another aortic vale replacement!

On March 2017 I had a second AVR at Cleveland Clinic after the first AVR failed after 5 years. Now my Echo is showing that the 2017 valve is becoming stenotic and will have to be replaced- another heart surgery!! My cardiologist ( in Philadelphia) who has been with me for many years believes that my body doesn't like having a foreign oblect in it ( I have a bovine valve) and is creating calcium deposits on the valve which is causing the stenosis. My husband wanted to be proactive and to find out whether I may be a candidate for a TAVR procedure. The thought of going through open heart surgery a third time in 13 years is very upsetting. So we are going back to Cleveland Clinic to meet with a cardiologist and to have another Echo, and to discuss my options for another AVR. I am a healthy 76 year old who is very physically active and at an ideal weight. The only symptom I am experiencing is not physical, but emotional. I am frustrated and anxious. I am hoping that the Dec. 9 appointment and testing go well. Has anyone else experienced what I am facing? I welcome any suggestions, advice, assurance.

Bubbe Judy said:

Has anyone else experienced what I am facing? I welcome any suggestions, advice, assurance.

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I am very sorry to hear about your problem. I understand that this is very upsetting, and I will pray for you. Remember that you do have options; focus on the positive.

Cleveland Clinic is a wonderful hospital and I'm sure they will take excellent care of you. If you want to get a 2nd opinion, I found that Mayo Clinic has a very easy and effective process to get a 2nd opinion using your existing records.

There are some people on the forum who have had 3 surgeries, so you will get feedback from people who have had that experience.

You have an interesting dilemma. For unclear reasons you have at two biological valves fail in a relatively short period of time. Surgically implanted non mechanical valves would be expected to last longer than a TAVR valve. So if your valves didn't last very long then one might expect a TAVR valve to fail also in a relatively short period of time. Then what? Another TAVR?

At 76 in good health otherwise you could go on living for a significant period of time. So contrary to what might be suggested for a typical 76 year old patient (TAVR) you might have to consider other options such as a mechanical valve. After the short valve lifetime for your first valve was a mechanical valve placement discussed for the second valve procedure? That would be the most likely to not require more intervention.

It would be interesting to hear what your physicians have to offer. And yes, I have had three open heart procedures with a range of other procedures. I am not a big fan of open heart surgery but without it I would not be writing this.

This piece came across my email.
https://cardiovascularbusiness.com/...ry/robotic-aortic-valve-replacement-savr-tavr

Besides the main topic of using robotic surgery it suggests that TAVR is not without issues. Not a definitive review but something to think about.

Medical decisions are often varied in deciding on various approaches. In my field (Retinal Surgery) there are sometimes a variety of different approaches on how to fix various things and when to fix various things. I think in cardiovascular surgery there is also a range of options with phyicians and institutions often having different approaches. When I had my first valve in 1977 I had it done at Stanford by Norman Shumway who was one of the preeminent surgeons of his time. At Stanford way back then given the mechanical valves that were available they strongly felt that biological valves were a better choice. At other institutions at my age I would have had a mechanical valve. It turned out I got a mechanical valve 5 1/2 yrs later due to failure of my tissue valve. But by then the design of mechanical valves had improved and I got a St. Jude valve which lasted for over 20 yrs until I needed aortic surgery.
So Good luck with your choice.

Bubbe Judy said:

On March 2017 I had a second AVR at Cleveland Clinic after the first AVR failed after 5 years. Now my Echo is showing that the 2017 valve is becoming stenotic and will have to be replaced- another heart surgery!!

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has anyone asked you to test for Lp(a) as this could explain the rapid failure of bioprosthesis ... however at this point I would strongly present the case for a mechanical valve (which are now pyrolytic carbon).




These are recent findings and I'm pretty confident that most cardiologists are as yet unaware of this correlation.

I'm not sure why you've so far steered away from a mechanical valve, perhaps its because of some other condition that makes you contra-indicated for warfarin therapy.

Best Wishes

https://heart.bmj.com/content/110/4/299




well worth the read: https://heart.bmj.com/content/heartjnl/110/4/299.full.pdf

DISCUSSION In this retrospective cohort study including 210 patients,high serum concentrations of Lp(a) were associated with a higher risk of SVD after aortic valve replacement at a median follow-up of 4.4 years. The results were consistentin the univariable analysis and in the multivariable analysis after adjusting by risk factors that have been associated with SVD such as young patient age, smoking, hypertension,renal failure, increased body surface area, LDL levels and patient-prosthesis mismatch of the implanted valve. 13 14 To the best of our knowledge, this is the first report demonstrating an association between Lp(a) and SVD. Although Lp(a) has received less attention compared with other cardiovascular disease treatment targets, emerging medications to lower Lp(a) levels are being developed.9 Therefore, a deeper understanding of its role as predictor of cardiovascular conditions could be crucial. Lp(a) is a well recognised risk factor for cardiovascular disease, including myocardial infarction, ischaemic stroke and calcific AS,15 but its association with SVD was not clear in the literature.

