How long does it take the heart to adjust to a new bovine aortic valve?

[d333gs]

I have read a lot about the sternum healing process but not much about the heart healing process; Apparently, my aortic valve is the size of my little finger and I will be getting a new one about the size of my big toe. In videos I have watched, the doctors say the heart responds immediately well to the bigger valve. On the other hand, I have heard that it takes time for the heart to adapt to the new valve. I currently have only minor symptoms: carrying heavy items upstairs. Up until December, I was doing full out biking about 10 hours a week. I would expect with a new large valve, my biking performance will dramatically improve.....am I delusional?

 

[pellicle]

I think it makes no difference if its a bovine, porcine, pericardial tissue or mechanical valve.

As I understood it much depends on

1. the level of fitness you had fallen to directly prior to the surgery
2. your age
3. individual factors

in about that order.

IIRC when I had my 2nd OHS (and was 28 or so) I went from "tapping out on max HR" and struggling walking up my "reasonably steep" hill from the shops to being able to improve my time and not even approaching max HR and being breathing limited (which had fallen in parallel with my failing valve)

Within a few years I was cycling stronger than perhaps since I was 20.

PS: on that occasion I was implanted with someone else's valve and I made no specific efforts to train up because I was busy then with the last two years of my (second) degree (IT). After I started in my job after graduation I decided to start riding to work (11km) and within a year was doing 27km loops on the way home.

After my third (a mechanical) I was jogging on the beach (in the hard sand) with Nordic poles by 6 months and almost keeping up with my wife (who jogged on the soft sand to have a handicap but was always more of an athlete than me)

Perhaps @Chuck C will have something to say as he's now back slogging up his mountain (with a mech valve too)
Best Wishes

 

[pellicle]

I have read a lot about the sternum healing process but not much about the heart healing process

I meant to give you (an IT guy) a bit of a wrist slap for failing to search much here.

At least Chuck has written a LOT on recovery ... indeed if you use Google you'll find a ton of recent stuff

https://www.valvereplacement.org/th...nd-need-to-make-a-decision.887879/post-912206
https://www.valvereplacement.org/threads/lets-set-some-goals-a-throwdown.888136/page-3
oh, and maybe I should have given you an angry face too ;-)

(*but that's not me)

 

[Chuck C]

Up until December, I was doing full out biking about 10 hours a week. I would expect with a new large valve, my biking performance will dramatically improve.....am I delusional?

Hi there.

As to whether your biking performance is likely to improve, that is certainly possible. It depends on many variables, including how much your narrowed valve is impeding your performance now. My aortic valve narrowing was similar to what you are describing- going down to .87cm2 just before surgery and now, with my new mechancal valve, it is over 2cm2, per my echo last week. @pellicle linked two threads in which I document my recovery and some of my fitness training. From those threads you will see that my fitness has returned over the course of months and I now can go at it pretty hard again.

Today I hiked my favorite local mountain again for the 10th time in the past 3 weeks. I hiked it a lot in the year leading up to my surgery- about 5x per week and, although I can't claim that I am climbing it any faster now, I do feel as fit now as I did then, and go up the mountain, a 1,200 ft elevation gain, without any difficulty once again. It is much easier now than it was 2-3 months after surgery. Keep in mind that I was not experiencing any symptoms prior to surgery, and I was flying up the mountain at a fast pace back then, so it is not as though I am now setting world records, but I am very pleased that I am comfortably able to challenge myself and climb at a similar pace as I did prior to surgery.

Many members report an immediate difference in their cardio- but those are typically folks who are very symptomatic- out of breath climbing a flight of stairs for example. It does not sound as if you are that symptomatic at this point and it is hard to know without more information whether the larger valve area will translate into immediate results. But, if your narrowed valve is slowing you down, once you have recovered from surgery and slowly return to physical activity with your cardiologist's guidance, you very likely will experience a higher performance level with enough training.

It sounds like you are eager to test yourself with your new valve, that is fine and good, but really important not to push too hard too soon. Follow the guidelines of your medical team in how hard you train. It is not worth risking a paravalvular leak just to see if you can beat your previous athletic performance too soon. Most physicians give the green light for return to vigorous cardio training after about 3 months. I waited 4 months before I really pushed myself, even though physically I felt as if I could have done so a lot sooner.

