Bucuspid valve replacement and ascend aorta

[Duff Man]

There is a 'Valve Sparing' type of Aorta Repair / Replacement that can be used IF your BAV is still in 'good working order'. Again, it is best to find a Surgeon who has done this procedure enough to be proficient in it. Be sure to Ask the Right Questions about Experience and Results when interviewing Surgeons. A surgeon who primarily sees only Coronary Artery Bypass patients with the ocassional Valve Job is NOT the kind of Surgeon you want to put your trust in.

'AL Capshaw'

Al, I've seen you talk about how important it is to see an extremely experienced surgeon who has high volumes with aorta repairs, but are there any studies that prove this is an absolute indicator of greater probability of success? Could I not have accidentally picked a very experienced surgeon who just isn't as "good" as the general cardiac surgeon with aortas?

The reason I ask, is because it seems like I read that the society of thoracic surgeons claim the surgeon's adherence to correctly executed procedures/protocol is more important than the volume/experience of the surgeon.

I have to believe there are some surgeons who are just naturally better at this surgery than the high volume surgeons are.

 

[ALCapshaw2]

Al, I've seen you talk about how important it is to see an extremely experienced surgeon who has high volumes with aorta repairs, but are there any studies that prove this is an absolute indicator of greater probability of success? Could I not have accidentally picked a very experienced surgeon who just isn't as "good" as the general cardiac surgeon with aortas?

The reason I ask, is because it seems like I read that the society of thoracic surgeons claim the surgeon's adherence to correctly executed procedures/protocol is more important than the volume/experience of the surgeon.

I have to believe there are some surgeons who are just naturally better at this surgery than the high volume surgeons are.

I have a friend who is a surgeon in another field.

He confirmed what others here have also said, i.e., "The more they do, the Better they are (or tend to be)". One of the factors he cited was that the more they do, the more their 'muscles' remember how to do the procedure. It becomes more 'automatic' and requires less conscious thought about how to proceed.

Didn't the non-invasive? Heart Surgeon from NY (member "heartdoc" I think) also recommend that patients who wanted to avoid a sternotomy to find a Surgeon who has experience performing the procedure of interest?

We've had a couple of members who had Connective Tissue Disorders who had to have their first valves replaced because the stitching from their first surgeon didn't hold. Those Stories raised my interest in BAV and CTD issues.

Yes, there are probably some excellent low volume surgeons who are fully capable of doing surgery of the aorta but how would you be able to recognize them from their less qualified counterparts with comparable (in)experience?

I have urged a few members who needed aorta surgery (which were second surgeries) but wanted to stay closer to home to interview experienced Aorta Surgeons and even provided some names for them. I recall two who followed that advice and immediately recognized that their local surgeons couldn't hold a candle compared with the experienced Aorta Surgeons they interviewed at the Major Heart Hospitals. They went with the Majors and are doing well.

 

[ALCapshaw2]

SNIP

At the risk of irritating other members, during my time with the forum, I've seen numerous posts from members concerning replacements of tissue valves which last less than five years. In fairness, there have also been some posts indicating failures of mechanical valves.

SNIP

There are great valves on both sides of the tissue v. mechanical debate.

-Philip

I recall a few mechanical valves that needed to be replaced due to 'extenuating circumstances' such as Pannus Tissue Growth (which can happen with either Tissue or Older Mechanical Valves) and Endocarditis which is an infection of the Heart that will require replacement of any affected valve (tissue or mechanical). I don't recall any members reporting a mechanical valve that "failed". Can you cite any specific examples?

To imply that the durability of any Tissue Valve can approach the durability of a Mechanical Valve, all of which are designed to operate for more cycles than anyone can expect to live, would be Grossly Misleading at best. It would also be misleading to not mention that Tissue Valves tend to Wear Out Faster in patients under age 60 than in patients over age 60 at the time of their surgery.

Dick0236 has had his (discontinued) Ball and Cage Mechanical Valve for 43 years and counting.
I expect there are many early recipients of the St. Jude Master's Series Bi-Leaflet Mechanical Valves that have been around for 20 to 30 years now. (Note that VR.org has only be around for 10 years or so)

On the other hand, we have had several reports of Tissue Valves (both Bovine and Porcine) failing prematurely in 1 to 5 years and there are several studies showing that 50% of (admittedly older) Tissue Valves needed replacement in 10 to 12 years. Several 'new and improved' Tissue Valves "hope" to have improved durability but we won't know that for sure for several more years.

