Aortic valve repair vs mech valve replacement

[Marco]

Hi cldlhd, Thanks for your post! I am 40 and have just found out hat I have severe aortic regurgitation which has led to decreased EF and a severely enlarged LV will need to have OHS soon. It came as a shock as I am extremely energetic, active and have never felt any fatigue symptoms. The cause is the aortic valve but it still remains unknown whether I have a BAV and additionally, whether my aortic root (3.9) will also need to be dealt with. I have just undergone further tests this week and will meet with the cardiologist again soon to know what they recommend. I have done research however and spoken to a few experts and these are my considerations:
1) Repair - if this is something both the cardiologist and surgeon say they can repair easily and have experience in doing then there's no doubt that this will be the best option, for all the reasons you have mentioned above and more. Even if they say that this will not be lifetime solution and that reoperation will be necessary in say 10-15 years, I will certainly still go for this option.
2) A Tissue valve - THese valves now last from 15-25 years and have the advantage over mechanical valves of not requiring long-time medication with Warfarin. This is my second best option - again it would mean reoperation when I am around 60 but I think (am still thinking about it, not sure) that to me that is preferable than the need for Warfarin and risks of infection, bleeding and complications if I need any other unrelated surgery or medication in the coming 15-20 years.
3) A mechanical valve - certainly has the advantage of being a lifelong solution, but there seems to be no evidence that the total lifespan is any different from people that have done repair or have tissue valves. Has the disadvantage of possible complications related to infections and Warfarin for the rest of your life, which of course many people find more than okay to live with.

So it really remains a personal -and no easy - choice! I will let you know what my surgeon suggests- -I will meet with him around the date you will meet with yours.
What option currently has your personal preference?

 

[Marco]

Oh I forgot to mention that one of the experts I spoke to said he envisions that heart valve operations in the not too distant future will be minimally invasive for everyone and even safer than they now already are.

 

[Marco]

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.

Thanks for your post, Bryan- this reinforces my current line of thought. At age 40, about to do my first surgery in a month I too like you am more inclined towards tissue, even knowing that surgery 15-20 years down the line will be inevitable. An expert I spoke to (nvolved in cutting-edge techniques in valve surgery) has assured me that TAVR or other Valve-in-valve procedures will be widely used at that time, so the risks will be minimal.

 

[pellicle]

Hi

but there seems to be no evidence that the total lifespan is any different from people that have done repair or have tissue valves.

I would disagree with no evidence. Perhaps not enough to satisfy you, but there exists enough evidence to compel this senior surgeon from the Mayo clinic to put together a presentation on that evidence.

http://mayo.img.entriq.net/htm/MayoPlayer1.html?articleID=4071

I dug up some of the references he cites and found interesting trends, for instance:

On the subject of death, I personally feel there are worse things than death. I have known people who until their death consumed all of their savings and mortgaged their homes in surgeries and followups and treatments. They often anguished about this and wanted their family to not be impoverished by keeping them alive.

People can have their quality of life shattered by the little issues which can occur during surgery (like infections, damage to nerves, issues to do with collapsed veins ...) when it comes to ReDo then this list gets longer and more likely.

So death is not the worst thing that can happen from my perspective.

With respect to TAVI, well in my experience the data just isn't there yet and anything to the positive is perhaps talking things up. Surgeons are well known for talking up procedures which they are interested in (and perhaps profit from).

I would recommend this reading
http://cartagenasurgery.wordpress.com/2012/08/09/the-truth-about-tavi-and-tav/

As one cardiologist explained:

“Importantly, the thrombogenic potential of mild leaks was recently demonstrated by Larry Scotten ( Vivitro System Inc. Victoria, Canada). High reverse flow velocities expose glycoprotein GP Ib-IX-V platelet receptors to circulating Von Willebrand molecule with, as results, platelet aggregation and fibrin formation. The incidence of brain spots and stroke after TAVI was of great concern in the PARTNER A and B studies. Whereas, Aspirin is not mandatory in patients implanted with bioprosthetic valves, Plavix + Aspirin is recommended for all TAVI patients. The rationales of such therapy were not explained so far.”

hmmm

Also I'd ask will the tissue valve you get actually be a candidate for valve in valve, or would they need to open you up to actually remove that valve and put in the required one (for the next time).

