12 week update: Work in process

Background: 55 yr old male. Always led active and healthy lifestyle, athletic, competitive sports (previously), recreational long-distance runner. First referred to AVR some 22 years ago (2002) when I was 33, but that’s a separate topic for another day
Valve anatomy changed overtime - originally regurgitation, then stenosis (so mixed). Preserved systolic function. Ejection Fraction (EF) 50-55% before/at surgery.
No symptoms prior to surgery, except my 1-hr runs started getting harder and slower for the last 2 years. More input, less output: From 7-7.5 miles to 6.5-7 miles, then barely 6 miles in 1-hr running. I classified myself as recreational runner (8-9 min/mile guy), not elite by any means

Surgery: July 23, 2024 - Bentall procedure (AVR with On-X mechanical valve, aortic root and ascending aorta). 200 mins on heart-lung bypass machine (valve too calcified, other issues encountered during surgery).

Lowlights:

• Buy 1, Get 1 (got a stent): Felt great after surgery since I woke up in the ICU. No issues, felt invincible. As they were getting ready to discharge me on day 6-7, my surgeon ordered a CT scan. On CT, they saw a “pinch” or “kink” in my left main coronary artery (which happened when it was plugged-back into the newly replaced ascending aorta). They sent me back to heart catheterization/angiogram for confirmation, and put a stent upon confirmation.

• Go home, then come right back: A couple of days after discharge, I went from walking miles to not even able to move. My condition deteriorated significantly over that weekend and I went to ER Monday AM in a very bad shape. They found a large effusion around my heart. I was sent to heart catheterization lab again and they drained 1 liter of fluid around my heart. I felt good instantly but was kept in the hospital for another 7 days for effusion monitoring.

• AFib: A day after the effusion drainage (see above) while I was still in hospital, my heart went into AFib. Stayed in AFib for 2 days, and just when they were contemplating cardioversion, it went back to sinus rhythm on its own. No prior history of AFib, or any repeat since.
• Long hospital stay: 22 days = 15 days (original AVR surgery + stent etc) + 7 days (effusion issue). Spending most of first 4-weeks at the hospital.
• Echo (EF and Pericardial Effusion): I’m most disheartened by the drop of my EF post-surgery. Not sure what caused that. I had never been below 50-55% ever, including months before, and at the surgery itself (pre and post Cardiopulmonary bypass EF was 50-55%).

• Covid: I picked up Covid during week#6 perhaps from someone at the lab where I went for INR tests, or at cardio rehab. 2-3 days of low-grade fever and cough, and 5-6 days of no cardiovascular activity or exercise.

Highlights:

• Walk, jog, run: Despite my post-op issues and lengthier stay at the hospital, I was walking 1-mile at 1-week there, and then 3-4 miles/day (total of all 3 sessions of a given day) after 10-12 days. Nurses teased me if I was training for Olympics (since Paris Olympics was happening then)

• • MHR (Maximum Heart Rate)/RHR (Resting Heart Rate): As I started incline jogging or flat running, I was able to maintain average HR of ~145-150 BPM (~85-90% MHR) with peak hitting close to MHR. Just as I did that, interestingly my RHR also dropped significantly (by 20 BPM to 60-65 BPM) within 10 beats of my pre-surgery RHR (50-55 BPM). In my case, MHR (theoretical) = 220 – age = 220 – 55 = 165
  • VO2 max: My pre-surgery VO2 max was 46 as per Garmin watch, and is now at 43 post-surgery.
  • Body weight: Right after surgery, gained ~10lbs (fluid retention), but lost all that while still in hospital (thanks to Lasix). Then after most of 1st month at hospital with no appetite, I dropped another 10 lbs (muscle mass etc). Now I’m back to where I was before surgery (156-158 lbs).
• Echo: My most recent echo after 11-weeks post-op at my 1st cardiologist appointment showed somewhat improved EF of 45%. Some relief. The pericardial effusion is minimal/trace so that’s better too. A couple of other lingering attributes which time will resolve hopefully.
• Life returning to normal: I officially started working after 7 weeks and have been traveling soon after (work involves travel). Life is largely back to normal, what more to ask for

I would like to thank this wonderful community for its tremendous support, experience and wisdom, and overall attitude to help others during the most challenging times.

tjay said:

Life returning to normal: I officially started working after 7 weeks and have been traveling soon after (work involves travel). Life is largely back to normal, what more to ask for

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Glad things are working out for you. It sounds as tho you have taken an around about way to get to "normal". I hope you have smoother sailing now