I am sorry that this happening to you. Your previous decisions were perfectly rational. It is normally very unlikely to get through tissue valves so quickly at your age.

You need to look around your family, if they are living into their 90s and you are fit at 76, then you could reasonably expect to live till that ripe old age as well.

With a TAVR, they can probably repeat it once or twice. But the tissue is the same. Assuming you would get a TAVR every 5 years. that would still only take you to 91, that is assuming that they take to TAVR in TAVR repeatedly.

Perhaps a mechanical valve is your best option after all?

You also dont know to keep having cardiac interventions, since the probability of something going really wrong can increase significantly after 3 or more

Sorry to hear that your valves have not been lasting as long as expected.

As Pellicle has suggested, I would recommend getting your Lp(a) tested. Lp(a) has been shown to be causal for aortic valve disease and more recent studies link it to faster SVD for bioprosthetic valves. It is a very simple test and can be done the next time that you get blood work. If Lp(a) is the culprit, it would be good to know, as that may factor in to the next valve choice. Also, there is a powerful Lp(a) therapeutic which is in the Phase III trial stage and expected to get FDA approval next year. If you do have elevated Lp(a) and decide to go tissue again, taking Lp(a) lowering medication should be strongly considered as it could extend your valve life.

If you do discuss Lp(a) and its relation to faster SVD for bioprosthetic valves with your cardiologist, he will probably just give you a blank stare. I would suggest printing the Feb 2024 study and bringing it to your next appointment. Most cardiologists are aware of the link between Lp(a) and aortic stenosis, but most are not yet aware of the relationship between elevated Lp(a) and faster SVD for bioprosthetic valves and the primary study was only published this past February.

Sorry to hear this news. At 64 for your first valve (if I did the math right) it was reasonable to expect tissue to last longer … but for whatever reason not for you.

In my case I just had a mechanical mitral put in (I’m 56 and guidelines for mitral are mech up to age 65). In addition in my case the surgeon said he’d only 3-4 years from a tissue valve because I have rheumatic heart disease and my own immune system will attack a tissue valve (same as it did my native valve). I’m glad I didn’t have to agonize and that I have the best chance of not needing repeat surgery. This is mostly to say our bodies can obviously react in non typical ways.

In terms of the emotions I can see it is very difficult news especially when you’ve tried to care for your health. But honestly with valve disease there is not as much in our control as say coronary artery disease. (I am in the middle of cardiac rehab right now so I’m a little irritated by the promises of how a cardiac diet will fix me - I know it won’t, just a minor boost). It’s just bad luck - genetics, infections, autoimmune disease … Or you can look at it as good luck that we’re all not dead long ago, unlike people who had valve issues in the past. I hope they come up with a more durable plan for you and again so sorry you’re facing this again.

Many thanks to all of you who responded to my query. I have printed out all your excellent and detailed replies, and will address the issues discussed when I meet the cardiologist at Cleveland Clinic in early December.

Bubbe Judy said:

and will address the issues discussed when I meet the cardiologist at Cleveland Clinic in early December.

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Not far away, that's great!!

To me this is a ghastly failure of duty of care to you. I mean its serious enough to require someone at 69 to require a surgery but that this was your second surgery in such a short time should have sent alarm bells clanging.

I hope you get resolutions and if I was you I'd be firmly advocating for myself on this. So to summarise the above (please correct me where I'm wrong):

• the quite reasonable choice was made for a bioprosthesis for your first surgery when you were 64 years old
• this lasted 5 years before some sort of issue caused it to presumably calcify and become stenotic.
• that should have been a shock to your cardiologist and your team (it apparently wasn't, so they're not the sharpest scalpels on the table)
• they proposed another bio and after 7 years that failed ... this slight increase in duration actually isn't inconsistent as due materials variations in bio's and to age (and slightly decreased metabolism associated with increased age)
• now at 76 you are contemplating another surgery

So going forward you need to get that Lp(a) test done and I've got a strong feeling that it will return a number that's high ... very high. Armed with that you can make better decisions on what you should choose and what the risk analysis profile is for whatever valves are chosen.

