Choosing valve for surgery #2

[tezza]

A quick update...saw the cardiologist after the MDT case conference. TAVR is definitely out of the question...anatomically, my valve is not suited to a TAVR, as it will block the coronary artery, so that at least is thoroughly removed from the equation, at least for now! And the coarct, while stable, is also an issue with insertion, but not impossible, due to the fact that it is a double coarct. So back to the old chestnut of mechanical vs biological! Discussed the idea of a warfarin trial but was told that that isn't an option. Also discussed alternatives to warfarin, and that wasn't entertained either! A visit to the surgeon next week to discuss further...if it weren't for the bleeding issue, I would probably opt for mechanical and be done with surgery, but have been strongly advised against this by the MDT team, so it looks like another biological valve might be in my future. I just wish I could feel happy with either option. I'm getting more and more symptomatic each week, and have been recommended for surgery within the next few weeks, so I need to make a decision now. Thanks for listening.

 

[pellicle]

So back to the old chestnut of mechanical vs biological!

well dunno if I've previously posted this, but:

https://cjeastwd.blogspot.com/2014/01/heart-valve-information-for-choices.html
and if you don't see it in there do not miss this URL reference

Discussed the idea of a warfarin trial but was told that that isn't an option.

I can understand why.

1. something like 1% of people have warfarin intolerance, of that most of them don't have any warfarin intolerance but have an allergy to one of the dyes or excipients (so change brand)
2. starting warfarin takes care and needs to be managed, so its not taken lightly in a profession which sees itself as being about minimising harm.

The main problems for warfarin are clear at the start

Absolute contraindications
Absolute contraindications to warfarin include:

• large esophageal varices
• within 72 hours of major surgery
• a platelet count less than 50 x 109/cu.mm which constitutes significant thrombocytopenia
• hypersensitivity to the drug, such as skin ischemic necrosis or priapism
• clinically significant bleeding condition – reassess risks after three months
• pregnancy and within 48 hours of delivery because of its known teratogenicity, as well as its capacity to induce spontaneous abortion and fetal/perinatal bleeding
• coagulation defects at baseline such that the INR is over 1.5
• decompensated liver disease

I understand that macular degeneration is also complicated by it and it reduces your treatment options with arthritis.

...if it weren't for the bleeding issue,

do you have a history of bleeds, or are you meaning some fictitious issues conjured up by well meaning but ill informed practitioners?

 

[tezza]

well dunno if I've previously posted this, but:

https://cjeastwd.blogspot.com/2014/01/heart-valve-information-for-choices.html
and if you don't see it in there do not miss this URL reference



I can understand why.

1. something like 1% of people have warfarin intolerance, of that most of them don't have any warfarin intolerance but have an allergy to one of the dyes or excipients (so change brand)
2. starting warfarin takes care and needs to be managed, so its not taken lightly in a profession which sees itself as being about minimising harm.

The main problems for warfarin are clear at the start

Absolute contraindications
Absolute contraindications to warfarin include:

• large esophageal varices
• within 72 hours of major surgery
• a platelet count less than 50 x 109/cu.mm which constitutes significant thrombocytopenia
• hypersensitivity to the drug, such as skin ischemic necrosis or priapism
• clinically significant bleeding condition – reassess risks after three months
• pregnancy and within 48 hours of delivery because of its known teratogenicity, as well as its capacity to induce spontaneous abortion and fetal/perinatal bleeding
• coagulation defects at baseline such that the INR is over 1.5
• decompensated liver disease

I understand that macular degeneration is also complicated by it and it reduces your treatment options with arthritis.



do you have a history of bleeds, or are you meaning some fictitious issues conjured up by well meaning but ill informed practitioners?

Thanks Pellicle, I think I have viewed those resources but will look again. I do have long term thrombocytopenia, in the mild range, and a bit of a history or bleeds - post partum haemorrhage, haemorrhage after the first OHS, and frequent spontaneous nose bleeds, prolonged bleeding after small procedures, and constant bruising for seemingly little effort eg. carrying a couple of books on my forearms will result in bruising from elbow to wrist. I haven't been told I definitely can't have warfarin, but it is recommended that I don't. I am wary of warfarin as a result, as the risk of bleeding for me appears that it might be more of a problem than otherwise, but the attraction of just one more surgery is there luring me in...

 

[pellicle]

Hey Tezza

those resources presuppose you don't have anything contra-indicating warfarin; which this suggests you may.

