Diff in surgical opinion

[Guest]

Miller at Stanford : replace root and asc aorta leave existing mechanical valve inside. Cut just before the valve is placed.
his justification is new mechanical valve puts a risky 6 month period and a well working mechanical valve should run forever so no need to change

Svensson at Cleveland : if we have to replace root we will put new composite graft fitted with valve beforehand. So basically replace all 3 valve and root and asc aorta. his reason is that even though valve is working 100 percent still some tissues can come over and new is better

 

[dixitworld]

Don’t know why it is posted as guest. I did posted this .

 

[Superman]

For what it’s worth, I did the second option about 9 years ago. Can’t believe it’s 2018 already.

Same logic as the second surgeon, plus they were able to resize since I was only 17 when I got my first mechanical. Went from a 23mm to a 25mm.

 

[dixitworld]

Which valve they put in first and Second time? St Jude only? I heard st Jude need more INR than ONX and ATS.?
Does they said anything about your old valve after surhery?

on the contrary see what Miller at Stanford says :

But, you are getting very bum advice regarding extracting your normally functioning old ATS valve (jack-hammer and chisel). That adds a lot of operative time and increases risk, plus it exposes you to another 6 months of high hazard phase for all valve-related complications. You are not listening to experienced expertswho have special expertise in this field! The words you quote must come from amateurs.

 

[Superman]

St Jude both times.

I don’t know that there are any amateur cardiothoracic surgeons out there. My gut steers me away from professionals that will speak disparagingly of other professionals. Disagreement is fine. Just be professional.

I find the lower INR to be a marketing tool that helps some folks sleep at night. I’m perfectly comfortable at 2.5 -3.5.

 

[dick0236]

I find the lower INR to be a marketing tool that helps some folks sleep at night. I’m perfectly comfortable at 2.5 -3.5.

I certainly agree with this. 2.5-3.5 has been my range since the introduction of the INR system in the 1980s with absolutely no issues.........plus it is very easy for me to stay within those limits without really tryi

Oops....didn't mean to hijack thread. This issue will always cause uncertainty if the diagnoses and/or remedies don't agree. I'd probably have to get a third opinion unless I was very comfortable with one of the proposed remedies

 

[pellicle]

Hi

firstly I'll say that speak to two surgeons (both with solid histories of good outcomes) and you may just find you have two opinions which are quite far apart. After you ask about 50 I reckon you'll start to see a scatter plot showing quite an amount of overlap.

Watch this video of a conference where a panel of surgeons discusses their work
https://www.youtube.com/watch?v=_iVVmBgWsiE&t=64s

you'll see some variance of opinion (each defending their own)

I can see the logic both ways. An important factor is to reduce time in surgery and reduce time on the heart lung bypass.
If you replace the valve you run the risk of damaging the AV node which is right beside that (meaning "hello pacemaker"), but (assuming you don't) you can then install a device which has the graft pre-attached at the factory and will reduce operation time and (if you've done any plumbing around the house) reduce the likelihood of leaks around that join (search on paravalvular leaks).

But if you leave the valve and attach a graft to the existing valve seat you need to be sure that you can securely attach the graft to the remaining tissue (which will likely no longer be in perfect condition due to previous surgeries, scar tissue ... bla bla bla ... you get the picture.

on the contrary see what Miller at Stanford says :

But, you are getting very bum advice regarding extracting your normally functioning old ATS valve (jack-hammer and chisel). That adds a lot of operative time and increases risk, plus it exposes you to another 6 months of high hazard phase for all valve-related complications. You are not listening to experienced expertswho have special expertise in this field! The words you quote must come from amateurs.

I'm not sure I'd believe that a Surgeon would say that ... are you sure you're not paraphrasing and perhaps misunderstanding his meaning?

As to the issue of the lower INR, I sit with Superman here in that to me it is nothing more than a marketing ploy. I have not seen even a single claim from the maker that all it does is "reduce bleeds". I see many studies (would you like me to post a few) that suggest that a well controlled INR between 2 and 3 has few bleed complications.

