3-weeks Post Op Things going well, but...

[conk]

I have a thread in the Pre Surgery forum so will try to spare some of the detail, but at 3-weeks post op, I have some nagging concerns.

First, the good news is that at 3-weeks, I?m able to exercise an up to an hour on an upright lifecycle at level 10-11. I?m feeling very good and the scar is healing nicely with no pain of note. Did not need to use pain medicine after 32 hours post op. I use a heart monitor to ensure that I?m not pushing too hard, but feel underwhelmed at the lack of guidance I received upon release from the hospital. No limitations except to driving and lifting. This leaves a significant amount of room, at least for me, to stretch beyond what might be recommended for recovery. I just don?t think most surgeons deal with the average citizen/patient as athletes unless it?s emphasized.

Now for the concerns. I underwent a homograft aortic valve replacement (without root) at USC. I understand from what I've read on Cleveland's site and other research, that the preferred method for a homograft AVR is to remove the existing root as well. Can anyone provide the rationale for this approach? I had thought that this was going to be the method of replacement for my valve, but found out after surgery that they thought my root was good, and therefore decided to leave it as is. I?m confused by this logic if the preferred method is to take the self-contained aortic homograft in the overlapping aortic tissues and insert as a whole conduit. Can anyone provide the pros and cons of this decision?

In addition, I originally consulted for a Ross procedure. I'm in excellent physiological condition, however was told I was not a candidate for the Ross because I needed a Tricuspid valve repair and therefore this would involve three valves and wasn't advisable and I had possible compromise to my other valves due to Radiation received for Hodgkin?s Disease about 18 years ago. As it turns out, my Tricuspid valve did not need repair and my other valves (not including the AV) appeared to be normal (I don?t have the Op report yet, so this is based on what I could surmise so far). I feel that I may have still been a candidate for a Ross? Anyone have any experience/knowledge that they could share on this point.

I have now found out that I have a potential paravalvular leak around the aortic homograft replacement. My cardiologist is recommending a TEE. Anyone that share their experience with a TEE and what I can expect. I've done some preliminary research and know what the procedure is and how it is done.

I?m also trying to determine my options if this leak is significant? Valve repair or another valve replacement? Should I consult with another main center like Cleveland to evaluate me for a Ross if another replacement is necessary?

I very much look forward to your responses.

Regards?.Denis (Conk)

 

[Ross]

Hi Denis, great to hear from you.

As far as a Ross procedure, I would not recommend it. That's just my personal thoughts, as mine went South within 6 years. In my opinion, they just don't last long enough to justify the odds in surgery.

As far as root replacement, you got me there. I thought they always replaced that along with a Homograft. This should be interesting.

The T.E.E., Gives the best view of the heart or at least from an angle unseen by other methods. It's not the most pleasant experience, but it's not terrible either. You'll be sedated and won't know what's going on til their done. You may have a sore throat for a day or two. Just be sure they numb the back of your throat thoroughly and administer the sedation before they gag you. I didn't get enough sedation and was with it for about 2 minutes, hence my "No Love" for TEE's.

I think I would consult anywhere that you feel a need to. It sure can't hurt and may give you better insight should you need to go another round which I would hope not. Not this soon anyhow.

 

[ALCapshaw]

Welcome Denis,

You are the third Hodgkins / Valve recipient on this board to my knowledge, preceded by Johnny Stephens and myself.

I've had two TEE's and several endoscopies. I've have both light and heavy sedation. Once, I awoke during the procedure (I don't remember it but apparently it did cause me to gag. You do NOT want to get the gag reflex started. That leaves your throat quite sore. Make sure they spray your throat well and swallow the yucky residue. With enough Demoral and Versed, you shouldn't be aware of anything and will have no recollection of the tube going down your throat. You 'may' want to ask them to check for any constrictions in your esophagus using an endoscope. If you have any, they may want to 'stretch' them before doing a TEE since the transducer for the TEE is fairly large and forcing it through a constriction could be uncomfortable (or even cause tearing which is not a good thing).

My surgeon dismissed the Ross procedure as having more risks than benefits, at least in my case, especially considering my radiation treatments. It may also mean that he doesn't do them or doesn't like to do them.

Regarding exercise, if your insurance covers Cardiac Rehab, I highly recommend that. There, you will be monitored by cardiac nurses who will adjust your exercise level to be 'challenging but safe'.

