Fourth surgery anyone?

[Gail in Ca]

I spoke w my cardiologist and I will need another procedure to replace my severely leaking mitral valve. He said it’s better to do it sooner than later.
When I told him that the interventional cardiologist’s nurse said the TMVR valve lasted 5-7 years and they have patients at 10 years, he was surprised at this. He is going to talk to them about the 5-7 yr thing.
So, I’ll need a CT scan and then I’ll talk again with the robotic surgeon at Cedars
about risks, valve type (he had already mentioned bovine but I wondered about a mechanical since I already have one in the aortic position). I’ll be 70 soon so I’m just a bit more worried now with a fourth surgery.
Has anyone gone thru a 4th?
I also would appreciate it if people could contribute what questions they would ask the surgeon. Thanks!

 

[pellicle]

Hi there Gail

sorry to read that ... there are people here who've had 5, so its totally doable. I get the feeling that your mitral has not had too many replacement surgeries so there should be less scar tissue to get through there.

I get the issues at concern about the surgery at 70 ... but what can you do?

I wish you an uneventful surgery and a straightforward recovery. Being a veteran of this you know what to expect. I hope you have some helpers too.


Best Wishes

 

[Chuck C]

I'm very sorry to hear this news Gail.

I will need another procedure to replace my severely leaking mitral valve. He said it’s better to do it sooner than later.

I'm always in favor of this.

I also would appreciate it if people could contribute what questions they would ask the surgeon.

One point of discussion I would have is why bovine, when you already have a mechanical valve and are already on warfarin. Usually, the reason to go tissue and not mechanical is to avoid warfarin. I am not sure what your current INR target is, but adding a mitral mechanical will almost certainly raise the target and perhaps the motivation is to keep the lower INR target. Regardless of the reason, that needs to be carefully weighed against the possibility of needing another procedure when the bovine mitral valve experiences SVD. I would think that you would really want to do everything to avoid surgery #5 and a bovine might put you in that situation in your 80s.

Best of luck in the discussions and decision ahead and best of luck with your procedure. We're here for you and please keep us posted.

 

[V__]

When I told him that the interventional cardiologist’s nurse said the TMVR valve lasted 5-7 years and they have patients at 10 years, he was surprised at this. He is going to talk to them about the 5-7 yr thing.

Would be interesting to know what the cardiologist would expect himself.

I’ll be 70 soon so I’m just a bit more worried now with a fourth surgery.

Well, at least it is still possible. AFAIK they don't like to operate on people in their 80s.

I also would appreciate it if people could contribute what questions they would ask the surgeon. Thanks!

Well, you have a lot more experience with OHS in general... But here are the questions I'd ask if I were you:

• How many mitral valve operations does the surgeon do per year? (The outcome is better if it's at least 25.)
• How many robotic surgeries has he done? (There is a learning curve with the tool. From memory, it's something like 50-100 operations.)
• How problematic having the previous OHSs would be in this case? (From your other posts, it seems this operation would be of minimally-invasive type. I hope (but don't really know) that the different access method would mean less scar tissue to work through and fewer problems than another sternotomy would've had.)

 

[vitdoc]

I had three previous surgeries and was faced with a possible fourth for a decompensated leaking mitral valve. I was about to have the surgery at a place known for mitral surgery. I also was in discussion with a cardiologist about mitral clips. At the last minute the surgeon called just before I was getting on the plane and suggested the clip. Two days later 8 years ago I got two clips. Worked like a charm and are still working well. Not everyone is a clip candidate however. But compared to open heart it was fantastic. Check about this.

 

[tommyboy14]

Hi Gail,

I wouldnt worry too much about your age. Yes it isnt nice to need to have this again, but we need to remember that 70 is a normal age to have the surgery. Some people have several repeats in their 70s and are ok. See Arnold Schwarzeneger.

But perhaps it is worth exploring if you can have the MitraClip @vitdoc mentioned. But you probably need to go to a specialist for that, given it is still fairly new technology.

I would also seek out surgeons that are experts in reoperations. Out of the several sugeons I spoke to in the UK, 2 had done a 6th AVR on someone successfully and without complications. You really want to go to one who has a ton of reoperation experience.

Best of luck and I am sure you will be ok.

 

[Gail in Ca]

I appreciate the kind, thoughtful replies.
Unfortunately, after the TEE was done, the interventional cardiologist said I’m not a candidate for the mitraclip. This is why he said I would now be a candidate for a TMVR.

 

[tommyboy14]

Given your age, I wonder whether TVMR is the right solution. Can they do valve in valve like with TAVR? Or valve-in-valve-valve?