Personally, I have found recovery and the return to fitness very rewarding and I hope you do as well. Don't be discouraged if it takes a few months longer than you anticipated to get to the fitness level that you want. With such a narrowed valve it is very likely that there was an invisible ceiling on your performance, so in time and with training, you have a good possibility of improving on your previous level.

 

[d333gs]

Hi there.

As to whether your biking performance is likely to improve, that is certainly possible. It depends on many variables, including how much your narrowed valve is impeding your performance now. My aortic valve narrowing was similar to what you are describing- going down to .87cm2 just before surgery and now, with my new mechancal valve, it is over 2cm2, per my echo last week. @pellicle linked two threads in which I document my recovery and some of my fitness training. From those threads you will see that my fitness has returned over the course of months and I now can go at it pretty hard again.

Today I hiked my favorite local mountain again for the 10th time in the past 3 weeks. I hiked it a lot in the year leading up to my surgery- about 5x per week and, although I can't claim that I am climbing it any faster now, I do feel as fit now as I did then, and go up the mountain, a 1,200 ft elevation gain, without any difficulty once again. It is much easier now than it was 2-3 months after surgery. Keep in mind that I was not experiencing any symptoms prior to surgery, and I was flying up the mountain at a fast pace back then, so it is not as though I am now setting world records, but I am very pleased that I am comfortably able to challenge myself and climb at a similar pace as I did prior to surgery.

Many members report an immediate difference in their cardio- but those are typically folks who are very symptomatic- out of breath climbing a flight of stairs for example. It does not sound as if you are that symptomatic at this point and it is hard to know without more information whether the larger valve area will translate into immediate results. But, if your narrowed valve is slowing you down, once you have recovered from surgery and slowly return to physical activity with your cardiologist's guidance, you very likely will experience a higher performance level with enough training.

It sounds like you are eager to test yourself with your new valve, that is fine and good, but really important not to push too hard too soon. Follow the guidelines of your medical team in how hard you train. It is not worth risking a paravalvular leak just to see if you can beat your previous athletic performance too soon. Most physicians give the green light for return to vigorous cardio training after about 3 months. I waited 4 months before I really pushed myself, even though physically I felt as if I could have done so a lot sooner.

Personally, I have found recovery and the return to fitness very rewarding and I hope you do as well. Don't be discouraged if it takes a few months longer than you anticipated to get to the fitness level that you want. With such a narrowed valve it is very likely that there was an invisible ceiling on your performance, so in time and with training, you have a good possibility of improving on your previous level.

Thank you Chuck for writing this!!

 

[d333gs]

I meant to give you (an IT guy) a bit of a wrist slap for failing to search much here.

At least Chuck has written a LOT on recovery ... indeed if you use Google you'll find a ton of recent stuff

https://www.valvereplacement.org/th...nd-need-to-make-a-decision.887879/post-912206
https://www.valvereplacement.org/threads/lets-set-some-goals-a-throwdown.888136/page-3
oh, and maybe I should have given you an angry face too ;-)

View attachment 888383

(*but that's not me)

Hi pellicle
Ok, so what I am beginning to understand is that the valve itself needs time to adapt and settle in before we can push it too hard . I think Chucks reference to dangers of a paravalvular leak sum up what I was looking for . We need to wait for a solid bond of the new valve to the heart before pushing it too hard;
" In most cases, paravalvular flow is present immediately after valve implantation ....)
I found this:
https://www.escardio.org/Journals/E...s a,increased risk of infectious endocarditis.

 

[d333gs]

Hi pellicle
Ok, so what I am beginning to understand is that the valve itself needs time to adapt and settle in before we can push it too hard . I think Chucks reference to dangers of a paravalvular leak sum up what I was looking for . We need to wait for a solid bond of the new valve to the heart before pushing it too hard;
" In most cases, paravalvular flow is present immediately after valve implantation ....)
I found this:
https://www.escardio.org/Journals/E...s a,increased risk of infectious endocarditis.

I am still unclear of a timeline for the bonding between the heart and bovine tissues. I was guessing it was about the same time duration as the healing of the skin of the chest incision........about two weeks ? But that must be wrong?

 

[pellicle]

e valve itself needs time to adapt and settle in before we can push it too hard . I think Chucks reference to dangers of a paravalvular leak sum up what I was looking for . We need to wait for a solid bond of the new valve to the heart before pushing it too hard;

agreed ... and its all down to endothelisation. This post covers some of it from a different angle
https://www.valvereplacement.org/threads/cuts-on-warfarin.888098/post-907317
its like the ivy that grows onto a wall that you can't rip off and thus make a good seal

 

[d333gs]

I am still unclear of a timeline for the bonding between the heart and bovine tissues. I was guessing it was about the same time duration as the healing of the skin of the chest incision........about two weeks ? But that must be wrong?

