Homograft Replacement?

[Bill Hall]

Hi All - It looks like I will need surgery soon. I have an aneurysm along the suture line where my aortic valve was replaced six years ago. The doctors in Arizona, (where my sister lives) tell me I should also replace the homograft with a mechanical valve. My local doctors tell me I should not replace the homograft, it is working fine. So, I am still undecided. It seems to be a trade between the possible additional future surgery and the additional risk of having the valve replaced in conjunction with the aorta surgery. I plan to call Cleveland, where my valve was replaced and ask their opinion. Here are some other considerations:
1 - They had a difficult time restarting my heart after my long surgery in Cleveland.
2 - If I don't replace the homograft now, I have the risk of the additional third surgery and associated scar tissue. I don't know much about the scar tissue, but plan to investigate further.
3 -I don't have a problem with coumadin, since I was afib for a month after my surgery. Even if I keep the homograft, I might end up afib and needing to take it anyway.
This might come down to a coin flip, so if someone has an opinion, I am interested. Thanks in advance and thank you to those who replied to my earlier posts.

 

[Susan BAV]

Hi Bill -

Sorry to read this. I don't know what I'd do in your shoes, besides get another opinion (but if the valve is fine I might keep it depending on more expert opinions and I'm thinking your local doctors probably know your overall health situation better than the AZ doctors do). How is your mitral valve doing after the repair? Are you a bicuspid? Is that unusual for an aneurysm to show up this many years later along the suture lines?

(edit - after reading some of the following posts, I think I might not keep the homograft, depending on more expert opinions; and I'd get another opinion sooner rather than later.)

 

[Christina]

What a bummer!

What a bummer!

Bill,

You are one of the old time members here and you and I have met several times at the VR.com reunions.
So sorry to hear that you are in need of another OHS soon to take repair an aneurysm on the aorta.
I think your idea of calling Cleveland Clinic for another opinion is a good one. The more opinions the better for you to make an informed decision about this. May I ask you the name of the doctor in AZ who gave you the advice of replacing the Homograft with a mechanical?
If it were me having to decide and knowing about the difficulty they had restarting your heart during your first surgery I think I would replace the valve with a mechanical and get it over with because they have to open you up anyways. We all have learned that Homografts don't last as long and you certainly don't want to have your chest opened again unless there are no other options.
You are correct, Coumadin is not that bad. So far so good for me after nearly 7 years.

Hope this helps and wishing you all the best.

 

[StretchL]

From the research I've done, I've learned that homografts in the aortic position deteriorate more quickly than xenografts, and, depending on a patient's age, will almost certainly require a re-op in 5-15 years.

Just my 2 cents, but if I were already on Coumadin, I'd have the homograft replaced with a mechanical valve while they're in there this time, thus hoping to avoid a third surgery down the line.

 

[Arlyss]

Hi Bill,

I am so sorry that you face such tough decisions. When I checked your profile it states that you had your aortic valve replaced with a homograft and your mitral repaired in 2001. I am wondering if you have BAV or some other connective tissue disorder? Your valves and your aortic tissue must be somehow "special" to give you problems while still young really, and I'm wondering if the underlying cause was explained to you?

Regardless, if it were myself or my husband, I would look at the following:

1) In the immediate term, are my blood pressure and activity level/exercise levels controlled, to give me a safety margin until surgery? (Especially since there is a pseudoaneurysm at the stitching line). Am I taking blood pressure medicine to reduce the stress on the aorta, including at this fragile stitching line? What physical activity is appropriate for me now? (no lifting, etc......)

2) I would look at valve options - which you are doing. I have heard it said that homografts become like "lead pipes" when they calcify and can be very difficult to remove. This aneurysm is forcing you to have surgery now. Along with it, there is an opportunity to put in a different valve solution.

3) I would try to understand how much risk there is that I could end up in an emergency situation. As quickly as possible, I would be in touch with major aortic centers and have my records reviewed. I would try to find the surgeon who understands the aorta as well as valves - someone who specializes in complicated repeat surgeries like this one. There are really only a few surgeons like this.

A surgeon will offer the solution that they do best. That is appropriate for them, but may not match up with what is best for an individual.

To say a valve is working fine now avoids the issue of dealing with it while the chest is open. It may make the surgery easier - although I would question how well the aorta will be handled when the homograft is left in place. It postpones the issue to another day - possibly it will become some other surgeon's problem. But it is always the patient's problem. I hope you can find the right surgeon to give you a comprehensive solution now.

If Rachel sees this post, perhaps she will comment. She managed to get to the right surgeon in a major aortic center in time. But she did not have any time to spare.

Best wishes,
Arlyss

 

[Bradley White]

Hi again Bill,

It seems to me that it would be difficult, if not impossible to repair (and especially replace) the pseudo aneurysm without removing the valve. Obviously, a surgeon would know the answer to this question best.

