AVR with Replacement of Ascending Aorta and Triple CABG

[Chuck C]

My head does spin a little when I think about the %'s like 3-8% chance of death, 3-6% chance of stroke as its a big operation and also the potential impaired renal function once its all done.

This is a time when it's best to focus on the positive and be optimistic. A friend of mine was nervous facing his aortic valve surgery. I shared with him that the mortality is only about 2% for this surgery and since he was getting it done at a very experienced nationally ranked clinic, with a very experienced surgical team, his risk was probably only about 1%. His reply was "Yeah, but somebody is that 1%." Technically true.

I think that there is a time for extreme optimism. When the outcome is totally out of your control is that time. You are doing exactly as you should do and losing weight to improve your odds going into the surgery. This is within your control and the thing which you should focus on. The rest is in the hands of the experienced team who will take care of you. It is time for you to know that the overwhelming odds are in your favor and believe that you "will" wake up on the other side and begin your recovery journey.

This also gives you a second chance at improving your lifestyle to significantly have a good chance at having a long life after surgery. You are already trying to make yourself as healthy as possible going into surgery. You have the opportunity to continue this after surgery and take control of your future as best you can. I would encourage you to do so.

BTW, my friend who was worried that he might be one of the 1% did just fine and had a great recovery.

 

[Jase_101]

Hi Timmay

I have agreed to go with my surgeon's suggestion of a mechanical valve as I am hoping for a "one and done", so mechanical seems the logical choice.

Thanks
Jase

 

[Jase_101]

Hi Chuck

Thanks very much and yes you are 100% correct, think positive and make the right choices so its onward and forward.

Best wishes

Jase

 

[Jase_101]

Such direction of thinking is meaningless, nothing you think about is anything within your control.

So unless you enjoy spinning your wheels in the mud instead focus on what your role is. Don't feed the beast of anxiety unless you want to be it's slave.

View attachment 889733

Thanks very much I will focus on the positives.

Take care

Jase

​

 

[pellicle]

Hi

Thanks very much I will focus on the positives.

yes, that's also good, but if you find yourself obsessing about things then bring your thinking mind (your conscious mind) to bear on this and reassert yourself as caption of the ship.

Stoic thought guides us here:

(Marcus Aurelius)

If you believe in God then God is Nature. You must accept that there are things outside your control (almost everything) and to not pretend that you can control those things. It is like being anxious that the sun will soon arise.

In my view anxiety is the stress that arises from wanting to control something but either not knowing how to or not accepting that you can't.

If you believe in God in a Christian way then you should be accepting of what God wants for you and go into it willingly. If you are Atheist then you should look to understand that the world is not your video game to win. Its a rules based universe that is made absurd by the existence of human consciousness.

Statistically what can go wrong is very small, and what can and is likely to go right is overwhelming in your favour.

So meditating on what brings you agitation and anxiety is not only poinless its self destructive. Animals which are highly strung (like cats) are unable to stop licking themselves in an anxious self harming way ... and so we do things to protect them from themselves.

You are, of course, a human, not a cat and so you can do what is needed by seeing your thought and rejecting those which are self destructive.

So maybe what you "have to do" is to see these things anew (or for the first time) and make them truly part of you. To be fully Grokked (to quote Heinlein)

https://www.psychologytoday.com/au/blog/hide-and-seek/202207/the-metaphor-the-stoic-archer-explained

KEY POINTS​

• The metaphor of the archer encapsulates the essence of Stoic action.
• An archer can shoot as accurately as possible and still miss his or her target. But this is no reflection on the archer.
• We need only concern ourselves with the quality of our actions. If we worry about their success, we will be unhappy on false grounds.

Best Wishes

 

[Timmay]

Hi Timmay

I have agreed to go with my surgeon's suggestion of a mechanical valve as I am hoping for a "one and done", so mechanical seems the logical choice.

Thanks
Jase

This is why I chose mechanical too. I was 50 when I got mine. After your open heart surgery is done and you’ve recovered a bit, you’ll say to yourself ‘wow, I’m so happy that I’ve put the odds in my favor for never doing this again’. Will you actually have to do it again? Maybe. But probably not. And - you didn’t choose the option that would mean that you would have to do it at least 1 more time (plus other hospital visits for at least 2 TAVR procedures).