Lastly, one of the members here (clay) recently raised a point which I had not considered before and thought it quite a wise perspective
URL

My choice of a mechanical valve was not to avoid reoperations so much as the possible decline in health brought on by a failing tissue valve prior to the next replacement. Before my AVR, I was suffering pretty badly with CHF and absolutely did not want to revisit that territory. A year and a half after surgery, my LVEF is still in the upper 40s, so I don't really have a lot of "reserve" which just makes me all the surer of my choice.

I am by no means wishing to promote one choice over another, I am simply attempting to assist you in making an informed choice and addressing what I saw as a lack of information.

Best Wishes

 

[Marco]

Pellicle, thanks for these valuable insights, which were new to me. Have just seen the Mayo presentation. Will also try to find the original sources. Opens up new lines of thought.
Could you please share your experience with your mechanical valve? In what way has your life changed since you got yours -and what are factors that make it the righgt choice for you?

 

[cldlhd]

Hi cldlhd, Thanks for your post! I am 40 and have just found out hat I have severe aortic regurgitation which has led to decreased EF and a severely enlarged LV will need to have OHS soon. It came as a shock as I am extremely energetic, active and have never felt any fatigue symptoms. The cause is the aortic valve but it still remains unknown whether I have a BAV and additionally, whether my aortic root (3.9) will also need to be dealt with. I have just undergone further tests this week and will meet with the cardiologist again soon to know what they recommend. I have done research however and spoken to a few experts and these are my considerations:
1) Repair - if this is something both the cardiologist and surgeon say they can repair easily and have experience in doing then there's no doubt that this will be the best option, for all the reasons you have mentioned above and more. Even if they say that this will not be lifetime solution and that reoperation will be necessary in say 10-15 years, I will certainly still go for this option.
2) A Tissue valve - THese valves now last from 15-25 years and have the advantage over mechanical valves of not requiring long-time medication with Warfarin. This is my second best option - again it would mean reoperation when I am around 60 but I think (am still thinking about it, not sure) that to me that is preferable than the need for Warfarin and risks of infection, bleeding and complications if I need any other unrelated surgery or medication in the coming 15-20 years.
3) A mechanical valve - certainly has the advantage of being a lifelong solution, but there seems to be no evidence that the total lifespan is any different from people that have done repair or have tissue valves. Has the disadvantage of possible complications related to infections and Warfarin for the rest of your life, which of course many people find more than okay to live with.

So it really remains a personal -and no easy - choice! I will let you know what my surgeon suggests- -I will meet with him around the date you will meet with yours.
What option currently has your personal preference?

You don't know if you have a BAV or not but you do have an enlarged Lv which I believe is a result of the heart working too hard. This could be due to the regurgitation alone or it could also be due to a restrictive BAV. I'm not a medical professional but I have a lot of experience with pumps and valves and I know that a restrictive valve ,or any other restriction , makes the pump less efficient and forces the pump to work harder to achieve the same goal. I can understand the fear that if on warfarin you could have future medical issues that won't allow warfarin use but who knows the future. If you go tissue your guaranteed a future reop.
I'm open to repair but only if he's sure it's robust enough to last a long time and he can assure me it isn't going to restrict the flow and be too hard on my heart.Either that or I'm going mechanical.

 

[Tom C]

I also found the Mayo presentation to be very good, but the presenter, Hartzell Schaff, was my surgeon and for me he recommended an aortic valve repair over a mechanical valve. I was a little surprised, because he said I could count on getting 12 years from it - possibly more. That seemed a little low to be the preferred choice. It was a Mayo cardiologist, however, who suggested the new repair techniques could possibly allow the repair to last the rest of my life. I had the repair done.

