AVR recommended after endocarditis therapy due to risk of embolism from vegetation?

[VegasBAV]

Hi everyone-

This is my first post. I've known for decades that I would probably need AVR at some point. I'm 40, I've have moderate to severe aortic regurgitation for a long time, but no symptoms or dilation of the heart yet. I had an echo in February; there was no discussion of surgery.

In March I contracted endocarditis. TEE showed a mobile vegetation on a subaortic membrane. They decided surgery was not necessary at that time. I completed the antibiotic therapy at the end of April.

A recent echo showed that the vegetation is still there, apparently sterilized as a I fell fine. My cardiologist is now recommending that I get the valve replaced and have the membrane with vegetation removed. His recommendation seems to be based on two things: (a) I have a lot of turbulence across the valve and a mobile vegetation which could break off at any time and give me an embolism, and (2) I have a regurgitating valve that would need surgery at some point any way so it might as well be now.

I'm a little surprised by this recommendation, because my research is telling me that the odds of a vegetation breaking off and causing embolism decrease substantially after the first week of antibiotic therapy and are very low after the treatment is concluded. Maybe as low as 1%.

I certainly don't want an embolism, but I also don't want to have a major surgery when I'm asymptomatic, a surgery which includes many risks, including embolism. Also, I would probably get a tissue valve, so I'd like to delay this as long as possible, as the valves keep getting better and the longer I wait the less chance of needing 2 or more future surgeries to replace the valve. So I'm very much inclined to get a second opinion.

Has anyone else here had AVR with no symptoms, or AVR after endocarditis due mainly to the risk of embolism? Has anyone else been in a similar situation and decided not to have the surgery?

Maybe I'm just in denial and I need to have the surgery and get all of this over with.

Anyway, I appreciate anyone else's input.

Thanks.

 

[escargome]

I can't say that you are in denial, but yes, get a second opinion. It certainly never hurts. Information about our bodies only makes us stronger. I had a murmur since I was 12. It was monitored yearly until I was around 18 when I thought I was 10 feet tall and bullet proof, then it "I don't feel bad, so why go to cardiologist" Flast forward to the year 2008, I got bacterial meningites, hosptialized, cardiologist assigned to me by hospital darn near had a hissy fit cause I had not taken care of myself. Long story short, he gave me his opinion after an ech, TEE and CT Scan. I listened to him (still in denial) went to second cardiologist with all my tests. 2nd cardio looked as results, said finish your anti-biotic treatment via PICC line then off to surgeon you go. So information makes us stronger and sometimes (in my case) opened my eyes.... Good luck to you as you begin this jouney.

 

[ElectLive]

I would guess that your cardiologist may be recommending surgery not because your risk of embolism is high, but because the risk of surgery may actually be lower. Again, my guess only. I had AVR with no symptoms and I had AVR prematurely (by a few years probably). It was under very different circumstances, though, I had an aneurysm. For me, it wasn't so much a question of delaying as long as possible, but was it ok to delay long enough for my pregnant wife to deliver and fully recover. Well, to postpone about 6 months or so, in my case, the risk of aorta dissection or rupture was fairly low, about 2 1/2 %. All the major risks of my surgery (including stroke) when combined were about equal. So my surgeon told me he would conceivably be ok waiting 6 months, since I would theoretically be no worse off. Well, but here's the catch, I had to have surgery sooner or later, so the surgical risk never goes away. So I decided to go ahead with the surgery, and just not add the risk of dissection or rupture to the mix.

Now, let me emphasize this, I'm not suggesting this as a model for what to do at all. But I would suggest that you might want to go ahead and discuss your case with a surgeon to try and identify the risks both ways as precisely as possible. That may make the situation and decision easier. Unfortunately, I can't speak to the vegetation situation at all. Perhaps someone else will be able to. It really stinks when factoring in a tissue valve, though, I know the feeling well. I would have given anything to have kept my own valve a few years longer. But it just wasn't the best option for me. I have no regrets, after the fact. Everything went well and back to normal in near record time. I figure if I live as long as I want to, which I certainly plan on doing my best to, those few years of valve life won't matter that much in the end.

Best wishes to you learning more and working through the decision process.

 

[Bryan B]

Hi Vegas,

My situation was similar to yours. I had a VSD causing one of my aortic leaflets to prolapse, which in turn caused moderate regurgitation. Even though I knew I would probably need my valve replaced in the future my condition was "stable" so I was just followed annually. Then I got endocarditis and after 7 weeks of IV antibiotics the echo revealed that I had NO vegetation remaining. Unfortunately while the vegetation was there it left perforations in my aortic leaflet(s) and my valve was leaking worse. My surgeon gave me the choice of putting me on ace inhibitors for 6 months to see if that would stabilize my condition or move forward with the surgery. He said that the ace inhibitors may or may not help and that it would probably only buy me a few years before I needed the surgery anyway. Not wanting that hanging over my head I chose to go forward with the surgery.

My suggestion would be to have a surgical consult. I would be much more comfortable in your situation with the advice of a well qualified surgeon. Personally if I had ANY sterile vegetation left on my valve after antibiotic treatment was completed I would opt for surgery regardless of what the risk of embolism is. The reason is how serious the consequences would be if the vegetation did break loose. The two leading causes of mortality for persons with IE are embolisms and heart failure. Here is a good article on endocarditis.

http://www.rjmatthewsmd.com/Definitions/infective_endocarditis_in_adults.htm