I was also wondering if the bovine valve retains the genetic characteristics of a cow, for instance, lifespan. It does look like there is a correlation; Both the cow and the transplanted valve have a lifespan of 15 to 20 years.

 

[d333gs]

agreed ... and its all down to endothelisation. This post covers some of it from a different angle
https://www.valvereplacement.org/threads/cuts-on-warfarin.888098/post-907317
its like the ivy that grows onto a wall that you can't rip off and thus make a good seal

Thanks Pel!

 

[bizinsider]

Hi D333gs,

I'm going on 2 years with my bovine, which was replaced when I was 67 and in good physical shape. Unbeknown to me our my surgeon, I had a unicuspid valve. The general rule, is that it takes 6 week for your valve to start settling in and scar tissue starts making it official part of your body. That's when the concern of infection is the greatest. (FWIW, the biggest change I noticed with my heart itself is that I could feel the beats - VERY LOUDLY and strongly - immediately after surgery and for quite awhile thereafter... of course, with a unicuspid valve, I never knew what a normal valve felt like.)

As for how you feel... I agree with Chuck that the recovery part is actually quite fun because you see and feel first hand the improvement every day. I recall distinctly, probably nearing week 4, when I started to speed up my walks and could go up a slight incline without having to slow down or feel any tightness in my chest, which is normal post-surgery.

By week 8 I was back to my regular walking routine, which is typically 4 miles, including steep hills. By week 12 I had no concern about laying on a roam roller vertically - or doing anything that would hurt my sternum. I had a full sternotomy (had other things done inside, as well) and my sternum healed fine, with no issues. Like many people, my pain was in my shoulders.

While I had considered myself generally asymptomatic, post-surgery I was able to walk faster and further...and to this day walk longer than I did pre-surgery. What I assumed was boredom (I always slowed toward the end of my route) was probably just valve-related fatigue. I also now try to throw in light interval jogs on the uphill parts of my walk.

Since exercise is part of your regular routine, you probably will do what many of us do and push too hard, which will cause a day or two of setback. Just make sure you follow your surgeon's protocol.

Here's a link to something I wrote at the eight week mark.

Cheers,
Herb

 

[d333gs]

Hi D333gs,

I'm going on 2 years with my bovine, which was replaced when I was 67 and in good physical shape. Unbeknown to me our my surgeon, I had a unicuspid valve. The general rule, is that it takes 6 week for your valve to start settling in and scar tissue starts making it official part of your body. That's when the concern of infection is the greatest. (FWIW, the biggest change I noticed with my heart itself is that I could feel the beats - VERY LOUDLY and strongly - immediately after surgery and for quite awhile thereafter... of course, with a unicuspid valve, I never knew what a normal valve felt like.)

As for how you feel... I agree with Chuck that the recovery part is actually quite fun because you see and feel first hand the improvement every day. I recall distinctly, probably nearing week 4, when I started to speed up my walks and could go up a slight incline without having to slow down or feel any tightness in my chest, which is normal post-surgery.

By week 8 I was back to my regular walking routine, which is typically 4 miles, including steep hills. By week 12 I had no concern about laying on a roam roller vertically - or doing anything that would hurt my sternum. I had a full sternotomy (had other things done inside, as well) and my sternum healed fine, with no issues. Like many people, my pain was in my shoulders.

While I had considered myself generally asymptomatic, post-surgery I was able to walk faster and further...and to this day walk longer than I did pre-surgery. What I assumed was boredom (I always slowed toward the end of my route) was probably just valve-related fatigue. I also now try to throw in light interval jogs on the uphill parts of my walk.

Since exercise is part of your regular routine, you probably will do what many of us do and push too hard, which will cause a day or two of setback. Just make sure you follow your surgeon's protocol.

Here's a link to something I wrote at the eight week mark.

Cheers,
Herb

Thanks for that Herb! I remember when you were getting ready to go in. I am 67 now and I will be curious to see what they find when they open me up: The first cardio thought the valve was torn , the next said it look like a bicuspid but was not sure............ so we will see.
I am also a hill climber, love the exertion , I switched to a bike when my foot started bothering me on the walks. Now I am in love with vintage mountain bikes.