Strech is correct for the most part. In older patients aortic homografts don't last as long as xenografts, but in young patients no one really knows which one lasts longer. However, conservatively you should not expect it to last anymore than 10 years, although some have lasted 20+ years. Thus, even if they could leave the homograft in (which I don't think is possible) I would likely elect to get it replaced with a mechanical valve. My opinion

Brad

 

[LUVMyBirman]

Hi Bill! Great to see you posting. Hopefully, we will meet up again at a future reunion

Tough decision. Guess I would lean towards the mechanical. BUT.....if your valve is intact. Would hesitiate to mess with a good thing!

Wish you all the best in your decision process. Take care and keep us posted.

 

[Bill Hall]

Thanks for the replies:
Susan - I heard my valve was bicuspid, I'm not sure about your suture question and I don't think it matters whether they see me. I think the disk is all they need to see. Thanks for your thoughts.
Christina - We were both at the Scottsdale, Denver and first Las Vegas reunions. You are a real sweetheart. Thanks.
Stretch - I went to the best hospital (Cleveland) and found the best surgeon (Cosgrove) and took their advice and here I am. Somehow I made a mistake.
Arlyss - Thanks for all that detailed information. They tell me that the aneurysm is small and not an emergency. I want to make the right decision regarding the homograft and find a good, experienced surgeon who is in a nearby hospital. This might take some time, I am hoping for some good luck.
Brad - I am leaning in your direction.
Gina - It is so good to hear from you, back from my original surgery, right? We met in Chicago and Denver, if I am remembering correctly.
Rachel - Thanks for sharing your experience. I guess you know how I feel, since you had to go through it yourself. Thanks for the PM.
Bill

 

[Arlyss]

Hi Bill,

If your aortic valve was bicuspid, please be sure that your entire aorta is imaged. Then, depending on what is found, understand exactly what kind of surgery will be done on the aorta. If someone is proposing to leave the homograft and most of your remaining asacending aorta in place, you could have multiple problems later - with the rest of the ascending aorta, the under side of the arch, the homograft....

You really need someone to take a complete look at you that also has the skill set to give you what will be best for you in the long term.

Best wishes,
Arlyss

 

[StretchL]

Stretch - I went to the best hospital (Cleveland) and found the best surgeon (Cosgrove) and took their advice and here I am. Somehow I made a mistake.

Hi, Bill.

Just to clarify, I wasn't implying you made a mistake in your valve choice, or that you didn't do your due diligence. I was only saying that because of the longevity issues with the homografts, I'd opt for getting it out of there when they have you open this time, rather than awaiting another surgery down the road.

 

[Bill Hall]

Thanks for the further replies. I guess you can tell I am really frustrated by my future repeat surgery. I thought my homograft would last longer than average, maybe 20 years. Maybe there would be advancements by that time which would make the second surgery even less invasive and simpler.

I have read all your posts over carefully and decded to get a second opinion through the Cleveland Clinic. I figure that since they did my initial surgery, they will have access to my surgery records and will know their own methods. Also, they have experience with homografts and will be able to make my decision with better experiences. If they determine that I should not replace the homograft, I will have the surgery local and have my cardiologisdt help me find the best available. If they determine that I should replace the homograft, then I have a bigger decidion to make, which may require traveling. Thank you all again for your help.
Bill

 

[Superbob]

Bill,

I don't have the research to support an opinion on this, though Stretch's take sounded plausible. I think getting a second opinion is a good idea.

Even though I don't have anything to add, I did want to pass along to you my very best wishes. I remember your kindness here when I was one scared scout facing surgery at Inova Fairfax near you in early '05. Just want you to know that I am sending my best thoughts/prayers/vibes to you now.

Best wishes,

 

[Arlyss]

Dear Bill,

I am so so sorry that you must face surgery again so soon after the last one. It is not at all what anyone would have wanted for you. It is hard to work though feelings about the past, wishing with our current knowledge we could change decisions made then. You did the very best that you knew to do at that time.

We still live in a time when bicuspid aortic valve disease is not very well understood. It has for much too long been looked at as a simple valve condition. It is not.... and approaches taken for just an isolated valve problem, no matter how well intentioned, can lead to problems.

Now you know you have fragile tissue - the tissue of your aorta is not normal; and the stitches put into it when attaching the homograft have caused a tearing and stretching. But you can get it fixed!!

If this were my own body or my husband, I would have an aortic surgeon, not a valve surgeon only, evaluate this. Aortic surgeons generally are valve surgeons, but not the other way around.

I just hope this time you get the longest lasting solution possible. That could mean taking the entire ascending aorta and possibly the underside of the arch..... to avoid another surgery in the future. This is where the aortic surgeon comes in.


