Can doctors insert a larger Mechanical valve on later surgery? My first AVR was a Porcine 27mm, Current is a Bovine 23mm.

[Earthsciencerocks]

Can doctors insert a larger Mechanical valve on later surgery? My first AVR was a Porcine 27mm, Current is a Bovine 23mm.
Anyone have history of getting a larger valve at a later date?

 

[nobog]

So that would be # 3? In the history of the world, as far as valve replacement goes, the Drs. will always stuff the biggest valve they can into size X hole. Actually, the problem is they tend to stuff to big a valve in, which can be as bad as to small. It's difficult to judge valve flow by size (i.e. 23mm) - you really need to look through a bunch of technical papers to figure out which one is "better". To make matters worse, some tissue valves can have a 100% difference in pressure drop (mmHg) for the same size valve. You or your Dr cannot tell by looking at the valve. Mechanical valves, of course, are consistent but do vary by manufacturer.

 

[Earthsciencerocks]

A “Y” Incision/Rectangular Patch to Enlarge the Aortic Annulus by 4 Valve Sizes in TAV and BAV Patients​

Fascinating article!

https://www.ctsnet.org/article/“y”-...ic-annulus-4-valve-sizes-tav-and-bav-patients

 

[Earthsciencerocks]

So that would be # 3? In the history of the world, as far as valve replacement goes, the Drs. will always stuff the biggest valve they can into size X hole. Actually, the problem is they tend to stuff to big a valve in, which can be as bad as to small. It's difficult to judge valve flow by size (i.e. 23mm) - you really need to look through a bunch of technical papers to figure out which one is "better". To make matters worse, some tissue valves can have a 100% difference in pressure drop (mmHg) for the same size valve. You or your Dr cannot tell by looking at the valve. Mechanical valves, of course, are consistent but do vary by manufacturer.

That's good info!
My valve was decreased from a 27mm to a 23mm, and I notice it in a negative way every day.
The replacement valve measurements shown refer to differing parts of the annulus' diameter. Some manufacturers refer to inner diameter, some outer diameter, some exterior diameter.
Some studies show the size of valve is directly correlated to patient survival.
I posted the article containing this data.
I think consistencies in stating valve size should be controlled.

 

[nobog]

That's good info!

I think consistencies in stating valve size should be controlled.

The understatement of the year. It's a game the manufactures play.

 

[carolinemc]

Can doctors insert a larger Mechanical valve on later surgery? My first AVR was a Porcine 27mm, Current is a Bovine 23mm.
Anyone have history of getting a larger valve at a later date?

that would up to the surgeon. you need to discuss with the surgeon.

 

[Timmay]

Aortic root enlargement is a common practice these days. There are multiple ways to do it. They did one on me just to stuff a 23mm On-X valve in me.

Please tell me that your post title about Mech valves means that you've seen the light and you're going to get a mech valve. Because even at 54yr old (your signature), if you get another tissue valve then you'll have to have at least a 4th OHS later in life for yet another tissue valve.

 

[Gail in Ca]

Yes with each surgery the sortic valve placed was larger than the last. The 3rd surgery my surgeon mentioned he would give me a larger valve if he could for better blood flow. He had to place it higher up the aorta due to tissue damage from endocarditis and was able to give me a25mm mechanical valve (2nd).

 

[tom in MO]

I believe there was a person on here who had too small a valve installed. It was tissue though and when it failed she got a bigger size for the replacement.

 

[pellicle]

Can doctors insert a larger Mechanical valve on later surgery?

sure can ... I got a mech on my 3rd OHS

 

[pellicle]

In the history of the world, as far as valve replacement goes, the Drs. will always stuff the biggest valve they can into size X hole.

Sadly the opposite of this happens more than you'd like to think
https://www.valvereplacement.org/threads/tissue-valve-failing-after-6-months.40490/post-40490

 

[nobog]

Sadly the opposite of this happens more than you'd like to think
https://www.valvereplacement.org/threads/tissue-valve-failing-after-6-months.40490/post-40490

The Biocor is known as a very durable valve with not the best-in-class EOA. He never should have gotten a tissue valve at 38.

 

[Earthsciencerocks]

Aortic root enlargement is a common practice these days. There are multiple ways to do it. They did one on me just to stuff a 23mm On-X valve in me.

Please tell me that your post title about Mech valves means that you've seen the light and you're going to get a mech valve. Because even at 54yr old (your signature), if you get another tissue valve then you'll have to have at least a 4th OHS later in life for yet another tissue valve.

