Bicuspid valve , aneurysm and complication

[Deepak khanka]

Hello All
I had a valve sparing surgery I.e David’s procedure were my bicuspid aortic valve was saved and the aortic aneurysm on my ascending aorta was removed. However my valve was left with severe regurgitation. During the surgery my left coronary artery got injured and the surgeons had to do a bypass and seal of the injured artery. In other words the material graft which replaces the aneurysm has 2 coronary arteries attached the left one got injured . CABG was done.
Has anyone experienced any complication during surgery any injury or anything’s else
I am due to have one more surgery to replace the valve . Having a bypass makes the surgery complicated . Any advise will well . Many thanks
Regards
Deepak

 

[pellicle]

Sorry to read this.
No I haven't experienced anything like that. Where was this done?
Why didn't they replace the valve?

 

[Deepak khanka]

In UK, Essex . I was 40 I.e 2019 the surgeons felt I will benefit from valve saving surgery but I think changing the whole would have been better. I don’t advice David’s procedure to anyone

 

[pellicle]

In UK, Essex . I was 40 I.e 2019 the surgeons felt I will benefit from valve saving surgery but I think changing the whole would have been better. I don’t advice David’s procedure to anyone

wow ... 40 ... tha'ts just strange risk analysis ... the chances of the valve lasting you another 30 years are nearly nil. As I understand it you also had an aneurysm fix, is that right?

Was the valve calcified? If not then you'll likely get 20 years from that.

 

[cldlhd]

In UK, Essex . I was 40 I.e 2019 the surgeons felt I will benefit from valve saving surgery but I think changing the whole would have been better. I don’t advice David’s procedure to anyone

I had the valve sparing David procedure at the age of 45. I was leaning towards just replacing the valve with a mechanical and a graft for the aneurysm shooting for a one and done but my surgeon was big on repairing the valve since I had only trace leakage (aneurysm was cause for surgery);and I had great numbers ( i.e. pressure gradient , flow etc ) and no calcification. I told him I didn't want him to do a repair because possibly it was a more challenging surgery for him and he wanted a challenge. He appreciated my directness, at least he said so, then said he thought it was the best option for me. Reiterated I only wanted the repair if he thought it had a shot at lasting a lifetime once he laid eyes on it. He ended up repairing it and the surgery came out great. In fact he used my surgery as a positive case at a North American valve repair/ replacement conference. I'm very sorry to hear what happened to you but disparaging an entire procedure based solely on personal and anecdotal evidence doesn't cut it.
I hope your surgery is a success.

 

[cldlhd]

I wanted to add I hope your surgery is a suc

wow ... 40 ... tha'ts just strange risk analysis ... the chances of the valve lasting you another 30 years are nearly nil. As I understand it you also had an aneurysm fix, is that right?

Was the valve calcified? If not then you'll likely get 20 years from that.

Well Pell there are a lot of BAVs that last a lifetime and I assume we don't know how many. I mean if they never cause an issue many probably never know they have one. I think the question is the condition of his valve. Is it calcified? How much regurgitation? I agree if the valve isn't in decent shape I would say replace it while in there. I was kind of pushing that with my surgery but I was told my native valve would perform better than any replacement option. I had no calcification when they saw it and trace leakage. I mean who knows one day it might need replacing but I was adamant I didn't want to kick the can down the road as a test case or a challenge and I had no issue with anti coagulation compliance ( hell I have like 4 or 5 pharmacies within 3 miles if my house) but at the end of the day I decided to take the world class experts advice.

 

[pellicle]

I mean if they never cause an issue many probably never know they have one

true ... but when the cause an issue, and require surgery and the guy is 40 it leaves me scratching my head.

Mine lasted 20 years or so on a repair ...