 

[pellicle]

Now I am in love with vintage mountain bikes.

not sure what a vintage mountain bike is, but I sure do miss my 1996 Giant Yukon now (not really in love with my current Giant ROAM)

 

[bizinsider]

Thanks for that Herb! I remember when you were getting ready to go in. I am 67 now and I will be curious to see what they find when they open me up: The first cardio thought the valve was torn , the next said it look like a bicuspid but was not sure............ so we will see.
I am also a hill climber, love the exertion , I switched to a bike when my foot started bothering me on the walks. Now I am in love with vintage mountain bikes.

What part of France? If Paris, I'd say the best news is that you get to recover in one of the most walkable cities in the world. If somewhere else, well, you're in France!!! Truth is they don't know what they'll find until they get in there. Given your physical condition and seemingly positive emotional state, you should sail through. Expect bumps, it's not a straight line, but even if it gets a bit crooked it'll straighten up. I viewed it as an adventure, and it was! For me, in a good way. Can't wait to hear about your recovery. Feel free to reach out here or privately.

 

[pellicle]

I was also wondering if the bovine valve retains the genetic characteristics of a cow

This was probably "tongue in cheek" but no, it does not. It is essentially no more like the cow than your leather wallet. Its no longer living tissue (or it would cause severe rejection reactions) and is chemically treated to fit a purpose in an environment which is by nature hostile towards foreign things.

I recommend you have a read through this to better understand what you're getting
https://www.ahajournals.org/doi/10.1161/JAHA.120.018506
This is a good selection of some "plain language" parts:

Pathophysiological Features of SVD​

Native heart valves are a complex multicomponent system enabling self‐regulation because of valve interstitial cells (VICs) that produce and remodel the extracellular matrix (ECM).25 They provide a compensatory adaptive response to changing hydrodynamic and biochemical parameters of the body.25 In the absence of VICs, the lifespan of BHV directly depends on the durability of the chemically cross‐linked ECM. This chapter critically reviews the mechanisms that underlie SVD development.​

Durability of Xenografts and Homografts​

The onset of SVD generally occurs 7 to 8 years after BHV implantation, with freedom from SVD rates substantially decreasing 10 to 15 years after surgery.6, 13 The durability of xenograft BHVs implanted in the aortic position has been well investigated.14 On the contrary, THV durability is less well studied because of relative newness of this approach as well as poor health conditions of candidates for such minimally invasive intervention.8 Although clinical studies report similar durability between THVs and classical BHVs for the aortic position 5 to 10 years after intervention,15, 16, 17, 18 there is currently a lack of data on the durability of THVs for a longer follow‐up period​

...​

The durability of both xenografts and homografts also depends on host factors. For example, young age of graft recipient is one of the most significant risk factors determining early SVD onset...​

...​

Conclusions​

SVD is a complex multifactorial process implemented through several interrelated mechanisms, both passive and active. Passive deterioration of xenografts and homografts is inevitable because of the lack of live resident cells capable of maintaining the valvular homeostasis and repairing damaged ECM within the graft. The major driving force of such passive deterioration is graft fatigue, resulting from persistent damage to its ECM under the influence of cyclic loads and in some cases accelerated by a prosthesis‐patient mismatch, a modifiable yet underestimated risk factor. Another passive mechanism is dystrophic calcification emerging from CaP precipitation on a graft surface, which is caused by abundance of potential nucleation foci, such as fragmented fibers or cell debris.​

As I always say, it depends on your age at implant and how long you want to bet on getting. (*personally I always find it amusing when someone says my valve is doing good at 5 years ... like shouldn't it be?)

Best Wishes

 

[AZATADINE]

I am still unclear of a timeline for the bonding between the heart and bovine tissues. I was guessing it was about the same time duration as the healing of the skin of the chest incision........about two weeks ? But that must be wrong?

I believe it's closer to 10 - 12 weeks for new tissue to surround the ring of the new valve and the stitches to dissolve. I'm in week 12 myself and I asked my surgeon that exact question at my 6 week check up - that's what he told me. I guess that could also explain why they don't want people to do too much more than walking until that point too, even if they feel up to it (in case it might affect that process physically). I also had a bovine valve implanted and although I feel like I'm bursting with energy now, I have adhered to that advice although I'm dying to hop back on my bike or go for a swim. I'm walking around 18 km per day and I'm itching to step it up to cycling/swimming now.

