Aortic valve repair vs mech valve replacement

[cldlhd]

First I want to say this site has been very helpful and so have a few members I've contacted so thanks to all. I was diagnosed with BAV with some leakage and no stenosis or calcification visible just before my 45th birthday. I also have a dilated root and an ascending aneurysm ( 4.8 cm ). The aneurysm is the main worry but when that is done I'll have the valve addressed. Other than this issue I'm in great health- active non smoker, good blood pressure, etc- and I plan on living a nice long life and watching my 7 year old son grow up. As OHS wasn't on my bucket list I would like to make it a one and done if possible so I've been leaning towards a mechanical valve as I fear the repair wouldn't last as long as I plan to. The surgeon (Dr. Bavaria from U of Penn) I plan to use does top quality work as far as I've heard so I assume that makes a difference on longevity of repair. As far as I can see each way has it's positives and negatives.
The repair negatives: 1) A longer more complex operation
2) Good possibility of need for reop although that would likely be yrs down the road
and in the meantime I'd have the positives of no warfarin and lower infection risk. Also
during those years I assume medical tech will continue to improve including the design
of mechanical valves during those years.

3) Even if the leakage is fixed even a perfect BAV doesn't open all the way and makes it
harder on the heart.
Positives: 1) Likely won't need to be on warfarin ( admittedly this isn't the most important deciding
factor after talking to some people on this site but I look at it as a bonus )
2) Less risk of Infective Endocarditis. I know the risk of IE still won't be as low as
someone who never had surgery and has a tricuspid valve but I assume it'll stiil be
lower than a mech valve. As I work for a Water and Sewer Authority and I'm occasionally
exposed to more strains of bacteria and viruses this is the more important to me than
avoiding warfarin.
3) Lower risk of thromboembolism although if I maintained my INR and take good care
of myself I realize the risk is pretty low.

The mechanical negatives: 1) higher risk for IE. Also as the risk is highest in the first year then appears to
level out so it's possible you could get the operation then during your recovery get
infected and if your fortunate enough to survive your likely to need a 2nd operation
while still getting over the first-doesn't sound fun. I take good care of my teeth,
I mouthwash then floss and then brush (electric) for 2 minutes followed by
another swish of mouthwash twice a day but apparently the gums aren't the only
entry point and as I'm prone to scrapes and small cuts it does make me think. The
fact that the symptoms are similar to the flu could turn me into more of a
hypochondriac- I've always been the type to go to the Dr approximately once a
decade.
2) The need for warfarin- not a big deal to be honest

Positives: 1) if endocarditis is avoided its the best chance at a long life without a reoperation
2) the valve opens more fully than my BAV so easier on the heart
3) quicker operation which has to be a good thing -I'd probably get the On-x
valve already in the graft.
Whatever choice I make I'm going to do my best to not 2nd guess my choice and proceed to live life to it's
fullest.
Sorry for the long post but have a lot to think about before my surgeons appointment on May 20th and I appreciate all the help and advice from those who have also been through this. I hope everyone has as good a day as I will- heading to a recital at my sons school in a half hour then a baseball game tonight.

 

[Blair]

I can't offer much advice since I'm trying to make the same decision regarding mitral valve. I'm personally leaning toward getting a mechanical. Will talk to the surgeon tomorrow and see what he thinks is possible. Then make my decision and have surgery Monday!

Many here have said it's like choosing between a maserati or a ferrari, both are great. I may just have to flip a coin.
(I wonder if anyone has actually done that)

Best wishes.

 

[Duffey]

If you don't mind the INR management, I'd go mechanical if you want the greatest certainty of no further operations.

 

[cldlhd]

funny you say that as I've joked a few times about possibly flipping a coin

I can't offer much advice since I'm trying to make the same decision regarding mitral valve. I'm personally leaning toward getting a mechanical. Will talk to the surgeon tomorrow and see what he thinks is possible. Then make my decision and have surgery Monday!