I do have long term thrombocytopenia, in the mild range, and a bit of a history or bleeds - post partum haemorrhage, haemorrhage after the first OHS, and frequent spontaneous nose bleeds, prolonged bleeding after small procedures, and constant bruising for seemingly little effort

well that'd be enough to give you pause on warfarin. Even if you did a test and even if it was ok for even a month a lot can happen in 20 years.

also be wary about the "one and done" mantra as nature has a way of throwing in curve balls.

What is the aortic diameter at the moment on last measure?
Your bio is a bit scant, so how old are you, do you have a bicuspid valve and what's the risk of future aneurysm (tightly correlated with bicuspid).

Tissue may be the better option for you ...

 

[tezza]

Hey Tezza

those resources presuppose you don't have anything contra-indicating warfarin; which this suggests you may.



well that'd be enough to give you pause on warfarin. Even if you did a test and even if it was ok for even a month a lot can happen in 20 years.

also be wary about the "one and done" mantra as nature has a way of throwing in curve balls.

What is the aortic diameter at the moment on last measure?
Your bio is a bit scant, so how old are you, do you have a bicuspid valve and what's the risk of future aneurysm (tightly correlated with bicuspid).

Tissue may be the better option for you ...

As a recap from my first post in this thread, I'm 11 1/2 yrs post replacement, which was a bovine valve. Age 57 in two weeks. First surgery was for a bicuspid valve that was picked up at birth, so long history of monitoring. I asked about the risk of future aneurysm, because I know the correlation but didn't get a definite response, so that is something I am mindful of. Aortic diameter I don't know...previous valve was a 23mm, but I'm now classed as severe stenosis. Can't make it up a flight of stairs or walk with any pace or carry anything without getting short of breath, dizziness and some angina currently.

 

[pellicle]

As a recap from my first post in this thread,

sorry for not scanning back ... sometimes its unclear

I'm 11 1/2 yrs post replacement, which was a bovine valve. Age 57 in two weeks. First surgery was for a bicuspid valve that was picked up at birth, so long history of monitoring.

so this'll be #2 OHS right (checks subject)?

I asked about the risk of future aneurysm, because I know the correlation but didn't get a definite response

understandable ... that's because there isn't one ... its "a correlation not a certainty"

Aortic diameter I don't know...previous valve was a 23mm

which is on the edge of possible influence from pannus ingrowth ... just one more issue against the one and done scenario

my view is that on this occasion you go bio-prosthetic (speaking as just a layman) and perhaps porcine ... consider #3 as it arises.

Because frankly life regularly throws curve balls and so rather than look at that might be look at what's likely. To my mind your bloods suggest that AC Therapy is fraught.

I reviewed what I wrote earlier, at least my decision process is internally consistent. Despite appearances that links to my first response

https://www.valvereplacement.org/threads/choosing-valve-for-surgery-2.887850/post-902158

 

[tezza]

sorry for not scanning back ... sometimes its unclear



so this'll be #2 OHS right (checks subject)?



understandable ... that's because there isn't one ... its "a correlation not a certainty"



which is on the edge of possible influence from pannus ingrowth ... just one more issue against the one and done scenario

my view is that on this occasion you go bio-prosthetic (speaking as just a layman) and perhaps porcine ... consider #3 as it arises.

Because frankly life regularly throws curve balls and so rather than look at that might be look at what's likely. To my mind your bloods suggest that AC Therapy is fraught.

I reviewed what I wrote earlier, at least my decision process is internally consistent. Despite appearances that links to my first response

https://www.valvereplacement.org/threads/choosing-valve-for-surgery-2.887850/post-902158

I'm sorry, I hope I didn't come across as being rude...don't apologize for not scanning back.
So yes, my #2 OHS. Thank you for your thoughts on this, and yes, that is what you thought in your first reply. If I am really honest with myself, the biological valve is probably the option that I think I should take, given the blood issues. I just have to get my head around that there will be more procedures in my future, accept that and just get on with it.
Would be nice to have a crystal ball, but I don't.
I will discuss at length again next week with the surgeon, and hope that my surgery is not too far off, I am starting to feel quite tired and just want to get it over with so I can move on and get back to health and fitness again.

 

[MdaPA]

the biological valve is probably the option that I think I should take,

Have you Dr.'s mentioned if you are a candidate for a ROSS procedure? This is where your PV is removed and used to replace the your diseased AV and then your PV is replaced with a homograft. This is a more complex surgery and you would be going from single valve to a multi-valve disease but could potentially buy you more time until your next/3rd OHS than going with a biological (pig or cow) AV could. A ROSS could potentially buy you 20+ years versus 10+ years with a biological AV.

