Decision made....nearly

[Captain Cavemen]

Hi all, saw the surgeon face to face very knowledgeable guy. I was keen on a Ross Procedure but due to the shape of my arotic root he is not keen on me having the Ross Procedure (although he will do it if I ask him, confused) he also gave a number of reasons why it wouldn't be good in my age group which sort of made sense mainly associated with redo risks.

After a number of scans he advised an Resilia Bio Valve with a graft on the ascending aorta. I was happy he can do this via either a Mini Sternotomy, Right Anterior Thoracotomy (more painful apparently) or Portal access (no incision just a load of holes for cameras and surgical tools). He said the aortic root looks ok on the scans but if needed he can do a root replacement (Bentall procedure) using the same minimally invasive approaches. The heart is performing ok with completely normal ejection fraction but the valve is bicuspid / with calcification and at 0.98/0.99 cm2, aorta 4.9cm. Surgical risk is 1% risk for the op and all going well his patients are out of hospital after 5 days and driving after 4 weeks of course there is a chance he may need to fully open should he see something unexpected or if there is a complication. So the conclusion was op is needed and is urgent but not urgent urgent if that makes sense, fortunately I have absolutely no symptoms.

Several points of interest and some feedback from forum members would be welcomed.

1. When I discussed the benefits and risks of minimally invasive surgery he said the cosmetic impact was low on the list the main benefit is a notable reduction in infection and bleeding risk along with much quicker healing time. It this anybody's experience?

2. He measured me up for TVAR post the Resilia Valve and said all looked ok bit seemed completely at ease with a redo op with low surgical risk assuming reasonable health at the time. He then discussed the annual risks of anti coagulants being around 2% per annum even for well controlled INR for what he termed a significant event (undefined) and the compound effect of this over the expected 20 year plus life of the Resilia Valve being much greater vs a redo operation. There was also a mention of an increase in Vascular Dementia associated with long term anticoagulant use.

3. I asked if the valve life was all a bit of a promise his answer after fitting over 400 was yes but on evidence so far he has seen no SVD in over 5 years and this is as expected. He did joke that after 20 years many other things can happen in terms of the later years of life.

4. After the op they keep patients in so called twilight anesthesia so everyone is intubated / has tube removed in this state which is proven to have important psychological benefits in terms of the post operative experience. He said you won't remember a thing.

Thats about all I can remember for now.

 

[pellicle]

Good morning
reading your post your Surgeon sounds reasonable, which means conservative and prudent (IMO exactly what you'd want

. I asked if the valve life was all a bit of a promise his answer after fitting over 400 was yes

Firstly what does fitting over 400 (500, a thousand) of these valves make if you don't have a shred 10 year data?

but on evidence so far he has seen no SVD in over 5 years and this is as expected.

And really who the hell would expect it at 5 years? I would only expect that if you were under 40 (and compounded if you were athletic). As you don't have age data in your bio (and I can't be bothered searching through posts and digging it out) I'll have to conjecture you are between 50 and 60, so given that: of course it is to be expected ...

I don't think there has been a tissue prosthetic made in the last 20 years that doesn't fit that description.

He did joke that after 20 years many other things can happen in terms of the later years of life.

very true, but what is the usual driver for reoperation? How much is driven by:

1. SVD
2. aneurysm
3. extension of aneurysm beyond the graft
4. another valve failing (looks at The Ross)
5. pannus
6. congestive heart disease from say plaques or cholesterol (are you diabetic or prediabetic?)

I would wonder about the 2% pa on "well managed" ACT (and wonder what defines "well managed") is it Usual Care of 70% in range or Best Practice of >90% in range?

While surgeons love to talk about risk (usually of death) of reoperation let me ask how many people have you spoken to (I believe there are none on this board) who had a reoperation at 76?

• how well did they recover
• what actually emerged (not death) from that to reduce their quality of life
• what sort of drop was it actually

Having had an OHS at 48 and having had some experiences I can say that I would not take lightly a OHS in my 70's, I'd classify it as life altering.

