My thoughts on my upcoming Aortic valve surgery

[Silver Bullet]

Early in the NY, I'll be having my aortic valve either repaired (35% chance) or replaced. At my blog, I share my thoughts on the operative choices ahead. Please share your experiences and thoughts as you see fit. This is a really great forum with plenty of important info from very well informed patients, so I welcome your opinions.

http://skepsisdoxa.blogspot.ca/2015/...decisions.html

 

[honeybunny]

You have carefully considered the pros and cons of each option and appear comfortable with your decision to opt first for repair then AVR with a mechanical valve if a repair cannot be accomplished. i see no reason to question your choice. Best of everything as you journey down this road.

 

[LondonAndy]

Your analysis should be required reading for people facing this decision SilverBullet - a calm and well researched blog post, and I agree with honeybunny, and see no reason to question your choices. I was 49 when I had my mechanical aortic valve (because of severe stenosis), as I too would prefer to only undergo such major surgery only once if I can help it. I too find ticking watches and clocks irritating, banning them from my house, but for some reason I hardly notice my valve 98% of the time. The other 2% I notice it but am not irritated, and perhaps somewhat reassured all is well - I am not sure why, but if you end up having one too I hope you will have a similar experience.

 

[pellicle]

Hi

Early in the NY, I'll be having my aortic valve either repaired (35% chance) or replaced. At my blog, I share my thoughts on the operative choices ahead. Please share your experiences and thoughts as you see fit. This is a really great forum with plenty of important info from very well informed patients, so I welcome your opinions.

good post. I'd say to you that (I may have missed it) that the replacement of a mechanical due to infection is MUCH lower than 5% (you used 95% against), my point is that its not infection but rather other issues such as pannus growth (obstructing it) or the development of an aneurysm which drives its replacement. At that point (aneurysm) its irrelevant which valve you had as they'll most likely put in a new one.

I see absent from your discussion also the issue infections. With each surgery there is an increasing risk of an infection. The infection may be horrific (MSR) or milder like mine (propionibacteria), but the residual of scar tissue and other "bits and pieces" left lying around in surgery (Eg wires, sutures, coverings...) may allow an infection to take hold instead of being digested by your body. Add to this the fact that we are seeing a reduction in the effacy of antibiotics (as bacteria become resistant) and you have another point in there to make reoperations less desirable.

My particular journey is here, however others journeys may be tougher (my friend is one such. His MSR caused https://en.wikipedia.org/wiki/Wound_dehiscence )

So these are points you may wish to consider.

Also, knowledge (you know, the informed bit) about anticoagulation therapy is important. Make sure you knowledge is well informed, not misinformed. Not that I'm saying you are, but it is rampant that anticoagulation therapy is poorly understood.

Best Wishes

 

[cldlhd]

Seems like you have a well thought out plan although I may be thinking that because it's basically the same one I came to earlier this year. I had mine repaired and my aneurysm replaced with a graft. My backup was an On-x valve also. When I was researching surgeons who specialize in valve repair Dr Tirone seemed highly rated . I ended up getting mine done by Dr Bavaria at the University of Pennsylvania. As for the stats on repair failure I was told it varies greatly depending on the valve and the surgeon . I was concerned about the possibility of the " within 2 year " failure so I floated the idea of just getting the mechanical and getting it over with. He said my valve looked easily repairable and he had been doing an improved repair technique since 2004 and had zero reops due to repair failure so I was sold.

 

[W. Carter]

I agree with Pellicle, beware of what you perceive to be the truth concerning anticoagulation therapy. The new medicines coming out are no safer than Warfarin nor will they ever be. They all slow down the clotting factor of blood and each has the same risk factors. Warfarin is the safest one out there because they can reverse the effects with vitamin k injections in emergencies. I found that the use of Warfarin caused me to clean up my life by quitting bad habits (drinking and tobacco) to stabilize my inr. You can still have a couple of high balls or beers a day but a couple never was enough for me. And the rap about dietary worries is pure b.s. You can eat foods with vitamin k, they just ask that you don't pig out on them and try to keep the consumption the same every week.

It's the people that don't respect anticoagulants and the small lifestyle changes needed for them to be safe that get bit in their butts.

 

[Silver Bullet]

the replacement of a mechanical due to infection is MUCH lower than 5% (you used 95% against), my point is that its not infection but rather other issues such as pannus growth (obstructing it) or the development of an aneurysm which drives its replacement. At that point (aneurysm) its irrelevant which valve you had as they'll most likely put in a new one.

Thanks for your kind comments, pellicle.

The research I did suggested that the risk of endocarditis is about 0.5% per year (http://circ.ahajournals.org/content/119/7/1034.full), and that's cumulative. Over 10 years, that would equate to a risk of about 5%, but surely we expect to get more than 10 years out of mechanical valves.

Another study identified a cumulative risk of prosthetic valve IE of close to 5% at about 3 years follow up (http://www.ncbi.nlm.nih.gov/pubmed/4006134), too. Note: that's only about 3 years of f/u.

The 15 year follow up in the VA randomized trial found a 7.7% rate of IE on mechanical aortic valves.

Now, not every case of IE translates into valve surgery, but for mechanical valve IE, *a majority* do. Accordingly, I don't think that a 5% re-operation risk for IE over the life of the valve is that unreasonable an estimate. The VA study showed that over 15 years of follow up, there was a 10% reoperation rate for mechanical aortic valves, so that still leaves room for non-endocarditis related indications for re-operation like the ones you mentioned.

What do you think?

 

[Silver Bullet]

I see absent from your discussion also the issue infections. With each surgery there is an increasing risk of an infection. The infection may be horrific (MSR) or milder like mine (propionibacteria), but the residual of scar tissue and other "bits and pieces" left lying around in surgery (Eg wires, sutures, coverings...) may allow an infection to take hold instead of being digested by your body.

That's a good point. Supportive of it may be the observation in the VA randomized trial (JACC 2000;36:1152-8) that IE occurred twice as often with a tissue valve strategy (15%) than a mechanical valve strategy (7%).

 

[pellicle]

Hi

I'm glad you saw that I was attempting to be helpful and add to this

What do you think?

well I was not trying to quibble stats (although I may quibble with the stats gathering and what they ignored and how long they went for) but to try to insert a whole line of thought you seemed to have omitted from your (well written and wide ranging) post. IE Pannus and Anuerysm (I've not experienced pannus).

I myself write a few things too and its good to see others take the ball (even if its another ball) and run with it

endo is a tough one, and to be honest I feel that its not "accidental" (like some sort of spontaneous generation) but the result of ingress of bacteria. Dental hygene has been identified as a culprit (to me perhaps the most likely). When I was doing my Biochem Microbiology degree I found that the group MOST ignorant and most uninterested in bacteria were the Doctors. So the way the issue of Endo is presented to me represents that.

Best Wishes

 

[cldlhd]

Ive read that IE might be cumulative. My surgeon touted lower risk of infection as one benefit of having my valve repaired and also stressed the importance of dental hygiene.