Best wishes for your continued recovery.

'AL'

 

[joy]

Hi Denis, great to see you are back! I can only tell you what my surgeon told me, and that is that they do not to homographs at the UW, and he definately doesn't do them for one reason...they are too new and they haven't been around or researched enough for his liking. so I went with a bovine. I still have to take coumadin, but that's only for 3 months because I threw a clot and have a history of a-fib. I am looking forward to another surgery in about 10 years(HA)Other than that, I can't tell you too much about the homographs. Hope you figure this out soon. Other than that it sounds like you are doing great!

 

[ken]

The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve replacements.

The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve replacements.

http://www.ncbi.nlm.nih.gov/entrez/...6&dopt=Abstract

1: J Heart Valve Dis 2001 May;10(3):334-44; discussion 335

The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve
replacements.

O'Brien MF, Harrocks S, Stafford EG, Gardner MA, Pohlner PG, Tesar PJ, Stephens
F.

The Prince Charles Hospital and the St Andrew's Hospital, Brisbane, Queensland,
Australia.

BACKGROUND AND AIM OF THE STUDY: The study aim was to elucidate the advantages
and limitations of the homograft aortic valve for aortic valve replacement over
a 29-year period. METHODS: Between December 1969 and December 1998, 1,022
patients (males 65%; median age 49 years; range: 1-80 years) received either a
subcoronary (n = 635), an intraluminal cylinder (n = 35), or a full root
replacement (n = 352). There was a unique result of a 99.3% complete follow up
at the end of this 29-year experience. Between 1969 and 1975, homografts were
antibiotic-sterilized and 4 degrees C stored (124 grafts); thereafter, all
homografts were cryopreserved under a rigid protocol with only minor variations
over the subsequent 23 years. Concomitant surgery (25%) was primarily coronary
artery bypass grafting (CABG; n = 110) and mitral valve surgery (n = 55). The
most common risk factor was acute (active) endocarditis (n = 92; 9%), and
patients were in NYHA class II (n = 515), III (n = 256), IV (n = 112) or V (n =
7). RESULTS: The 30-day/hospital mortality was 3% overall, falling to 1.13 +/-
1.0% for the 352 homograft root replacements. Actuarial late survival at 25
years of the total cohort was 19 +/- 7%. Early endocarditis occurred in two of
the 1,022 patient cohort, and freedom from late infection (34 patients)
actuarially at 20 years was 89%. One-third of these patients were medically
cured of their endocarditis. Preservation methods (4 degrees C or
cryopreservation) and implantation techniques displayed no difference in the
overall actuarial 20-year incidence of late survival endocarditis,
thromboembolism or structural degeneration requiring operation. Thromboembolism
occurred in 55 patients (35 permanent, 20 transient) with an actuarial 15-year
freedom in the 861 patients having aortic valve replacement +/- CABG surgery of
92% and in the 105 patients having additional mitral valve surgery of 75% (p =
0.000). Freedom from reoperation from all causes was 50% at 20 years and was
independent of valve preservation. Freedom from reoperation for structural
deterioration was very patient age-dependent. For all cryopreserved valves, at
15 years, the freedom was 47% (0-20-year-old patients at operation), 85% (21-40
years), 81% (41-60 years) and 94% (>60 years). Root replacement versus
subcoronary implantation reduced the technical causes for reoperation and
re-replacement (p = 0.0098). CONCLUSION: This largest, longest and most complete
follow up demonstrates the excellent advantages of the homograft aortic valve
for the treatment of acute endocarditis and for use in the 20+ year-old patient.
However, young patients (< or = 20 years) experienced only a 47% freedom from
reoperation from structural degeneration at 10 years such that alternative valve
devices are indicated in this age group. The overall position of the homograft
in relationship to other devices is presented.

PMID: 11380096 [PubMed - indexed for MEDLINE]

 

[ken]

Primary aortic valve replacement with allografts over twenty-five years: valve-relate

Primary aortic valve replacement with allografts over twenty-five years: valve-relate

http://www.ncbi.nlm.nih.gov/entrez/...0&dopt=Abstract

1: J Thorac Cardiovasc Surg 1999 Jan;117(1):77-90; discussion 90-1

Primary aortic valve replacement with allografts over twenty-five years:
valve-related and procedure-related determinants of outcome.

