Making the choice: RP, homograft, mechanical, tissue

[Andy in Montana]

My two cents worth

My two cents worth

Hi All,

I am 50 yrs old - had bad mitral valve - and was going to have it replaced with a Medtronic Mosaic porcine valve. Fortunately they were able to repair my valve. The Medtronic mosaic valve uses a different anticalcification process and they're supposed to last a lot longer (up to 25 years). A friend of mine had the same surgery as mine the day after I did and he received the Mosaic valve, as they were unable to repair his. He's actually having less trouble than I am. I have been having other complications from the surgery - we both had the same surgeon.
It might not hurt to check out this valve as my surgeon highly reccommended it. Of course his first choice would have been mechanical...
One thing I can tell you after going thru this on June 12th 2001 - is that I never want to have that done again. Too many things can go wrong - so I would greatly consider picking a choice that involves the least amount of surgeries.
I had my surgery on June 12th went home after four days - then on June 26th became very ill - went to emergency room - they found that my heart had not stopped bleeding and the heart sack filled up with blood - 1200 cc's - they had to drain it and stop the Blood thinner - two days later I had a TIA (mini stroke)while in the hospital, so they put me back on blood thinner - was in for a week this time. Then last week I began having fainting spells - back to emergency room and another three days - another bad spell this week - back to emergency room - two days - am wearing a monitor full time now and if I have another episode I push a button and it records the episode so they can figure out what is wrong. I am scheduled for a cardioversion on Aug 20th to put my heart back into the proper rhythm - I'm in Atrial Flutter - this procedure however can cause a major stroke if their are any clots in the heart due to the abnormal heart rhythm. Before the operation my heart was in the correct ryhthm.
So, as you can see - the fewer operations the better. After I got out of the hospital the first time I thought I was going to sail thru this - boy was I wrong. Not trying to scare you - just trying to inform you that the choice you make is important.
Hope this helps
P.S. Just to let you know I am on Coumadin also and I've had my valve repaired - If they ever get things straightened out I may be able to get off it after a few months but there's no guarantee. The worst part about it is having to go get your blood drawn once a week to see what your INR/PT level is - but they have home finger stick machines for that now - and also they may be coming out with some new blood thinners that do not require the blood testing - as they are more stable. Food for thought.

Andy

__________________
Andy


08-03-2001 01:10 PM

 

[Christina]

Hi Andy.. What a rough road to hough for you. But like you said, there are no guarantees, and many things can go wrong. I hope everything will go better for you, and many good wishes are coming your way right now.

I had to have my new mechanical valve replaced again within eleven days after the first. Not fun I can tell you that, but it had to be done because I had a blood clot underneath the new valve.
I did okay during the second surgery, and something good came out of that one because I find the St. Jude's a breeze compared to the one I had. (Sultzer Carbomedics) That first one was loud and really bugged me. This one I can hear slightly when I want to go to sleep. I have to be very quiet and can only hear it when there are no other noices in the bedroom.

I am on Coumadin.

Christina
Mechanical St. Jude's 2000

 

[Mike in Florida]

Excellent choice Peter!

Excellent choice Peter!

Hello Peter,
Glad to see you picked Dr. Martin at Shands
at U.F.! He is one great surgeon! I have never
heard a bad word about him in my 6 yrs. employed
at Shands. He implanted mechanical St. Judes
aortic and mitral valves in my heart on Jan. 29,
1998. I've been following your posts, and wanted
to say thanks for bringing so much information
to this site. Your research will be of great
value to many people. Steve in Florida treated
me to lunch today, and after seeing how great
he looked since last time I saw him (day before
discharge after surgery),and seeing how upbeat
he still is, I would recommend the Cryovalve.
You will be making a very informed choice on
whatever valve you choose, and I hope your
decision becomes easy for you. Like I told
Steve, sit back, relax, and enjoy the ride!
Steve and I will help you in any way possible at
Shands,we will be there for you.
Mike in Florida GO GATORS!!!!









he

 

[ticktock]

choices choices

choices choices

Decisions. Dont know when your surgery is to be, maybe you dont either. I have had 4 aortic valve surgeries, two valvotomies (1960 and 1970); a bjork shiley with autograft in 1978, and a new procedure by Dr. Denton Cooley in 10/99; Houston Texas. I can say I have VAST experience with Coumadin, having been on it since 1978. I am female, 46 years old. I am a relatively "healthy" person, ie; I am independent, fully functional, successful and .. well... happy! Just some general info, for a baseline!!!