A somewhat similar story about the stents. I previously had two valve surgeries but had to have another due to a 6.5 cm aneurysm. My surgery went OK and I was discharged in about 1 week. But about 6 months later I started to have angina symptoms which I had never had. My right coronary artery was "too short" to reconnect and they had taken some saphenous vein to extend it and reconnect to the new aorta. It too had "kinked" with a 90 degree bend due to scarring. Due to this the lumen was narrowed and led to the angina. I had three stents placed to "straighten it out". Couldn't take Plavix since I had a pretty severe allergic reaction to it. So I used an older antiplatelet drug along with the warfarin for my St. Jude valve. Amazingly the angina went away but not too long after it started up again. So back to the cath lab for three more stents placed within the initial stents. Got better. Then perhaps six months later got angina again. Back to the lab for this time two more stents placed within the previous stents. During the procedure I was awoken and told they could not fix it because it appeared to be already closed. I told the cardiologist to try harder and I said I don't care if you kill me. He did and found a way to open things up.
Now about 14 yrs later it is open and no angina. I only took the antiplatelet drug for perhaps 6 months after the last procedure. Just on warfarin now.

tjay said:

Ejection Fraction (EF) 50-55% before/at surgery.
...

Because I was in the hospital for so long for other subsequent complications, they did echos many times (mainly for effusion tracking), and all were <40% (38-39%) EF. Surgeon’s office kept saying it would get better overtime …..​

Pericardial Effusion continued to be there, although dropped gradually.​

If anyone has similar experience with reduced EF after surgery, please share.​

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Thanks for sharing. Really glad things worked out (and that outgoing CT was ordered before the discharge!) - seems like this was a complicated case.

Regarding reduced EF:

• IIRC, mine was not very reduced. However, I had a different surgery type (MVr). And the surgeon actually warned me ahead of time that EF might get smaller. This is a bit artificial though. With regurgitation, it's easier for the heart to contract, since some blood just goes back (in the low-pressure cavity, instead of being pushed in the high-pressure system). So when the valve is repaired/replaced and the regurgitation is removed the heart has to work harder and EF looks lower.
• I did find an article (for MV) where the evolution of EF was studied. Statistically, the improvements were still happening at 1 year mark, although they were going progressively smaller by that time. Would imagine that similar things are happening for AV.
• I know a case with a reduced EF for about a hear after AVR. From memory, it was something like 40-45%. The patient was young and fit, but it was a 2nd surgery. I guess these things do happen. He got much better.

If you don't mind me asking, which hospital did you use? (It's purely a curiosity, no problem if you don't want to mention it.)

Thanks so much for the report! As a runner myself, who hasn't yet gone through surgery (next control echo in December), it's great to see that you're coming back to form. While my regurgitation is severe, my EF is still in the high sixties, as it has always been since I was diagnosed (some twenty years ago too).

vitdoc said:

A somewhat similar story about the stents. I previously had two valve surgeries but had to have another due to a 6.5 cm aneurysm. My surgery went OK and I was discharged in about 1 week. But about 6 months later I started to have angina symptoms which I had never had. My right coronary artery was "too short" to reconnect and they had taken some saphenous vein to extend it and reconnect to the new aorta. It too had "kinked" with a 90 degree bend due to scarring. Due to this the lumen was narrowed and led to the angina. I had three stents placed to "straighten it out". Couldn't take Plavix since I had a pretty severe allergic reaction to it. So I used an older antiplatelet drug along with the warfarin for my St. Jude valve. Amazingly the angina went away but not too long after it started up again. So back to the cath lab for three more stents placed within the initial stents. Got better. Then perhaps six months later got angina again. Back to the lab for this time two more stents placed within the previous stents. During the procedure I was awoken and told they could not fix it because it appeared to be already closed. I told the cardiologist to try harder and I said I don't care if you kill me. He did and found a way to open things up.
Now about 14 yrs later it is open and no angina. I only took the antiplatelet drug for perhaps 6 months after the last procedure. Just on warfarin now.

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Wow, what a story you have. I'm so glad your instinct during the 3rd round paid off

So in my case, surgeon said my left coronary was longer as it was plugged back into the aorta, and hence sagged. It didn't make sense since, like in your case, I would expect it to be a bit shorter since the newly replaced ascending aorta is thinner than previously dilated one. But then it's not a 2-dimensional plane, rather a 3-D frame in which there're so many moving parts (e.g. the length of coronary arteries is the same before or after the aortic aneurysm). So I guess any of those situations (long or short) can play out.

I'm so glad they did a CT scan before my discharge. I wonder if all hospitals or surgeons do this as a condition of discharge or only I was the lucky one... Because they could've easily discharged me without a CT scan, only to encounter this situation weeks or months later, like in your case. My surgeon was very conservative and wanted to ensure everything was perfect before discharging me, so he was ordering so many other tests too. If other hospitals or surgeons are not requiring CT scans before discharge for the aortic surgery, I guess they should.

My left coronary bend wasn't a complete 90 degree, rather about 70-30 (i.e. it was losing 30% diameter because of kink) while 70% was still available. So potentially I could be doing fine for months or years without knowing, who really knows.

Thanks for sharing your experience.

V__ said:

Thanks for sharing. Really glad things worked out (and that outgoing CT was ordered before the discharge!) - seems like this was a complicated case.