One must be clear that as you age the "risk" of a bleed increases for everyone, yes even for people who have never taken warfarin. They make no claims of other "benefits" of reduced warfarin (and to be frank in well over 50 years of usage history among millions of people warfarin isn't strongly linked to any specific problems anyway).

To me its a teddy bear for those who've been led to believe its a problem (when actually all the evidence points to clinics being the problem)

 

[Superman]

To me its a teddy bear for those who've been led to believe its a problem (when actually all the evidence points to clinics being the problem)

I agree and will expand on this point.

There are a variety of issues with clinics that people encounter.

Formulaic responses to changes in INR, when we all have different metabolisms and responses to dose changes.

Outside of any ones control at the clinic is that the testing is two infrequent at once a month. A lot can happen in terms of volatility over the course of a month, as anyone who tests weekly can confirm.

In addition to volatility, it's a lot harder to remember triggers after four weeks than after one week. So did you change your diet? Your exercise? Miss any doses? etc. Remember all this for one month and try to see what single dose change will get you back on track.

Then there are just back clinics that over-react to things and put you on a rollercoaster that's really hard to get off once we start overcorrecting doses, and that overcorrection is going to last for one month.

All of the above can be a factor regardless of whether you're maintaining 1.5 - 2.0 or 2.0 - 3.0 or 2.5 - 3.5.

Remember too that 1.0 INR is general population. That's my other issue with the low INR. Clot risk, to me, seems to be a bigger danger than bleed risk. I may be wrong in this, but risk of stroke scares me more than risk of hemorrhage. 1.5 doesn't give you much downside margin of error for the occasional missed dose. And, speaking only for me, but 0.5 INR seems like an awful tight window to manage INR while staying in range. I think I would find it frustrating.

 

[cldlhd]

Hi

firstly I'll say that speak to two surgeons (both with solid histories of good outcomes) and you may just find you have two opinions which are quite far apart. After you ask about 50 I reckon you'll start to see a scatter plot showing quite an amount of overlap.

Watch this video of a conference where a panel of surgeons discusses their work
https://www.youtube.com/watch?v=_iVVmBgWsiE&t=64s

you'll see some variance of opinion (each defending their own)

I can see the logic both ways. An important factor is to reduce time in surgery and reduce time on the heart lung bypass.
If you replace the valve you run the risk of damaging the AV node which is right beside that (meaning "hello pacemaker"), but (assuming you don't) you can then install a device which has the graft pre-attached at the factory and will reduce operation time and (if you've done any plumbing around the house) reduce the likelihood of leaks around that join (search on paravalvular leaks).

But if you leave the valve and attach a graft to the existing valve seat you need to be sure that you can securely attach the graft to the remaining tissue (which will likely no longer be in perfect condition due to previous surgeries, scar tissue ... bla bla bla ... you get the picture.



I'm not sure I'd believe that a Surgeon would say that ... are you sure you're not paraphrasing and perhaps misunderstanding his meaning?

As to the issue of the lower INR, I sit with Superman here in that to me it is nothing more than a marketing ploy. I have not seen even a single claim from the maker that all it does is "reduce bleeds". I see many studies (would you like me to post a few) that suggest that a well controlled INR between 2 and 3 has few bleed complications.

One must be clear that as you age the "risk" of a bleed increases for everyone, yes even for people who have never taken warfarin. They make no claims of other "benefits" of reduced warfarin (and to be frank in well over 50 years of usage history among millions of people warfarin isn't strongly linked to any specific problems anyway).

To me its a teddy bear for those who've been led to believe its a problem (when actually all the evidence points to clinics being the problem)

Hey I recognize that video!

 

[pellicle]

Hey I recognize that video!

Was going to credit you but thought you'd forgive me ;-)

 

[cldlhd]

Was going to credit you but thought you'd forgive me ;-)

As long as it wasn't used for malicious purposes

 

[Agian]

I don’t know that there are any amateur cardiothoracic surgeons out there.

I dabble a bit, but it's not really my thing.

 

[dixitworld]

Hi

firstly I'll say that speak to two surgeons (both with solid histories of good outcomes) and you may just find you have two opinions which are quite far apart. After you ask about 50 I reckon you'll start to see a scatter plot showing quite an amount of overlap.