I have found through these 23 years, that Coumadin rates about a 2 on the nuisance scale of 1-10. To me, it is no more bother than taking a Tylenol for headache. I have a home test machine, I test no less than once a month (finger stick). My diet remains pretty stable, thus my INR remains stable. This is not magic. If I eat broccoli every day for a week, you can bet my INR will lower. So, I just use a little God given common sense, and eat about the same all the time. I am either extremely blessed, or a good care taker, Im not sure which. Maybe both. I would NEVER let the idea of Coumadin therapy keep me from a particular choice. Longevity and quality of life were my only considerations.

Forgive my ramblings here, but one more thought. I talked to Dr. Elkins in OKC, about the Ross Procedure years ago. About 1980. I talked with Drs. in Kansas City, Mo about a fourth surgery. I met with Dr. Cooley who seemed to put everything into perspective on 10/4/99. On 10/6/1999 he operated on me. Each surgeon I spoke with had their "favored" procedure. Each believes in his just as strongly as the next guy believes in HIS. Everyone of them can do a sales job, they have to. Get more than one opinion. Remember that they dont have ALL the answers. Ever. Go into it informed, with your chin up. Keep a good attitude and positive thoughts. Pray.

Best of luck to you! Only my opinion here, but it sure felt GOOD to give it!! What a place!!

 

[Peter Easton]

Warring with warfarin?

Warring with warfarin?

Thanks, Mindy Jo, for these real insights based on what sounds like a TON of experience. The mechanical valve and Coumadin remain at least background possibilities in my case (as in everyone's, I guess); and it's heartening to hear how feasible they have been for folks. On the one hand, it seems that no surgeon or patient knows exactly what is going to be implanted until the operation is underway, since the situation in the chest cavity may turn out to be different than what was foreseen. So I get the sense that, at most, one goes in with a preference list or priority order -- and a good chance of it being respected if things stay predictable. On the other, even tissue prostheses or RP may require Coumadin as a short-term, long-term or even permanent follow-up under certain conditions.

As related above, my own preference order at present starts with either the Cryolife SG valve or the CE Pericardium, but que sera sera. I do have a date: September 4th, It's farther ahead than I had anticipated, but I kind of like the idea of having that much time for mental, physical and spiritual preparations. So I've started asking how people (who have had that kind of lead time, or wish they had) advise getting ready -- in a thread over on the Pre-Surgery forum entitled "Prepping for the Big One."

Thanks again for your story -- it's what makes this such a rich place for exchange and support.

Peter

 

[ticktock]

thanks

thanks

Thanks Peter, for your welcome and comments. I was up very late last eve when I posted, and later was afraid I blabbed too much! It was just SO exciting to find this place! I have felt very isolated, re; my valve problem, as I am relatively young. I have been living with this all my life, and know so few people like me.

Your surgery is scheduled for Sept 4, I once had surgery on Sept 8th. It was a GOOD one!! Funny the dates of each one stay in my brain. Unlike some things (pumphead). I am not familiar with your valve options, thought I was fairly well educated, but seems Im NOT in this regard.

I thought the 3rd surgery was going to be a repair. When they got in, they decided on a Bjork Shiley. Thank goodness, NOT the one that has been recalled. It served me well for what, 21 years! You never know what you will get. I was 23 and invincible, so I didnt much care. Im smarter now . Im glad for the choices I have made. The primary concern at time of the 3rd surgery, was MAKE IT LAST! 4th surgeries are rare, and difficult. I had some complications but I made it.

I dont know your age, but that was a big factor in my Dr opinion. The fourth surgery was a life saving measure, and my list of options was almost nil. I got one response from my previous surgeon something like "well, we will give it a try", to Dr Cooley who said, I will fix it, this is how, this is why, and are you available at 4pm today? He is an amazing man. 77 years old when he did my surgery. Rambling again.

Thanks for making me feel welcome here. I am in awe of you folks, your experiences, your attitudes and willingness to share information. Will talk to you again, Im sure.