Also, if you don't already have any arrhythmia then the chances of that being a gift from this 3rd surgery (either presenting in recovery from surgery or in the following years) is very high. I would also ask pointedly what is the chance of requiring a pacemaker as a result of surgery #3 due to damage to SV and or AV nodes on your heart.

Google's Ai summary is pretty reaonable:

• SA node
  Also known as the heart's natural pacemaker, the SA node generates electrical signals that cause the atria to contract. The SA node is located in the right upper chamber of the heart. In a normal adult heart, the SA node causes the atria to contract about 60 to 100 times per minute.
• AV node
  The AV node acts as a bridge between the atria and ventricles, passing electrical signals from the atria to the ventricles. The AV node is located in the posteroinferior portion of the interatrial septum.

https://www.hopkinsmedicine.org/hea...-and-function-of-the-hearts-electrical-system

I would sack your cardiologist immediately, they are clearly a dope. I mean really, what kind of twaddle is "you body doesn't like foreign objects in it" ... for gods sake this is obvious to everyone who's even had a splinter!! Now I don't know what was said at that time, but if a mechanical was not proposed then I'd be shocked even more than I am.

Of course there is so much I don't know about all this process so its hard for me to be sure.

Your third OHS will be risky because its your third and because your older so I understand why TAVR is being mooted. But those valves are made of the same stuff as a bioprosthesis (just without the frame and delivered as an origami). So I would demand to know what makes them think that this would last you even another 5 years?

Its a very tough situation and I feel a lot of sympathy for you. I've had a life time of 3 OHS's but had about 20 years between each, so that's a fair return on investment each time.

Best Wishes

My stepfather got a mechanical mitral valve at age 76 and lived to be 93. He knew that the recommendation for 76-year-olds was biological valves, but felt very strongly that he didn't want to risk a second heart surgery, and his surgery was one-and-done as he had hoped.

Zoltania said:

My stepfather got a mechanical mitral valve at age 76 and lived to be 93

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love the good news stories ... 17 years. Thank you.

https://pmc.ncbi.nlm.nih.gov/articles/PMC8894170/

This single-center prospective study enrolled patients aged > 70 years who underwent isolated SAVR for severe AVS. Data were collected on each participant’s clinical status, physical performance, cognitive status, mood, and health-related quality of life. This multidimensional geriatric assessment was performed before surgery (T0), and again at 45 days (T1), 3 months (T2), 6 months (T3), and 12 months (T4) post-surgery. Baseline (T0) and follow-up (T2-T4) data were compared separately for patients grouped by gender using paired t-tests.

Results​

Data from a total of 35 patients were analyzed. Compared with the baseline (T0), nutritional status worsened at T1, then gradually improved through to T4. Physical performance, mood, and health-related quality of life improved significantly after surgery. Cognitive function showed no change through to T3, but then deteriorated at T4.

I’m sorry your valve has caused you to now be facing a 3rd surgery in 13 years.
I’ve had 3 surgeries in 20 years and that seemed like a lot to deal with, so I empathise with you. My thoughts for you are these: Find the best, most well respected surgeon who deals with difficult cases or even just multiple surgeries. Realize that a 3rd surgery requires possibly a few hours just for the surgeon to cut through scar tissue from previous surgeries. My surgeon was one of the best, but I could sense he was a bit concerned about my 3rd surgery. He had so much knowledge and was such a confident surgeon, that I felt I would be fine. My surgery took many hours. But, I awoke feeling good. My only hiccup was a partially collapsed lung, but I didn’t feel symptoms of that. I was in ICU just a day longer than my previous surgeries, then over to CCU. I was discharged 6 days after surgery. I did go into chronic a-fib 3 years after my 3rd surgery. I was 54 for my 3rd surgery. Now, at 70, I recently looked into mitral valve replacement via TMVR and was told to expect only 5-7 yrs from the valve. They decided I’m not a candidate for it so I’m on hold until my symptoms worsen and I’ll be forced to replace my mitral valve in some way.
Try to be calm and trust in your gut feeling about what to do and what you can go through. I eventually came to the conclusion that I could go through a 4th surgery if I have to, but I’ll find the most recommended, best surgeon if I need that in the future. Also, I play clarinet next to a man who got a TAVR at 80 and is doing really well. But I worry that this valve won’t last that long for him, and he is very fit and travels a lot. I wish you all the best in this 3rd surgery journey.