?

Thanks ever so much for your input- this is something i've wanted for so long but am getting a little nervous.

[Guest F16PilotMD]

Collarbone fracture is nothing to worry about as long as it is well healed at the time of your physical. If not, you will be DQ. My advice is not to do the physical until it's healed.

The murmur is another issue. It all comes down to WHY you have a murmur. Some are DQ, others are not. Details??? You will get an echocardiogram during Medical Flight Screening. That should answer all questions about your specific problem. I'm not a cardiologist, but I doubt there is anything you can do to lessen your murmur.

For any and all issues that you have, I would bring documentation. Offer it if they WANT it and not before. You should always have papers that can answer (1) specific diagnosis by a physician and how the diagnosis was made (2) treatment (3) results of treatment (4) restrictions, if any. (5) likelihood of future problems.

[Guest upthopeful]

f16pilotmd- thanks for the quick response. I'm not sure how to answer *why*, except that its congenital- definitely passed through DoDMERB with the the ECG though.

If I can post any other specifics I'll try.

Thanks again for your time and comments!

[Guest F16PilotMD]

A murmur is turbulent blood flow in the heart, or more specifically, through the heart valves. There is usually something abnormal about the valves to cause a murmur and that is the "WHY" part...the specific diagnosis (i.e.: mitral valve regurgitaion, MV insufficiency, aortic valve regurg or insufficiency, etc.) Or do you just have a "flow murmur"...that is, nothing is wrong, the blood just rumbles through your heart for some reason.

When you look at the regulations, murmur isn't the problem for you. It's the abnormality that CAUSES the murmur that may be a problem for you.

[Guest d_nordman]

Recently, I went to get my DODMERB physical for the service academies. They found a heart murmur and requested that I get an echocardiogram. I went to get this and they said that I have mitral valve prolapse. They said I have a whiff of mitral insufficiency and a trace of tricuspid insufficiency. How will this affect my chances of receiving an appointment to the Air Force Academy or the Naval Academy? How will this affect my chances of becoming a fighter pilot or any other pilot for the military? Also, is there any chance of getting a waiver for this to go to the academy or to be a fighter pilot?

My heart rate is completely normal and so is my blood pressure. Will this have any positive effects on receiving a waiver? My dream is to become a fighter pilot and I really don't want to be disqualified for something like this, especially when I'm physically fit and play sports consistently. Also, I lift weights a lot and have absolutely no symptoms. Any thoughts? Thanks for everybody's time.

[Guest F16PilotMD]

Complicated to say the least. Step one is getting in the USAF. Step two is getting into the Academy. Step three is a flying physical.

This is from AFI 48-123:

Getting in the USAF to begin with:

A3.13. Heart..

A3.13.1. All valvular heart diseases. Including those improved by surgery, except mitral valve prolapse

and bicuspid aortic valve. These latter two conditions are not reasons for rejection unless there

is associated tachyarrhythmia, mitral regurgitation, aortic stenosis, insufficiency, or cardiomegaly.

For you this will depend on the severity of your mitral valve insufficiency/regurgitation. MVP with any regurg may very well be DQ for enlistment.

For flying:

A7.17.1.6. History of valvular heart disease to include pulmonic, mitral, and tricuspid valvular

regurgitation greater than mild, aortic regurgitation greater than trace, and any degree of valvular

stenosis. Mitral valve prolapse (MVP) and bicuspid aortic valve are also medically disqualifying.

This doesn't sound good for you. I think that MVP will DQ you for the Initial Flying Class I. It's different if you are already flying...then you can get a waiver.

The waiver guide for flying is at this web site. Go to the "Cardiovascular" button and follow your nose from there.

https://www.brooks.af.mil/web/consult_servi...ver%20guide.htm?

"MVP is not waiverable for FC I/IA candidates." This comes from the waiver guide.

Sorry. I wish I had better info.

[Guest d_nordman]

Does this basically mean I can't even get a waiver? Is it basically impossible for me to become a pilot in the Air Force?

[Guest d_nordman]

I went to the DoDMERB website and found this. https://dodmerb.tricare.osd.mil/detachment/detachment.asp

If you click on old disqualification codes it seems that MVP was deleted. It is number 197. Does this mean that it was added again as a disqualification code or it is no longer disqualifying?

[Guest F16PilotMD]

I don't know about the old and new stuff. AFI48-123 is current as far as I know. You always have the option to apply for a waiver. Even things that say "not waiverable" you can try...they will just most likely say no.

[Guest parkjd]

I have been told that I have a bicuspid trileflate aortic valve (I'm not sure how to spell it). I am active duty in the Marines, and I have no physical symptoms. Could I get a waiver for this? Is there anyway that I could get a flight physical at Luke in Phoenix?

[Guest F16PilotMD]

Disqualifying.

A7.17.1.6. History of valvular heart disease to include pulmonic, mitral, and tricuspid valvular

regurgitation greater than mild, aortic regurgitation greater than trace, and any degree of valvular

stenosis. Mitral valve prolapse (MVP) and bicuspid aortic valve are also medically disqualifying.

USAF Waiver Guide:

CONDITION: AORTIC STENOSIS/BICUSPID AORTIC VALVE

I. Overview. Aortic stenosis (AS) is defined as the reduction in the functional area of the aortic valve. It is most commonly considered to be congenital in origin especially when it is noted in individuals less than 30 years of age. This may be due to the valve being congenitally bicuspid which occurs in 1-2% of the population. Two thirds to three fourths of these are predisposed to progress to aortic stenosis late in life. Consideration has also been given that it may at times be secondary to fibrosis, rheumatic inflammation of the Aortic Valve (AV), or due to coronary artery disease or degenerative calcification of the Aortic Cusps, especially in the elderly. It is the most frequent cardiac valvular abnormality occurring in about one fourth of all patients with chronic valvular disease. Approximately 80% of symptomatic patients are male.