 

[Peter Easton]

Further phone consultation with surgeon

Further phone consultation with surgeon

Hi again folks --

I had a telephone conversation with my surgeon, Dr. Tomas Martin of Shands Hosptial (University of Florida), to nail down a little better the plans for my surgery and seeks answers to some questions, many of which have surfaced here in this forum.

Here, FYI, are the questions that I posed to him, copied from an e-mail that I sent early today to his program assistant, Ms. Allision Kleinfeldt:

Hello Allison --

I talked things over with folks on the homefront during the weekend, and the September 4th date still seems best to us. I will plan on making a trip to Shands the previous Thursday (August 30th) for the prep work, unless you say otherwise.

I gather from the person with whom I talked late Friday in your offices that I had better nonetheless plan on coming down to Gainesville on the 3rd, the day prior to the scheduled surgery, as there is no knowing when exactly my operation will be scheduled and it may be early. Doubtless more about these matters is covered in the written material that I will soon be getting from the clinic.

Are we still a "go" for my phone contact with Dr. Martin this afternoon at, or sometime after, 5 PM in my office? The questions that I would like to discuss with him are roughly the following, though some may fall into a category covered by the prep materials you are sending out and others can perhaps best be answered by someone else on staff or at another time. I imagine that he can refer me elsewhere for those issues.

1. Does the September 4th date seem to him feasible given what he knows of my level of calcification? (I continue to have few symptoms.)

2. The Big One -- I would like to discuss further with him the choice between Cryolife SG and C-E Pericardium, and have a few questions in that regard.

3. What is the practice or advice with respect to banking my own blood ahead of time?

4. I have fairly heavy keloid scarring, which has posed some problems for me on previous smaller surgeries and has evidently been an issue for others with the same tendencies who have had AVR. I'm suspecting that a hefty keloid scar from just below Adam's apple to the lower sternum could be a mean sucker, so to speak. Some suggest making sure a plastic surgeon, dermatologist or dermatological surgeon is associated with the AVR procedure in order to take the necessary steps to minimize post-operative scarring problems. What is your take on this?

5. What has been Dr. Martin's experience with magnesium therapy before, during and/or after surgery to minimize risks of atrial fibrillation?

Thanks!

Peter E.

When I talked with Dr. Martin at about 4:30 PM, he had received and read all these questions. Here is the upshot of our conversation.

1. September 4th date is fine.

2. We went back over the tradeoffs between the CE Pericardial (stented bovine) valve and the new Cryolife SG valve (a homograft) -- the one that MIGHT last 25 years or more, if our human organism repopulates it with native cells the way that animal subjects have. It still appears to be a roll of the dice.

* The Cryolife SG valve has intriguing promise, but there is little data (obviously, in the case of something introduced so recently) to back it up. Steve Wieland, who had his implanted here at Shands, seems so far to have excellent results -- but of course he's only a few months out from his operation at present, and he is only the second patient to receive the procedure at Shands (or one of two to date -- maybe he was the first.) They have lots of experience at Shands in implanting homografts and Cryovalves of earlier makes but are now forging out in this new direction.

* The Carpentier-Edwards Perimount pericaridal (bovine) valve has a long track record and is expected to last 10-15 years, maybe more. (Lots of data on that one.) The wager is that either it will hold out somewhere nearer the upper end of that range, and/or when reoperation times comes around we will have made such forward bounds that reoperation with a permanent alternative will be a lead pipe cinch. Interestingly, Dr. Martin said one study showed that something like 24 of 27 heart surgeons (or was it cardiologists?) who have had to undergo AVR themselves chose this valve as the way to go.

Another element has to be factored into the decision, though how it is weighted is also up for grabs. Implantation of the Cryolife SG valve is a considerably more complicated operation and takes significantly longer (both in general and in terms of cross-clamp time), similar in that respect to the stentless bioprostheses and other homografts and sort of midway between the mechanical valves (shortest, simplest) and the Ross Procedure (longest, most complex).

So the ball's back in my court on this one! Dr. Martin said one could virtually decide up to the last moment (so I'd better be on guard for my own proverbial tendency to hang fire on choices!) -- the more so as any choice is a shared expression of preference that the surgeon may or may not be able to respect (80%/20%?) once the old sternum is opened up and the real lay of the land becomes clear.