I couldn't find too much (and I'm a bit flat out atm) but:

Long-Term Durability of Bicuspid Aortic Valve Repair

Freedom from aortic valve reoperation at 10 years was 78%.​

Risk of reoperation was highest immediately after operation and fell rapidly to approximately 2.6%/year up to 15 years​

which is interesting because:

From 1985 to 2011, 728 patients, mean age 42 ± 12 years, underwent BAV repair at Cleveland Clinic. Mean follow-up was 9.0 ± 6.2 years (median, 8.3)​

which is again hilarious because mean age (doesn't say much in iteself is used (no StandardDeviation used) then mean and median are both used for the follow up ... however with a follow up median of 8.3 years that 15 years is a lot of speculation.

Its the sort of stuff I see time and time again. Stats which would not pass muster in undergad level let alone be satisfactory for research publication. But that's just how the Art of Surgery rolls.

PS: some of the names in the Author list seem a bit "I think I've seen that guy before" ...

 

[cldlhd]

true ... but when the cause an issue, and require surgery and the guy is 40 it leaves me scratching my head.

Mine lasted 20 years or so on a repair ...

I couldn't find too much (and I'm a bit flat out atm) but:

Long-Term Durability of Bicuspid Aortic Valve Repair

Freedom from aortic valve reoperation at 10 years was 78%.​

Risk of reoperation was highest immediately after operation and fell rapidly to approximately 2.6%/year up to 15 years​

which is interesting because:

From 1985 to 2011, 728 patients, mean age 42 ± 12 years, underwent BAV repair at Cleveland Clinic. Mean follow-up was 9.0 ± 6.2 years (median, 8.3)​

which is again hilarious because mean age (doesn't say much in iteself is used (no StandardDeviation used) then mean and median are both used for the follow up ... however with a follow up median of 8.3 years that 15 years is a lot of speculation.

Its the sort of stuff I see time and time again. Stats which would not pass muster in undergad level let alone be satisfactory for research publication. But that's just how the Art of Surgery rolls.

PS: some of the names in the Author list seem a bit "I think I've seen that guy before" ...

Think I've read that before but I'll read it in the morning. I believe if the repair makes it the first 10 years it's more likely to last. Either way my point was more to the fact that in some cases, including mine, where the valve is "repaired" more as a tweak while we're in here doing the aneurysm is different then if the valve is the primary cause for the surgery.

 

[Deepak khanka]

true ... but when the cause an issue, and require surgery and the guy is 40 it leaves me scratching my head.

Mine lasted 20 years or so on a repair ...

I couldn't find too much (and I'm a bit flat out atm) but:

Long-Term Durability of Bicuspid Aortic Valve Repair

Freedom from aortic valve reoperation at 10 years was 78%.​

Risk of reoperation was highest immediately after operation and fell rapidly to approximately 2.6%/year up to 15 years​

which is interesting because:

From 1985 to 2011, 728 patients, mean age 42 ± 12 years, underwent BAV repair at Cleveland Clinic. Mean follow-up was 9.0 ± 6.2 years (median, 8.3)​

which is again hilarious because mean age (doesn't say much in iteself is used (no StandardDeviation used) then mean and median are both used for the follow up ... however with a follow up median of 8.3 years that 15 years is a lot of speculation.

Its the sort of stuff I see time and time again. Stats which would not pass muster in undergad level let alone be satisfactory for research publication. But that's just how the Art of Surgery rolls.

PS: some of the names in the Author list seem a bit "I think I've seen that guy before" ...

My valves are not calcified but post David’s procedure have a severe leak and one of the leaf has prolapsed. Surgery and aortic valve replacement is the only option. On-x is the valve I am going for. Resilia very limited data. The surgeons say mechanical valve have life time Gaurantee?

 

[Deepak khanka]

All this has impacted my LV which is 6.7 cms..which is dialated. I am not showing any signs of heart failure . Hence considering surgery before the worst

 

[pellicle]

On-x is the valve I am going for. Resilia very limited data. The surgeons say mechanical valve have life time Gaurantee?

so you mean you're up for a second surgery? That's dreadful.

