Aortic Root Replacement with Valve Resuspension

[A_Arias]

Hello-

My wife (37 and otherwise healthy) has been diagnosed with a dilatation of the ascending aortic root, a functional bicuspid aortic valve and malformed mitral valve. Her left lateral ventricle and portions of the right heart are mildly enlarged.

Today we met with a surgeon who hopes to replace the ascending root with a Dacron graft and resuspend her aortic valve inside the graft - provided the valve is reparable. If it is not, we are leaning towards one of the newer anticalcification treated tissue valves. We discussed a mechanical valve, but are not at all comfortable with the prospect of life with Coumadin for the next fourty odd years. He will also be remodelling the mitral valve.

She is a good candidate for the Ross procedure, and our surgeon has done upwards of a hundred of them. But he feels that the Ross is more risky long term than dealing only with the aortic root. After some discussion, I agreed.

So all that to say, I know many of you have faced the same decisions. Being a glutton for information and knowledge, I thought I would plumb the depths of your collective experience for any insights you might offer.

Thanks,

Chris Arias

 

[Ross]

Chris I'm for anything that keeps her away from more surgeries down the road. The choice is yours and no one can tell you otherwise, but before you shoot down mechanical for the fear of Coumadin, please go to www.warfarinfo.com and learn all you can. A lot of the stories you hear about Coumadin are unfounded or wives tales from days of old.

 

[Mary]

Welcome Chris!
Your wife's situation sounds complex, so I'll defer to members with more knowledge (that's most! )
I have a bicuspid valve. I also was a good candidate for the Ross procedure, but when push came to shove, I went with a bovine valve.
However, she has different issues to deal with than I did.
Others will be along to offer their experiences, so please stick around.
I'm glad you joined us, but wish it was under different circumstances.

 

[MrP]

Aortic Root Replacement with Valve Resuspension

Having faced this decision also, I recommend your wife consider risks associated with more surgeries down the road to replace the tissue valve (lasts 15-20 years)....not to mention the downtime, pain, and expense of these additional surgeries. And believe me, this type of surgery is not one she will want to repeat. Since your wife is relatively young at age 37, a mechanical valve will most likely last a lifetime if she chooses this versus the tissue valve. Granted there are risks of mechanical valve failures also, but these risks are low compared with for-sure risks associated with additional surgeries to replace a tissue valve. And I'm sure you'll find many in this forum who will tell you that coumadin is not so difficult to manage afterall.
Preston

 

[RCB]

Consider this poll

Consider this poll

Chris,
Welcome to the site! I realize you must have a lot on your mind thinking about HVS for your wife. As well as what Ross has said to study, you might be interested in what people who have actually been on warfarin have to say
about their expectations before surgery and after they had been on warfarin for a while. It is first hand experience, not speculation:

http://www.valvereplacement.com/forums/showthread.php?t=14408


Did your dr. offer any statistics on how long he expected a tissue valve to last in your wife?

Whatever your decision, your in the right place and your wife will be fine!

 

[A_Arias]

Wow...Thanks for the info!

Wow...Thanks for the info!

Thanks for all of your postings. I'll respond in order.

Ross and Preston:

I hear ya' on reoperation. While my research is admittedly incomplete, I haven't seen much to assure me that a mechanical will last anywhere near 40 years without other complications. What I've seen so far seems to indicate that we're most likely up for another surgery in 20 - 30 years regardless. We're thinking that operating when she's in her 50's is better than in her 60's or 70's and that the advancements in technology will likely render both a permanent solution and less risky reoperation at that time.

Also, if the re-suspension is successful, there's a 50/50 chance it could be life-long.

Mary:

What was the deciding factor for you to go with a bovine valve?

Curmudgeon:

My word! Talk about been there, done that, got the T-shirt! If anything, you bolster my hopes that reoperation is indeed quite survivable!

Thanks so much for your time. This is an invaluable resource and I'm sure that I'll be back soon!

chris

 

[Mary]

Chris,
The bovine choice was my surgeon's.
I had the Magna Perimount Model 3000 implanted. I believe that early data is showing it has a longer life than the porcine Medtronics Mosaic.
I'm treading VERY CAREFULLY here, because I don't want to suggest that one is better than the other (and Tobagotwo would probably give me a sharp rap on my knuckles if I did )
There's a thread running in valve selection titled, What type of tissue valve did you receive? You might look at that to see other members' experiences and choices.
Good luck!
Mary

 

[Karlynn]

Welcome Chris! I am so sorry that you and your wife have to venture into this arena of life, but you came to the right group of people.