Lund O, Chandrasekaran V, Grocott-Mason R, Elwidaa H, Mazhar R, Khaghani A,
Mitchell A, Ilsley C, Yacoub MH.

Academic Department of Cardiac Surgery, Harefield Hospital, Middlesex, United
Kingdom.

OBJECTIVES: Allografts offer many advantages over prosthetic valves, but
allograft durability varies considerably. METHODS: From 1969 through 1993, 618
patients aged 15 to 84 years underwent their first aortic valve replacement with
an aortic allograft. Concomitant surgery included aortic root tailoring (n =
58), replacement or tailoring of the ascending aorta (n = 56), and coronary
artery bypass grafting (n = 87). Allograft implantation was done by means of a
"freehand" subcoronary technique (n = 551) or total root replacement (n = 67).
The allografts were antibiotic sterilized (n = 479), cryopreserved (n = 12), or
viable (unprocessed, harvested from brain-dead multiorgan donors or heart
transplant recipients, n = 127). Maximum follow-up was 27.1 years. RESULTS:
Thirty-day mortality was 5.0%, and crude survival was 67% and 35% at 10 and 20
years. Ten- and 20-year rates of freedom from complications were as follows:
endocarditis, 93% and 89%; primary tissue failure, 62% and 18%; and redo aortic
valve replacement, 81% and 35%. Multivariable Cox analyses identified several
valve- and procedure-related determinants: rising allograft donor age and
antibiotic-sterilized allograft for mortality; donor more than 10 years older
than patient for endocarditis; rising donor age minus patient age, rising
implantation time (from harvest to aortic valve replacement), and donor age more
than 65 years for tissue failure; and rising donor age minus patient age, young
patient age, rising implantation time, and subcoronary implantation preceded by
aortic root tailoring for redo aortic valve replacement. Estimated 10- and
20-year rates of freedom from tissue failure for a 70-year-old patient with a
viable valve from a 30-year-old donor and no other risk factors were 91% and
64%; the figures were 71% and 20% if the donor age was 65 years. The rates of
freedom from tissue failure for a 30-year-old patient with a 30-year-old donor
were 82% and 39%; the figures were 49% and 3% with a 65-year-old donor.
Beneficial influences of a viable valve were largely covered by short harvest
time (no delay for allografts from brain dead organ donors or heart transplant
recipients) and short implantation time. CONCLUSIONS: Primary allograft aortic
valve replacement can give acceptable results for up to 25 years. The late
results can be improved by the use of a viable allograft, by matching patient
and donor age, and by more liberal use of free root replacement with
re-implantation of the coronary arteries rather than tailoring the root to
accommodate a subcoronary implantation.

PMID: 9869760 [PubMed - indexed for MEDLINE]

 

[ken]

Natural History of Early Aortic Paraprosthetic Regurgitation

Natural History of Early Aortic Paraprosthetic Regurgitation

click the URL below to read the complete study in detail:
http://www.medscape.com/viewarticle/417205_print

Natural History of Early Aortic Paraprosthetic Regurgitation: A Five-Year Follow-Up


Loukianos S. Rallidis, MD, Ioannis E. Moyssakis, MD, Ignatios Ikonomidis, MD, Petros Nihoyannopoulos, MD, FACC, FESC, Cardiology Department, Hammersmith Hospital, Imperial College School of Medicine and Technology, London, United Kingdom.
Am Heart J 138(2):351-357, 1999. © 1999 Mosby-Year Book, Inc

Abstract and Introduction

Abstract

Objectives: To assess the incidence and natural course of paravalvular leaks detected early after aortic valve replacement.

Background: Although the use of echocardiography has simplified the postoperative assessment of patients with aortic valve replacement, there are no data regarding the natural history of early detected paravalvular aortic leaks.

Methods: Eighty-four consecutive patients with aortic valve replacement were prospectively followed clinically every 6 months and by echocardiography early (11 ± 7 days), at midterm (27 ± 3 months), and late (63 ± 4 months) after aortic valve replacement. The competence of artificial valves was assessed by Doppler color flow mapping.

Results: Paraprosthetic leaks were detected in 40 (47.6%) aortic prostheses during the early study; the majority (90%) were small. All leaks remained unchanged during the follow-up period. Left ventricular dimensions and function did not differ between patients with or without paravalvular leak during the follow-up. Left ventricular fractional shortening, however, increased during the intermediate study in both subgroups, indicating improved left ventricular function overall. Three patients had severe paravalvular regurgitation suddenly develop from late infective endocarditis, and 1 patient had a degenerative tissue valve failure 4 years after implantation.