There is of course the old gag about the lifetime warranty. However I am of the view that for your age group (now having had one surgery) planning to clear it up is a good call. I had a mechanical and aneurysm repair on my 3rd surgery.

I would look carefully at the major players in the mech valve area and to my eye the only thing that On-X has going for it is an appeal to the hysteria about managing INR and its "lower INR" rating. I'd summarize it as:

• they didn't have anything much to sell a new valve into an established market (such as St Jude) and decided to tap that vein
• the lower INR is one of those things that you think is a huge thing when you know nothing about it, but when you're actually into it and get past the "worried about it" phase then the reality is that you should target INR=2.5 and pretty much all the modern bileaflet pyrolytic carbon mech-valves are quite the same (and tolerant of lower INR levels)

There is some discussion here about the On-X compared to St Jude (and indeed I have neither, I have an ATS tikkin away).

The single biggest thing you can do to make your life better is a well managed INR and self testing really helps that.

This may help
http://cjeastwd.blogspot.com/2014/09/managing-my-inr.html
Best Wishes

 

[Warrick]

I remember reading stats somewhere 50% of bicuspid valves will give issues and of that 50% that give issues, 80% get replaced.
So I guess that means 40% of all BAVs get replaced . However.. and theres varying opinions on this but its around 65% of all BAVs also result in aneurysm, so I guess if you get get thru life and dont get bitten by either valve failure or aneurysm hopefully you win lotto as well
https://badaorta.com/double-trouble-bicuspid-aortic-valve-bav/
A friend of mine had one of his coronary arteries inadvertly blocked during surgery for valve replacement and anerysm repair, he has a donor heart now.

My father passed a few months ago from cancer, he had a St Jude mechanical that was still ticking after 36 years, so yip mechanicals do exactly what it says on the tin- last a lifetime.

Interestingly I contacted St Jude (Abbott now) to let them know Dad had passed and his valve was 36 years young, his model was a 21A-101, to which Abbott said they had no records on this model... I would have thought theyd be a bit more onto it than that considering most of the literature still say mechanicals last 20 years. 20 years and then a whole lot more

 

[cldlhd]

I remember reading stats somewhere 50% of bicuspid valves will give issues and of that 50% that give issues, 80% get replaced.
So I guess that means 40% of all BAVs get replaced . However.. and theres varying opinions on this but its around 65% of all BAVs also result in aneurysm, so I guess if you get get thru life and dont get bitten by either valve failure or aneurysm hopefully you win lotto as well
https://badaorta.com/double-trouble-bicuspid-aortic-valve-bav/
A friend of mine had one of his coronary arteries inadvertly blocked during surgery for valve replacement and anerysm repair, he has a donor heart now.

My father passed a few months ago from cancer, he had a St Jude mechanical that was still ticking after 36 years, so yip mechanicals do exactly what it says on the tin- last a lifetime.

Interestingly I contacted St Jude (Abbott now) to let them know Dad had passed and his valve was 36 years young, his model was a 21A-101, to which Abbott said they had no records on this model... I would have thought theyd be a bit more onto it than that considering most of the literature still say mechanicals last 20 years. 20 years and then a whole lot more

Thanks for those numbers. I guess as the years go on we'll probably get better data on that as back in the day as they say there were less tests being run. This thread isn't about me so I don't want to hijack it but it is relevant information I guess, I fall into the aneurysm bit me category. My valve was still functioning just fine at the age of 50 according to my last echo a year and a half ago. Maybe it'll last a long long life or maybe I'll need to replace it who knows? I'm sorry to hear about your friend and your father.

 

[cldlhd]

All this has impacted my LV which is 6.7 cms..which is dialated. I am not showing any signs of heart failure . Hence considering surgery before the worst

Just curious if the leak is worse after the repair than it was before. Either way it sounds likely that the surgeon didn't Do a good job as he could have. Like I would be curious if the leak was immediately after surgery or developed shortly later as when I had my surgery I know they tested the valve for leakage at the time. I agree with you that at your age you would be better off replacing the valve with a mechanical if it needs to be replaced. That would be the best opportunity to avoid a third surgery in my humble opinion. Best wishes

 

[cldlhd]

true ... but when the cause an issue, and require surgery and the guy is 40 it leaves me scratching my head.