I've not seen anyone here on this forum who had their second OHS at that time of life, but from what I've personally seen, when a first OHS is done on someone in their 70's its not always "bounce back to before onset" sort of good (although better than death).

There is not much data (and no real follow up because nobody is interested) but basically what is there isn't encouraging looking out another 5 years from that point. Nothing seems to exist on what impacts on life there are, only data that is relevant to surgical KPI's

I found one which is strangely no longer freely published in fuller form (only the Abstract seems to be)

I'll mark up words which I think are significant

https://pubmed.ncbi.nlm.nih.gov/6704819/

Abstract​

From January 1978 to December 1982, 165 consecutive patients aged 70 to 81 years underwent various open-heart surgical procedures at the St. Boniface General Hospital in Winnipeg. Preoperatively, most of the patients were in functional class III or IV (New York Heart Association classification). Overall operative mortality for the series was 10.9%. Isolated coronary artery bypass surgery, performed in 71 patients, had an operative mortality of 2.8%. Results were also good in isolated single and double valve replacement in 58 patients (operative mortality 8.6%); there were no deaths in a group of 27 patients who underwent isolated aortic valve replacement [me: at what time frame]. Thirty-six patients with various combined, extensive procedures had the poorest result (operative mortality 30.5%). More than 90% of surviving patients were in functional class I or II postoperatively. The complication rate, although high, was acceptable.[me: acceptable ... hmmm] Immediate and long-term clinical improvement in the majority of patients justifies a surgical approach except in patients who require combined, extensive procedures.​

Lots of interesting assumptions and probably highly specific definitions of acceptable in there.

Lastly I've no skin in the game; meaning I in no way benefit or suffer from your choices (unlike say, your surgeon or you). I'm only here to add what insight I've had from not only a lifetime of being involved with this (so, since I was about 10 in 1974) and in the (because of my involvement) personal observations I've made in that time of myself and of others around me. Once you've had surgery you'll discover your friends wind up talking to you about it for themselves or their parents.

Given what I know of your posts I would posit that the Resilia is what will be the better choice for you (of what it seems are your preferences, your psychology and your desires). But will that be optimal?

Let me pose something: Have you had any OHS yet? I think not right?

Why do I ask?
Well I can vouch for the observation that personal views held frequently change over time, by time I mean decades. Are you expecting (or even thinking about) decades? I don't know your age, so I can not say, but my observations of being here is that almost nobody talks about "20 years on" sorts of outcomes. Some (say, Superman, Dick and myself) do, and have had that.

So let me ask you: why did I just spend 25 minutes writing this and thinking about it? Personal gain? or is it perhaps just that I care?

who'd know. Place your bet and roll the dice I say.

Best Wishes

 

[Timmay]

Definitely list your age Capt Caveman. As we all know, that makes a huge difference in valve choice. I'm scheduled for aortic valve replacement in 9 days from today. If I was 60, I'd be going with the Resilia (no doubt). But I'm not 60. I'm 50. So, mechanical valve is my choice.

No matter what - this forum is great and welcome to the community!

 

[Superman]

@pellicle, our friend @Superbob had a second operation at 78 due to an aneurysm. Recovery had its ups and downs, but to my knowledge he’s doing well.

Not saying it’s a good time in one’s later years, but it’s been done. Perhaps he can shed some light on his experience for the OP?

Difference being he didn’t have the aneurysm the first time around. I actually think (I’ll defer to him) that his tissue valve was doing okay when the aneurysm issue came up. I believe it was roughly a decade after the first.

 

[Superman]

I’ve read some pretty remarkable recovery stories with minimally invasive. But I understand it takes a really skilled surgeon. However, as I haven’t read about any royal screw ups, I’m guessing they don’t even do them unless they’re really good.

Most of the recovery has to do with the meat-grinder your whole body has been put through, so if one can lessen that, good. As your surgeon notes, a smaller scar is just a cosmetic side benefit.