3. Yes, he recommends banking my own blood, and arrangements are now being made.

4. He says that there are some precautions that they can take to hopefully minimize the formation of keloid scarring, but nothing works like a silver bullet in this regard and he is not convinced that the direct participation of a plastic surgeon or dermatological specialist ensures any better results, given the additional operative complications created. I may want to see my own dermatologist about this.

5. He says that they do some magnesium therapy (though "not as much as at Emory") and feels it lessens somewhat the chances of AF. So I will keep exploring this.

As Arthur Koestler once said, if memory serves me well, "there is no problem, however complex, which -- if examined studiously and rationally -- doesn't turn out to be still more complex!"

Yours for more cud chewing,

Peter

 

[ticktock]

yikes!

yikes!

Janie
Your comment was enough to have me digging out my implant card!!! It shows a serial # and and identification #, but no "name" or "type". I do know it is a polycarbonate valve, by St. Jude. Help!! ! I may be recalled and not even know it!! Do I call Firestone??
mindy

 

[ticktock]

recall

recall

Janie
Well, it turns out I do not have retreads. After reading your post, I called St Jude today and found that my valve was not one of the recalls. That was a relief for me, but did you say yours does have silzone?
mindy

 

[ticktock]

2% per year/per annum/per diem/per

2% per year/per annum/per diem/per

Just posting here to say good-bye. If what all these Docs and reports are saying is true, I have been dead for about 10 years. Im a 23 year veteran of coumadin therapy.
mindy

 

[Peter Easton]

Don't jump -- All is forgiven!

Don't jump -- All is forgiven!

Hi Mindy --

Thankfully, the average rates suggested by the doctors and statisticians -- even if true (and everybody in this field seems to be exaggerating or "winging it" to some degree and in some direction) -- are only averages and don't apply to individuals. Thank God for good luck and may you continue to break all records (or prove them wrong)!

I'm told there was a poster put up in the quonset huts of the US airmen early in World War II, when things weren't going so good. It said, "Engineers have proved that, given its wingspan, wingbeat rate and weight, the bumblebee is incapable of flight. But the bumblebee doesn't know anything about this and goes on flying anyways."

I'm grateful for your contributions!

Peter

 

[ticktock]

Blessed

Blessed

Peter
Im a bumblebee. I believe this. I live this. Honestly, I read what I can about my "condition". I live a fairly healthy lifestyle. I pray. I love life every day and am thankful for every morning. I love birthdays, and worry about those who dont. I suffer when I see others suffering. I help when I can. I smile when I dont want to. I complain about my health rarely. I get outside myself as much as I can. I love people and dogs. Dogs mostly. I am SO blessed, that somedays Im just amazed at the absurdity of it all!! The fact that I am here. Alive. Though I may be somewhat "physically challenged", I am MORE alive than most folks I know.

I believe that every day everyone has a decision to be made. To be either cheerful or grumpy. 99% of the time I chose cheery! And I succeed at it. That bumblebee story is a great reminder of the seemingly impossible. Thanks for sharing.
mindy

ps i also love a good martini. vodka. three olives.

 

[DickV]

Ticktock, refreshing comments. Some non Coumadin folks and respective doctors ariund here have all us Coumadin users dead or dying already.

Hey M7, I've been in Rio since Friday and am sorryy to say I have abused the 2 drink rule (and am still living to tell about it). K is here too. Life is good.

 

[ticktock]

margaritaville!

margaritaville!

Janie
Thanks for the note! Sure, I can choke down a margarita. Doesnt everyone in South Texas?? Nice and cold. Did your Doc make any suggestions about the valve? Surely you would have to have a complication for them to reoperate. OR I suppose if you just totally freaked out about it. It wouldnt be impossible, you know. Sounds like our attitudes match. Hang in there!

 

[ticktock]

make mine a double!

make mine a double!

Janie
I too wish I had found you last year!!! Shoot!! You had
a reunion in SAT?? Wonderful!! I see mention of another
one, is it in Arizona?? How often do you all do this?? It
is wonderful!! I still want the T SHIRT!!

 

[Mara]

Making choises

Making choises

Okay, I am going to put my 2 cents in.
I had the Ross Procedure 4 weeks ago today. So far So good. the replacement pulmonic valve was the highly touted CryoValve SG.
I guess it's working coz i'm not croaked.
Will know more after 8/14 check-up. But like Steve in FL I feel good about this choice. My surgeon said the CryoValve was the only logical choice. Unlike Steve, mine is on the low pressure side. Here's hoping it's great for both.

