Angiograms before surgery?

[a_dalhouse]

So I've picked my surgeon - Dr. Todd Rosengart, at St. Lukes, in Houston - to do my Mitral Valve Repair. We had scheduled it for June 18, but then while on vacation in early June I developed a staph infection from an ingrown hair (very ironic timing as I've never had that happen before!)!! So I am on a month of antibiotics and my surgery is now scheduled for Aug. 13.

My question now is about the routine angiogram before surgery. My doctor does not feel it's necessary since I'm 45, thin, a moderate exerciser and a non-smoker. However, the other 3 surgeons that I interviewed all wanted me to have an angiogram just to be sure. My surgeon explained it to me that angiograms come with their own risks and that because of my make-up it's highly unlikely that i have artery problems and that those risks are unnecessary to take. While I really appreciate his thoughtfulness and common sense, I still wonder if this is a safe decision?

Another view of his. that is different from the others, is that if by some chance I do need a replacement that he would recommend a tissue valve! All the others said mechanical since I'm so young. But he said that by the time I would need another valve they would successfully be doing valve-in-valve, which he considers a much better option than a life on coumadin. I was quite shocked. And I think one of the reasons I'm going with him is because of his forward thinking.

Anyway, I'm just curious about other thoughts on this.... though I may be opening a can of worms, and a chance to find more things to worry about instead of blindly trusting my doc?
thanks all!
Andrea

 

[Guyswell]

Hi Andrea,

I'm not qualified to offer medical opinions but here are a few thoughts...

The surgeons I spoke with had the same recommendation about angiograms when I was 41 and when I was 49. Like you, I'm a nonsmoker and a moderate exerciser. However, I'm 20-30 pounds overweight and I'm a guy. They wanted to rule out the need for bypass. Here's an analogy, anytime I have the timing belt replaced on my car, I also have the water pump replaced because the labor charges to replace either item is quite high and you have to take off a lot of the same parts to get to the timing belt and the water pump. The one time I didn't replace both at the same time, the water pump failed within 6 months and I had to incur a lot of expense that could have been avoided.

Back to you... an angiogram can sometimes provide surprising results. Surgeons like to avoid surprises by knowing as much as possible about your condition before they open you up. I don't think the risk of an angiogram is that high.

I received a tissue valve at age 41 that calcified within 8 years (I was hoping the valve would last 15 years). Even if placing a valve within a valve was an approved and common procedure, we probably wouldn't have done it because my body probably would have calcified it too. I went with a mechanical valve the second time with hopes that it will be the last surgery I need. I take Coumadin and it has not been a big deal.

 

[AZ Don]

Predictions of the future are a rather tricky business. Surely there will be advances and your Dr. may well be right that a valve replacement will be easier in the future, but there are no guarantee's. For the aortic valve, currently the minimally invasive procedure is higher risk. Isn't minimally invasive relatively common for the mitral valve already?

Re. the angiogram, when I had mine done the Dr. performing it said that it was routinely done to determine if coronary bypass was needed, because then they would do this during my aneurysm repair. I was livid! I have no symptoms of coronary disease, the CT scan showed no buildup, and I am firmly convinced that lifestyle is a better treatment than bypass surgery for all but the most dire cases. I had no intention of having a coronary bypass and no one had discussed this with me, though in thinking about it frankly I didn't believe this Dr. When I spoke to my surgeon later, he said it was done so that he could have a better view of my heart and arteries prior to the surgery. In repairing my aortic root, the plan was to re-implant the coronary arteries into the graft, and the angiogram provided a good look at the coronaries. In particular he was concerned that one of my coronaries was too short for him to have enough to work with, and that he might have to graft my coronary. Turned out he was able to spare the portion of the aortic root the coronaries attach to and so he didn't have to re-implant or graft the coronaries.

In any case, the point of the angiogram was to get a better look in advance at what the surgeon would be working with. In my case this was probably worth the risk. Perhaps the surgeon's recommending the angiogram are doing so just to see if you might need coronary bypass. To do so with no significant risk factors makes no sense to me, especially when the angio carries risk (something like 1% chance of a life threatening complication). I suggest to trust your surgeon.

 

[Luana]

I wasn't much older than you when I had VR. I was considering a tissue valve and surgeon said if I got a tissue valve, I would need an additional 2, maybe 3, surgeries. That didn't sound good to me at all, and I went along with his suggestion for a mechanical valve.

I consider taking warfarin the rest of my life much better than having more surgeries.

 

[pellicle]

I had an angiogram pre op. They wished to explore the aneurysm better and know what was in there.

Personally I saw benefits in doing good pre-surgery planning.

I didn't know there were that many risks.

 

[epstns]

I guess I would go with whatever your chosen surgeon wants. Sometimes they get "hissy" if we don't supply them with all the pre-op tests they want.