Many here have said it's like choosing between a maserati or a ferrari, both are great. I may just have to flip a coin.
(I wonder if anyone has actually done that)

Best wishes.

 

[pellicle]

funny you say that as I've joked a few times about possibly flipping a coin

Have you asked your wife to pick for you?

Don't miss that baseball game

Best Wishes

 

[cldlhd]

I think I may be driving her nuts-lol, she's coming to the surgeons appt with me and will definitely have input but ultimately its my decision. I promised my boy some cotton candy at the game and since she's driving a couple ales for myself!
best wishes to you as well

Have you asked your wife to pick for you?

Don't miss that baseball game

Best Wishes

 

[dick0236]

FWIW, I have never had endocarditus(?), nor have I ever had a doctor caution me about a high risk of heart infection such as endocarditus(?) because I have a mech. valve. Their only advice has been to maintain a sound dental program and to not let conditions such as "strep throat" or other serious infections go unattended......and I consider that to be simply using common sense while living a normal life.

 

[cldlhd]

thanks for the response as you've had your mech valve a long time that makes that choice seem less scary. My son recently had a stomach virus and they did a swab and he came up positive for strep throat even though he wasn.t showing symptoms for that . They have him taking 8 days worth of amoxicyllin- seems right as rain now

FWIW, I have never had endocarditus(?), nor have I ever had a doctor caution me about a high risk of heart infection such as endocarditus(?) because I have a mech. valve. Their only advice has been to maintain a sound dental program and to not let conditions such as "strep throat" or other serious infections go unattended......and I consider that to be simply using common sense while living a normal life.

 

[river-wear]

Hey, cldlhd, I'm seeing Dr. Bavaria on the 20th too! We should have our own VR meetup in the waiting room. The nurse warned they always run late. I'm having a CTA in the morning (part of the pre-op routine) because I've already decided to swing for the fences and go for the repair. The possibility of going back to "normal" is compelling for me - but I wouldn't go for a tissue valve, knowing another op or two was a certainty. (I'm 46.)

 

[cldlhd]

Small world, I'll be there for a 10:00 appt . I don't mind waiting if that means he'll patiently listen to all my questions. I'v been having the same thought- back to "normal" and all that -but seeing as were about the same age I think the odds of the repair lasting 40 yrs are a little on the low side. Kind of like trading convenience now for higher likelihood of a reop down the line. I guess I'll see what Dr. B has to say about that. I always hear how surgeons say your repaired valve is better but they don't say why.

Hey, cldlhd, I'm seeing Dr. Bavaria on the 20th too! We should have our own VR meetup in the waiting room. The nurse warned they always run late. I'm having a CTA in the morning (part of the pre-op routine) because I've already decided to swing for the fences and go for the repair. The possibility of going back to "normal" is compelling for me - but I wouldn't go for a tissue valve, knowing another op or two was a certainty. (I'm 46.)

 

[river-wear]

Bummer, I guess we won't cross paths then. My appointment is at 2pm. I'm going for the blood tests at 11 and then the CTA at noon. I have a whole page full of questions too.

A repaired valve is better because it's your own native tissue instead of a prosthetic that will wear out and/or require blood thinners. The first surgeon I talked to about repair said that if he didn't expect the fix to be permanent, he would replace it. Of course "expecting" it to last is different from the reality. At least Dr. Bavaria has more experience than most. I wouldn't be traveling across the country for a "simple" replacement.

 

[cldlhd]

Bummer, I guess we won't cross paths then. My appointment is at 2pm. I'm going for the blood tests at 11 and then the CTA at noon. I have a whole page full of questions too.

A repaired valve is better because it's your own native tissue instead of a prosthetic that will wear out and/or require blood thinners. The first surgeon I talked to about repair said that if he didn't expect the fix to be permanent, he would replace it. Of course "expecting" it to last is different from the reality. At least Dr. Bavaria has more experience than most. I wouldn't be traveling across the country for a "simple" replacement.