 

[pellicle]

Hi

so mechanical seems the logical choice.

I suggest that you sit with a coffee and a notepad and just review this presentation from 2009 ... pretty much nothing has changed since then.



You may want to take a few notes along the way. But the bottom line is that if you get a mechanical you can get a better long term outcome than any other surgical option if you simply properly manage your INR. Its not rocket science to do so.

When the time comes reach out if you want a hand with that.

Best Wishes

 

[tom in MO]

Hi


I suggest that you sit with a coffee and a notepad and just review this presentation from 2009 ... pretty much nothing has changed since then.



You may want to take a few notes along the way. But the bottom line is that if you get a mechanical you can get a better long term outcome than any other surgical option if you simply properly manage your INR. Its not rocket science to do so.

When the time comes reach out if you want a hand with that.

Best Wishes

2009 is 15 years ago. Things have changed in valve surgery in the last 15 years. That video is no longer on the Mayo site.

 

[pellicle]

2009 is 15 years ago. Things have changed in valve surgery in the last 15 years

Some things have, and some things haven't. You still eat food, metabolize the same, and mechanical valves still don't wear out. What's important isn't that research is old, but when its superseded or contradicted by new research ... why don't you be a love and post the research which contradicts what Dr Schaff communicated? Or maybe even one or two points you think he's wrong about?

Is your mechanical valve still working?

 

[Protimenow]

I agree with Pellicle - mechanical is the way to go (although I won't recommend one approach over another).

Warfarin is not the scary thing that a lot of people seem to think it is. You won't bleed to death if you get a small cut. Nicking your face when you shave won't necessitate a trip to the emergency room because you're bleeding to death.

The real thing about anticoagulation with warfarin is that it takes a little longer to clot than it does without warfarin. If I have a small cut that would normally clot in 15 seconds, it may take 30-45 seconds to clot, depending on my INR. If I even FEEL the cut, putting pressure on it will stop the bleeding in a shorter amount of time.

I've been self managing since 2009, and I know that there are others on this site who have been doing it for even longer. And, as Pellicle said, he (and others) can help you get started with INR management.

As for 'thumping' when you have a mechanical valve - not everyone gets this. As far as 'ticking,' I don't think it will take long for you to get used to it - and it probably won't be an issue that keeps you awake at night. Plus, over time, it doesn't seem to be as loud.

You should be able to adjust to the ticking pretty quickly.

The INR management should be easy, and there are probably many 'clinics' who can do the testing and INR management for you - should you choose to put your fate into the hands of a clinic that may be using old dosing protocols and that probably know less about INR management that you soon will, if you read the posts on this site and get advice from Pellicle (or others).

Of course, the choice of valves is yours (and your surgeon's), but I advise not to let fear of warfarin or ticking weight too heavily on your ultimate decision.

 

[tom in MO]

Some things have, and some things haven't. You still eat food, metabolize the same, and mechanical valves still don't wear out. What's important isn't that research is old, but when its superseded or contradicted by new research ... why don't you be a love and post the research which contradicts what Dr Schaff communicated? Or maybe even one or two points you think he's wrong about?

Is your mechanical valve still working?

The video was pulled by Mayo. Probably because it's out-dated, but maybe because it is now factually incorrect. Either way you don't know...so are you trying for more hits on your blog

 

[Gail in Ca]

I was told my risk was 5% in ‘89 for my first surgery. It was about the same for my second in ‘00. When I needed that third surgery after endocarditis, I didn’t ask about my risk factor, nor did I want to know and no one offered to tell me. That was fine for me. I knew my top surgeon was taking it very seriously.
When I woke up after surgery, I came to realize my surgery was over, that I survived, and I was very content.
Turns out my risk was about 25%. I was glad I hadn’t researched that beforehand!

 

[pellicle]

The video was pulled by Mayo

oh, so you *know* it was pulled and not just that they did a site reorg (which I observed that they did) and they just decided to not give space to it anymore.

but maybe because it is now factually incorrect.

if you can identify one aspect which is not factually correct with respect to the mechanical valve side of things I'll be very interested to engage with that with you ... because I sure can't.

