Bicuspid valve , aneurysm and complication

[pellicle]

Hi

Stuff

If your going to quote me then don't just edit your comment into my block or it's nearly impossible to find what you wrote. Go look yourself, it appears all as my words.

If you want to add the quote below a section, then edit it.

Anyway my question is is that Dr the same Dr that is in the article I cited?

 

[cldlhd]

Sorry about that Chief, I was doing that this morning as I was just starting to sit my first coffee. I feel like I should start a new thread as this is feeling like a hijack a bit. Strange though I just decided for s**** and giggles to look back over my last echo stress test and it shows the results as having no regurgitation whereas before it said trace but you know I'll go with the no regurgitation I guess....

 

[cldlhd]

Hi


If your going to quote me then don't just edit your comment into my block or it's nearly impossible to find what you wrote. Go look yourself, it appears all as my words.

If you want to add the quote below a section, then edit it.

Anyway my question is is that Dr the same Dr that is in the article I cited?

I believe so- Dr. Svensson

 

[boneysjoint]

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
[/QUOTE

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

Hi Deepak
Sorry to hear about the complications you have had.
Could I ask where you had your operation as my Husband is looking as though he will have to have his aortic root replaced. We are seeing his Surgeon tomorrow at Basildon CTC. Thank you in advance.

 

[pellicle]

I feel like I should start a new thread as this is feeling like a hijack a bit

no worries, between that and zombie threads I think this is "the norm" here. Anyway, as I asked is your Dr Svensson the same as the one in the article I mentioned?

previously you wrote:

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'm not sure what a lot of this means, it appears to be written as I know all the details as well as you do (I'm sorry, but I don't, its been a long time). However if you had the aneurysm dealt with then it seems absurd to not properly finish the job. There is scant evidence that a repair lasts 20 years or more in a younger patient.

Personally I still can't understand that while you've go the engine laid bare you decided to not do the water pump (because "they last another thousand easy") when you can simply remove all the variables with new parts >for no extra risk because you're already doing surgery< and replace with a mechanical or tissue prosthetic based on patient variables.

Just because a surgeon likes to tinker and be an artisan is not a good justification to set a patient up for repeat surgeries and to be totally honest its hard to see any other justification for that.

As Warrick put it

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

what is unclear about that is ages, I'd say that the vast majority of BAV give issues when the person is older. So if you happen to be a younger patient then just get it done in a durable way. For surgeons to not have had this thought is hard to believe.

I believe (and one sees it again and again in the literature) that the main issue with a mechanical prosthetic is anticoagulation and its proper management. Take care of that issue and you're on a winner.

 

[cldlhd]

no worries, between that and zombie threads I think this is "the norm" here. Anyway, as I asked is your Dr Svensson the same as the one in the article I mentioned?

previously you wrote:


I'm not sure what a lot of this means, it appears to be written as I know all the details as well as you do (I'm sorry, but I don't, its been a long time). However if you had the aneurysm dealt with then it seems absurd to not properly finish the job. There is scant evidence that a repair lasts 20 years or more in a younger patient.

Personally I still can't understand that while you've go the engine laid bare you decided to not do the water pump (because "they last another thousand easy") when you can simply remove all the variables with new parts >for no extra risk because you're already doing surgery< and replace with a mechanical or tissue prosthetic based on patient variables.

Just because a surgeon likes to tinker and be an artisan is not a good justification to set a patient up for repeat surgeries and to be totally honest its hard to see any other justification for that.

As Warrick put it


what is unclear about that is ages, I'd say that the vast majority of BAV give issues when the person is older. So if you happen to be a younger patient then just get it done in a durable way. For surgeons to not have had this thought is hard to believe.

I believe (and one sees it again and again in the literature) that the main issue with a mechanical prosthetic is anticoagulation and its proper management. Take care of that issue and you're on a winner.