Best wishes,
Arlyss

 

[Nancy]

Aw, gee Bill-

I am so sorry you are facing such things. Just want you to know you'll be in my thoughts. I think you may be leaning this way anyway, but if you can save yourself from having to do this at another time in the future again, that would be to your benefit. I don't think it matters what the surgery is, if it is a MAJOR thoracic surgery, it stresses all your body systems. I saw what Joe went through with 3 hearts and two lungs. He was a very strong man, but with each one, he bounced back slower and slower.

I am glad you are consulting with Cleveland Clinic.

 

[Turkey Hunter]

Bill,
Very sorry to read this; as you may have read.....I am in a "similar" position. CCF has identified another aneurysm in my ascending aorta and aortic arch; but my valves look and are doing great.
I am not in the "need surgery soon" catagory but I understand the need for input and oppinions. Avoiding the chance of another operation is my best oppinion. Especially due to the issues you had comming out of the last procedure.

Take care and God Bless.

Ben

 

[Bill Hall]

Thanks once again for the replies.
Bob - Thanks for the good wishes and prayer.
Arlyss - I plan to read your posts over and over. Thanks for all the advice.
Nancy - I was hoping to hear from you. I know Joe had multiple surgeries, so I thought you might have an opinion. I should already know, since I have read a few thousand of your posts over the years.
Ben - Sorry to hear you are suffering from nearly the same problem as me. I hope you can postpone your surgery, until they figure how to do it flawlessly. Tell them to be careful with the scaring.

I see my cardiologist on Wednesday, March 28. We will schedule a catherization, as a minimum.

Bill

 

[Arlyss]

Hi Bill,

Is the cath to evaluate the valve, the coronary arteries, or both?

Rather than assume a cath is needed, you can talk to your cardiologist about a 64 slice CT scan. This is a very fast device and captures amazing detail about a beating heart. The most experienced radiologists and cardiologists with this technology should have considerable skill with it by now, and I am aware of surgeons who now are willing to do surgery based on these images - they are that good.

Many BAVs have clean coronaries, but perhaps it is the degree of stenosis of the valve that is being questioned. It is very important to know everything possible before having surgery. You want no surprises and neither should the surgeon!

Here are a couple links re. the 64 slice CT - just some I found quickly.

http://www.medcompare.com/spotlight.asp?spotlightid=147

http://www.cnn.com/2007/HEALTH/03/01/chest.pain.ap/index.html

If it were my own aorta with a pseudoaneurysm, I would try to avoid invasive diagnostic procedures if possible. It is definitely worth a discussion with your docs!

Best wishes,
Arlyss

 

[Bill Hall]

I met with my cardiologist on Wednesday and here is what he told me:
1 - I need to have the surgery soon. The aneurysm is unpredictable and a rupture would likely cause death.
2 - He implied that my second opinion was a delay tactic to postpone my surgery.
3 - I asked about restarting my heart after the problems they had in Cleveland. He said that my heart was in better shape this time (the chamber had reduced in size) and a shorter surgery would help that also (my first surgery was 11 hours with 4 on the heart lung machine)
4 - Second surgeries are more risky.
5 - I asked about the homograft tissue, but we didn't communicate very well. Maybe I asked the question wrong.
6 - He said this was routine surgery, but that this type of aneurysm is rare.
7 - He said nice things about the surgeon we met at Fairfax, my leading candidate for doing the surgery.

To Arlyss - Thanks for the good information. Unfortuntely, I didn't read it before the dr appointment. I am having the cath to assess the coronary blockage status. I think it will show my arteries clear like in 1980 and 1999. Anyway, I am prepared to do it again.

Bill

 

[Arlyss]

I would never call surgery on the aorta in the chest "routine" - and I cannot imagine that comment in connection with a pseudoaneurysm.

I am wondering why your last surgery was so long, since that is being mentioned as one of the reasons for problems restarting your heart?

Do you know how many surgeries the surgeon you are considering does on the ascending aorta in a year - how many deaths, how many complications within 30 days? Has this surgeon ever done surgery for a pseudoaneurysm? Will he take the entire ascending aorta and replace with Dacron using Total Hypotheric Circulatory arrest?

Also, it is the surgeon who needs the picture of the coronary arteries so he knows if a bypass is needed while in the chest. Ask the surgeon if he will order a 64 slice CT for you.

One of the controversies in cardiac medicine currently, and there are several right now regarding those with coronary artery disease, is the contention that cardiologists who currently receive revenune from angiograms do not want to lose those dollars to radiologists and 64 slice CTs.

Patients and families need to be informed consumers regarding their choices.

Best wishes,
Arlyss

 

[Bill Hall]

Arlyss,
Thanks again for your interest. My previous surgery was long because Dr. Cosgrove decided to repair the Aortic valve twice before giving up and putting the homograft in place.
I will ask more questions about the surgeon, but am not optimistic about finding negative information like death rate. I think the best I can find is how many times.
I will ask about the 64 slice CT scan.
Thanks - Bill