NEWBIE: Needs advice

[Paleowoman]

Hi @W84Me - re tissue valves, the latest tissue valve being offered is usually the Inspiris Resilia which is meant to have a much longer life than the previous generation of tissue valves. In addition they apparently can now do valve in valve for when that valve fails which is a TAVR so not a second open heart surgery.

I was given one of the previous generation of tissue valves ten years ago when I was 60. The Inspiris Resilia had not yet become available then. My valve is still going strong. Some people on this forum with tissue valves have been going many more years than me. I don't take any medication for my valve/heart.

I had a bicuspid aortic valve which a person is born with - they become stenotic due to the blood turbulence through the valve.

 

[W84Me]

Thank you all so much for hand holding. Naturally I am stressed and frightened relating to impending AVR but am aware it is essential for my survival.

 

[Superman]

How long have you been now with the mechanical valve? How about the noise issue that I hear about? How inconvenient is it?

For me, I’ve been ticking and taking warfarin for close to 33 years now. Since 1990. I’m 50. The noise doesn’t bother me, but I can’t play tooth fairy for my kids. I can never sneak the money under the pillow quietly. My wife finds the sound soothing. Although if I have a rhythm issue, it’ll wake her up. I can sleep through that though. Some say theirs is absolutely quiet. Mine is not. But after 30 plus years it’s just a sound. Doesn’t bother me.

Anyone who takes a daily vitamin can take warfarin. It’s just a pill. It’s that easy. With home testing, our lives are far easier than diabetics. Once every week or two is a finger poke. Sometimes I have a conversation with the clinic if I need a change. Refills are pretty much automatic and I get them in the mail. In short - aside from the occasional cardiologist follow up, I never have to leave the house for my situation. And if I travel, I can pack my meds and testing supplies with my toothbrush and shaving kit.

 

[V__]

I was told that you can have minimally invasive surgeries when tissue valves wear out.

You can... And the recovery with the minimally-invasive surgery is faster and easier than with the open-heart version. That said, it still is a "major surgery", you are still wacked down at first (in many ways), pain is not supposed to be any better, etc. So I would caution against the perception that it's "easy" (just "easier"), compared to OHS.

Don't know if the minimally-invasive method is better for re-operations, compared to OHS. At least one re-operational issue mentioned in this forum is working through the scar tissue left from a previous surgery, before even getting to the valve. This got to be a very similar effect, no matter how scalpel got to the heart. (But there could be other operational aspects.)

 

[carolinemc]

Mechanical valves have a greater vulnerability to infection? I haven’t heard that one. Always open to new info - just don’t recall that being mentioned before.

No mention of that to me when I got my St. Jude's in 2001. Just that with being diabetic, it messes the immune system up.

 

[Paleowoman]

You can... And the recovery with the minimally-invasive surgery is faster and easier than with the open-heart version. That said, it still is a "major surgery", you are still wacked down at first (in many ways), pain is not supposed to be any better, etc. So I would caution against the perception that it's "easy" (just "easier"), compared to OHS.

Don't know if the minimally-invasive method is better for re-operations, compared to OHS. At least one re-operational issue mentioned in this forum is working through the scar tissue left from a previous surgery, before even getting to the valve. This got to be a very similar effect, no matter how scalpel got to the heart. (But there could be other operational aspects.)

Minimally invasive is open heart surgery, it's just the cut down the sternum is not as long as conventional sternotomy, or it can be between the ribs - but not easier. TAVR (Trans Aortic Valve Replacement) isn't open heart surgery and, apparently, it can be done when tissue valves wear out - the replacement valve is 'threaded' through an artery and 'sprung' into place 'inside' the replacement valve - that is a very simplified explanation !

 

[pellicle]

Don't know if the minimally-invasive method is better for re-operations, compared to OHS

As far as I know there is no difference in that regard.