I was quite a bit older at time of surgery (was 63), but I was also thin and had been an active exercise nut for decades, yet in the angiogram we still found one artery that was blocked about 50%. They said that if I was not having surgery, they would have stented it, but since I was having valve surgery the surgeon said he would do a bypass "while he was in there."

 

[Bryan B]

I had one for both of my surgeries, and both surgeons said they usually order one for anyone over 40. Because of a high prevalence of coronary artery disease in patients with aortic valve disease, coronary angiography is recommended before aortic valve replacement.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2499740/

 

[ejc61]

With my mitral valve, I had TEE, heart cath and CT Angiogram. I believe that's pretty standard.

 

[big_L]

Personally, I've been pushing back on the pre-surgery angiogram quite a bit. While I'm 54, I'm in great shape and have no coronary artery disease symptoms and no family history of the same. So far they've been pretty 'hissy' about it, using the term already posted. I want them to do the valve and the valve only. If I need a coronary artery opened up in the future, they can stent it. We'll see next week how the Mayo Clinic Drs respond to my position.

 

[Jkm7]

What is your primary reason for push back?
Risk?
Cost?
Other?

 

[Luana]

I want them to do the valve and the valve only. If I need a coronary artery opened up in the future, they can stent it. We'll see next week how the Mayo Clinic Drs respond to my position.

Coronary arteries cannot always be stented; it depends on the blockage.

 

[njean]

What is your primary reason for push back?
Risk?
Cost?
Other?

She's got an infection and is being treated with antibiotics for a month.

 

[njean]

Hey Andrea,
I think I'd be a little put off if my surgeon elected not to do an angiogram and/or TEE before the surgery, but that's just my opinion. And I think that if you feel uncomfortable about him not wanting to do further tests before your surgery, you should be frank with him and let him know how you feel. I always thought that angiograms were the norm before surgery but I guess I was wrong.

And as for having to live with coumadin the rest of your life if you decide on mechanical, I don't find that a big deal. I've been on coumadin for 38 years and have had 5 other major surgeries besides my 3 OHS, and I've managed to survive.

BTW, I've had my OHS all done at St. Luke's in Houston too! Great staff, excellent doctors!

I wish you the best of luck!

 

[Rachel]

I did not have the typical angiogram – but I did have a MRA (magnetic resonance angiogram) with contrast dye as well as a CT with the contrast. Because I had these two tests, I also had x-rays taken right before surgery but they were done without dye. The MRA is a long test.

I was 45 (weeks shy of 46 – not that a few weeks matter) when I had my surgery and I selected a tissue valve.

 

[sood]

If your surgeon isn't doing a ct angiogram at the very least instead of a cath angiogram I would be a little concerned. For me they wanted to do a ct angio prior to op but the insurance wouldn't approve it for some reason so we did a cath test.

 

[kimcdougc]

They did an angiogram on me prior to surgery and discovered I had an artery in a very peculiar area, which made me not a candidate for minimally invasive surgery. It was explained to me that not do they only search to see if you need any stents but get a better look at your heart and the area's surrounding your heart before surgery. It was not a big deal. I chose a mechanical valve so as not to have another surgery in the future. Coumadin, so far has been no big deal. Good luck with all of your choices.

________________________________________________________________________________________________________________
In the waiting room for 10 years. 53 year old female. AVR May 23, 2013 at Swedish Hospital, Cherry Hill location, Dr. Glenn Barnhart. On-x valve 21mm.

 

[a_dalhouse]

Thanks for all the replies!! I posted that and then went away for the weekend so am just now catching up. I must say, now I'm feeling more worried about it - which is what I thought would happen. But it's good to get all of my concerns out and know that they are valid. I think now I will call my cardiologist here in Austin and see what she thinks. My surgeon was supposed to call her and talk (I think specifically about this matter) and I'm curious if he did. Also, when my cardiologist first told me that the time had come for surgery, she said I would be getting an angiogram first. So I'm really wondering what my surgeon is thinking. Will have to call him too. Luckily I have time with the rescheduled surgery date now.

Thanks again everyone for the responses! So glad I found this site! And please keep the info coming!
Andrea

 

[a_dalhouse]

big_L, if you don't mind, I'd love to hear your reasons for not wanting the angiogram. Is it just that you feel it's pointless, given your health and family history?

 

[epstns]

Andrea - I forgot to mention that I was initially more afraid of the angiogram than of the surgery itself. All of my fears proved to be totally unfounded. The angiogram was truly a non-issue. I was in no pain - during or after. I had mine done on a Thursday morning and was back up and around on Friday afternoon. I was back at work on Monday - just walking a bit slower for a couple of days.

 

[Jkm7]

She's got an infection and is being treated with antibiotics for a month.

Yes, but I was not clear my question was for Big _L.