Why don't you email Dr Schaff and get it from the horses mouth?

https://www.mayoclinic.org/biographies/schaff-hartzell-v-m-d/bio-20053174

...so are you trying for more hits on your blog

that's cute, and I long anticipated that some low life person would try that on me and so from the beginning there has been utterly ZERO advertising on that blog, despite Google pestering me to monetize it. None. It's been that way from the start by active decision.

Why? Because I never want to have it seem that (like Adam pick does) what I wrote on my blog to be anything more than a public service or an expression of my feelings. Free and without any ads or conflicts of interest.

If you read my blog you'd see that ... you'd notice that I'd been writing helpful and in depth analysis since 2008 before in 2014 I penned that bit.

https://cjeastwd.blogspot.com/2009/11/death-ray.html
https://cjeastwd.blogspot.com/2009/11/fifites-fd-14-compared-to-om-18.html
https://cjeastwd.blogspot.com/2009/03/nikon-iv-ed-vs-epson-flatbed.html
Congratulations for being the first to make that accusation at me.

So back to to the factually wrong points ... please, do mention one.

 

[tom in MO]

oh, so you *know* it was pulled and not just that they did a site reorg (which I observed that they did) and they just decided to not give space to it anymore.


if you can identify one aspect which is not factually correct with respect to the mechanical valve side of things I'll be very interested to engage with that with you ... because I sure can't.

Why don't you email Dr Schaff and get it from the horses mouth?

https://www.mayoclinic.org/biographies/schaff-hartzell-v-m-d/bio-20053174


that's cute, and I long anticipated that some low life person would try that on me and so from the beginning there has been utterly ZERO advertising on that blog, despite Google pestering me to monetize it. None. It's been that way from the start by active decision.

Why? Because I never want to have it seem that (like Adam pick does) what I wrote on my blog to be anything more than a public service or an expression of my feelings. Free and without any ads or conflicts of interest.

If you read my blog you'd see that ... you'd notice that I'd been writing helpful and in depth analysis since 2008 before in 2014 I penned that bit.

https://cjeastwd.blogspot.com/2009/11/death-ray.html
https://cjeastwd.blogspot.com/2009/11/fifites-fd-14-compared-to-om-18.html
https://cjeastwd.blogspot.com/2009/03/nikon-iv-ed-vs-epson-flatbed.html
Congratulations for being the first to make that accusation at me.

So back to to the factually wrong points ... please, do mention one.

I've been to your blog more than once. I've known it's ad-free since Day 1. Still, people like to see those hits, gives you a warm fuzzy with the morning coffee.

Since, like me, you're not an expert, I'd expect you to not know what is outdated in the video. Since you believe in current, expert, source material, I am surprised you keep the video alive since it's not current and the expert source has pulled the video.

 

[pellicle]

I've been to your blog more than once. I've known it's ad-free since Day 1. Still, people like to see those hits, gives you a warm fuzzy with the morning coffee.

I literally don't give a flying ... and as far as hits go I know its essentially zero (compared to friends of mine who do professionally blog.

Since, like me, you're not an expert, I'd expect you to not know what is outdated in the video.

yep ... I do ... the absence of discussion on technology which didn't exist then. But I can't find any fault in any of the things he mentioned about mechanical valve data because that hasn't changed. Just like many of the other things in life which we have established and it hasn't changed.

I am surprised you keep the video alive since it's not current and the expert source has pulled the video.

I keep it alive because (just like other lectures from the past they are still on the money with good points. Again you insist on pulled but you have no knowledge that it was pulled, that its not there could be any one of the following factors:

• it was a depricated media type (.SWF) and the original source was lost, nobody knew how to trans code it
• the resolution wasn't "sufficient" for modern audiences
• as Schaff himself said, it represents less than 30% of the nature of the surgeries performed so its not a money spinner for Mayo anyway
• ...

you have still to identify what you consider errors are.

Perhaps the real issue is "you feel some remorse about your valve choice"

¯\_(ツ)_/¯

Conjecture, but after all this time you've never said anything specific except that its old. Well my firend there are many things in science and medicine which are not restudied because nobody doubts the original findings.

Why do you think that they still compare everything to mechanical valve when durability is on the "requirements" table?

Lastly you talk about experts; you do love your binary divisions (no grey in the middle) and your dismissal of non experts, yet we are not presenting papers we are only required to be sufficiently informed to be able to read them and to decide if that applies to us.