Conclusions: Paraprosthetic aortic leaks detected early after surgery, in the absence of valve infection, are common, are usually small, and have a benign course. However, the development of new, usually severe, regurgitation should raise the suspicion of prosthetic valve endocarditis or bioprosthetic valve failure.

 

[conk]

Ken - Thanks for reports

Ken - Thanks for reports

Thanks for posting the reports. I had seen the third report, but the other two have extremely valuable information, especially the first report.

I believe that the studies show for the most part that when performing an aortic homograft/allograft replacement, that including the root provides somewhat better results.

Water under the bridge at this point, but can't stop mulling it over in my mind right now. I'm sure the Surgeon has reasons why he decided to not include the root. I should have the answers on Tuesday.

 

[Arlyss]

Some Thoughts Regarding Your Options

Some Thoughts Regarding Your Options

Hi Denis,
So sorry to hear that you my have a leak around your homograft. In all of the things originally mentioned to you regarding your options, I did not see anything about your being counseled based on the fact that you had a bicuspid valve. That is an important consideration when evaluating options. There are not too many centers that fully appreciate that the bicuspid congenital condition should be viewed from the big picture of the aortic root, and the aorta, as well as the aortic valve itself.
I would be glad to share my thoughts about this. I keep in touch with several bicuspid patients and their experience at some of the major medical centers. I also would be glad to speak with you regarding an excellent option here in southern Cal. My husband's surgeon is one of the few with expertise in aortic conditions, including bicuspid aortic valve/root/aorta. Also, here is a reference for you from the U of Toronto that is very comprehensive http://circ.ahajournals.org/cgi/content/full/106/8/900?eaf
The potential of problems with the aortic root and other parts of the aorta are very important to understand. If you would like to explore these thoughts further, please just email me. Take care.
Arlyss

 

[Nancy]

Hi Denis-

I'm so glad that you are feeling well after your surgery. I'm also sorry to hear that there is the "potential" for a paravalvular leak.The operative word your doctor used is "potential". I think that there have been several occasions shortly after surgery when some members have been told that there might be a leak, and it was watched for a while and eventually the body healed the leak over, and all was well. I don't think it's an uncommon thing. It's very good that your cardiologist is recommending a TEE. Joe has had many over the years. He's not a complainer, and there was one he did complain about. It was a young rather inexperienced doctor performing it, and he did not use enough numbing spray and did not use any sedation, so it was a very uncomfortable thing for him, and his throat was sore for days afterwards. Every other one has been a breeze by comparison. So do not have fear of the test, it's an excellent test to diagnose valve problems. Joe is in the hospital now, and just had one done. It went like clockwork.

My advice to you is to have it done and make sure to have a little talk to the doctor performing the test. Tell him/her you know that if it isn't done right, it will be very uncomfortable for you, and if it is done right, you will have no pain, so you want it done the painless way.

I'm sure it will go well, and I hope it is one of those leaks that will heal up postoperatively.

Best wishes.

 

[sylviayasgur]

hi denis!
i was sorry to read that there might be a leak only 3 weeks post surgery.
as nancy mentioned, and i have heard this too_ even from surgeons_ sometimes these suspected leaks
seal on their own. it's when you spring a leak later on that you need to worry more.

when joey went for his 6 month check up, they saw a moderate leak on the echo.
they couldn't be sure about it, because it wasn't very clear, so they did a tee.
the cardio who did it does numerous and sedated him well and numbed his throat well too.
i was allowed to stay in the room with joey and the doc and nurses up until joey was out.
i was then escorted into the waiting room and told i would be called as soon as the procedure was over.
exactly 25 minutes later i was taken back into the room as the nurse was waking joey up from his versed and demerol.

joey did not remember a thing and had no soreness in his throat afterwards.
it turned out that he had a trivial leak in his av upon leaving the hospital. there was a "fistula" (leaking vessel) that was spurting in the opposite direction, thereby causing the illusion of a big leak when in reality it was also minimal.
all is fine and they will just watch the fistula. it may seal itself up or not. if it gets worse, they can cauterize it by catheter.
so, the tee is definitely a worthwhile and very informative test.
i would, as nancy suggested, just let the doc performing it know that you are nervous and that he/she should be sure to numb your throat and sedate you sufficiently.
please let us know how it goes and when you go.
wishing you all the best, sylvia