Mine lasted 20 years or so on a repair ...

I couldn't find too much (and I'm a bit flat out atm) but:

Long-Term Durability of Bicuspid Aortic Valve Repair

Freedom from aortic valve reoperation at 10 years was 78%.​

Risk of reoperation was highest immediately after operation and fell rapidly to approximately 2.6%/year up to 15 years​

"At Cleveland Clinic, all bicuspid aortic valves are repaired in a minimally invasive “keyhole” operation. Patients are discharged home four to seven days after surgery and can return to driving—and often to work—in as little as two weeks." I saw that on the Cleveland clinic's website which I was a little surprised by. I mean who am I to question them but I figured a full sternotomy would be used. The other thing I didn't get is it Dr Svensson said that while doing the valve they repair / replace the aneurysm if it's greater than 5 cm. Again what do I know but I would imagine you would replace it even if it was smaller than that. I mean I figured that the normal size is less than 4 cm So once it's definitely shown that it's growing and will likely continue to I don't know why you would leave it in there? I mean they opened me up to replace mine when it measured at 4.8 cm turns out it was 4.99 but hey.

which is interesting because:

From 1985 to 2011, 728 patients, mean age 42 ± 12 years, underwent BAV repair at Cleveland Clinic. Mean follow-up was 9.0 ± 6.2 years (median, 8.3)​

which is again hilarious because mean age (doesn't say much in iteself is used (no StandardDeviation used) then mean and median are both used for the follow up ... however with a follow up median of 8.3 years that 15 years is a lot of speculation.

Its the sort of stuff I see time and time again. Stats which would not pass muster in undergad level let alone be satisfactory for research publication. But that's just how the Art of Surgery rolls.

PS: some of the names in the Author list seem a bit "I think I've seen that guy before" ...

 

[AZ Don]

I had a (Bicuspid aortic) valve sparing aneurysm repair as well. Not to be confused with a bicuspid aortic valve repair as my valve was well functioning at the time. It has worked out for me. My valve started leaking mildly after the surgery, progressed to moderate over the next year, and has been stable for 7 years now. From the point it started leaking I have taken it as a given that it will have to be replaced, though I've been told that isn't necessarily the case. At the time (age 51) I was given the choice my logic was simply if it ain't broke, don't fix it. Knowing what I know now, I might give more consideration to the mechanical valve because it is a less complex surgery and much less likelihood of future operations, but I have no regrets.

Best wishes on your upcoming surgery Deepak.

 

[Chuck C]

Hello All
I had a valve sparing surgery I.e David’s procedure were my bicuspid aortic valve was saved and the aortic aneurysm on my ascending aorta was removed. However my valve was left with severe regurgitation. During the surgery my left coronary artery got injured and the surgeons had to do a bypass and seal of the injured artery. In other words the material graft which replaces the aneurysm has 2 coronary arteries attached the left one got injured . CABG was done.
Has anyone experienced any complication during surgery any injury or anything’s else
I am due to have one more surgery to replace the valve . Having a bypass makes the surgery complicated . Any advise will well . Many thanks
Regards
Deepak

Welcome to the forum.
I'm sorry to hear that you have to get another operation so soon after your David's procedure. Hindsight is 20/20, and we can't know what data your surgeon was looking at when he decided not to replace your BAV during the repair of your aneurism. I think that your decision to go mechanical at this point is a very sound decision at your age.