 

[pellicle]

I often write that patient preference drives things but in the case of Minimally Invasive surgery its a 1 2 punch where the surgeon is second (perhaps pushed aside) to the ideas of patients (who clearly don't have a clue about any of this when its their first time and the real bosses, the bean counters.

https://pubmed.ncbi.nlm.nih.gov/32961136/

Conclusions: Open CABG via sternotomy and MICS CABG approaches are associated with similar, excellent perioperative outcomes. However, MICS CABG was associated with fewer transfusions, shorter length of stay, and ∼$7000 lower hospital cost, a superior resource utilization profile that improves patient care and lowers cost.​

So are we doing it because it has better outcomes or enables cost savings?

in the following abstract (note, I couldn't access the full article without paying 40 euro) the following points of interest are italicised by me.

https://pubmed.ncbi.nlm.nih.gov/26577232/

Abstract​

Minimally invasive procedures are the standard approach in many centres but are still under debate in regards of inferiority compared to conventional mitral valve surgery through a median sternotomy. The aim of this review was to summarize the current literature comparing minimally invasive mitral valve surgery (MIVS) and conventional mitral valve surgery. In this review of the current literature, we summarize our findings from a recent meta-analysis and add information from papers that were published afterwards. There were no differences between patients treated minimally invasive or through a conventional sternotomy approach in regards of perioperative stroke rate and mortality. Procedural time, cardio-pulmonary-bypass time and cross-clamp time were longer in the MIVS group. In contrast, length of intensive care unit (ICU) stay and length of in hospital stay were significantly reduced in this group. Need for blood transfusion was lower in the MIVS group. Other outcomes like i.e., the rate of rethoracotomies or renal failure didn't differ between the groups. Repair rates and long-term freedom from recurrence of mitral regurgitation and reoperation are similar. Newer publications underline these findings. The current literature shows that MIVS and conventional mitral valve surgery show a similar perioperative outcome. Minimally invasive mitral valve surgery is favourable with regards to ICU stay, in hospital stay as well as need for blood transfusion.​

so the points of longer bypass time and procedure time are important because they are statistically demonstrated indicators of outcomes

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8955830/
table 4

much of this stuff is complex but I personally am wary of claims of profit driven institutions feeding in to patient anxiety and especially when surgeons are dubious.

 

[Gkeraney]

You have gotten great input from everyone here. I felt like maybe I shouldn't say anything. But I want to add I think both choices are good ones. The odds are with a bio valve, a good one and a good surgeon, you would get 10-15 years out of it. Re-surgery would be at age 68-73 ODDS are. BUT you might be able to do a tavr then, and they might be able to tell you that now. The tavr could take you to 78-83.

If your family has great longevity, you probably then need another complex open heart when you are pretty old for that. A better idea would be open heart, open heart, tavr. So bio open heart now, at 68-73, then tavr at 78-83 which gets you across into late 80's early 90's.

From my own experience and obsession about the data, I think that's a good plan. Open heart, open heart, tavr.

Any open heart after tavr is not a good plan, at least with current stats. It's a tough surgery that not that many surgeons have a lot of experience with. I am likely faced with this between now and 73, but more likely at 68 to 73.

Ok, now if you do mechanical now, it's quite possible you have another surgery at age 78-88...sort of worst case scenario. Open heart. You can't do a tavr. On average this would happen at 83, but I would defer to others. You CAN survive that surgery. This seems like a better option. If outlive that valve past 88 that's almost worse.

 

[pellicle]

I felt like maybe I shouldn't say anything.

personally I'm glad you did, not only is every one who has been through this able to provide actual experience, you seem to have had your fair share of experience over the years and thus had time to reflect, think and understand the actual outcomes of decisions made.

Eg from your Signature:

July 2000 St. Jude Toronto SPV 27 mm Aortic, age 40.​

Jan 2011 Medtronic Mosaic 27 mm Aortic​

Nov 2019 EW Sapien 3 Ultra 26 Tavr inside failed Mosiac​

Best Wishes

 

[V__]

Minimally invasive is open heart surgery,

AFAIK "open heart" description is identical to "full sternotomy". And "minimally invasive" is NOT that. Here is the quote from Clevland Clinic's explanation [1] (emphasis mine):

Minimally invasive heart surgery is a term for procedures performed through one or more small chest incisions. In contrast, open-heart surgeries use one long incision down the center of your chest. The minimally invasive approach may offer less scarring and pain and a faster recovery.


However, it may be confusing that in surgery statistics they are typically lumped together.

- but not easier.

In the sense of the recovery trajectory and duration I believe it is.

TAVR (Trans Aortic Valve Replacement) isn't open heart surgery

I'd rather refer to TAVR and other transcatheter methods, that don't involve taking a scalpel to the heart, as "procedures".