 

[epstns]

I'll have to agree with Al. The only other thing I would add is that the choice of one of the newer varieties of tissue valves is a bit of a gamble. These valves are projected to have long usable life spans, but the haven't been in use long enough to test and document the projections. In my case, at age 63, I'm going with a tissue valve (planning on the Edwards bovine pericardial valve) and we'll see how many miles I get with it.

 

[jake]

So after reading all the responses, I will toss my two cents on the table. I was in exactly the same boat you are in. Good Bicuspid valve with an aneurism on the aortic root (5cm at time of repair). I visited several very competent surgeons and all were like minded in that they felt that because of my age (45) and the leaps and bounds there is on valve replacement technology, AND that my bicuspid valve is working 100% perfectly, that no one recommended replacement of the healthy valve. I ended up with a new ascending aorta and a re-suspension of my existing healthy bicuspid aortic valve.

I got, pretty much, the same story from everyone. The bi-cusped could go south in six months, or last the rest of my life. You will get the same guarantee on all hart valves including your own. The guarantee is that there is no guarantee! The statistics were defiantly in my favor considering a tissue valve (at your age) guarantees you another trip to the surgical suite and a mechanical puts you on anti-coagulants for the rest of your life.

If you have a good valve, think long and hard about swapping up to a new one. Even bi-cusped valves can last a lifetime and frequently do. You should be given the option to keep your existing valve.

 

[Navin323i]

Well I was diagnosed with the aorta valve being bicuspid when I was 1 year old.. Many ecg's in my life showed the valve was operating ok... Now I am 41 the last few ecg's have showed that the valve is still working ok but the ascending aorta is 49mm. It has grown 3mm in one year which is a concern. Well I am booked for a MRI early feb and if it proves that it's 49mm its time to talk to a surgeon. My Cardio said that they will replace the valve while they are there but he says the ascending aorta is a complicated operation which scares the "you know what" out of me...
I have private insurance and was looking at the Prince Charles Hospital for the operation.... Anyone have any other ideas??
Anyone out there had sane operation as I am looking at?? Love to hear the choices you made and some more info ...
Thanks
Dave
Brisbane , Australia

Hi Dave,
Believe it or not, I had the same scenario as you... in my case, I was born with bicuspid aortic valve, had numerous open heart surgeries, and eventually developed an aortic aneurysm in the ascending aorta.

There is a correlation between folks born with bicuspid valves and developing aortic aneurysms later on in life. Not sure why this is the case, but there is a definite correlation. My ascending aorta and original mechanical aortic valve was replaced by a St. Judes Composite Graft which is a mechanical aortic valve connected to a dacron tube which replaces the ascending aorta.

The surgery can definitely be a complicated one, DEPENDING ON VARIOUS THINGS, including where exactly the aneurysm is and how far it goes... in other words is the aneurysm affecting the aortic arch. If it does then you have to take into account the carotid arteries supplying blood to your brain that are connected at the aortic arch... basically the surgeon would need to put the patient on bypass to supply blood to the brain while the carotid arteries are disconnected from the aortic arch, remove the arch, replace with the dacron tube and connect the carotid arteries to the tube... this is all assuming of course that the aortic arch has the aneurysm as well. Another thing that can make the surgery complicated is the number of previous heart surgeries you've had and the amount of scar tissue that has resulted from those surgeries. In my case, I had 4 previous heart surgeries and quite a bit of scar tissue.

Best advice I can give you is to find a good surgeon with experience with aortic aneurysm surgeries. Dr. Duke Cameron was my surgeon at Johns Hopkins University Hospital in Baltimore, Maryland USA.

Feel free to contact me if I can be of more help.

Cheers,
Navin

 

[ebjlady2]

Hey Carol....I am having my second OHS, Tuesday, Feb. 8 at Duke University Medical Center. I had my first aortic valve surgery when I was 37....25 years ago. I now have a St. Jude Mechanical Valve which means I have been on coumadin for 25 years. I also have a TAA measuring 4.2 cm which will be repaired. The mechanical valve has calcified and is the main reason for surgery at this time. I am seriously considering having a tissue valve this time because of the problems that coumadin has presented. Most people do well on coumadin with no problems but I guess I am an exception. My surgeon said that he would recommend the tissue valve because of my history with coumadin...but still not made my decision yet. I have a list questions to take with me Monday when I am admitted. I am also very nervous even though I have been through this before...and like you, want to get it over with.

Take care.
Jane

 

[epstns]

Jane - I'm not much older than you (now 63) and my surgeon recommended that I get the Edwards bivube pericardial valve. He says that over 90% of the valves he now does (hundreds per year) are now tissue. Cleveland Clinic also is now using something like 85% tissue valves. Their opinion is that the newer valves will last plenty long for patients in their 50's and 60's.