Aortic Valve Choices

[cldlhd]

Hi
Curious
When is minimally invasive AVR not an option? When is the Full Zipper necessary? I would not think twice about minimally invasive AVR .....Its being split open I don't like
TIA
John

I didn't like the idea of being split open as you call it either, just to visualization of the rib cage being cracked open, but I felt like with a complicated surgery the ultimate outcome would be better if the surgeon had easier access. It may be a stupid analogy but it's like working on an old classic car with a ton of room under the hood ( bonnet) or a new one that's stuffed full of gubbins..... I'm happy I went full sternotomy as my surgery turned out really well, obviously no way to know how it would have turned out with a mini, and my scar is virtually unnoticeable 6 years out.

 

[cldlhd]

yet people here regularly do plan for exactly that:

I'm going to have a tissue prosthetic, which will get me 20 years (and then get 15 or less) and a TAVR (oh, sorry you're not a candidate) after that and I'll skip on in without ever a care in the warfarin world...​

just to avoid a little pill.

In the past when I said things like that I'd get called a tissue valve hater.

Yeah I guess people here 20 years and they think it's a long time which I guess in a way it is but now that I've managed to hit the ripe old age of 52 somehow it doesn't feel like that long a time. I would definitely not want to plan on another major heart surgery especially not knowing how you will be health wise later on or what kind of support you will have

 

[d333gs]

Just to clarify, I am not talking about a TVAR.
This is more along the lines of what I am talking. This video is 5 years old:

 

[d333gs]

I didn't like the idea of being split open as you call it either, just to visualization of the rib cage being cracked open, but I felt like with a complicated surgery the ultimate outcome would be better if the surgeon had easier access. It may be a stupid analogy but it's like working on an old classic car with a ton of room under the hood ( bonnet) or a new one that's stuffed full of gubbins..... I'm happy I went full sternotomy as my surgery turned out really well, obviously no way to know how it would have turned out with a mini, and my scar is virtually unnoticeable 6 years out.

Love cars!

 

[d333gs]

No sound, but look at the chunk of calcium that is removed!

 

[Unicusp]

I can understand you looking for more information about differences with the specific valves because in my humble opinion surgeons are like other humans who have a particular specialty and like to go with what they know. Also for what it's worth I agree with your choice to only have one more surgery and I'm sorry to hear you need another surgery in the first place. I worry a bit about a potential future surgery but there's no point thinking about it too much. I had my BAV repaired 6 years ago while they were replacing my aneurysm with the dacron graft. It sounds like you're in good shape and also in good hands so I'm sure you will come out of this well.

Thanks. I had full sternotomy OHS in February. Got an On-X valve, chosen by my surgeon.
Comparing surgeries, the full sternotomy had less overall issues than the mini I had in 2013, by the same surgeon. Based on my experience, I recommend full over mini. And you leave with a much cooler scar! Ha, just kidding.

 

[nobog]

Nobog , are you in the waiting room or on the other side? If so what did you get done?
Thanks

I am just an interested party that knows a bit about heart valves, fortunately my heart and valves are in good condition.

 

[dick0236]

What's the big deal about full Sternotomy surgery........you're asleep thru it......and you have a "war story" fpr the beach.

What's the point in working thru the keyhole when you can open the door?

 

[d333gs]

Another video ;

 

[Flymark]

If I’m going to Saville Road to have a suit made, why would I want to start telling the tailor how to cut the fabric?

“Dr. please do what your training and experience (and my anatomy) lead to the best possible result. That’s why I selected you as my surgeon in the first place.”

Now, if there’s a choice that the surgeon is agnostic about, sure, I would love to be asked. Can’t imagine what this one would be .. suture colors!!

 

[pellicle]

Hi

Just to clarify, I am not talking about a TVAR.

sure, I was actually responding to nobog on that point, not you. I find that by quoting someone you can remove the ambiguity.
I did say to you:

You may well be frail enough that TAVR is your only remaining choice if the progression of SVD leaves you in a difficult position.

which was not to say "you said that" but to say that if you have a prosthetic which you are fully aware has a lifespan of less than your own then you are planning to face a redo (as nobog was saying is a bad idea). I was saying if you read that again that it may just be that because of advanced age and other issues that a TAVR may be your only option ...