In an ideal world you get 10 years out of each TVMR, but if you only get 5 each or they cant do TVMR in TVMR llater for whatever reason, one has to wonder whether mechanical mitral valve replacement wouldnt be the best solution, given you are on Warfarin anyway

 

[Gail in Ca]

Yes, my thoughts exactly. I am definitely leaning towards the robotic replacement with a mechanical valve if possible.
I will have my questions for my appointment with the surgeon about that.

 

[vitdoc]

If there is thought about a robotic approach make sure this is feasible. My understanding is that in re ops especially after multiple surgeries due to scarring the access to the surgical site can be difficult. Hence open surgery may be preferred. Ask the surgeon about this issue and the likelihood of needing to convert to a more open approach.

 

[pellicle]

I am definitely leaning towards the robotic replacement with a mechanical valve if possible

why?

for a super complex surgery like a redo, I'd take a skilled surgeon any day working with every sence they have.

"never send a machine to do a humans job" (Dune, Butlerian Jihad)

unless "robotic" is basically no more than this

distancing the human from the thing being operated on.

In which case; why??

 

[Gail in Ca]

Third surgery entailed 3 hours just to get thru scar tissue. This surgeon would enter on right, hopefully avoiding the scar tissue mess. Of course I’ll get more from him at my appointment. Plus the CT shows whether this is feasible for me.

 

[vitdoc]

Good luck.

 

[Eva]

Best of luck.

 

[V__]

why?

I think it's a good question. The points from @vitdoc (about feasibility and odds of conversion to sternotomy) are relevant.

The tools and techniques between the minimally-invasive access and sternotomy one are different. Which might just mean that the surgeon is much more comfortable using one or another. Which would be important.

On the other hand, an article from Cleveland clinic team stated that they prefer sternotomy for re-repair. But it could be that they have surgeons skilled in both types of access and tools.

The bottom line is, it seems to make sense to follow @vitdoc's suggestions

"never send a machine to do a humans job" (Dune, Butlerian Jihad)

The "robot" in this case is "haptic" interface that aims to make the movements more precise. Which may help in some (rare?) cases. Here are some examples:
- Grape peeling.
- Grape stitching.

Kinda impressive

 

[Croooser]

Gail,

Had my one and only at age 71. It was nowhere near as complex as your situation. However, FWIW, 70+ seems doable if one is in decent shape otherwise and has the right team in place.

I assume that you are considering a world class clinic/hospital and surgeon. One of the things I learned at CC is that the very best are prepared and experienced in dealing with the really, really unusual and difficult situations. Sounds like your case qualifies.

You have met some serious challenges already. Wishing you the very best with this one.

 

[tommyboy14]

@Gail in Ca
I think it is probably fair to ask the surgeon how many reops he has done previously with the robotic approach. I would also ask him to give you a probablility assesment what he thinks the risk of a conversion to a sternotomy are, how many sternotomies he has done, or whether there will be another surgeon onsite to do the sternotomy in case he cant do his approach.

I guess a final question from me would be, will you have to be on the heart lung machine the whole time while they convert from one operation to another?

Finally, I think it is fair to ask how many complex reops he has under his belt. You want to make sure you are not of his first more complex cases.

Having said all of that, I think that us heart valve folk arent really that complex from an OHS perspective. Surely a heart transplant or transposition of the great arteries, elephant trunk procedure are all much more complex operations.

Good luck.

 

[Survived03]

Good luck Gail. Sorry to hear you may have another surgery.

 

[tommyboy14]

@Gail in Ca

In the UK, there is this doctor, https://londonmitralclinic.com/team_members/toufan-bahrami/, who has done 500 minimally invasive mitral valve repairs via endocospy. I.e. the access through your rib cage.

Here is the interesting bit of his webpage: Beating Heart Mitral valve repair. Mr Bahrami is the only UK surgeon recognised by Edwards (US) to perform the beating heart Harpoon mitral valve repair, alongside 5 other European institutions.

Now I would said that the name 'Harpoon' is not a great name for a heart valve repair machine.

But in your shoes, I would try to find the equivalent of this person in the US. If there was a way to replace your mitral valve without heart lung bypass machine that would probably be beneficial.
There must be somebody as skilled in the US. After all, the US is six times as large as the UK and is said to be medically more advanced.

 

[tom in MO]

Good luck Gail. If I recall correctly you are a flautist. I was one once. Poulenc's Sonata is one I like to return to as well as the Mozart concerto.