On another note, these surgeons are really unbelievable in what they do. Around the same time I was having my AVR, my surgeon (Lars Nolke) was also saving the life of a new born baby. We are so lucky to live in modern times with modern medicine/surgeons.

https://m.independent.ie/irish-news...me-from-hospital-after-100-days-41261658.html

 

[d333gs]

What part of France? If Paris, I'd say the best news is that you get to recover in one of the most walkable cities in the world. If somewhere else, well, you're in France!!! Truth is they don't know what they'll find until they get in there. Given your physical condition and seemingly positive emotional state, you should sail through. Expect bumps, it's not a straight line, but even if it gets a bit crooked it'll straighten up. I viewed it as an adventure, and it was! For me, in a good way. Can't wait to hear about your recovery. Feel free to reach out here or privately.

Thanks Herb! Love Paris, as an artist I love walking the city But I am in the south and I will spend 4 weeks in Hyere out on the peninsula at a rehab. It's beautiful out there, mostly sunny and warm in the afternoons and the spring flowers will be starting. We are an hour from the coast but even here it was tee shirt weather yesterday afternoon. So the season is with me, longer days and warmer temps to look forward to.

 

[d333gs]

This was probably "tongue in cheek" but no, it does not. It is essentially no more like the cow than your leather wallet. Its no longer living tissue (or it would cause severe rejection reactions) and is chemically treated to fit a purpose in an environment which is by nature hostile towards foreign things.

I recommend you have a read through this to better understand what you're getting
https://www.ahajournals.org/doi/10.1161/JAHA.120.018506
This is a good selection of some "plain language" parts:

Pathophysiological Features of SVD​

Native heart valves are a complex multicomponent system enabling self‐regulation because of valve interstitial cells (VICs) that produce and remodel the extracellular matrix (ECM).25 They provide a compensatory adaptive response to changing hydrodynamic and biochemical parameters of the body.25 In the absence of VICs, the lifespan of BHV directly depends on the durability of the chemically cross‐linked ECM. This chapter critically reviews the mechanisms that underlie SVD development.​

Durability of Xenografts and Homografts​

The onset of SVD generally occurs 7 to 8 years after BHV implantation, with freedom from SVD rates substantially decreasing 10 to 15 years after surgery.6, 13 The durability of xenograft BHVs implanted in the aortic position has been well investigated.14 On the contrary, THV durability is less well studied because of relative newness of this approach as well as poor health conditions of candidates for such minimally invasive intervention.8 Although clinical studies report similar durability between THVs and classical BHVs for the aortic position 5 to 10 years after intervention,15, 16, 17, 18 there is currently a lack of data on the durability of THVs for a longer follow‐up period​

...​

The durability of both xenografts and homografts also depends on host factors. For example, young age of graft recipient is one of the most significant risk factors determining early SVD onset...​

...​

Conclusions​

SVD is a complex multifactorial process implemented through several interrelated mechanisms, both passive and active. Passive deterioration of xenografts and homografts is inevitable because of the lack of live resident cells capable of maintaining the valvular homeostasis and repairing damaged ECM within the graft. The major driving force of such passive deterioration is graft fatigue, resulting from persistent damage to its ECM under the influence of cyclic loads and in some cases accelerated by a prosthesis‐patient mismatch, a modifiable yet underestimated risk factor. Another passive mechanism is dystrophic calcification emerging from CaP precipitation on a graft surface, which is caused by abundance of potential nucleation foci, such as fragmented fibers or cell debris.​

As I always say, it depends on your age at implant and how long you want to bet on getting. (*personally I always find it amusing when someone says my valve is doing good at 5 years ... like shouldn't it be?)

Best Wishes

Thanks Pellice "It's no longer living tissue " ! No, I did not know that . I am surprised it works considering it is not reacting to nerve impulses or that dead tissue would graph to living tissue. I will go to your links,.

 

[AZATADINE]

Thanks Pellice "It's no longer living tissue " ! No, I did not know that . I am surprised it works considering it is not reacting to nerve impulses or that dead tissue would graph to living tissue. I will go to your links,.

Remember, the new tissue grows around/through the material at the base of the valve (the ring), not through the leaflets.

 

[d333gs]

Thanks Pellice "It's no longer living tissue " ! No, I did not know that . I am surprised it works considering it is not reacting to nerve impulses or that dead tissue would graph to living tissue. I will go to your links,.

Of interest; Bovine Pericardium - an overview | ScienceDirect Topics.