Yes it was Dr Svensson from the Cleveland clinic I was talking about, he's not my surgeon but in the article in which he's quoted it says they only fix the aneurysm while repairing the valve if it's greater than 5 cm, which seems absurd. I told my surgeon I wanted everything that needs done while he has the wheels off. He laughed, agreed and the aneurysm was replaced all the way up to and including the hemi arch. Regarding the longevity of the repair understand where you're coming from and agree to an extent. I mean I was adamant that if he thought the repair didn't have a reasonable chance of lasting , as in like possibly a lifetime, then give me a mechanical.

 

[cldlhd]

no worries, between that and zombie threads I think this is "the norm" here. Anyway, as I asked is your Dr Svensson the same as the one in the article I mentioned?

previously you wrote:


I'm not sure what a lot of this means, it appears to be written as I know all the details as well as you do (I'm sorry, but I don't, its been a long time). However if you had the aneurysm dealt with then it seems absurd to not properly finish the job. There is scant evidence that a repair lasts 20 years or more in a younger patient.

Personally I still can't understand that while you've go the engine laid bare you decided to not do the water pump (because "they last another thousand easy") when you can simply remove all the variables with new parts >for no extra risk because you're already doing surgery< and replace with a mechanical or tissue prosthetic based on patient variables.

Just because a surgeon likes to tinker and be an artisan is not a good justification to set a patient up for repeat surgeries and to be totally honest its hard to see any other justification for that.

As Warrick put it


what is unclear about that is ages, I'd say that the vast majority of BAV give issues when the person is older. So if you happen to be a younger patient then just get it done in a durable way. For surgeons to not have had this thought is hard to believe.

I believe (and one sees it again and again in the literature) that the main issue with a mechanical prosthetic is anticoagulation and its proper management. Take care of that issue and you're on a winner.

Maybe BAVs are like drug users, you only notice the obvious ones that have a problem but the lawyer or accountant who smokes a joint on his back patio while laying by the pool goes unnoticed...

 

[Chuck C]

Personally I still can't understand that while you've go the engine laid bare you decided to not do the water pump (because "they last another thousand easy") when you can simply remove all the variables with new parts >for no extra risk because you're already doing surgery< and replace with a mechanical or tissue prosthetic based on patient variables.

This is generally how I feel as well. You may recall that Dr. Shemin decided to go against the medical guidelines and replace my aortic root and ascending aorta, even though the max diameter was only 3.5cm. He was using his experience- that the aorta tissue appeared to be the type that will aneurism eventually. He also used his recollection of my wishes. We had two lengthy consults and he said he specifically remembered me telling him I wanted to be "one and done" and believed the right thing was to replace the aorta while he had me opened up, rather that need to open me up again in 10 years.

 

[pellicle]

just as a guide for average age of aortic valve replacement
https://www.reliasmedia.com/articles/144956-life-expectancy-after-aortic-valve-replacement

Patients who underwent cardiac procedures other than concomitant coronary artery bypass graft surgery, those with infective endocarditis, and those who underwent emergent surgery were excluded. The outcome measures were survival, relative survival, and loss of life expectancy after AVR. ... During the study period, 23,528 patients met the entry criteria. Mean age was 71 years, 40% were women, 58% had undergone isolated AVR​

so while those who undergoe AVR may be young, they are tyically NOT.

This is logical given the stats that Warrick stated above, were it in the main a disease that afflicted younger people it would have been a genetic selection pressure to remove it from the population. I myself would have died before 15 were I born as recently as in my mothers time, when such surgery was unavailable.

 

[pellicle]

I mean I was adamant that if he thought the repair didn't have a reasonable chance of lasting , as in like possibly a lifetime, then give me a mechanical.

Myself I'd have said not "possibly" ... I'd have said "a reasonable chance of lasting a lifetime". There's too much wiggle room (and he may not have listened anyway, knowing he can do pretty much exactly what he wants).

Here's the rub, and its my own opinion based on decades of observation and discussion with friends who have dealt professionally with cardiac surgeons. These friends include people who made specialist catheters for cardiac surgeons, pathologists and doctors.