Symptomatic AS usually occurs in the 5th to 7th decades of life after existing for many years. Exertional dyspnea, angina pectoris, and syncope are the three cardinal symptoms. Dyspnea, orthopnea and pulmonary edema are symptoms of impending left ventricular failure.

A primary hemodynamic concern of importance in AS is obstruction to left ventricular outflow. A systolic pressure gradient occurs between the left ventricle and aorta. Critical obstruction is considered present with a peak gradient exceeding 50 mm Hg even in presence of a normal cardiac output. This usually correlates with a reduction of the cross-sectional diameter of the orifice by at least 35% of its original size. Cardiac output at this level has been noted to fail to rise normally during exercise or as a response to stress (including Gz forces). Hypertrophic left ventricular muscle mass eventually is a sequelae which elevates myocardial O2 requirements. Other items of concern include interference with coronary blood flow and intensification of other likely associated valvular diseases like mitral regurgitation.

Syncope has been reported in up to 20% of cases of aortic stenosis; it can occur even in mild cases. Sudden death occurs in 15-30% of all cases, with 3-5% occurring in symptom-free patients. Once patients have symptoms attributable to left ventricular decompensation, 50% survival is less than 2 years.

Avoidance of strenuous physical activity is only suggested for patients with severe AS. The most critical decision in management concerns the advisability of surgical treatment in extensively symptomatic patients. Considerable hemodynamic improvement has been seen with simple commissural incision. However, aortic valve replacement is often necessary with calcific or damaged (bicuspid) valves having a peak systolic pressure gradient of 50 mm Hg or a orifice less than 35%. Early intervention yields an operative risk which is relatively low at 5% in centers with experience. Waiting until Left Ventricular failure (with congestive heart failure) supervenes, increases it to up to 25%.

Because AS usually doesn’t present until late in life, its course is variable. Treatment with beta blockers are contraindicated, as they depress LV function and may precipitate acute decompensation. Diuretics should be used with caution, as hypovolemia may reduce cardiac output through its effects on preload reduction. The prognosis of symptomatic AS significantly improves with intervention for either mechanical or bioprosthetic valve replacement.

Antibiotic prophylaxis is necessary for all dental manipulations and potential bactermia in patients with bicuspid aortic valve as well as those with aortic stenosis.

II. Aeromedical Concerns. Most patients with AS remain asymptomatic over the greater part of the illness. There is a risk of sudden incapacitation even in moderate, asymptomatic aortic stenosis with usually angina, syncope, or left ventricular failure being the first event. Thus, the condition is most common in a population of patients in whom the risk of ischemic heart disease is also high. There are no specific aeromedical concerns in bicuspid aortic valve although most have mild aortic insufficiency and have a greater risk of developing aortic stenosis as they age.

III. Information Required for Waiver Submission. Complete Cardiology consultation is necessary. Electrocardiography, Doppler echocardiography, 24-hour Holter Monitor, chest x-ray and cardiac catheterization with angiography, if performed, are required.

IV. Waiver Considerations. Unrestricted waiver can be considered for very mild cases of aortic stenosis (with gradients up to 20 mm Hg) but other cases will be considered for Flying Class IIA waivers at best and may be disqualified. Patients with bicuspid aortic valve and no other abnormalities on examination will remain on unrestricted flying duties.

While cardiac valve replacement has traditionally been considered disqualifying for military aviation duties, USAF documentation has noted one pilot who recently underwent AV replacement and was subsequently returned to flying status in low-G aircraft. Thus, with careful evaluation and close follow-up, military aviators with homografts can now be considered for return for flying duties in low-G aircraft.

Over 81% of waiver applicants evaluated at the ACS have received waivers. Initial presentations of mild AS without progression or other disqualifying conditions have resulted in an 89% waiver rate.

[ 24. February 2005, 18:03: Message edited by: F16PilotMD ]

[Guest doctidy]

Both Luke or Davis-Monthan Flight Medicine shops can do a flying physical for you.

Heart valve defects are tough to get a waiver for, especially if you are just trying to get on flying status.

[Guest bussman]

I just got a pilot slot and will be graduatin this Dec. I am headed to Brooks in June but have a question regarding my health.

During DODMERB, the Doc said I had a slight heart murmur. After getting additional tests at my expense , this is what the specialists came up with.

FYI: I was waived initially but I'd like to know if this is something that would DQ me for pilot.

Here are the basics:

Vital Signs: Good

Heent: Grossly intact

Neck: Supple: There was no definite bruit heart in the neck

Chest: Clear. Regular rhtym to cardiac ausculation. No gallop was heard. He does have a soft 1-2/6 systolic murmur present at the apex, which diminished slightly by standing, and increased slightly with exercise.

Diagnostic Data: Electrocardiogram showed early repolarization, but no evidence of significant left ventricular hypertrophy by ST-T wave criteria. His 2-D echo was entirely within normal limits for his age, showing normal valves, normal chamber dimensions, and trivial mitral regurgitation.

Assesment: Systolic murmur, almost certainly benign w/ the findings of otherwise normal physical examination and electrocardiogram, as well as normal echo.

Thats all of it. Sorry it was so long.

Thanks for the help.