At a crossroads for potential surgery

[Guest]

Hello folks,
Here is the backdrop of my story. I started seeing a cardiologist about 5 years ago based upon a mild leak being shown in my Aortic valve from a regular heart echo.
Flash forward to 2014, I was sent to talk to a cardio thoracic surgeon in August to talk about surgery, what to expect, etc. Upon his advice, I had a TEE done.
This TEE showed moderate to severe (what he terms "significant") leakage and my aortic root is currently at 4.8 or 4.9. (root dilation up from say...4.5 a couple of years ago)
This surgery is still in my court, but the surgeon feels 94% confident (his words) based upon the TEE, that he can REPAIR this valve, and repair my aortic aneurysm at the same time.
It is my understanding that this surgeon is the go-to person for aortic surgeries in my neck of the woods, Atlanta.

That said, I received a second opinion from another highly respected surgeon, that did not feel confident that my valve could be repaired to any significant state that justified surgery. He felt that i should just continue monitoring this situation and wait for surgery at some point down the road.

Now here is the dilemma: Do you have the surgery now, when I am relatively young (45) and the valve is deemed as highly likely for repair...or do I wait 5 years and gamble that the valve suffers more stress from the regurgitation, becomes stiff or stenotic, thus being less likely for repair?

I am trying to figure out if I should just have the surgery, get the valve repaired, keeping my own equipment; having the aneurysm pre-emptively addressed at the same time...OR...do I push this decision down the road. I am afraid that this is going to continue to nag at me, but I don't want to be overreactive in my decision.

Anyway, I know it is a personal decision for me to make, but I hope that there are others on here that have come to the same point and can give me some advice or perspective.

 

[ajc1991]

In my opinion, it's better to get the surgery done sooner than later. When there's leakage of the heart the heart works harder to try and make up for the blood that it's not giving to the rest of your body. And if you wait longer it could lead to other problems of the heart as well. It's best to have the surgery now since you're relatively young. The more leaky the valve, the harder it is to repair it from what I understand, and the less time the repair will last. I have a severely leaking mitral valve, and as a result my aortic arch is also a bit enlarged and my surgeon is not sure whether he will need to repair it or if he will leave it alone and keep an eye on it. He said he'd need to see it with his own eyes first. Says the dilation may go down when I have my mitral valve replaced along with my whole heart since it is enlarged from my heart working harder. I'm 23 years old by the way.

 

[big_L]

I'd get your echo results and really do over them alone and with your cardio with an eye on changes to the heart which may be irreversible. It's been awhile since I've thought about it and I can't pull up the exact terms, but you'll be looking at left ventricle measurements.

 

[AZ Don]

Surgery is inevitable so the way I looked at it is that I incurred extra risks (aortic dissection, and in your case possibly additional heart damage) by waiting. The risks from surgery are there either way. Doesn't sound like you need to rush into it but I think waiting 5 years is gambling with little upside and a lot of downside risk.

Valve repair has been discussed often lately. It's a subject of interest for me as my BAV started leaking after I had surgery to repair my aneurysm last year. Repair would be my choice IF I felt confident in the surgeon and the hospital that the repair could last a long time. In checking the "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease", it states:
Despite advances in primary aortic valve repair, especially in young patients with bicuspid aortic valves, the experience at a few specialized centers has not yet been replicated at the general community level, and durability of aortic valve repair remains a major concern. Performance of aortic valve repair should be concentrated in those centers with proven expertise in the procedure.


Full document here: http://content.onlinejacc.org/articl...icleid=1838843

 

[river-wear]

I think you need to address two separate issues independently:
1) Is it time to have surgery? If you aren't sure yet, talk to another doctor. Why did your cardiologist say it is time? Is your heart function declining, do you have symptoms (shortness of breath, etc.)?
2) After it's determined you need surgery now, then you can research repair vs. replacement. If you don't need surgery yet, then it's better to wait. If it is time, even if you have someone confident of repair they may find out when they open you up that you need a replacement. Always have that backup plan in your head and choose what you'll want in that case (mechanical or tissue).

FWIW, the first surgeon I talked to was pretty confident (at least 50/50) that he could repair my valve. Turns out he really wasn't experienced with repairs (and his approach probably wouldn't have lasted), so I went to the best guy I could find. Even then I had my backup plan. Sometimes you swing for the fences (repair) and still only get a single (replacement).

 

[mxtexas]

Thanks for the feedback.
The first surgeon that I consulted said that it was "reasonable" for me to have surgery and that I should come in and have it done. To my knowledge, my heart function is not declining, it is just that my valve is leakier than it was (now it is mod-severe) and my aortic root is getting larger (4.9 at this point). The first surgeon is definitely the one that I would use for the procedure, be it repair or replace. His name is Ed Chen and he is generally considered the foremost expert on this procedure in the southeast(from what I can tell), based at Emory/St. Joe's hospital, here in Atlanta.

The consideration is if waiting perhaps makes my valve less repairable down the road, then why wait? I will have to have this procedure done at some point and want the best option for repair, first.