I am now one year out and my aortic valve continues to show only trace regurgitation, which is quite normal. Every other measurement is within normal ranges. I now have a very well-functioning bicuspid aortic valve. The Mayo's own data show that %72 of aortic repairs are free of reoperation at 15 years, but those numbers don't necessarily reflect more recent improvements in the procedure. Right now I feel great and am hoping for the best.

Cldlhd, in my own experience I never read that a bicuspid aortic valve or a repaired valve will necessarily make the heart wear out faster. Regurgitation and/or stenosis will make the heart work a lot harder, but a functioning bicuspid or a working repair seem to allow pretty normal function. My own leaking valve opened just fine, it just didn't close very well. Now it does.

Not many surgeons attempt aortic valve repairs. The procedure can only be done on a small percentage of patients and until recently, the results were just not that great. I believe Dr. Bavaria is one who has kept working to improve aortic repair and can give you a good outcome. Your discussion with him will be very helpful.

Tom

 

[pellicle]

Hi

Could you please share your experience with your mechanical valve? In what way has your life changed since you got yours -and what are factors that make it the righgt choice for you?

The operation for my mechanical was my third OHS, in discussion with the surgeon he made it clear to me that another redo after this was quite risky in terms of dealing with scar tissue, such things as pacemakers and other more serious eventualities. He mentioned to me that each time they cut through the sternum there was an increasing chance it may not heal and then it would need to be removed.

I wanted most to get on with the rest of my life and believed that whatever issues may arise from being on warfarin (which I knew bugger all about at that time btw) would be far less serious than the issues of redo operations. In fact I learned even more about the issues with redo operations as I got a propionibacteria infection as part of the operation. It has not needed a redo on the valve, and (last I looked) I'm not dead: thus I do not appear in any statistics about redos (which in the main focus on death, endocarditus and reoperation).

How has it changed my life?

I take a pill daily (and you know, if you live long enough you end up doing that anyway right...) I check my INR weekly (sometimes more because I'm curious) and I can hear my heart beat.

That is the sum total of my lifestyle changes.

Hell I just got back from about 2 weeks in backpacking around UK and Ireland (see my post on that) and I'm in the middle of packing to leave Finland and go back to Australia and do stuff there. I still ride my motorbike, I still work with power tools, I still cut myself and I still bang my finger with the hammer (not on purpose).

As well I have developed a great interest in understanding wafrarin management, I have learned a lot, and I try my best to help people realise that its not "the horror" its made out to be, in the main that's anxiety.

 

[cldlhd]

Thanks for the input . It does seem that I'm fortunate to be seeing Dr Bavaria and who knows I may not even qualify for a repair . I just want to have all the right questions for him when I see him and it's always good to hear from people with personal experience.

 

[cldlhd]

Hi



The operation for my mechanical was my third OHS, in discussion with the surgeon he made it clear to me that another redo after this was quite risky in terms of dealing with scar tissue, such things as pacemakers and other more serious eventualities. He mentioned to me that each time they cut through the sternum there was an increasing chance it may not heal and then it would need to be removed.

I wanted most to get on with the rest of my life and believed that whatever issues may arise from being on warfarin (which I knew bugger all about at that time btw) would be far less serious than the issues of redo operations. In fact I learned even more about the issues with redo operations as I got a propionibacteria infection as part of the operation. It has not needed a redo on the valve, and (last I looked) I'm not dead: thus I do not appear in any statistics about redos (which in the main focus on death, endocarditus and reoperation).

How has it changed my life?

I take a pill daily (and you know, if you live long enough you end up doing that anyway right...) I check my INR weekly (sometimes more because I'm curious) and I can hear my heart beat.

That is the sum total of my lifestyle changes.

Hell I just got back from about 2 weeks in backpacking around UK and Ireland (see my post on that) and I'm in the middle of packing to leave Finland and go back to Australia and do stuff there. I still ride my motorbike, I still work with power tools, I still cut myself and I still bang my finger with the hammer (not on purpose).

As well I have developed a great interest in understanding wafrarin management, I have learned a lot, and I try my best to help people realize that its not "the horror" its made out to be, in the main that's anxiety.