Watch this video of a conference where a panel of surgeons discusses their work
https://www.youtube.com/watch?v=_iVVmBgWsiE&t=64s

you'll see some variance of opinion (each defending their own)

I can see the logic both ways. An important factor is to reduce time in surgery and reduce time on the heart lung bypass.
If you replace the valve you run the risk of damaging the AV node which is right beside that (meaning "hello pacemaker"), but (assuming you don't) you can then install a device which has the graft pre-attached at the factory and will reduce operation time and (if you've done any plumbing around the house) reduce the likelihood of leaks around that join (search on paravalvular leaks).

But if you leave the valve and attach a graft to the existing valve seat you need to be sure that you can securely attach the graft to the remaining tissue (which will likely no longer be in perfect condition due to previous surgeries, scar tissue ... bla bla bla ... you get the picture.



I'm not sure I'd believe that a Surgeon would say that ... are you sure you're not paraphrasing and perhaps misunderstanding his meaning?

As to the issue of the lower INR, I sit with Superman here in that to me it is nothing more than a marketing ploy. I have not seen even a single claim from the maker that all it does is "reduce bleeds". I see many studies (would you like me to post a few) that suggest that a well controlled INR between 2 and 3 has few bleed complications.

One must be clear that as you age the "risk" of a bleed increases for everyone, yes even for people who have never taken warfarin. They make no claims of other "benefits" of reduced warfarin (and to be frank in well over 50 years of usage history among millions of people warfarin isn't strongly linked to any specific problems anyway).

To me its a teddy bear for those who've been led to believe its a problem (when actually all the evidence points to clinics being the problem)

Hi brother

i have pasted the response from Dr Miller Mail itself. I am not sure if I understand your response fully. Do you mean that replacing valve with composite graft can lead to pacemaker?
while composite graft is faster?
i always think that attaching the graft to existing valve can always lead to issue due to deceased root with lot of sutures already.
i didn’t quite understood what your opinion is which procedure is better

 

[pellicle]

Hi

i have pasted the response from Dr Miller Mail itself

wow .. he put that in writing verbatim?

I am not sure if I understand your response fully. Do you mean that replacing valve with composite graft can lead to pacemaker?

I mean that subsequent surgery where the valve is replaced makes removing that valve AND NOT dammaging the AV node harder.

I encourage you to read this page about the anatomy and think about the proximity of the node to the location of the valve

https://en.wikipedia.org/wiki/Atrioventricular_node

while composite graft is faster?

it will be faster to install if understand properly. What I don't know is if one is riskier than the other as every human has slightly different placement of nerves (by a few mm at least)

i always think that attaching the graft to existing valve can always lead to issue due to deceased root with lot of sutures already.

I would share that view and indeed I wrote that too ...

i didn’t quite understood what your opinion is which procedure is better

I don't have an opinion on which is better, I wrote what I did for consideration. I (if I were you) would take those points to your surgeon and say "what do you think".

I was attempting to explain why two surgeons could have different opinions and why.

Best Wishes

 

[dixitworld]

Yes I am also not happy with wordings Dr. Miller used for another opinion. Regarding taking these info to the surgeons both are stubborn wiTh their recommendation.
Dr Svensson at CC will not meet anyone more than 1 time before surgery nor he will personally answer more questions

Dr Miller on the other hand has told him that he is the expert so no more argument on the decision

 

[pellicle]

Hi

wow, you sure have some bad examples of surgeon bedside manners there.

...
Dr Miller on the other hand has told him that he is the expert so no more argument on the decision

"him" is who?

so far I lean towards Dr Svenssons opinion

 

[Agian]

... and the golden ****** award for 2018 goes to...

 

[Superman]

... and the golden ****** award for 2018 goes to...

Hey now! Pellicle has had his moments, but is that really called for?

:coolhank:

 

[pellicle]

Hey now! Pellicle has had his moments, but is that really called for?

I think he's voting for Dr Miller...

 

[Agian]

We should have one of those online polls.