I have previously been of the opinion that a BAV patient undergoing aneurism repair should also have valve replacement to avoid the possibility of a future operation. But, after reading the study linked below I am not so sure and I think that a case can be made either way:

This study on those with BAV who underwent a David's Procedure was small but interesting. 50 BAV patients, mean age 46:

"The rates for freedom from valve-related reoperation at 1, 5, 10 and 20 years after initial surgery were 98%, 88%, 79% and 74%, respectively."

https://pubmed.ncbi.nlm.nih.gov/32243510/
So, 74% being free from valve related reoperation is pretty good. But, perhaps the other 26% wished that they had their valve replaced as well during OHS.

On the other hand, this study suggests that having the aortic valve and aorta replaced, aka Bentall Procedure, has remarkably good long term outcomes, which could make the case to replace the BAV during OHS for aneurism repair:

" Long-term survival was 93% after 5 years and 89% after 10 years. Discharged patients enjoyed survival equivalent to a normal age- and ***-matched population and superior to survival reported for a series of patients with aortic valve replacement alone. "

The bold is mine.

https://pubmed.ncbi.nlm.nih.gov/178...al was 93,with aortic valve replacement alone.

I wish you the best of luck with your upcoming valve surgery. Please keep us posted.

 

[cldlhd]

Welcome to the forum.
I'm sorry to hear that you have to get another operation so soon after your David's procedure. Hindsight is 20/20, and we can't know what data your surgeon was looking at when he decided not to replace your BAV during the repair of your aneurism. I think that your decision to go mechanical at this point is a very sound decision at your age.

I have previously been of the opinion that a BAV patient undergoing aneurism repair should also have valve replacement to avoid the possibility of a future operation. But, after reading the study linked below I am not so sure and I think that a case can be made either way:

This study on those with BAV who underwent a David's Procedure was small but interesting. 50 BAV patients, mean age 46:

"The rates for freedom from valve-related reoperation at 1, 5, 10 and 20 years after initial surgery were 98%, 88%, 79% and 74%, respectively."

https://pubmed.ncbi.nlm.nih.gov/32243510/
So, 74% being free from valve related reoperation is pretty good. But, perhaps the other 26% wished that they had their valve replaced as well during OHS.

On the other hand, this study suggests that having the aortic valve and aorta replaced, aka Bentall Procedure, has remarkably good long term outcomes, which could make the case to replace the BAV during OHS for aneurism repair:

" Long-term survival was 93% after 5 years and 89% after 10 years. Discharged patients enjoyed survival equivalent to a normal age- and ***-matched population and superior to survival reported for a series of patients with aortic valve replacement alone. "

The bold is mine.

https://pubmed.ncbi.nlm.nih.gov/178...al was 93,with aortic valve replacement alone.

I wish you the best of luck with your upcoming valve surgery. Please keep us posted.

Yeah it makes sense to me as well that patient selection plays a role. In other words the health of the patient, the condition of the valve etc would rationally make a pretty big difference in valve repair success. Also after reading that link you provided It really doesn't make sense to me that the Cleveland clinic site said they only replace the aneurysm if it's over 5 cm at the time of the surgery.

 

[Chuck C]

Also after reading that link you provided It really doesn't make sense to me that the Cleveland clinic site said they only replace the aneurysm if it's over 5 cm at the time of the surgery.

I’ll put on my cynic’s hat for a moment: Perhaps it increases the probability that their customers will return for future business.

I sure hope that’s not the reason, but it does make you wonder.

 

[cldlhd]

I’ll put on my cynic’s hat for a moment: Perhaps it increases the probability that their customers will return for future business.

I sure hope that’s not the reason, but it does make you wonder.

Yeah I'm not an expert but it does seem a little crazy to me. Especially considering when I had my David V procedure my valve didn't even need to be operated on It only had trace leakage which it still has now. My aneurysm measured 4.8 cm and My cardiologist recommended I wait and my surgeon said I could either wait or get it done it was up to me. He said it was on the cusp in other words it was big enough that the insurance company would pay for the surgery. So if the University of Pennsylvania thinks that a 4.8 cm aneurysm in and of itself is big enough to justify an operation then why would the Cleveland clinic not replace one that size while they're already in there doing the valve?