 

[bruizer]

Hi Denis,

I'm sorry to hear about the leak. I had the Ross Procedure performed at USC University Hospital in December, 2000 by the same surgeon you had. I was running 4 miles a day, 6 days a week, lfiting weights, and playing tennis up until the day before the surgery with no symptoms. Four months after my surgery one of the leaflets on my new aortic valve began to prolapse. My surgeon recommended surgery again to either repair of replace the valve. He said he wouldn't know if he could repair it until after he got in there. He also recommended a homograft, given my life style.
I subsequently got a second opionion from the head of Stanford's cardiothoracic department who happened to performed the first successful heart-lung transplant. After reviewing the surgery report and lastest echo, he recommended I wait a while before having another surgery. He felt the regurgitation was moderate, my left ventricle was still within the normal parameters, and I was able to run 3 miles daily with no symptoms.
He explained to me that there is no right or wrong answer with regard to root replacement when performing AVR. He said he would not second guess my surgeon's decision. In my case, my root looked good and by not replacing the root, my surgeon avoided having to disconnect my coronary arteries which would have meant longer surgery time and more scar tissue. In hindsight, he believes my surgeon would have elected to do a root replacement.
I have the utmost respect and confidence in my surgeon and his staff. However, if I were you, I would consider getting a second opinion like I did. If I hadn't, I would have had a second surgery five months after my first.
Please feel free to e-mail me privately with any questions or concerns. I live about 20 miles from you in the Woodand Hills area of Los Angeles and would be more than happy to answer any questions you might have.

God Bless

 

[conk]

Thanks to all who have responded!

Thanks to all who have responded!

Bruizer...I've sent you a Private post, couldn't find your email, but would like to talk with you.

I see the Surgeon in a couple of hours, so will let you know what I find out.

Regards...Denis

 

[Bunny_Rabbit]

TEE HEE HEE

TEE HEE HEE

Hey Conk,

I'd have to say that going back for another TEE would not be on the top of my list, but it in my opinion, it was better than the Valvuloplasty that I had.

I knew of someone who had gone for a TEE and it took him 3 tries to get the tube down, so I just had to beat him. It was what motivated me to get through it. And yes, I did...2 TRIES BABY! WOO! Can you beat that?!

It really wasn't that bad. The drugs were very relaxing.

 

[conk]

Update...Not so good!

Update...Not so good!

Well I haven't posted anything since Jan 14th. I've been doing very well physically, back to a normal routine of work and exercise (riding bike 60-70 miles on weekends and a round of golf here and there).

Unfortunately, today I found that the Aortic valve leakage I have is now causing my heart to compensate with a size increase and decrease in ejection fraction. I have gone from 72% to 61% in about a month. There goes my exercise regimen, no more heart rates over 110 for now.

What is really irritating is that I had to have a second TEE completed to find out the extent of the real problem. My first TEE was completed by a doctor recommended by my original Surgeon (Dr. Vaughn Starnes). It?s almost as if they have tried to cover the tracks about the extent the AVR (homograft) is not working and at the time I was less than 2 months out from surgery. The report did not even really address the real reason that my cardiologist recommended I have the TEE (to evaluate the aortic valve leakage and determine the extent and exact location(s)).

My cardiologist when he saw the tape and the report from the first TEE said that I needed to have another that was better conducted to evaluate my aortic insufficiency. I have now had the second TEE, and another echo (was going to be have a stress echo as well but didn?t get that far).

I now have a prosthetic (homograft) valve that has a cusp that is in prolapse casuing severe aortic regurgitation and the jet that is generated is impacting my anterior cusp from my mitral valve causing moderate mitral regurgitation. What does all this mean? The news?not good. Even though I have no present symptoms, I need another valve replacement soon. Didn?t I just do this (12/20/02)? I have so many questions now, that I wish I had asked prior to my Homograft AVR.

- How do they pick the homograft?
- Is it from a patient that did not have other heart problems?
- Can you specify some parameters about the homograft selected (other than size), like age of patient, physical activity of patient, etc?
- How do they know that there is no problem with the homograft (original cadaver aortic valve), even though it is not what the person died of?