As far as valve choice, in the absence or other data, far be it from me to argue with your surgeon. I have no idea how old you are or your time spent navigating and thinking about this. Some folks, it’s a surprise later in life. Others (myself and @pellicle at least) are lifers that have always been aware of our issues. I can’t recall ever not going in for regular cardiology checkups. My issues were identified in infancy.

But life goes on. Just ran (okay, jogged) 3.5 miles this morning. Takes a licking and keeps on ticking!

 

[Keithl]

Definitely list your age Capt Caveman. As we all know, that makes a huge difference in valve choice. I'm scheduled for aortic valve replacement in 9 days from today. If I was 60, I'd be going with the Resilia (no doubt). But I'm not 60. I'm 50. So, mechanical valve is my choice.

No matter what - this forum is great and welcome to the community!

Heck, I was 58 and I still went mechanical. Did not want to deal with another even minimal procedure in the future if I could avoid it.

 

[Timmay]

... Just ran (okay, jogged) 3.5 miles this morning. Takes a licking and keeps on ticking!

Jealous! Can't wait to eventually get back to doing cardio ... especially jogging. Haven't been able to do that in awhile. It's one of the reasons I look forward to surgery. I don't need to be Superman ... I'd be happy with Robin at this point (lol).

 

[Seaton]

For the record, @Captain Cavemen was 51 last year:
https://www.valvereplacement.org/threads/freshly-hatched-and-new.888094/#post-907203

 

[Martin1962]

Heck, I was 58 and I still went mechanical. Did not want to deal with another even minimal procedure in the future if I could avoid it.

Same here, I was nearly 60 and went mechanical. Didn't fancy another ohs in my 70's. That's for mitral valve, might be slightly different for aortic.

 

[pellicle]

) are lifers that have always been aware of our issues

this is not to say that I've always coped with these issues in the most rational way and its probably resulted in (or exacerbating) some of my personal idiosyncrasies.

PS: thinking about this I'm clearly some type of idiot (see definition here) and the reality is that most people are not enthusiastic and motivated about working towards better health. Looking at the data we see this.

Allow me to quote from a paper (which actually centers on warfarin compliance)

Keep a watch…on the faults of the patients, which often make them lie about the taking of things prescribed. For through not taking disagreeable drinks, purgative or other, they sometimes die.​

Hippocrates, Decorum​

In its 2003 report on medication adherence,1 the World Health Organization (WHO) quoted the statement by Haynes et al that “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.” Among patients with chronic illness, approximately 50% do not take medications as prescribed.

Graph.

Its truly scary.

Perhaps I should just tell most people to get a tissue prosthetic and suffer the risks of reoperation. I thought I'd made clear in my various statements of my position here that (in summary) unless you want to have a hand in the outcomes and achieve the best outcomes probably for you, then you should choose a tissue prosthetic valve and let the system manage you.

Thus I said above

Given what I know of your posts I would posit that the Resilia is what will be the better choice for you (of what it seems are your preferences, your psychology and your desires).

 

[Woodcutter]

I'll share a couple thoughts on #1 as I had both. Just over 9 years ago I had a minimally invasive mitral valve repair and that was followed ~ 6 months later with a full sternotomy mitral valve replacement. [note: I was/am an endurance runner. The repair was to address a deteriorating regurgitation (leakage) issue. It corrected that but at the expense of reducing the effective valve area such that - for a runner - it was effectively stenotic and I literally could not run.]

- Hospital stay was similar. May have been one day longer for the second. (about 6 days)
- The pain associated with healing of the sternum is simply not present when it is not cut! However, the surgeon will pry the ribs apart pretty aggressively to make space between the ribs and, at least in my case, I had a pretty severe back pain for 6 weeks. If the surgeon needs visual or physical access for any reason, opening up all the way is quite important.
- I was 50 at the time, and as mentioned, pretty active (marathoner). I was walking in the hospital within 24 hours and walking several miles daily at home in week 2. In both cases I was doing computer work at home in week 2. I can't do a fair comparison of outside activity because my timing was May/December and where I live that is good weather/poor weather. (Superman, I live about 30 min. from you and should input that some day!)
- Subjectively, I'd say recovery for me was about a week longer/slower with the full sternotomy (but, the induced stenosis renders a solid comparison quite shaky!)
- Obvious difference in the wound healing. A couple of 1" incisions vs. one completely over the split sternum. However, the minimally invasive did leave me with a baseball sized hematoma in the groin area that took a good 4+ weeks to dissipate. Makes sense to me that the wound infection risk would be different.

