aortic repair, plus valve; or just aortic repair?

[djroy]

What do you folks think of this...maybe you've been through it or someone else could benefit from the answer too. Looks like I'm landing in the waiting room for ascending aortic repair, dilated at 4.5 - 4.6cm according to a 3D CT scan.

I'm also gifted with a bicuspid aortic valve but have very little regurgitation, it's still flexible, no stenosis. Maybe that's due to being a marathoner for years, who knows.

The doc tossed an idea on the table to think about. I'm 44 years old. They tell me I can keep running, but keep it "fitness jogging" at a conversational pace. No fast running. No heavy lifting, etc. When it comes time to repair the ascending aorta, I have two options...replace the valve too. Or just repair the aorta.

Based on my overall health and fitness level, and quality of the bucuspid aortic valve, he said iit wouldn't surprise him to see that piece stay stable until I was about 60. It could be replaced then...and by then, maybe valves improve even further, etc. But, it would lock in the idea of a second surgery.

Alternatively, he said it could be replaced at the time of aortic repair...date not set for that yet...next tests are in October and it will depend on how stable it remains....but let's say one is 45 years old or so, goes for a mechanical valve which requires blood thinners, and decides to have both procedures at once.

The tradeoff is 15 extra years on blood thinners (potentially...nothing is a sure thing here and the valve may not remain okay until 60 of course). I'm hearing that some mechanical valves are starting to last 30 years (true?)....and so it's possible (not a sure thing) that doing both things now could mean just one surgery...at least until age 75 or so. And a lot can happen in that timeframe.

Have you come across this? Or have thoughts / reactions you'd like to share?

Dan

 

[Nancy]

Mechanical valves last a very, very long time, perhaps for a lifetime. Most of the failures happen around the sewing area where it attaches to the patient's own tissue. Some people have built in tissue problems.

My husband had a very early mechanical valve. He passed away in December (not from valve failure) with two mechanical valves in place, a 29 year old one (aortic Bjork-Shiley), and a mitral St. Jude of recent vintage. Both valves worked perfectly up until his last moments on this earth. He was 75 years old.

His Bjork-Shiley was implanted when he was in his forties.

The mechanical valves being used today are much, much better than my husband's 29 year old valve, smaller with more streamlined hemodynamics, plus being quieter.

Coumadin was not a huge problem for Joe.

 

[67walkon]

Dj, you have the unfortunate dilemma many of us have.

I'm 57 and have a bicuspid valve. You mentioned "fitness running" which suggests you are a somewhat more serious runner. In my younger years, I was a serious recreational runner, including several marathons in the 3:20 range. As I grew older, I switched to biking and became a semi serious recreational road biker.

The valve is down to approximately 1cm and has never, ever bothered me. It wasn't that small when I was running, but it has started narrowing pretty significantly in the last couple of years.

My ascending aorta was 4.3 in October, 2005; nobody seemed concerned and I didn't know as much as you do, so I didn't question it. I just kept on doing what I had always done. In May of this year, it was up to 5 cm and I scheduled surgery.

Ross will tell you that aorta's can dissect at much smaller than 5 cm. It is probably a situation that changes from person to person. I know that the AHA/ACC don't recommend aorta replacement until it reaches 5cm, unless there are other complicating factors. However, they can pop at much smaller sizes and I have no idea why one does and another doesn't.

They are working on catheter valve replacement, which is less invasive. However, if they have to open you up to do the aorta, I can't imagine a surgeon not recommending the fully monty-valve, root, etc.

Ask what size your valve is at this point. That might help your decision.

The aorta issue is much more life threatening than the valve.

I am going to get a tissue valve, knowing I will have to have a second, future replacement, unless something else kills me first. They are claiming we might get 15 to 20 years on the current generation of tissue valves. My personal theory is that I may be dead from something else before my valve wears out, or most hopefully, that they will have an improved technique in 15 years.

You have a tough decision and I don't know what I would do. My decision was pretty easy, so it was a no brainer!

Good luck.

 

[beth]

Hi Dan
My husband Alan just went through something similar so I hope my response will be helpful. We are also from NH (Loon Mt area) and all our family lives in the Manchester area.