When is minimally invasive AVR not an option?

well while I don't recall saying minimally invasive was occasionally not an option I can say that people here have gone in under the view that they would get minimally invasive and once in there the surgeon discovers they need better access

I note you did not address my question of "Have you had much experience in repairing things? " and its a question of significance because (to my personal surprise) more and more people have never fixed anthing more than with sticky tape or glue. People haven't got down into their engine bay of their car or tried to remove some buried part in a motorcycle.

If you have done these things you'll know that many times you'll find yourself wishing for better access to make the work shorter or even possible.

In heart surgery time is of the essence (not if you have had your chest cracked or not).

When is the Full Zipper necessary?

when better access is necessary, due to say scar tissue build up on a redo.

I would not think twice about minimally invasive AVR .....Its being split open I don't like

then your thinking is clouded by emotions and ignorance. I love these highly emotional words like "chest cracked" or "split open" ... its a nonsense. To this day full sternotomy is the "gold standard" because it allows them to do the job. There is no study showing its worse. If you find one, please post it because its good for me to keep abreast of these things.

When you read the surgical guidelines and you see "informed decision of the patient" I think its important to be "informed" and not after wards say "oh, I didn't know that".

 

[cldlhd]

If I’m going to Saville Road to have a suit made, why would I want to start telling the tailor how to cut the fabric?

“Dr. please do what your training and experience (and my anatomy) lead to the best possible result. That’s why I selected you as my surgeon in the first place.”

Now, if there’s a choice that the surgeon is agnostic about, sure, I would love to be asked. Can’t imagine what this one would be .. suture colors!!

I get what you're saying and I agree to an extent but surgeons are human as well and they come with their own preconceived notions in a lot of cases. Experts in all kinds of fields go with what they know, not all of them are always up on the latest and greatest. I know it might not be a great analogy but back when they invented wire nuts and newer ways of connecting wires older electricians wanted to stick with twisting and soldering them. Not that anything is wrong with that method but they assumed the newer methods were junk. It happens to everybody ,time passes by. Not to mention the fact that quite a few surgeons have financial relationships with certain manufacturers, I'm not saying they would intentionally install a valve they consider to be inferior for that reason but again they are human and maybe it's subconscious or maybe even conscious....

 

[pellicle]

Experts in all kinds of fields go with what they know, not all of them are always up on the latest and greatest.

which is probably more than any of us will ever know. My view is like this:
If you like what they're saying, then go with it, if you don't why?

To answer "why" then conduct some reading, join a forum like this, ask for reasons, listen to reasons (even ones you may not like). Get comfortable with the reality that probably a good part of your reaction is stemming from the fear / shock / misunderstanding of many of the points.

Then get second opinions and discuss these ideas and what you've learned.

If the above sounds too complex then just do what the first surgeon offered, its certain to be more right than (third person infinitive) "you". Why? Because they are still registered and hopefully you haven't picked a quak (most major hospitals with a good history of surgical outcomes don't employ them anyway).

 

[Chuck C]

I would not think twice about minimally invasive AVR .....Its being split open I don't like

I'm a big believer in surgeon shopping, but not procedure shopping. In my view, you choose the surgeon and clinic you want to perform your operation and then go with their recommendation on what they think is best on whether a full sternotomy or more minimal procedure is the right course.

I met with 3 different surgeons before deciding on which one to go with.
Personally, my criteria was that ideally I wanted the surgeon to meet the following 3 criteria:
1. A top rated clinic
2. A surgeon who had excellent survival statistics- significantly better than the national average
3. A surgeon who was very experienced- with many thousands of surgeries like mine under his belt.

Two of the surgeons I met with met the above- both of them the head of cardiac surgery at their institution.