My opinion:

To become a heart surgeon you must have clearly shown that you are:

• diligent
• reliable
• intelligent
• detail oriented

This is not to say that you are not a little bit arrogant, a little bit convinced of your correctness and a little bit willing to explain away the outliers in an industry that has its primary focus on 10 year longevity. Note I did not say "10 year reoperation event free".

Its like the Ross, many surgeons look unfavourably on it, except those who love it (a minority btw). Its their pet subject.

Professionals are no less subject to psychology than the rest of us, having personal confirmation biases and living in a reasonably well formed bubble. They are prone to making judgements about the opinions of their colleagues and may not be very interested in "the truth" so much as "their statistics".

That's my opinion.

Anyway buddy, the specifics of your situation will play out over time. I hope you get the lifetime (but not in the other way).

 

[vitdoc]

I had my third surgery about 15 years ago. It was primarily for a large 6.5 cm aneurysm. I had a mechanical St. Jude in for 23 years without any issues. But the valve and the aortic conduit come as one piece so my 23 year old St. Jude was removed for a new St. Jude and aorta. Somehow there was difficulty in reattaching my right coronary artery. I was told that it was "too short" so during the surgery a piece of saphenous vein was connected to the end of the artery to extend it. Anyway I did ok initially but perhaps six months later I started to get angina. The vein artery connection had "kinked" and was shutting down flow.
Not good. So I had stents placed to open up the kink. They initially worked but perhaps a year later got angina again from closure of the opening. Restented in the same place with now a total of 5 stents. Worked again for a while. Finally got symptomatic again back in the cath lab for stenting number 3. While on the table under sedation the cardiologist wakes me up and tells me that the vessel is closed and can't be reopened. I told him to try harder and I don't care if you kill me. He did. And magically reopened the vessel and now over 10 years later it is still wide open. Total of 8 stents in one place.

So like everything else if you can imagine a problem it will happen sooner or later. You just hope you won't be the one.
That is why I tend to believe that the fewer procedures if possible the better. Every procedure has risk. So when I hear people talk rather cavalierly about having a tissue valve and then pop in a TAVR they often forget the possible issues with each procedure.

I have had a lot of procedures but for the most part I didn't have a choice. I made one mistake way back in 1977 having a tissue valve at age 29 for severe aortic stenosis. In those days the longevity of the valves was not well understood. Mine only lasted 5 1/2 years - then the St. Jude. On the positive side the St. Jude wasn't around in 1977 so I lucked out by having those 5 1/2 years of research and getting the St. Jude. Otherwise I might have had a Starr-Edwards ball valve or a tilting disk valve which were popular then and proved not to be very good.

As a physician and surgeon I don't think that most cardiovascular surgeons are not doing surgery so they can do another procedure later due to money. I think however that many physicians don't look at the big picture some times and to them a procedure is just a procedure. To the patient it is a big deal.
If there was one obviously perfect solution then everyone would be doing that. Clearly there are many ways to skin a cat so we have these discussions on this forum.

 

[cldlhd]

Myself I'd have said not "possibly" ... I'd have said "a reasonable chance of lasting a lifetime". There's too much wiggle room (and he may not have listened anyway, knowing he can do pretty much exactly what he wants).

Here's the rub, and its my own opinion based on decades of observation and discussion with friends who have dealt professionally with cardiac surgeons. These friends include people who made specialist catheters for cardiac surgeons, pathologists and doctors.

My opinion:

To become a heart surgeon you must have clearly shown that you are:

• diligent
• reliable
• intelligent
• detail oriented

This is not to say that you are not a little bit arrogant, a little bit convinced of your correctness and a little bit willing to explain away the outliers in an industry that has its primary focus on 10 year longevity. Note I did not say "10 year reoperation event free".

Its like the Ross, many surgeons look unfavourably on it, except those who love it (a minority btw). Its their pet subject.