Another irritating thing is that it is now 1.5 months after my first TEE, and Dr. Starnes has not called to consult with me. I have only had one surgery follow-up appointment. I have called and left messages to no avail.

I have an appointment to meet the first surgeon my cardiologist (Dr. Declusin) had recommended about my present situation on Thursday. My cardiologist is recommending a mechanical valve. I think I?m listening with more clarity to him at this point after this result. This was certainly some devastating news after I?ve been doing so well. Certainly not looking forward to another heart surgery so soon after the first.

Anyone have any thoughts on whether I have a potential case/issue concerning the first surgery? Obviously, something did not go right. Do I have any recourse?

More later?Conk (Denis)

 

[Kevin M]

Denis, this sucks. I'm so sorry to hear that this has happened to you. Particularly since you were doing so well with your exercise and getting back to your pre-symptom lifestyle.

I wish I had more knowledge so I could help you to answer your questions, but I do not.

I do know that it is rare for this type of occurance to happen. One would think they would examine and test the cadaver tissue closely prior to grafting it, but in this day and age, who knows.

Personally, I could understand why you'd go along with a mechanical valve at this stage. You do not need to put your body, yourself and your family through another one of these unnecessarily.

I'm sorry to hear this since you are the ultimate candidate for the homograft. Age, activity level, etc. all mean that you would be the type that would make good use of this valve type.

If you are still not too put off by biologicals, perhaps you could consider a stentless pericaridal or porcine valve instead. They have about as much proven durability for persons your age as the human biologicals.

I sympathize with you, however, I know that your excellent attitude and physical condition will get you through this next bout as quickly as the first.

Keep your chin up.
Kev

 

[joy]

Hi Conk, I am sorry about the fact that you have to have another VR so soon! I think Christine had to have two valves withing 11 days on one another. She would really be one who would understand! I know I wouldn't want to have another vlave done so soon! I don't blame you for wanting a mechanical, and you know...Coumadin isn't too bad! The main rule I follow is, consistancy is my best friend with coumadin! THe finger sticks aren't even too bad! Good luck, and keep us posted!

 

[Anne-Marie]

Hi Denis,

I'm sorry to hear that after doing so well post-op, things have not continued to in that direction. I don't have the voice of experience to contribute much here. I just wanted to add a "hello" from another hodgkin's survivor. I've been in remission since March of '78 (diagnosed in Dec. '73, relapsed in March '77).

Only recently was I told that my aortic stenosis, diagnosed in Jan '02, was probably related to the radiation I had received 29 years ago!

Best wishes to you, Denis.

A-M

 

[Nancy]

Hi Conk-

Gee Whiz--that's a terrible situation for you. I can understand your feelings after doing so well. There are a few others who've had to have re-ops fairly soon after a valve replacement. It isn't a normal thing, but it can happen.

Joe had to have a small leak repaired in his relatively new mitral mechanical. It was a small tear around the sewing cuff. I think the cause of his was that something tore lose when he fainted and he landed square (and forcefully) on his chest. He even partially dislocated his jaw. This happened shortly after his mitral replacement when the surgery hadn't healed yet, but it took a very long time to get his cardiologist to agree to another surgery because it would be his third one. Eventually he became so symptomatic that there were no other options. It took 2 stitches to close.

We're still all here for you and will extend our friendship and encouragement through this difficult time. You did very, very well post surgery with your first, and I have no doubt that you will do just great after this next one. I would vote for a mechanical for you this time. Who needs to go through that again?

I'm wishing you all good vibes, and hope you can get it taken care of forthwith so it isn't hanging over your head any longer and before you have major symptoms.

 

[taranjit]

Hi Dennis,
Sorry to hear that but you should not be discouraged either.. Some 5 years ago, Arnold Schwarznegger also had to get his AVR redone with in a few days/weeks... Coincidently his surgeon was the same as yours... Althought I am not sure but I think he got the Ross procedure done at first.. then, one of his flaps of the valve in the aortic position collapsed.. I believe he now has a tissue valve there..

We all know Arnold is doing so well right now (check him out in Terminator III).. your good physical shape will always keep you ahead of others when it comes to advantages during an AVR.. May be discuss with your surgeon what happened during Arnold's case, as he operated him as well..

good luck in whatever you have to go thru - new valve or not..
taranjit