Even though the RP is not for everyone, it was my best choice. I am only 33 and didn't want to face a life of Coumadin, being pre-menopausal and all. Not that Coumadin is bad, it was just not for me. It's one of the female things...my mom had troubles at meopause and so did my aunt, so excess bleeding was not favored.

But, hey those mechanical vlaves kick butt too. and the Coumadin scariness is not as bad as I once thought because you all seem to be doing great with it.

-Mara

 

[Peter Easton]

Synergraft in RP

Synergraft in RP

Yoho! Now I understand. So these days the pulmonary valve replacement in RP is a Synergraft SG. Interesting wrinkle.

I had understood that one of the mild downsides of RP was the possibility that the patient's pulmonary valve transplanted to the aortic position would do fine, but that the replacement of the pulmonary valve might calcify or have some problems. These were judged less serious, I gathered, because the pulmonary valve isn't called on to do as much or undergo as much pressure as the aortic valve -- and, at the outside, one can even function without it.

But if the new Cryolife SG is being used in the Ross Procedure to replace the patient's pulmonary valve -- and if it repopulates with the recipient's own cells over time -- then that would seem to eliminate one of the mild downsides to the RP.

What won't modern science do next?

Peter

 

[Peter Easton]

Pulmonary allografts and autografts and the whole nine yards

Pulmonary allografts and autografts and the whole nine yards

The following exchange of messages over on the RP listserve regarding uses of the pulmonary valve in AR may be of interest to some:

ORIGINAL MESSAGE SENT OUT

Hi folks --

A question.

One of the big advantages to replacing a diseased or stenotic aortic valve with one's own pulmonary valve is, I gather, reducing the risk or rate of immune reaction and calcification to near zero.

There seem to be a few other cases where pulmonary valves are used to replace aortic valves -- for example, in the new Cryolife SG pulmonary allograft technique or some earlier homograft procedures.

The potential downside to use of the pulmonary valve appears to be that it isn't structurally as strong as an aortic valve, since the pulmonary side doesn't undergo, and isn't "built" to undergo, the same pressures and flow.

In the Cryolife SG approach, it is claimed/expected/hoped that the recipient's organism will repopulate the replacement valve with its own stem cells, effectively turning the implanted pulmonary homograft into a native aortic valve over time.

So, after that long bit of throat-clearning, here's the question: In RP patients, is it also expected or observed that the recipient's body (which is the same body, after all!) will repopulate the pulmonary valve transposed to the aortic position in such a way that it will take on more of the structure and durability of an original aortic valve? Or did I go astray somewhere earlier in the understandings laid out above?

Good to think about these things before my ejection fraction gets to low for that much concentration!

Peter

TWO INTERESTING REPLIES AND THE REJOINDERS:

Date: Thu, 9 Aug 2001 18:50:46 -0700
Reply-To: "ROSS-PROCEDURE (Open Heart Surgery) Support and Discussion"
<[email protected]>
Sender: "ROSS-PROCEDURE (Open Heart Surgery) Support and Discussion"
<[email protected]>
From: Bob Brown <[email protected]>
Subject: Re: Pulmonary autografts and allografts
To: [email protected]


Peter:
I have never heard of any physical change to or strengthening of the "old
pulmonary valve now aortic valve" being claimed for the RP. The major claim
for children (which was the original application of the RP) was that living
tissue would continue to grow and thus prevent multiple reoperations on the
aortic side. The over sizing of the donated pulmonary valve is another
attempt at minimizing the number of reoperations, although most of what I
have read says that the pulmonary valve replacement is an "easier/shorter"
job than an aortic replacement. So if there has to be a reop, at least it's
a "relatively easier" job. (Easily said, unless it's on your child, right
Katie!!).


Also in regards to the repopulation issue of the cleansed Synergraft valve,
I have never heard that the repopulation of the valve would "strengthen" the
valve, only that the repopulation was "proof" that the body was not
rejecting the donated valve. The concept I was told is that the donors DNA
is completely stripped away and the remaining tissue (collagen) is therefore
a framework for the host body to make it "welcome". It would be a great side
effect if it strengthened it as well. Have you been told that it gets
strengthened by repopulation? The lack of information on this is of some
concern to me. Of course Synergraft is VERY new, and we want answers to
questions that only time will provide.