 

[pellicle]

Hi TearBear

I'm sorry, I hope I didn't come across as being rude...don't apologize for not scanning back.

not at all ... it was a gentle chide and was "point well taken". I simply have a lot of things going on and don't sit down, undertake analysis and then provide an opinion based on that. I tend to think more on my feet and try to look for answers to background questions to create what I need to answer the "stage 2" question

I will discuss at length again next week with the surgeon, and hope that my surgery is not too far off, I am starting to feel quite tired and just want to get it over with so I can move on and get back to health and fitness again.

I fully understand and you should. Please say Hi to Dr Jalali for me and you can identify me to him as his patient who retreats to Finland from time to time (that should narrow me down). Tell him I think about what he has done for me often.

Lastly my offer in my above reply still stands.

Best Wishes.

 

[tezza]

Have you Dr.'s mentioned if you are a candidate for a ROSS procedure? This is where your PV is removed and used to replace the your diseased AV and then your PV is replaced with a homograft. This is a more complex surgery and you would be going from single valve to a multi-valve disease but could potentially buy you more time until your next/3rd OHS than going with a biological (pig or cow) AV could. A ROSS could potentially buy you 20+ years versus 10+ years with a biological AV.

Yes, this was discussed earlier on. My surgeon said that if I had been younger, it would have been a viable option, but not one that he would offer me as a best solution now. I can't recall the specifics of the conversation now, but basically, he stated that here in Australia, I would be hard pressed to find a surgeon who would do that procedure at my age. He does them regularly on younger patients and particularly children.

 

[tezza]

Hi TearBear


not at all ... it was a gentle chide and was "point well taken". I simply have a lot of things going on and don't sit down, undertake analysis and then provide an opinion based on that. I tend to think more on my feet and try to look for answers to background questions to create what I need to answer the "stage 2" question



I fully understand and you should. Please say Hi to Dr Jalali for me and you can identify me to him as his patient who retreats to Finland from time to time (that should narrow me down). Tell him I think about what he has done for me often.

Lastly my offer in my above reply still stands.

Best Wishes.

Thanks. Yes, will give your regards to Dr Jalali. I am relieved that he is going to be my surgeon again, I have great respect for him and the utmost confidence in his work, regardless of which valve I choose. Will keep you posted.

 

[MdaPA]

I am relieved that he is going to be my surgeon

Tezza, glad you have decided on your surgeon.

My surgeon said that if I had been younger, it would have been a viable option, but not one that he would offer me as a best solution now.....
he stated that here in Australia, I would be hard pressed to find a surgeon who would do that procedure at my age.

It appears that the Ross is being considered more and more now in older patients than before.

Here's a related question and answer from a Dr. in NY (in 2010) who has extensive experience with performing this procedure:

Greg writes, “Adam – I’ve been diagnosed with severe aortic stenosis. According to my cardiologist, I’ll be needing surgery in the next few months. Thanks to you, I now know about the Ross Procedure. It seems like it could be a good option for me as I’m active and do not want to be on Coumadin for the rest of my life. However, unlike you, I’m a bit older at 57 years of age. I’m wondering if I’m too old for the Ross Procedure? Do you have any thoughts? Thanks for all you do! Greg”

In response to Greg’s question, Dr. Stelzer offers the following:

• Age is not just a number but a physiologic state. Because the Ross Procedure is designed to be a long term solution for aortic valve disease (e.g. aortic stenosis), it is suitable for anyone with at least a 25 year life expectancy.
• Usually that translates into someone less than 65, but a few older patients have had this operation quite successfully.
• For older patients, simpler alternatives of aortic valve replacement offer 15-20 year durability and are widely available.

“Am I Too Old For The Ross Procedure?” Asks Greg


Here's a current study that is evaluating 2 methods of AVR in adults aged 18-60, the Ross procedure versus conventional aortic valve replacement using a biologic or mechanical heart valve:

Ross for Valve Replacement in AduLts Trial (REVIVAL)

 

[pellicle]

It appears that the Ross is being considered more and more now in older patients than before.

for the reasons you cited above (move to dual valve disease) and from the results of Arnie I think that's a mistaken approach.

but of course what would I actually know.

I didn't observe results of that study... we'll know in 20 years I guess

 

[MdaPA]

for the reasons you cited above (move to dual valve disease) and from the results of Arnie I think that's a mistaken approach.