My husband has a well functioning BAV and HAD a 4.5 ascending aneurysm that went into his arch. He is 46. He was having symptoms that started in January - chest pain, shortness of breath, fatigue, and dizziness. With a well functioning valve, his symptoms did not make sense. We did plan on replacing the valve and had decided on a tissue valve.

Two weeks ago today he had surgery at Boston Medical Center. The surgeon confirmed that his BAV was functioning fine - no stenosis or regurgitation. His root was also in good shape - tissue was normal. So he kept the valve and the root and replaced his ascending aorta and part of his root. They were able to keep his coronary arteries intact.

Yes, his BAV could fail down the road. He could have an aneurysm in his root(but then he could have one any place along his aorta). The surgeon felt that there are the obvious risks that go along with a tissue and mechanical valve, so keeping his valve was the best decision for him and his circumstances at this time. The surgeon could not be absolute with what he was going to do until he got in there.

Fortunately, some of Al's symptoms have gone away. He has had no chest pain (except the obvious from the surgery!) and no dizziness. Too soon if the SOB and fatigue will go away. Unfortunately, he has a partially collapsed lung so time will tell. It is hoped that the aneurysm itself was messing things up enough to cause his symptoms.

Please feel free to ask more questions. I have left a lot out - don't want to get too lengthy. My husband has plenty of time on his hands for the next few months so would be glad to chat!

The time before the surgery was as stressful as the surgery itself. You hang in there!
Beth

 

[ScottInFlorida]

I chose to wait

I chose to wait

I faced a similar situation this past year.

My aneurysm (5.1 on the arch) was discovered during a "routine TEE" to get a baseline for stenosis of my bicuspid valve. The cardiologist threw me in the hospital thinking it had dissected already and sent me to a surgical hospital. Since I was showing no signs of distress, they performed many CT scans until they realized it was not an emergency. Their explanation - a younger heart jumps around a lot so the aorta walls are blurry and look "split".

If I had had the surgery then, I would have gotten the OnX. But, my aorta was not dissected so I did some research (mainly on this website). I sent my records to people at Texas Heart Institute and Duke and I talked to people at Cleveland Clinic. I was about 50/50 between the OnX valve and a tissue valve and leaning more and more toward the tissue valve when the Duke surgeon said he that he thought my valve would last about 10 more years. So I chose Duke and to keep my valve for now.

For me, choosing a tissue valve is similar to keeping my current valve. I probably will have to get another surgery in the future; but, I don't have to worry about coumadin for a few years and there is the possibility of a breakthrough in valve technology and/or surgical techniques.

I am comfortable with this decision but it is a gamble. I can understand why someone would want to get an artificial valve and hope to never have surgery again. Only time will tell if my choice to wait was truly a good one.

Hope this helps and good luck with your decision.

 

[Mike C]

Search this site and others for "David Procedure" or "valve sparing" and you should get quite a bit of information.

In some cases it is a great solution. If you choose to go with this solution, you need to have a backup plan, meaning valve type and brand. It can be a game time decision when surgeon actually sets eyes on your valve.


Mike

 

[GeorgeM]

Dan

I think the decision will rest much on how you feel personally about the choices.

Whether you opt for a replacement valve now or to keep your own valve will not have much impact on your longer term management after a few months post surgery.

I chose to have the aortic root repair & valve replacement, and my medication management is routine and easy to manage.

Which ever choice you make just feel comfortable that it is right for you.

Best Wishes

George Montgomery

 

[aussigal]

Hi and WELCOME...

I was in a somewhat similar position with a fairly good valve that could have lasted years and a rather more worrying aorta of 4.8cm...to fix them together or risk 2 operations?.

After researching my family history it turns out my Father died at 38 of what seems to have been a aneurysm/dissection., his parents also died before 60 of aneurysm and other heart-related problems...I didnt want to become another statistic in our family so I chose to operate now on both and worry about the long time on warfarin later. Warfarin turned out to be pretty easy...and I failed on my mission of trying to avoid further surgeries by needing an emergency surgery 1 hour after my aneuyrsm and valve were fixed.
PS...I am expecting my StJudes valve to last me a lifetime.I am 42

So basically., I suggest you check on your family history before you make any decisions just in-case there are others who have died of similar casues which may affect your choices. The results of my history check made a big difference.