As far as "measuring/confirming" the repopulation, besides the biopsy (not
on me, thanks!!) the best practical test seems to be a PRA (Panel Reactive
Agents?) blood test. A zero count indicates that the body is not attacking
the donated valve and correlates to repopulation occurring (at least in
sheep, which is where the testing was done!).


Bob Brown


Synergraft #29... 1 year and still holding strong


Date: Fri, 10 Aug 2001 03:34:00 -0400
Reply-To: "ROSS-PROCEDURE (Open Heart Surgery) Support and Discussion"
<[email protected]>
Sender: "ROSS-PROCEDURE (Open Heart Surgery) Support and Discussion"
<[email protected]>
From: Bradley White <[email protected]>
Subject: stem cells, repopulation
To: [email protected]


Peter,


I believe the justification behind your thoughts is that the
repopulating aortic valve cells in the autograft valve in the aortic
position would be specific to the aortic valve. I do not believe that
this is entirely accurate. These cells would be heart cells, there is
no specialization of heart cells from aortic to pulmonary to mitral
valves. Thus, in theory the new cells would not add any particular
strength to the valve. I believe the structure of the implanted
Synegraft valve in the aortic position would be the reason that it could
strengthen to aortic standards. Although cells may repopulate the
pulmonary autograph in the aortic position there would probably be an
insignificant number and no real structural change because the pulmonary
valve is in fact still a pulmonary valve just in a different position.
To me it seems unlikely that the cells would repopulate the autograph
and make its structure similar to the aorta. That, in essence, is the
advantage of a Synegraft valve in the aortic position or the freestyle
valve. The only arguments I have heard that make the autograph in the
aortic position better than a regular homograph are lack of rejection
and hemodynamic superiority. IT seems to me that these advantages would
be nullified by a Synegraft in the aortic position. This is truly
exciting research. If the Synegraft in aortic position was available
when I was making my decision I think I would have opted against the
Ross.


Brad

FIRST REJOINDER

Bob --

Excellent questions. Probably you're right and I'm wrong. I'll see what my surgeon has to say when I talk to him next Monday.

I have opted to have surgery on September 4th at Shands Memorial Hospital (University of Florida) with Dr. Tomas Martin and am still deciding between CG Synergraft and CE Perimount pericardial options, both of which he performs. Some of the details of the decision are in an earlier post to the RP listserve entitled "Decision half-made" or on the valvereplacement.com website in the Heart Forum under a (n endless!) thread entitled "Making the choice." The date is later than I anticipated, due (initially) to scheduling problems with the surgeon, but both he and the cardiologist feel it's OK, despite my advanced level of stenosis, because I still have such relatively mild symptoms -- and, on reflection, I like the idea. It gives me much more opportunity to prepare mentally, physically, logistically, spiritually...

What is "Synergraft # 29"? Was this an aortic homograft? Can you refer me to more of the details in something you posted previously?

Thanks again!

Peter

SECOND REJOINDER

Very helpful and insightful, Brad. Thanks! Your arguments seem to support and extend what Bob was saying. Questions nonetheless for you (and Bob):

Independently of the issues of immune reaction and hemodynamics, is durability of any concern in tissue valve replacements? In other words, do the thinner walls and less robust construction of the pulmonary valve affect its potential durability or performance in the aortic position in any way? I had gotten the impression that they did -- and that therein lay the reason, for example, why Cryolife is pushing ahead to develop an aortic version of the new Synegraft and not resting on their laurels with the pulmonary version. If so, and presuming you and Bob are right about what cell repopulation does and doesn't do, then this would remain an unsolved problem in both the RP and the new Cryolife SG technique/product.

Also someone on the valvereplacement.com site who recently had the RP done said their replacement valve for the pulmonary was a Cryolife SG. That must be a new tack, given the recency of the SG -- but would seem potentially to help resolve concerns about the durabilty and acceptability of the pulmonary valve graft in RP, no? I had gotten the impression that the pulmonary homografts in RP could calcify or degenerate, though this was of much less concern than improvements to the aortic apparatus, given the less critical function and lower demands on the pulmonary valve.

This is getting downright encyclopedic.