You may be right. Just trying to show that there are other options out there based on my research for my wife's surgeries (one of which was a Ross which she did get 20 years out of) so others can make their own informed decisions.

but of course what would I actually know.

I wouldn't say that. You are a wealth of knowledge with the INR stuff and your info has been very helpful in my wife's INR management (especially the rubber-band around the finger! ).

 

[pellicle]

You may be right. Just trying to show that there are other options out there based on my research for my wife's surgeries (one of which was a Ross which she did get 20 years out of) so others can make their own informed decisions.

and its that exact thing which makes this place so good. We can express our experiences and by doing so widen the breadth of what people (any lurkers and indeed anyone) see as options

my point about "what would I know" was intended to be specific to surgeries and outcomes on alternatives. I'm glad that I bring some value to some topics here but I know my own limitations when it comes to the plethora of surgical things out there.


Best Wishes

 

[tezza]

Tezza, glad you have decided on your surgeon.


It appears that the Ross is being considered more and more now in older patients than before.

Here's a related question and answer from a Dr. in NY (in 2010) who has extensive experience with performing this procedure:



“Am I Too Old For The Ross Procedure?” Asks Greg


Here's a current study that is evaluating 2 methods of AVR in adults aged 18-60, the Ross procedure versus conventional aortic valve replacement using a biologic or mechanical heart valve:

Ross for Valve Replacement in AduLts Trial (REVIVAL)

Thanks for that info. Interesting... have to say though that I don't like the thought of going from having one valve problem to having two, but that is just me. Will be interesting to see the results of the study...that's the problem isn't it, it's a time thing... and it might just not be in time for us when we need to know it, like right now! So glad it worked well for your wife. I think if I had been younger, it may have definitely been something I might have considered, but even first time round, I was considered by my doctors to be not in the best age bracket for what they know about it. I guess things can be done differently from country to country too...but from what I have been told best practice in Australia is to consider Ross for much younger patients. Always good to hear all the different opinions and ideas though.

 

[Luckyguy17]

Tezza, i have a whole lot of similarity to your case, but am 10 years older and in Canada vs Australia. Am also up for 2nd surgery and AVR . 11 years ago, is Also hoped for longer bio valve life, as well as easier surgery if/when needed, bus alas.
TAVR has also been deemed too risky for me as well, so OHS once again.
My surgeon says a new bio, would likely have the same life expectancy as the last one, body chemistry he thinks, determines calcification.
So Am tentatively scheduled for April surgery, angiogram to do in the next few weeks, Covid complexities to deal with, have delayed electives in Canada, but am severe and finally underway.
bio vs mech valve remains open at this time.

 

[tezza]

Tezza, i have a whole lot of similarity to your case, but am 10 years older and in Canada vs Australia. Am also up for 2nd surgery and AVR . 11 years ago, is Also hoped for longer bio valve life, as well as easier surgery if/when needed, bus alas.
TAVR has also been deemed too risky for me as well, so OHS once again.
My surgeon says a new bio, would likely have the same life expectancy as the last one, body chemistry he thinks, determines calcification.
So Am tentatively scheduled for April surgery, angiogram to do in the next few weeks, Covid complexities to deal with, have delayed electives in Canada, but am severe and finally underway.
bio vs mech valve remains open at this time.

Hi Luckyguy17, yes our situations are very similar. Good luck for the surgery in April...I see my surgeon on Wednesday and hopefully get a date then, but it is likely to be sometime in April as well. Angiogram is already done. Good luck with the decision making...it is a tough call.

 

[tezza]

An update on what's happening...saw the surgeon yesterday, and now have a date, at last! 23rd March is my big day. Looks like I will have to have the aortic root enlarged to be able to put a large enough valve in. Will never be a candidate for TAVR, due to my anatomy, so it is now a definite choice between mechanical or biological. Now that I know a 3rd surgery is in my future if I choose a biological, which has been recommended, due to bleeding issues and contraindication for warfarin, I will be seeing a haematologist to really nut out whether warfarin is a possibility or not. A definite 3rd surgery is not entertaining so I need to be really sure that I can't take warfarin before that is absolutely ruled out. Now to prepare my headspace for the upcoming surgery, get the mindset positive and prepare. So happy to have a date so I can move forward and get strong again.

 

[MdaPA]

I will be seeing a haematologist to really nut out whether warfarin is a possibility or not.

Tezza, perhaps you can do a trial run on warfarin before your surgery to see if/how you tolerate it?