Regarding reduced EF:

• IIRC, mine was not very reduced. However, I had a different surgery type (MVr). And the surgeon actually warned me ahead of time that EF might get smaller. This is a bit artificial though. With regurgitation, it's easier for the heart to contract, since some blood just goes back (in the low-pressure cavity, instead of being pushed in the high-pressure system). So when the valve is repaired/replaced and the regurgitation is removed the heart has to work harder and EF looks lower.
• I did find an article (for MV) where the evolution of EF was studied. Statistically, the improvements were still happening at 1 year mark, although they were going progressively smaller by that time. Would imagine that similar things are happening for AV.
• I know a case with a reduced EF for about a hear after AVR. From memory, it was something like 40-45%. The patient was young and fit, but it was a 2nd surgery. I guess these things do happen. He got much better.

If you don't mind me asking, which hospital did you use? (It's purely a curiosity, no problem if you don't want to mention it.)

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Thanks for sharing. Yes, for MVR, the EF is known to drop and is expected I hear. But mine was an AVR

As to your question about which hospital I had surgery at, I've no problem sharing that. But I want to make sure you are hearing my experience, or interpreting it correctly. I'm GLAD that I went to this hospital and that particular surgeon is the one who operated on me. The kink/pinch in my coronary was my sheer luck, not workmanship issues. Whatever they could do, they did more of. Like I mentioned in the Reply to another thread above:

"I'm so glad they did a CT scan before my discharge. I wonder if all hospitals or surgeons do this as a condition of discharge or only I was the lucky one... Because they could've easily discharged me without a CT scan, only to encounter this situation weeks or months later, like in your case. My surgeon was very conservative and wanted to ensure everything was perfect before discharging me, so he was ordering so many other tests too. If other hospitals or surgeons are not requiring CT scans before discharge for the aortic surgery, I guess they should."

My surgeon did so many other tests too before my discharge. Like Echo too. That's how I could find out that my EF was low right after the surgery. Then, he watched my RBC, Haemoglobin closely, and won't discharge me until it started coming back up, even though the drop was expected after the surgery. Same with my INR levels. He won't let me go until it was in the range. He did a whole suite of so many other tests I can list if necessary.

Having said that, my hospital was Stanford. One of the best in the country, and it lived up to its name. They solidly took care of me, and I felt at home with the nurses and staff there. My surgeon visited me EVERY day I was there and stayed with me as long as I wanted to ask him question. I highly recommend Stanford.

JoeWanderer said:

Thanks so much for the report! As a runner myself, who hasn't yet gone through surgery (next control echo in December), it's great to see that you're coming back to form. While my regurgitation is severe, my EF is still in the high sixties, as it has always been since I was diagnosed (some twenty years ago too).

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Please keep running since that's the best test for your valve's deterioration (or lack thereof). You would know your symptoms more proactively when it happens, based on your running performance.

I personally think the best time for surgery is obviously not too late, but also not too soon. A lifetime is a long time, and optimization as to when the intervention is needed is absolutely important. Runners have a distinct advantage to this regard in terms of assessing their symptoms, so keep up running

Hope your aorta is in a good shape and is not dilated in the range where it requires surgery by itself. Please keep an eye on that too, along with the valve, heart function and left ventricle etc.
All the best.

tjay said:

If anyone has similar experience with reduced EF after surgery, please share.

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My Ejection Fraction was lower after my mitral valve repair and installation of a mechanical aortic valve. We think this is because I am having 20% premature ventricular contractions (PVC) loading. We hope the EF will improve after I have cardiac ablation on Nov 6th.

tjay said:

Please keep running since that's the best test for your valve's deterioration (or lack thereof). You would know your symptoms more proactively when it happens, based on your running performance.

I personally think the best time for surgery is obviously not too late, but also not too soon. A lifetime is a long time, and optimization as to when the intervention is needed is absolutely important. Runners have a distinct advantage to this regard in terms of assessing their symptoms, so keep up running

Hope your aorta is in a good shape and is not dilated in the range where it requires surgery by itself. Please keep an eye on that too, along with the valve, heart function and left ventricle etc.
All the best.

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Thanks for the encouragement! My aorta is luckily nearly the same size in the last 10 years. I've run a relay race last weekend, two segments with ca. 7 km each, partly on the beach, partly on rather slippery terrain, and managed 4:24/km at the first segment and 4:32/km at the second (sorry, can't handle imperial units). Actually our team got the first place in our category, but it wasn't a very competitive race ;-) These times match my personal best, and I didn't feel any weird symptoms (such as chest pain) afterwards. Still, the (mostly psychological) challenge of being in this "wait-and-see" situation is not to know if, when there's a bad day (and we runners know that these happen all the time), it's just that or a sign of things deteriorating ...

I'd love that my (not so) good old natural valve could hold it until an alternative like the Novostia comes to market, but I know that's somewhat delusional. Meanwhile, all I can do is to be very attuned to my performance and my general wellbeing, to detect if any "tipping point" happens - besides the regular check-ups, of course.