 

[W84Me]

So I saw my primary care physician today. And he was saying that everyone is surprised (including the echocardiogram cardiologist) to learn about my AOR since there is no influencing element in my history as well as minimal symptom i.e., not pronounced short of breath (considering my aortic valve peak velocity number is 7.2). He heard my heart with stethoscope and said there is some murmur but nothing pronounced.

He advised me to keep doing my weight lifting but half of my earlier lifted weights and fewer repeat. Essentially just maintenance level. His reason is it will keep the physiological element still active without straining the heart.

Frankly, for the last four days that I did not exercise I noticed slight increase in symptom of breathing. But today following his advice of reduced weights (but not eliminating it), I feel like before. Very little breathing problem.

 

[pellicle]

o I saw my primary care physician today. And he was saying that everyone is surprised (including the echocardiogram cardiologist) to learn about my AOR since there is no influencing element in my history as well as minimal symptom i.e., not pronounced short of breath (considering my aortic valve peak velocity number is 7.2).

in which case I'd be very interested to know what your Lp(a) levels are.

https://academic.oup.com/eurheartj/article-abstract/43/39/3968/6670979?redirectedFrom=fulltextEuropean Heart Journal, Volume 43, Issue 39, 14 October 2022,

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6494952/

Lipoprotein(a) [Lp(a)], a major carrier of oxidized phospholipids (OxPL), is associated with an increased incidence of aortic stenosis (AS). However, it remains unclear whether elevated Lp(a) and OxPL drive disease progression and are therefore targets for therapeutic intervention.​

https://heart.bmj.com/content/107/17/1422

Conclusions Lp(a) is robustly associated with presence of AVC in a wide age range of individuals. These results provide further rationale to assess the effect of Lp(a) lowering interventions in individuals with early AVC to prevent end-stage aortic valve stenosis.​

You should also be, as if they are elevated then this would bode badly for a bioprosthetic too as its emerging that's a player in that area too.

 

[W84Me]

I am so glad to have found this wonderful community.

pellicle: I had a complete blood test done last year. Now I don't know if they did Lp(a) test or not. I certainly don't see Lp(a) in particular mentioned in the results. However, I am attaching my partial result of that blood test here that relates to cholesterol. Please share your thoughts.

As always, thanks a million to everyone!

 

[pellicle]

Hi

.... I certainly don't see Lp(a) in particular mentioned in the results.

its not a common test, so you'll specifically need to ask your GP for it. I understand that you may also need to pay a few bucks extra for it depending on how things go with your insurance ... sorry that you were just in there. Still, you've got time on your side

 

[W84Me]

Is the LDL Cholesterol above in my blood report Lp(a)? Running a Google search seems to say that.

EDIT: Never mind. Will get Lp(a) test done asap.

 

[pellicle]

I’m 50.

that picture sure looks good, you hold your age well mate.

;-)

 

[pellicle]

Naturally I am stressed and frightened relating to impending AVR but am aware it is essential for my survival.

You'll be fine

 

[pellicle]

EDIT: Never mind. Will get Lp(a) test done asap.

there are a few people here who know a lot more about this area than me. But whatever is the theory first one needs that data.

 

[Paleowoman]

AFAIK "open heart" description is identical to "full sternotomy". And "minimally invasive" is NOT that. Here is the quote from Clevland Clinic's explanation [1] (emphasis mine):

Minimally invasive heart surgery is a term for procedures performed through one or more small chest incisions. In contrast, open-heart surgeries use one long incision down the center of your chest. The minimally invasive approach may offer less scarring and pain and a faster recovery.

I can’t recall anyone on the forum who has had that type of surgery for aortic valve replacement. TAVR seems to be the nearest

I suspect the names of these types of surgery have changed over the years. When I had AVR I was initially told I was going to have "minimally invasive" open heart surgery which I see from the Cleveland Clinic is now called a “mini sternotomy”:

An alternative to sternotomy, a mini sternotomy or upper hemisternotomy, is the most common way to reach your heart without doing a full sternotomy. A mini sternotomy uses an incision that’s only 2 to 3 inches long, which is about half the length of a traditional sternotomy. The incision starts between your breastbones and only goes down to about your fourth rib. Sternotomy: Procedure Details & Recovery

I ended up having a full sternotomy as the surgeon couldn’t access my aortic valve with the shorter “mini sternotomy”.