Glad to hear I'm not the only one who wacks their hand with a hammer now and then , just steer clear of the circular,table or miter saw ( just got a real sweet 12"dual bevel, sliding, compound, laser sight hitachi about 6 months ago)

 

[cldlhd]

First I want to say that I have no medical training-I'm just a semi humble water and sewer operator, so I don't want anyone putting too much weight on my opinions. I'm just putting them out there hoping for advice from those who may know better than I do. Having said that from what I've read of TAVI or TAVR I'm not a big fan of it in someone who's relatively young and has a long life expectancy and seeing your only 40 and would be potentially getting the reop when your in your 50's that sounds like you . It seems like a good procedure for someone who's elderly or has some other health reason precluding them from a more traditional operation. The idea of a valve in a valve? Two objects can't occupy the same space so either you get a reduced opening-and flow- or the heart tissue would have to be stretched out to allow a valve of the same size you had previously to be fitted. To each their own but for me it's either repair or mechanical.

Thanks for your post, Bryan- this reinforces my current line of thought. At age 40, about to do my first surgery in a month I too like you am more inclined towards tissue, even knowing that surgery 15-20 years down the line will be inevitable. An expert I spoke to (nvolved in cutting-edge techniques in valve surgery) has assured me that TAVR or other Valve-in-valve procedures will be widely used at that time, so the risks will be minimal.

 

[Heart Of The Sunrise]

Hi cldlhd and river-wear- I see Dr. Bavaria this Thursday for my 1 year follow-up. It was supposed to have been on my surgical anniversary. But, Dr. Bavaria is an extremely busy man. He needed to postpone it two months.You will love him... he is brilliant! Yet I found him extremely easy to talk to. He is very down to earth.:thumbup:

 

[cldlhd]

Hi cldlhd and river-wear- I see Dr. Bavaria this Thursday for my 1 year follow-up. It was supposed to have been on my surgical anniversary. But, Dr. Bavaria is an extremely busy man. He needed to postpone it two months.You will love him... he is brilliant! Yet I found him extremely easy to talk to. He is very down to earth.:thumbup:

Thats good to hear. Even if he agrees with the first surgeon that I don't need my operation yet I'm going to ask a lot of questions about what we'll do when the time comes. With the first surgeon it was basically " you don't need the operation yet, don't lift this or that,get an echo in 6 months and I'll see you in a year". Also I'm going to push for another CT or an MRI sooner rather than later because I don't think an echo is that accurate for measuring an aneurysm and since mine is 4.8 cm ( at least it was before) I don't feel like waiting a year for an accurate measurement. How's that On-x valve doing? Not sure if I asked you this but can you hear it? If so has it gotten quieter over time as some people say they do?

 

[Heart Of The Sunrise]

cldlhd:
The valve is doing fine. Coumadin is not a problem. Bavaria recommended brand specific over warfarin. I only occasionally hear it usually late at night in bed.
It is not unpleasant.

 

[Heart Of The Sunrise]

cldlhd:
The valve is doing fine. Coumadin is not a problem. Bavaria recommended brand specific over warfarin. I only occasionally hear it usually late at night in bed.
It is not unpleasant.

 

[Marco]

Hi



The operation for my mechanical was my third OHS, in discussion with the surgeon he made it clear to me that another redo after this was quite risky in terms of dealing with scar tissue, such things as pacemakers and other more serious eventualities. He mentioned to me that each time they cut through the sternum there was an increasing chance it may not heal and then it would need to be removed.

I wanted most to get on with the rest of my life and believed that whatever issues may arise from being on warfarin (which I knew bugger all about at that time btw) would be far less serious than the issues of redo operations. In fact I learned even more about the issues with redo operations as I got a propionibacteria infection as part of the operation. It has not needed a redo on the valve, and (last I looked) I'm not dead: thus I do not appear in any statistics about redos (which in the main focus on death, endocarditus and reoperation).

How has it changed my life?

I take a pill daily (and you know, if you live long enough you end up doing that anyway right...) I check my INR weekly (sometimes more because I'm curious) and I can hear my heart beat.