In summary: if minimally invasive is suitable, I'd recommend it. Overall it is an easier recovery; however, I will contend that the difference is not quite so marked as I have read in a few places! My second surgeon told be what I consider most important: 'you'll have scarring . . .. I want maximal visibility and access to minimize risk and maximize the likelihood of success'.

 

[Dano64]

Good luck Capt. I just received an Inspiris Resilia valve on 2/7. I am 58. There are a number of people on this site who have this valve. Best wishes to you!

 

[Zoltania]

Most of the recovery has to do with the meat-grinder your whole body has been put through, so if one can lessen that, good. As your surgeon notes, a smaller scar is just a cosmetic side benefit.

I think Superman has it right here. My surgery was minimally invasive, but I still had a lot of weakness afterward and took quite a while to get back to full energy levels, perhaps because I was on the bypass machine for nearly three hours. (No pump-head, though.)

I'm glad I had the minimally invasive procedure; I'm guessing that my recovery would have taken as long or longer with a sternotomy, and this way I didn't have to worry about bones healing, leftover wires, etc.

 

[Superbob]

Wow, some well-informed folks here. I will just briefly give my history (as Superman suggested) in case it is in any way helpful:

Had no OHS until I was 63 years old. But had been told my an internist when I was in my 20s that he detected a heart murmur and attributed it to a leaky valve that would someday have to be replaced. Valve replacement was in its infancy then, I believe.

It was during a routine cardio checkup in 2005 when I was 63 living in DC area that my cardiologist said whoa Nellie, not only was my valve leaking badly but my aortic root was severely enlarged. I would need a Bentall's Procedure replacing both root and valve. He referred me to Dr. Alan Speir at Inova Fairfax, an eminent surgeon who later would do the full heart transplant for former Veep Dick Cheney. Dr. Speir encouraged me to do my own research and propose a replacement device for him. I choose the Medtronic Freestyle, with a porcine valve. All went swimmingly, the years tick-tocked away, I exercised actively, all was well.

Then during another routine cardio visit in South Carolina in spring of 2019, an echocardiogram showed I had a dangerously large aneurysm. I was in denial for a while since echos can have measuring errors, but a C-Scan convinced me. Forgotten the exact stat but it was plus-5, big bad booger. My cardio suggested a noted aortic aneurysm expert at UNC/Chapel Hill, Dr. John Ikonomidis, so I went to his shop. He said the piggie valve was working but since he was going in might as well do a valve job too, so he installed an Edwards bovine. The only complication was the release of some blood clots in my left arm, which got me an extra week in the hospital hooked to a Heparin IV. The nurses were sweet and walked me and IV stick through the hallways regularly. Being extra cautious they sent me to a rehab center back home in Myrtle Beach in a medical van driven by two gals just two weeks out of college. For an imaginative 78-year-old this was like going on a joy ride to spring break; turned out to be nothing like that, but they humored the old man, and I suggested good places for them to dine and party.

SO yeah the second old-age OHS turned out well, with just the clotting problem. A nurse was chatting with me in my room when we both noticed my left arm was larger than my right. So flirting with nurses has medical advantages.

Right now, my stenotic back is my main challenge at 80. My back doc has me on PT for that. Not lobbying for any flip-side surgery on that.

Best wishes to you!

 

[GradyWarren]

It's great that you had a thorough discussion with the surgeon, and I hope everything went well with your procedure. When it comes to minimally invasive surgery, I've heard from others that the quicker healing time and reduced infection and bleeding risks are indeed significant advantages. Cosmetic impact might not be the primary concern, but the overall outcome and recovery matter most.
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