Decision half made
Decision half made
Hi folks --
Long as this thread is, it seems to me worthwhile to finish out the story, so to speak, before I move into the presurgery and then post-surgery forum!
Today I pretty much REACHED A DECISION regarding my own surgery -- though, true to form as a Gemini (and one who even SEES double, would you believe?), I left some waffle room.
I have decided to have the procedure done at Shands Hospital at the University of Florida under Dr. Tomas Martin -- but have left in abeyance until I talk to him once more whether it will be a Cryolife Synergraft valve (new style pulmonary homograft to the aortic position, hopefully able to repopulate with the recipient's own cells) or a Carpentier-Edwards Perimount pericardial version (bovine).
Dr. Martin said that he himself would hesitate between these two options and tried to lay out the pros and cons.
The CE Perimount bovine valve has apparently shown very good results in 15-20 years of trials, with a relatively high proportion of patients remaining re-operation free beyond 15 years. It is, I understand, stented and so easier to implant than stentless valves or homografts and doesn't require as long an operation as those alternatives or as much "cross-clamp" time (i.e., time on the heart/lung pump). But I gather that as a bovine valve, and thanks to its particular design, it still does not calcify as quickly as other stented valves often do. In addition, I think that calcification tends to be slower in semi-senior citizens like yours truly (59 anos) than in younger folks. And I feel at home with the likelihood, in this case, of re-operation 15 or 20 years hence -- when technology may have made some new leaps and bounds. But I might be wrong on any of these particulars and would welcome corrections.
As for the Cryolife SG homograft valve, it is intriguing and holds out the hope of near permanence. It's a little like rolling the dice, though happily even if they come up snake eyes -- that is, even if the cell repopulation wager doesn't pan out -- you're not so bad off, since the homograft would likely last around 12-15 years, I think, and you'd just be back in a scenario a little like the one above. The operation IS more complex than the CE Perimount implantation and requires significantly more cross-clamp time (Dr. Martin estimates 90-110 minutes as compared to 60 minutes or so for the bovine valve). Steve Wieland ("Steve in Florida") has given some GREAT descriptions and analyses of the Cryolife SG valve in his postings, particularly those on the "New Advancements" forum. Any one vaguely interested should take a long look there, I think.
I was never much enamored of the mechanical valve solution, I'll have to admit, due to dislike of Coumadin and concern about the chances of thrombosis (small per patient year but appreciable in the cumulative aggregate). Ticking doesn't bother me: I make worse sounds at the drop of a hat. But circulatory mishaps and the problems of balancing anti-coagulant levels in someone who loves his greens do. There's some bright light on this horizon, though, as well -- hand-held INR verification devices, improvements in the mechanical valves (AHS models: did I get those letters right?), and somewhere in the offing a less virulent alternative to warfarin.
I gave some serious early (and middle) consideration to the Ross Procedure, which is a fascinating approach with some excellent results and seems particularly full of hope for younger people who need the valve to grow with them and/or want a real chance of not undergoing multiple surgeries down the long pike before them. But it is a much lengthier operation (cross-clamp time in excess of 150 minutes, sometimes over 200, I gather), due to the need to replace two valve systems (the aortic and the pulmonary) at the same time. The chances it gives of avoiding reoperation over the life expectancy of someone my age seemed not that much greater than the first two alternatives above and the hemodynamic results appear comparable (i.e., smoothness of blood flow). So, on balance, it didn't seem the way to go, though I certainly cheer for those who opt for that route.
Of course, the decision is as much -- it is rightly argued -- one among surgeons and hospitals as it is a choice of a particular valve solution. Some say with justification, "Pick the best surgeon available and do what he (still no "she's"?) says." But what is the "best," in either regard? There are certainly very highly reputed surgeons and clinics, though some of the best clinics by national ratings can take on a bit of a factory flavor, to judge by occasional stories of patients and cardiologists.
And what weight should one give to proximity and the support that it enables family, friends and loved ones to provide? I gave some, though not enough to impel me to have the operation here in Tallahassee, where the very friendly surgeon does mechanical and Toronto SPV, but couldn't offer the particular choice I felt best for my case. Gainesville is about 150 miles away and in the territory of that Other State University, but still a very friendly place and one relatively nearby on a Florida scale of things.
I think that the surgeon and clinic issues should factor into the decision and should always be kept in mind, but they probably weigh most heavily in cases where there seem to be reasons to anticipate operative complications. I'm hoping for few and do perceive a slight degree of favorable surgeon bias toward a non-smoker small-drinker like myself still hanging in around 160 pounds dripping wet and having few other health problems: probably looks like something that might raise the surgical batting average!
So I've opted for Shands and either the bovine or the Cryolife SG solution -- to be finally resolved upon further consultation with the surgeon. Now the trick is to schedue the thing, because Dr. Martin is a busy person! In fact, when I called in today and heard that the calendar of surgery had (understandably) filled up further since I had my appontment with him there on Monday, I was put in mind of the song Judy Collins sang: "Just when I stopped, opening doors, finally knowing the one I wanted was yours, Making my entrance again with my usual flair, sure of my lines --- no one is there." (!)
But it may in fact work out for the best. I was startled when the Administrative Assistant said the earliest available slot was now early September, and I lobbied for getting somehow slid in sidewise during August, given the minuscule aperture left me (0.61 cm2 at last glance). But the main factor in my case, the cardiologist seems to feel, is my relative lack of symptoms. I can still walk up several flights of stairs with light loads and have had no dizziness or pain. I am wondering then whether a later date -- e.g. September 4th -- might not allow me the time to do something valuable for me and the procedure that I otherwise seldom do: take time off BEFORE, rest up, smell the roses, eat my greens and generally get in the right frame of soul and body.
Should know more about that tomorrow. Please excuse the length of this contribution, but I figured a long thread merited a longish coda.
Beneath all this, I feel immense gratitude and wonderment at life. And I think of all those folks a century or two ago who never had this second chance. But then, as my Grandma used to say, "Very few of us get out of this world alive!"
Peter