Professionals are no less subject to psychology than the rest of us, having personal confirmation biases and living in a reasonably well formed bubble. They are prone to making judgements about the opinions of their colleagues and may not be very interested in "the truth" so much as "their statistics".

That's my opinion.

Anyway buddy, the specifics of your situation will play out over time. I hope you get the lifetime (but not in the other way).

That may not have been my exact wording. I found some pretty interesting videos from done of these valve repair symposiums. Maybe I'll try to link a few tomorrow. Thanks

 

[pellicle]

Hi

... While on the table under sedation the cardiologist wakes me up and tells me that the vessel is closed and can't be reopened. I told him to try harder and I don't care if you kill me. He did. And magically reopened the vessel and now over 10 years later it is still wide open. Total of 8 stents in one place.

glad you're still here.

That is why I tend to believe that the fewer procedures if possible the better. Every procedure has risk. So when I hear people talk rather cavalierly about having a tissue valve and then pop in a TAVR they often forget the possible issues with each procedure.

Agreed

I have had a lot of procedures but for the most part I didn't have a choice. I made one mistake way back in 1977 having a tissue valve at age 29 for severe aortic stenosis. In those days the longevity of the valves was not well understood. Mine only lasted 5 1/2 years - then the St. Jude. On the positive side the St. Jude wasn't around in 1977 so I lucked out by having those 5 1/2 years of research and getting the St. Jude. Otherwise I might have had a Starr-Edwards ball valve or a tilting disk valve which were popular then and proved not to be very good.

A bit like myself, technology was evolving mush more in the 70's than today in some ways.

As a physician and surgeon I don't think that most cardiovascular surgeons are not doing surgery so they can do another procedure later due to money.

A few too many double negatives in there for me to follow properly...

Clearly there are many ways to skin a cat so we have these discussions on this forum.

Agreed, and many different patient specifics too

Best Wishes

 

[Chuck C]

As a physician and surgeon I don't think that most cardiovascular surgeons are not doing surgery so they can do another procedure later due to money. I think however that many physicians don't look at the big picture some times and to them a procedure is just a procedure. To the patient it is a big deal.

I agree. In my experience, I have felt that every surgeon and every cardiologist has had my best interest in mind. I think that the issue, as you say, is that they don't look at the big picture often enough and don't look far enough down the road. Whey I hear Lars Svensson and others boast about their SAVR survival rates, they are talking about 30 day and 1 year survival rates. While that is important to me, I am far more interested in 10-year, 20-year and 30-year + survival rates. Not replacing an aortic aneurism that is 4.9cm will likely mean a re-visit to the operating table for the patient within 5-10 years; maybe sooner. That is a big deal for the patient, but for the surgeon, perhaps just another day in the office.
As I've said previously, very happy that my surgeon was thinking 10-15 years ahead and decided to replace my 3.5cm aorta.
And I believe that the same issue may be why some surgeons are so happy to put tissue valves in 50 year-olds. It's just that they aren't thinking far enough ahead and maybe being a little too optimistic when they do. A 10-year outcomes study is considered long term. Sure, you are going to have similar results after 10 years. For a 50 year old, the 30-40 year picture should be considered.

 

[pellicle]

It's just that they aren't thinking far enough ahead and maybe being a little too optimistic when they do.

...and maybe noncompliance with warfarin ...

 

[Wiles Darkwinter]

Couple of thoughts:
I feel as though if you've had a successful surgery and have had little or no complications you're always going to back that procedure. Likewise, if you've had a horror show, your opinion will be skewed.

Briefly for those who don't know; The David procedure is technically very difficult, and very few people meet the criteria. Usually, it is the procedure of choice for younger patients, who are physically active (I mean really physically active) who have aortic root/ascending aortic aneurysms, in the absence of any leaky valves. Often used for Marfan's patients and patients who's aneurysms weren't CAUSED by valve issues. The diseased aorta is cut out, dacron tube inserted and the native valve leaflets are resuspended into the dacron. Very fiddley stuff.