I think you are being too optimistic in thinking that, at the age of 37, your wife will get 20 - 30 years from a tissue valve. The statistics you see in tissue valve longevity have a mean age for people much older than your wife. The younger you are, the less time a tissue valves last. From what I've read, you would probably be wise to expect 10 - 12 years out of a tissue valve. If a doctor is telling you she could get 30 years out of a tissue valve at her age, find another doctor. Even doctors who strictly do tissue replacements would not tell you this.

With the amount of work she requires, her second surgery could probably carry more complications than a second surgery for someone who just had one valve replaced. They will be working on the aorta, the aortic valve and the mitral valve. The larger area you operate in, the more scar tissue you have. Scar tissue is one of the main problems with repeat surgeries. Personally, I'm with Ross on this one, I would do what would give you your greatest chance of not having to have surgery again.

If the thought of Coumadin scares you silly, you have not been given the correct information on Coumadin. It's a serious drug, but many of us live very normal, active, athletic lives with this medication. Feel free to ask any questions. We certainly won't chastize you and your wife for choosing tissue valves, we just want to make sure that you base your decision on solid, correct information related to all choices and unfortunately, it sounds like some of what you have been told isn't correct.

Ask questions like crazy - here and of your doctors.

 

[MrP]

Chris,
After waking in the middle of the night and not being able to go back to sleep for a couple of hours last night...listening to my St. Jude valve...thump, thump, thump (mine is loud)...I couldn't help but think of my earlier response to your message and wonder again about my decision two years ago to go with a mechanical valve. At the time, I had considerable concern that my aneurysm would rupture, became consumed by this thought and timing of surgery, and did not spend a great deal of time researching the mechanical vs. tissue pros and cons. I did put alot of faith in my cardiologist and his recommendation to go with a mechanical valve. And my surgeon, Dr. Coselli in Houston, told me that my age of 49 was a borderline age for mechanical vs. tissue (mechanical at younger ages vs. tissue at older ages)....tough choice. I also put a great deal of faith in one of my best friends in life who is a doctor and strongly urged me towards the mechanical valve to avoid a guaranteed reoperation in the future. Although I am still confident in my choice, I certainly second guess my decision from time to time. And I know how difficult this situation is for your wife and you. The best we can all do is share with you our experiences and hope that in some way this helps you. One thing is for sure, your wife will make an informed decision.
Also, I must tell you that I recall from all my reading over the past couple of years, I believe most experts will recommend replacement of a bicuspid valve (instead of attempting repair) at the same time of resecting an aortic aneurysm. I recall my doctors told me the same thing, and I believe Dr. Coselli has performed more of these types of surgeries than anyone in the world. In my case with moderate regurgitation, my bav was indeed calcified at time of surgery. So, I'm not so sure I would agree with the 50/50 probability you mention for successful repair of bicuspid valve. Seems to me this probability will be much lower and represents your surgeon's guess at best.
And finally, don't underestimate the emotional aspects of this type of operation....I certianly did as have many others.
All my best, Preston

 

[Karlynn]

Curmudgeon:

My word! Talk about been there, done that, got the T-shirt! If anything, you bolster my hopes that re-operation is indeed quite survivable!

Yes, we all owe a debt of gratitude to our Curmudgeon, as well as his Mother - who took the chance on a new, unproven procedure. We have all benefited from RCB's surgeries.

One thing I would like to highlight is something we've discussed briefly here, but not at length. We often talk about re-operations in terms of surviving or not surviving. It is not a black and white issue. There are many shades of gray in between. I'm sure RCB would probably agree that he is very glad he's survived his many surgeries. But I'd wager he'd also report that they didnot leave him brand-spanking-new each time.

 

[Tom F.]

The surgery you described is known as a "valve sparing" procedure. The technical term is a "T. David V", as this is the fifth varient or version of the valve sparing procedure first done by Dr. Tyronne David of Toronto.

There is a growing body of information available on the longevity of this procedure, and thus far it has held up very very well. They believe that a valve repair can last a lifetime. I had the same procedure done in December of 2002 at Rush University Hospital here in Chicago. My cardiologist has more than once said that he believed that, from the way things looked, I would not need another surgery. It is a perfect surgery for someone with an ascending aortic aneurysm and a normal or near normal aortic value.

In your wife's case however you have the complication of her having a bicuspid, not normal, aortic valve. I have read, and I would ask you to explore this with your doctor, that performing this surgery with a bicuspid valve is somewhat on the cutting edge, and the risk for resurgery may be higher than mine. But there are a small but growing number of articles I have seen that discusses the small but growing number of doctors that are performing surgery to repair, and not replace, bicuspid aortic valves. So maybe being on the cutting edge is not always bad.

And finally, while I certainly agree that open heart surgery is major event not to be considered lightly, when I was faced with the decision I gladly went down the road that, on paper, has a risk of resurgery. Having been through the surgery I do not for a second wish I had taken another way. I do not personally fear another surgery.