That is the sum total of my lifestyle changes.

Hell I just got back from about 2 weeks in backpacking around UK and Ireland (see my post on that) and I'm in the middle of packing to leave Finland and go back to Australia and do stuff there. I still ride my motorbike, I still work with power tools, I still cut myself and I still bang my finger with the hammer (not on purpose).

As well I have developed a great interest in understanding wafrarin management, I have learned a lot, and I try my best to help people realise that its not "the horror" its made out to be, in the main that's anxiety.

Hi, hats off to you (as to so many others on this forum) for your active lifestyle after three OHS and your positive energy - gives me a lot of hope and optimism. Cheers mate.

 

[cldlhd]

cldlhd:
The valve is doing fine. Coumadin is not a problem. Bavaria recommended brand specific over warfarin. I only occasionally hear it usually late at night in bed.
It is not unpleasant.

Thanks, good to know. I run a fan at night for white noise, helps me sleep so that shouldn't be a problem

 

[Bryan B]

Thats good to hear. Even if he agrees with the first surgeon that I don't need my operation yet I'm going to ask a lot of questions about what we'll do when the time comes. With the first surgeon it was basically " you don't need the operation yet, don't lift this or that,get an echo in 6 months and I'll see you in a year". Also I'm going to push for another CT or an MRI sooner rather than later because I don't think an echo is that accurate for measuring an aneurysm and since mine is 4.8 cm ( at least it was before) I don't feel like waiting a year for an accurate measurement. How's that On-x valve doing? Not sure if I asked you this but can you hear it? If so has it gotten quieter over time as some people say they do?

When they first detected mild dilation of my aortic root they just followed it with my yearly echo. After 2 years of steady growth they sent me for a MRI and found that it was larger than the echo showed (not trying to scare you). They also found that my ascending aorta was also dilated (which did not show up on echo). The following year it reached 5.2 root / 5.4 ascending so they sent me to a surgeon. He did a CT scan and got 5.4 / 5.8 readings and booked me for surgery ASAP (two weeks). I am still followed by my surgeon annually and he alternates between a CT scan and a MRI annually. He always says that a CT scan is the "gold standard" for accuracy when it comes to measuring the aorta and a MRI is close behind.

 

[cldlhd]

I pressed my cardiologist as to why an echo, she didn't seem like she wanted to contradict the surgeon but eventually admitted its not good for monitoring the size of the aneurysm but is good for looking at the valve. Seeing that my valve has some leakage but no stenosis I asked her why not another CT.She voiced a concrrn about the radiation but seeing this was my first set of measurements I have no idea how fast its growing so I'm going to push for better monitoring. If for no other reason than to get my mom to stop calling me and telling me I need to get it checked out sooner.
I think the first step when I have my surgeons meeting on the 20th will be that issue then once he tells me what size he feels we should intervene then I'll get into the whole repair vs replace decision.

When they first detected mild dilation of my aortic root they just followed it with my yearly echo. After 2 years of steady growth they sent me for a MRI and found that it was larger than the echo showed (not trying to scare you). They also found that my ascending aorta was also dilated (which did not show up on echo). The following year it reached 5.2 root / 5.4 ascending so they sent me to a surgeon. He did a CT scan and got 5.4 / 5.8 readings and booked me for surgery ASAP (two weeks). I am still followed by my surgeon annually and he alternates between a CT scan and a MRI annually. He always says that a CT scan is the "gold standard" for accuracy when it comes to measuring the aorta and a MRI is close behind.

 

[river-wear]

Hi cldlhd and river-wear- I see Dr. Bavaria this Thursday for my 1 year follow-up. It was supposed to have been on my surgical anniversary. But, Dr. Bavaria is an extremely busy man. He needed to postpone it two months.You will love him... he is brilliant! Yet I found him extremely easy to talk to. He is very down to earth.:thumbup:

Thanks! I have spoken with him on the phone and was impressed that he took the time to answer my questions, and was so willing to help out a stranger in need.