Peter

 

[srwieland]

Hi Peter et al.

Sorry I haven't been in touch. I posted a long response to your 'decision' message over a week ago but then my home computer crashed and my message doesn't seem to have registered here. I haven't been able to log on again since then (I've had no time at work and my wife left town that same day for two weeks and I've essentially been a single parent). Enough excuses, but at least my heart surgery luck has so far been a lot better than my computer luck!

Again, Mike and I here at Shands are eager to help you anyway you need with logistics, etc., here at UF. The only thing is, you can't expect us to change our opinion about Gators vs. Seminoles!

As far as the adjustment by the recipient's body of the implanted SynerGraft pulmonary valve in the aortic position, it was crystal clear to me from Dr. Tomas Martin that, within a year, my aortic valve, notwithstanding its origin, would "histologically" (i.e., from Stedman's Medical Dictionary, pertaining to "the minute structure of cells, tissues, and organs in relation to their function") become the equivalent of a native aortic valve, as long as the recipient cell repopulation process takes place as expected. This transformation occurs because the recipient's body responds to the changed needs of the implanted valve, which include the need to structurally and hemodynamically withstand greater pressure in its new location. In other words, he assured me that the implanted pulmonary valve (being living, 'transformable' tissue) will indeed be "remodeled" (as CryoLife terms it) into essentially an aortic valve. He gave this explanation in response to my presentation of precisely the same concern as you have been expressing to those on the Ross Procedure website. In any case, I wanted to clarify what I heard and understood from him, since it wasn't clear to me whether or not you had yourself discussed this with Dr. Martin or were just relying upon my communication of my conversation with him about it.

Dr. Martin also explained that the SynerGraft pulmonary valve is altered, by grafting, for implantation in the aortic position, including adjustment of the root and construction of an 'ascending aorta' replacement. On the one hand, all this adjustment sounds disconcerting, at least to me. On the other hand, it means that the pulmonary valves intended for replacement of an aortic valve are no longer ordinary pulmonary valves, with inherent limitations for placement in the aortic position, but rather ones that have been enhanced, by means of SynerGraft enzymatic washing as well as grafting, to be more suitable for aortic valve replacement. I guess I could be one of the first to find out how well it holds up!

In any case, I'm not sure that SynerGraft is "pushing ahead" to develop an aortic SynerGraft valve instead of a pulmonary one. Did you get this impression from me or some other source? If from me, I did not intend to convey that, since it is my impression, though I don't really know (confession!), that they are headed more in the direction of providing animal tissue versions of their SynerGraft valves, because, if their technology works as it should, all they need to start with is neutral collagen. I further must admit that we are surely delving into technical areas that probably only someone central to the development of SynerGraft valves could (and should!) answer.

On another front, my heart surgeon friend, Dr. Jim Alexander, Dr. Martin's mentor, previously connected the ability of the body of a particular individual to effect repopulation of the implanted valve to the general quality and quantity of adult stem cells that it can bring to bear on the situation. He had high expectations for me in this regard, though, given my age (50) and relatively good health.

Adding to what Bob Brown from the Ross Procedure website says about testing the performance of the SynerGraft valve implant, an important indicator, besides the PRA he mentioned, is its rate of calcification (which can be easily ascertained by echocardiogram) compared to regular homograft implants.

By the way, my impression of Bob Brown's reference to SynerGraft #29 is that he meant he was the 29th recipient of the SynerGraft valve. I guess we'll here from him whether that's correct or not.

You are definitely right about the compounding complexity of these issues. God, I'm glad this is your decision. I don't know if I could have handled this much information before making my choice! Hope I haven't contributed to making things worse for you!

Anyway, Good Luck and Godspeed!

 

[Peter Easton]

'Twixt Gator and Nole

'Twixt Gator and Nole

Hi Steve --

Great to have you back on line and glad to hear that things continue to go so well! One reason we can remain relatively unfazed by heart surgery between Tallahassee and Gainesville is that one of us regularly rips the other's heart out each year anyways. So let's just say "Go Nators!"

Actually, unless I'm already halucinating, it was Dr. Martin who told me about Cryolife working on an aortic-origin version of the Synergraft valve. I should be talking with him again next Monday, so will double check. Your details and explanations are, as always, really clear and helpful.

Peter