Main points are:
- We only have 20 years of data on the David's procedure - which isn't going to be enough for many people, especially die hard mech valvers. It was enough for me.
- The data we do have shows excellent results (Valve-Sparing Aortic Root Replacement as First-Choice Strategy in Acute Type a Aortic Dissection)
- Athletes who have received the David procedure have returned to PROFESSIONAL high intensity sport (e.g. Ronny Turiaf - LA Lakers)
- Highly dependent on surgeon's skill.

Personally, my surgeon laid out all the options, gave me pro's and cons, was upfront about the risks. I went with the David and no issues.

I'd be careful about citing studies which are too broad, and make sure you read the limitations of each study. More often than not, the publishers will acknowledge the short comings of the study before any critics do. Most people don't read that far down.

 

[cldlhd]

Couple of thoughts:
I feel as though if you've had a successful surgery and have had little or no complications you're always going to back that procedure. Likewise, if you've had a horror show, your opinion will be skewed.

Briefly for those who don't know; The David procedure is technically very difficult, and very few people meet the criteria. Usually, it is the procedure of choice for younger patients, who are physically active (I mean really physically active) who have aortic root/ascending aortic aneurysms, in the absence of any leaky valves. Often used for Marfan's patients and patients who's aneurysms weren't CAUSED by valve issues. The diseased aorta is cut out, dacron tube inserted and the native valve leaflets are resuspended into the dacron. Very fiddley stuff.

Main points are:
- We only have 20 years of data on the David's procedure - which isn't going to be enough for many people, especially die hard mech valvers. It was enough for me.
- The data we do have shows excellent results (Valve-Sparing Aortic Root Replacement as First-Choice Strategy in Acute Type a Aortic Dissection)
- Athletes who have received the David procedure have returned to PROFESSIONAL high intensity sport (e.g. Ronny Turiaf - LA Lakers)
- Highly dependent on surgeon's skill.

Personally, my surgeon laid out all the options, gave me pro's and cons, was upfront about the risks. I went with the David and no issues.

I'd be careful about citing studies which are too broad, and make sure you read the limitations of each study. More often than not, the publishers will acknowledge the short comings of the study before any critics do. Most people don't read that far down.

Kind of what I'm getting at but you said it in a more clear and intelligent manner. The mechanical valves are produced to a very high level of quality and are basically all the same so given a persons certain physical condition at the time of surgery you can more accurately predict outcomes I would imagine. Whereas with a valve sparing surgery like the David procedure There are so many more different factors such as: The quality of the surgeon, the quality, condition and geometry of the valve to give two examples. I would imagine this would make it much more difficult to get a set of odds on the longevity of a quality outcome.
I'm hoping the fact that I have one of these rare type zero BAVs Will help my valve last, I have two equal leaflets with no sign of a Raphe. My latest echo was in September 2019 and that's a summary so fingers crossed...
P.S in regards to your comment on professional athletes my surgeon operated on a player for the Philadelphia eagles and also for a military pilot who returned to full duty as well.

 

[tom in MO]

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

If you die in a car wreck or due to cancer w/o autopsy they will never know you had a bicuspid. If you BAV kills you and they don't do an autopsy, they won't know what killed you. Your stats are impossible to generate since people can have BAV and never get diagnosed.

 

[cldlhd]

If you die in a car wreck or due to cancer w/o autopsy they will never know you had a bicuspid. If you BAV kills you and they don't do an autopsy, they won't know what killed you. Your stats are impossible to generate since people can have BAV and never get diagnosed.

I agree but I think that is more likely changing as tests become more advanced and more available.

 

[Warrick]

You could say that about a lot of stats though couldn't you, if you die in a car crash with an inflamed appendix they aint gonna look for that either... but theres still stats on appendicitis.... just saying

I'm pretty sure if you die in a car crash the car crash killed you