If you don't believe that then simply stop adding anything or offering any thoughts on this forum because you just ain't an expert (by your own admission).

Since, like me, you're not an expert

Perhaps unlike you, I've done sufficient reading and have done a research masters so that I at least am recognised in being able to read sufficiently to inform myself and become an expert in a field. I can say I've put a lot more years of study into this subject than my masters field (which was about sustainable water sources).

Best Wishes

 

[pellicle]

Still, people like to see those hits, gives you a warm fuzzy with the morning coffee.

This guy sums it up .. at exactly this time code


Like him I don't give a flying fck about hits. I suggest you watch the whole video, it may benefit you.

You claim I'm no expert, you admit you aren't. Has it ever occured to you that on the highly specific topics that I discuss here I am reasonably expert? I mean, for instance, nothing I say contradicts well published experts and indeed almost verbatim. So even if I'm doing nothing more than saying what they say, its "expert knowledge".

I suggest you find something that motivates you ...

 

[3mm]

I just did a 5 minute search and found this:
https://www.bing.com/videos/rivervi...61192C8E692E59F0B00061192C8E692E&&FORM=VRDGAR
This is a presentation by Dr Hartzell Schaff in 2022 titled "Prosthetic Valve Choice in TAVR Era". I think it is very relevant to a "mechanical versus tissue" discussion.

When I was making my mechanical versus bioprosthetic decision in August 2023, I found Dr Hartzell Schaff's 2009 video very useful.

 

[pellicle]

I just did a 5 minute search and found this:
https://www.bing.com/videos/rivervi...61192C8E692E59F0B00061192C8E692E&&FORM=VRDGAR
This is a presentation by Dr Hartzell Schaff in 2022 titled "Prosthetic Valve Choice in TAVR Era". I think it is very relevant to a "mechanical versus tissue" discussion.

bing huh ... interesting, never really thought to use it or search for a new one.



Thanks for the update on his position.

I guess his older video is so wrong ... he's completely changed his mind. (read the opposite)

still huh ... I guess this shows how far I am out too ...

Thanks

 

[Chuck C]

bing huh ... interesting, never really thought to use it or search for a new one.



Thanks for the update on his position.

I guess his older video is so wrong ... he's completely changed his mind. (read the opposite)

View attachment 889812

still huh ... I guess this shows how far I am out too ...

Thanks

Another great presentation by Dr. Schaff! Thanks for posting this.

I really appreciate the studies presented, especially those in which all-cause mortality or survival % is presented. I believe that often times the cause of death is murky and am relatively certain that causes indirectly related to valves must get sometimes overlooked. For this reason, the % survival and all cause mortality are very important when comparing valve choices.

By way of example, let's say that a patient develops cirrhosis of the liver, caused by failure of their bioprosthetic valve. In fact, a member recently shared that this happened to him and his team determined it was caused by his valve failure. In such event, should the liver cirrhosis end up being fatal, which it often is, the death certificate will likely call out cirrhosis of the liver, and I doubt it would mention valve failure as the cause of the cirrhosis. If the patient is involved in a valve study, I expect this indirect (arguably direct) cause could very easily, in fact likely, be overlooked. The all-cause mortality is where something like this is going to show up, when compared to the general population or compared to another valve type.

Sometimes the cause of death will be directly tied to the valve, such as the case when there is a fatal leaflet tear. But, if the valve leads to the development of some other chronic condition, the link could easily be lost. Even when the patient dies of a stroke, often times it will not be known what the cause of the stroke was. Most follow up studies on valves are industry sponsored- it is just the reality of how it works. It does not mean that the studies are worthless, but critical analysis is always warranted. Industry valve studies tend to focus on mortality attributed directly to the valve, rather than all cause mortality. This is no accident, and I believe that it can lead to some misleading conclusions.

An example of where all cause mortality has played a critical role is with the use of niacin. Niacin lowers LDL and raises HDL. For decades has been used to treat high LDL and low HDL. As such, one would expect an improvement in mortality for patients at high risk being treated for dyslipidemia with niacin. However, studies in the past 15 years have shown that treatment with niacin gives no suvival benefit, despite improving the lipid profile. As such, it is no longer recommended in the guidelines for the treatment of dyslipidemia.