 

[Lynlw]

Karlynn, maybe I read it wrong, but since she is 37 and he said they think it would be better to have surgery in her 50's instead of 60s or 70s, I don't think he was hoping to get 20-30 years from a tissue valve. again I had gallbladder surgery on monday and my brain is a little fuzzy so i could be wrong, Lyn

 

[RCB]

Your a better man then me!

Your a better man then me!

I do not personally fear another surgery.

Tom, I feared every surgery I went in to. I realize that might make me less
than brave in your eyes, but I know a lot of men who have faced death in combat and they all said they were "Scared S.....!"

Perhaps, you might share some of your thoughts in the Presurgery Forum
where fear is a common emotion.


One thing I have learned in life is you never know how your going to react to
a situation until you are face to face with it. Things may change and you could lose your support system, you could get a chronic disease that will put you at high risk for surgery- of course everyone gets older, which in all cases
puts one in a high risk area.

Good luck my friend

 

[RCB]

For the understatement of the year award.......

For the understatement of the year award.......

...and the winner is........................

But I'd wager he'd also report that they didnot leave him brand-spanking-new each time.

 

[djexec]

Chris,
Glad that you found the site & as I mentioned to you...the people in here are amazing. One of the hottest & most debated topics on this site is tissue vs mechanical, everyone on the site has an opinion but ultimately all of us will agree that either choice is a good choice....no choice is a bad choice. You will be amazed at the support that you will receive here and as I said yesterday, if there is anything that I can do im available AND as of yesterday, Im mobile so I can meet you guys anywhere. Take care & God Bless...

 

[MrP]

Well, the Terminator has no fear either! Or does he? Arnold Schwarzenegger was born in 1947 with a bicuspid aortic valve also, and in 1997 his surgery entailed using his pulmonary valve to replace his bicuspid aortic valve and then replacing his pulmonary valve with a tissue valve. Within one day after surgery his aortic valve (old pulmonary) started bleeding and reoperation was necessary to save his life...his aortic valve is now a tissue valve also...two tissue valves. I wonder if he'd make the same decision if he could go back in time or if he'll make the same choice of tissue valve in the future?

 

[Karlynn]

Well, the Terminator has no fear either! Or does he? Arnold Schwarzenegger was born in 1947 with a bicuspid aortic valve also, and in 1997 his surgery entailed using his pulmonary valve to replace his bicuspid aortic valve and then replacing his pulmonary valve with a tissue valve. Within one day after surgery his aortic valve (old pulmonary) started bleeding and reoperation was necessary to save his life...his aortic valve is now a tissue valve also...two tissue valves. I wonder if he'd make the same decision if he could go back in time or if he'll make the same choice of tissue valve in the future?

Since he's pushin' 60 now, I imagine he will.

 

[Tom F.]

RCB - What I wrote was that I do not fear another surgery, and that is because I have been through it once, and generally know what to expect. Going into the first one I, like everyone else, was afraid. I do not want to have another one, but I am comfortable with having made a decision that may result in another surgery. Sorry, that's just how I feel. I know some others here do not share my feelings, but then I know others that do.

 

[RCB]

That's fine

That's fine

RCB - What I wrote was that I do not fear another surgery, and that is because I have been through it once, and generally know what to expect. Going into the first one I, like everyone else, was afraid. I do not want to have another one, but I am comfortable with having made a decision that may result in another surgery. Sorry, that's just how I feel. I know some others here do not share my feelings, but then I know others that do.

Tom,
I'm happy that you feel comfortable with your decisions. For me personally, being comfortable with all my decision and "not personally fear(ing) another surgery" are two different things. Being through four surgeries,
pervious experience doesn't make it less fearful, at least in my case. This might be a good poll question.

I guess I misinterpreted your original statement. To me, my fear of the
unknown lies more in the outcome, than what medical staff will do to me. As
we age and have more surgeries (not just heart, but others- see Nancy's Joe or Ross's history), the outcome of OHS becomes more and more uncertain- that is where the real fear lies.

I don't mean to offend the "first-timers" here, but in most cases your first, will be the easiest. As Karlynn hit the nail on the head in her post, experience is not a "good thing!" Everybody won't have my luck in the "Re-op Lottery" I'm at least a one in a billion shot. We have already tragically lost a member in a second re-operation.

 

[Perry]

Arnold's Ross Procedure

Arnold's Ross Procedure

All,

The way i heard it.......Arnold Schwarzenegger underwent the Ross Procedure. A heart surgeon I know explained that Arnold was up and around very quickly and said he felt great. Against the doctor's advise he hopped on an exercise bike. He elevated his BP and whatever else and was rushed back into surgery.

Arnold may have regrets but not specific to the Ross procedure.

Perry