I saw that you were from California , almost makes me feel guilty as I only have a 45 minute drive to get there.If a trip across the country to have him do the surgery was recommended to you then I guess he must be good. I'll ask him what"permanent" means when I see him. Your repair surgery may be simpler than mine ( if I go that route) as I have a dilated root and an ascending aneurysm and I don't see that in your description. Who knows if he's running late by the time I get done with my questions you may be waiting for me to get out of there.

 

[river-wear]

Well, my cross-country trip is "self-inflicted." The surgeon here says he has a 50/50 chance of repairing my valve, but he has done maybe 15 aortic repairs as opposed to 3,000 heart operations (many of them valve replacements). Dr. Bavaria didn't give me odds, but he was confident it can be repaired. He's done hundreds of repairs, so that makes me feel better about his ability to do it.

 

[AZ Don]

How likely is the need for a re-operation? My BAV was well functioning so when I had my aneurysm repaired I chose to spare my valve rather than replace it. For a replacement valve it's a pretty close call (for many at least) between a mechanical valve or a tissue valve which is almost certain to require re-op. By sparing my valve I got the benefits of a tissue valve but only an estimated 50% chance of requiring a re-op someday (when the techniques may have improved).

 

[cldlhd]

How likely is the need for a re-operation? My BAV was well functioning so when I had my aneurysm repaired I chose to spare my valve rather than replace it. For a replacement valve it's a pretty close call (for many at least) between a mechanical valve or a tissue valve which is almost certain to require re-op. By sparing my valve I got the benefits of a tissue valve but only an estimated 50% chance of requiring a re-op someday (when the techniques may have improved).

Thanks, It's a tough call and thats one thing I've been thinking-if the repair lasts 20 yrs who knows what they'll be able to do by then but then again I'll be 65 then and starting retirement with OHS doesn't sound fun.....I've read that many valves ,even normal ones, can get stenosis as you age but BAV's tend to get it a decade earlier on average. I guess that and the only other thing that has me considering mechanical is the thought that a BAV -even a well functioning one with no leakage or stenosis- doesn't open all the way and makes it harder for the heart to move blood. Can't this lead to the heart wearing out faster? I understand that each BAV would have different flow ability but would interesting to see a comparison between a mech valve and a good BAV in terms of LV ejection %. Also I'm sure there are people out there who have had repairs who have leakage down the road but and have to decide if it's significant enough to warrant an operation.I guess I'li see what the surgeon has to say about decades down the road, I'm pretty new to all this but I've been getting the impression they judge a successful procedure based on a shorter time frame. My situation is very similar to what you had, did your valve leak? I'm not even considering a tissue valve , it's either mechanical or repair.

 

[OldManEmu]

The majority of people with BAV do not require an AVR in their life time. If your BAV is functioning well and only an aneurysm repair is required, and an AV clean up is possible this would be my preference, however I would let the surgeon know my choice if the AV didn't function well after re implantation and the AVR was required.

 

[Bryan B]

Just food for thought, there really is no such thing as a permanent repair OR replacement of a valve regardless of what type of procedure you choose. The difference between a tissue valve and a repair/mech is that the tissue valve is guaranteed to wear out at some point where the other two options have an indefinite lifespan, thus a chance of lasting a lifetime. The younger you are the less chance it will last a lifetime simply because there is a longer time period for complications to occur. If this were me I would be looking at the statistics of freedom from re-operation between BAV aortic repair versus mechanical replacement. Then I would weigh that with my personal preferences as they might effect my life in the present and future along with the surgeon's expert opinion.