"Seen the light" is NOT the term. My tissue valves have served their purpose in my younger years. Mechanical valves also have a lifespan and other inherent risks I was not ready to take as a younger man. Where I am now in parenting and raising my kids, very physical lifestyle when younger, and diagnosed with Leiden Factor 5 blood disorder, I now have to be on blood thinners the rest of my time on earth, so mechanical makes sense now.
But with that in mind, I will go mechanical on my next AVR because it serves me better.
Remember hindsight is 20/20. Seeing the future is NOT my gift.
I still feel like my decisions were logical and very well thought out.

 

[pellicle]

He never should have gotten a tissue valve at 38.

agreed ... and especially not a small one.

Malicious Compliance

 

[pellicle]

best-in-class EOA

to be clear you're meaning

Effective Orifice Area (cardiology)

 

[nobog]

to be clear you're meaning

Effective Orifice Area (cardiology)

Yes

 

[pellicle]

Mechanical valves also have a lifespan

no they don't actually, but your other points are correct or at least your choice.

Again I write this not to you but to other readers and lurkers.

To underscore my position I have not really ever "chosen" until my prep for my 3rd operation. At that time I was given a clear choice. On my second surgery I took a homograft which in many ways was not presented to me as a clear "please choose A or B". I followed my sugeons advice (I was 28) and his words of "we don't want to see you on warfarin just yet" seemed to suggest a reason for his desire.

To be clear as a recent graduate of biochem I knew very little about the pharmacokinetics of Warfarin nor the details of its management.

Now however I do, and I can say that in 1992 we did not have Point of Care machines NOR did we have the notion of self management (and lab management was often non existent in reality as it really is non existent today).

So back then was different for those reasons.

Its often vexing to attempt to make an analysis of historical decisions from the perspective of today without properly couching that decision in the full extent of that time periods situation.

I think you made the best decisions in those times (both now and then).

Best Wishes

 

[pellicle]

I now have to be on blood thinners the rest of my time on earth

oh, and also not to seem to be spanking you (so much as using this as a springboard) I'd like to point to this example of why I don't think blood thinners is helpful as a term

https://www.valvereplacement.org/threads/bav-testosterone-replacement.888729/post-919056

 

[Woodcutter]

My experience was the mitral position. First a repair that solved a valve leakage problem but made the valve too small, then 6 mos later a mechanical valve was installed. I've always been a distance runner so, like you, from the time I had the valve work done I have always clearly noticed the change. Here are a couple thoughts in case they're helpful:

I'm a hydraulics guy by education/profession so I've done plenty of research and had plenty of conversations about the valve size. The thread Pellicle attached a few days ago captures the key points. Summarily, during the operation the valve opening is sized/measured and the correspondingly sized valve is picked for installation. Essentially this practice matches the cuff to the opening. Of course this is critically important so that the new valve is solidly installed and there is no leakage around it.

Aside from a good installation; however, what we (the patient) need is flow. Better still is flow without much pressure drop. The heart muscle is going to work to obtain the flow regardless and the harder it works . . .. . well, higher blood pressures, thicker walls, faster rates, etc. So generally speaking, more area is better.

My surgeon referred to the sizing as: "true sizing" is when the selected replacement valve correctly fits the opening as sized/measured. "+1" is a size bigger. "-1" is a size smaller. Knowing of the problems I had with the repair he was able to go +1 for me. Sure, a larger valve is always possible . . . . but at the increasingly larger risk of causing damage to the native structure(s) the valve lies within.

Effective Orifice Area is the generally accepted parameter in hydraulics to simplify the myriad of variables that cause the pressure/flow relationship through a "hole" to be other than theoretically predicted for the perfect orifice. In my personal case, with my initial repair, the major factor was that my leaflets were stiff enough (calcification?), that after being tightened up to stop the leakage, they simply did not move out of the way nearly enough in the open position. With my mechanical valve, there is the reality noted that the actual opening for flow is smaller than the cuff size but also the apparatus (leaflets, rotation structure, etc.) sit right in the middle of the opening! If you are comparing valve sizes, I do agree that EOA is the parameter to compare but it's best to understand that it is a calculation and hence not quite as clear cut as measuring the outside diameter of something. Of course, the surgeons are also dealing with our living, flexible, biologic heart that (I imagine) isn't quite as easily/accurately/consistently measured as, say, the inside of a pipe!

When the time comes for another replacement, definitely have the conversation with the doctors about sizing and make sure they know that you believe what you have is currently undersized. There are definitely things that can be done; but understand that just as definitely there are limits on those things.