Some may find this interesting- This study found that surgeon volume matters in terms of outcomes for SAVR:

https://www.annalsthoracicsurgery.org/article/S0003-4975(11)02302-2/fulltext
I was perfectly happy to get a full sternotomy if that was the surgeon's choice, but he felt that a mini-sternotomy was the right technique for my condition. I did not question it, nor was it really presented to me as a choice. Although perhaps if I lobbied him for a full he would have obliged. He has done several thousand mini-sternotomies, and his rate of patient survival is far above national average, in fact one of the highest I had ever seen, so I had great confidence in his ability to perform what he needed to do, even though the opening was smaller than a full sternotomy. And, all things being equal, especially outcomes, I was glad that he recommended the mini.

As I understand it, the main advantage of the minimally invasive procedures is the quicker healing time. I believe that the rates of mortality are the same. Dr. Doug Johnson at Cleveland Clinic acknowledged this in one talk, indicating that outcomes are not improved, but they have started doing a lot more minimally invasive procedures due to patient demand. I found that interesting.

Most patients are going to want the most minimally invasive procedure possible. This is certainly one reason why TAVR has grown in popularity, despite no evidence that long term outcomes are any better than SAVR, in fact they are worse at 5 years. That is troubling to me, although I do see TAVR as an advantage if SAVR is not an option due to the patient being in the very high risk category for SAVR.

 

[Flymark]

Most patients are going to want the most minimally invasive procedure possible. This is certainly one reason why TAVR has grown in popularity, despite no evidence that long term outcomes are any better than SAVR, in fact they are worse at 5 years.

The pressure to push TAVI on younger and younger patients ( not just those at high risk) in the face of unrequited evidence showing much poorer outcomes is because the surgery can be performed by interventional cardiologists.

Years ago the ophthalmic surgeons with their own surgery centers would send their vans to the shelters and assisted living facilities to pick up their patients for cataract surgery.

I pray it never comes to that, but when you see the FDA approve a drug for Alzheimer’s disease that has literally no efficacy and was green-lighted despite almost unanimous opposition from its own panel of subject matter experts, why should anyone expect different.

 

[pellicle]

I pray it never comes to that, but when you see the FDA approve a drug for Alzheimer’s disease that has literally no efficacy and was green-lighted despite almost unanimous opposition from its own panel of subject matter experts, why should anyone expect different.

Scary stuff right there... Which drug?

 

[Flymark]

Widely reported a week or so ago.

F.D.A. Approves Alzheimer’s Drug Despite Fierce Debate Over Whether It Works

 

[Daniel758]

For anyone making their decision between biological and tissue, this article has good information on the pro biological valve option/choice.

Biological Vs Mechanical Valves – Key Points

• Long-term survival is equivalent
• Mid-term morbidity is worse with mechanical valves
• Reoperation rates are low with biological valves and are not insignificant with mechanical valves
• Reoperative aortic valve replacement has similar mortality to primary valve replacement
• Complications of mechanical prosthesis are more devastating than those of biological valves
• Mechanical valves can have substantial negative impact on daily quality of life

I hope this helps anyone deciding valve choice is best for them.

Link To Article Below:

https://www.acc.org/latest-in-cardi...c-valves-are-better-even-in-the-young-patient

 

[rakesh1167]

For anyone making their decision between biological and tissue, this article has good information on the pro biological valve option/choice.

Biological Vs Mechanical Valves – Key Points

• Long-term survival is equivalent
• Mid-term morbidity is worse with mechanical valves
• Reoperation rates are low with biological valves and are not insignificant with mechanical valves
• Reoperative aortic valve replacement has similar mortality to primary valve replacement
• Complications of mechanical prosthesis are more devastating than those of biological valves
• Mechanical valves can have substantial negative impact on daily quality of life

I hope this helps anyone deciding valve choice is best for them.

Link To Article Below:

https://www.acc.org/latest-in-cardi...c-valves-are-better-even-in-the-young-patient

You are highlighting negatives of mechanical valve and hiding negatives of tissue. Do you have tissue valve implanted by any chance ?
Both are suitable based on person's age, lifestyle and many other factors.

 

[pellicle]

Mechanical valves can have substantial negative impact on daily quality of life

Example?

It's true that both have a place. The tissue prosthetic is well suited to patients having their first surgery at 60 years of age or older and people with conditions that make anticoagulant therapy inappropriate (which shouldn't mean stupidity or laziness).

It's pretty unambiguous