As someone else said both options are good ones, and there is no way to predict what may happen in the future. When I had my first surgery I suffered from isolated aortic regurgitation caused by a VSD and aggravated by bacterial endocarditis. I was a good candidate for the Ross Procedure and I liked the fact that barring complications it could last indefinitely. Unfortunately I developed aortic root and ascending aorta dilation that eventually required re-operation after 7 years. At the time of my initial surgery the known chances of this complication were there but low (especially since I didn't have a BAV). It is now known that the chance of this complication is higher than they thought and they have made changes to how the procedure is done (it is also recommended less often for adults). At age 50 (my age at 2nd surgery) I chose a tissue valve at the recommendation of my surgeon even though I knew that it would guarantee a 3rd surgery. My surgeon happened to be leading the clinical trials at Duke on the TAVR procedure and was adamant that barring complications I would be eligible for this procedure by the time I needed surgery again. To be honest I was having a difficult time choosing between a tissue or mechanical valve so the surgeon broke the tie.

 

[AZ Don]

I guess that and the only other thing that has me considering mechanical is the thought that a BAV -even a well functioning one with no leakage or stenosis- doesn't open all the way and makes it harder for the heart to move blood. Can't this lead to the heart wearing out faster?

I don't know, I haven't heard this but anyone with a BAV needs to be monitored so there should be some indication if there is a problem. I was very surprised to find out that I had a BAV because I was always very good aerobically and had no symptoms or clues. My echo prior to surgery showed the valve area and flow were all very good, but I don't think that is always the case for people with a BAV.

Also I'm sure there are people out there who have had repairs who have leakage down the road but and have to decide if it's significant enough to warrant an operation.I guess I'li see what the surgeon has to say about decades down the road, I'm pretty new to all this but I've been getting the impression they judge a successful procedure based on a shorter time frame. My situation is very similar to what you had, did your valve leak? I'm not even considering a tissue valve , it's either mechanical or repair.

My valve did not leak prior to surgery. Right after the surgery the Dr. said it was not leaking but my follow-up echo's showed that I now have mild regurgitation. I assume this means the odds of me requiring a re-op may be higher that they were. Still I think that is a long ways off for me and my Dr. also said that it is likely that they will be replacing valves through less invasive techniques in the future. He does some of these now in people that are not candidates for OHS.

I didn't really consider a tissue valve either, since the Dr. expected my native valve to last about as long as a tissue valve. I did have to pick a back up choice prior to the operation, in case he could not spare my valve. My back-up was the On-X valve.

 

[cldlhd]

Thanks for all the input from everyone. I'm trying to jam as much info in my head before my May 20th surgeons appt so I can ask all the relevant questions. I don't want to be kicking myself after thinking I should have asked this or that. I'll see what the surgeon says about a BAV being restrictive or not- I'd hate to enjoy the benefits of repair now if it means my heart will wear out prematurely. The aneurysm is something else I'm trying to learn about. I've read that the ascending is made of different genetic material than the rest of the aorta so the risk of aneurysm somewhere else is minimal. I've also read that the arch is similar in build to the ascending which I hope isn't the case. The aneurysm seems to caused by a combo of the tissue being prone to stretching and the hemodynamic influence (turbulence) of the BAV. If thats the case will the turbulence from the repaired BAV cause an aneurysm in the arch eventually or is the flow smoothed by the time it reaches there? The beginning of my arch is "mildly aneurysmal" but that could be simply because it's connected to the ascending aneurysm ( one continuous pipe after all ) and it seems reasonable that as the ascending expands it would have an effect on the beginning of the arch. As I'm an active 45 year old who act like I'm thirty IF I decide to choose repair I'm going to tell the surgeon only if he's confident it's a very robust repair likely to last a long time if not I'm planning on having the On-x valve and graft on hand.

 

[cldlhd]

If you don't mind the INR management, I'd go mechanical if you want the greatest certainty of no further operations.

I dont mind the idea of INR management, I'm sure the first month or so after I came hoe from the hospital might be a little scary but after that I assume it would just be part of my routine. Besides I assume sooner or later there will be an anti coagulant that doesn't require routine monitoring and dosage adjustments thats suitable for mech valves. To be honest I think the elevated infection risk troubles me more.