Possible Second OHS due to Aortic Valve being small from previous surgery

[iren_999]

Hello all,

Please kindly help me as I am very scared now. I need some opinions here if possible.

4 years ago, I had my aortic valve replaced (non-mechanical valve), and after a year, doctors had realized that the aortic valve that my surgeon inserted is small.

I had another consultation with another surgeon (same hospital), and gave all my details on what happened and all my past medical documents and he looked at it. He did agree that my aortic valve is small, and therefore, he recommends that I need another OHS in the near future, if not, it can lead to heart damage.

My question is, can this be corrected using the TAVR method or do I really need to have an OHS again?
He told me that this time the incision would be from the sternum almost to my stomach area.
When he told me this, I was freaked out and I am scared and need some advise.

Otherwise, at home, I do not feel any serious symptoms such as shortness of breath.

 

[ATHENS1964]

When you reboot with TAVI then the valve is smaller than the original. Think you have a hole and you put in something else it won't be smaller in diameter.

 

[iren_999]

Think the surgeon said that the inner part of the valve that was inserted from my previous OHS, is 18mm and actual ring around the valve is about 21mm. It’s small. Many doctors have even said this.

I really do not want another OHS because is it too risky and they need to also cut out the titanium struts which holds the valve in place.

Should I go get a second opinion for less invasive surgery?

 

[ATHENS1964]

It doesn't matter how big or small the cut, it does matter if it is done correctly. The surgeon knows

 

[iren_999]

So there are no less risky corrective procedures such as TAVI?

TAVI is where they insert a new valve through the groins ? Correct?

So there are no other options other than having another OHS?

 

[ATHENS1964]

They say that if you have a biological valve you can put it up with tavi to 2-3 times. because each one is smaller like the babushkas Russian dolls .
If you have 23mm valve the next maybe is 21 mm the next 19 mm e.a . So you need larger for this reason I believe you need replace it with new not put in new smaller .

 

[KatherineA]

I’m sorry, @iren_999 this sounds scary, is scary. I’m very new at all this valve stuff so do not have a lot of knowledge about various procedures and options it were me, I would try to get a second opinion from the largest most reputable cardiac hospital/surgical center I could get myself to. Having a brand new perspective and ideas from another source could help in sorting out what to do

 

[Paleowoman]

Hi @iren_999 - My replacement valve is also too small. I was given a 19mm valve (inner part is 17mm) which has meant that I have moderate patient prosthesis mismatch. I’ve had high pressure gradients since surgery, my current gradients are peak 56mmHg and mean 35mmHg. The effective orifice area of the valve is 0.76. Any doctor who listens to my heart hears "aortic stenosis".Three years after surgery my cardiologist thought I would need to have a redo right away and referred me to a new cardiac surgeon at a different hospital - this was a surgeon who I had read a lot of good things about. I had a transoesophageal echo (TEE) to thoroughly check the state of the valve leaflets. The valve leaflets were fine. When I saw the surgeon he gave me a lot of time, spent a lot of time explaining about prosthesis mismatch. He appreciated that I had never recovered to my pre aortic valve replacement fitness and health, but he was not going to do a redo at this point as there would be a high mortality risk (another surgeon said the same). They would not be able to put in a bigger valve in the aortic annulus since the annulus is very fibrous which is why the current valve is too small - a bigger valve cannot be put in the annulus as there is no ‘give’, so they would have to do either a supra-annular position with a stentless valve or a mechanical valve or do an aortic root replacement. So I now get an annual “expert echo" done by a cardiologist - most technicians cannot visualise my replacement valve well due to interference from the scar tissue and wires. The plan is that the valve will be replaced when it deteriorates, but the replacement will have to be one of the options mentioned to put in a bigger valve. Definitely not TAVR.

 

[Zippylin]

Hello all,

Please kindly help me as I am very scared now. I need some opinions here if possible.

4 years ago, I had my aortic valve replaced (non-mechanical valve), and after a year, doctors had realized that the aortic valve that my surgeon inserted is small.

I had another consultation with another surgeon (same hospital), and gave all my details on what happened and all my past medical documents and he looked at it. He did agree that my aortic valve is small, and therefore, he recommends that I need another OHS in the near future, if not, it can lead to heart damage.

My question is, can this be corrected using the TAVR method or do I really need to have an OHS again?
He told me that this time the incision would be from the sternum almost to my stomach area.
When he told me this, I was freaked out and I am scared and need some advise.

Otherwise, at home, I do not feel any serious symptoms such as shortness of breath.

I hope everyone is staying safe. I am in Florida, highest Covid cases daily.
I had my first AVR in 2013. After that I felt ok, but never felt completely well. Kept going to my then cardiologist who
Kept telling me everything is good. I didn’t feel like it. Stupidly, it took me 3 yrs to change doctors. I believed
My first one. My mistake. Within 6 months, my echo showed leakage, and following ones worsened
I was told after tests that I needed another AVR. They could not do the easy way. The doctors here told me in
March 2017, I need to do it now!,,,,I refused to do second op in Fla hospitals and found one of the top
Surgeons in New York. After my replacement op, found out my first valve, was too small, like you and it
Was not fully attached, bottom line. Make sure you have the right surgeon. My 2nd op was a 1000 times better then
My first. Out of bed day 2, walking stairs day 4, home day 7. I have an Edwards,Peric Ardial Tissue Heart Valve,Aortic. 23 Mm. Try not to be too afraid. Second op saved my life. 3 Yrs later, I feel great. I did not have Tavr
My scars are small, and truth be told, I wouldn’t have cared if my scars went from my neck to my toe,
I AM ALIVE. I hope this helps in a small way. Take care and stay safe

 

[DebbyA]

Hi iren_999. I have some opinions, but have no medical qualifications. I read over some of your previous posts and saw that you were 72 when you got the first valve 4 years ago. It seems you lead an active and healthy life. I can understand your fear because of the error in the first valve selection. Part of your fear seems based on the incision size because your original surgery was minimally invasive. The incision you describe, "from the sternum to the stomach area" is what many of us have. Even though the procedure is scary to read about, the incision itself is more of an inconvenience. Your activity will be restricted for several weeks to allow the sternum to heal. I had my aortic valve replaced twice and didn't have pain from the incision.
Have you discussed with doctors what kind of life you would have without another replacement? You say you have no symptoms, and you were told heart damage "can happen", but has any damage been detected? I'm 73 and would be thinking along those lines as well as considering what kind of surgery to have. I realize I only have the sketchiest idea of your situation and may have missed something. I second KatherineA's advice about consulting a star medical center.
I know all this is troubling and hard not to obsess about.

 

[nobog]

They say that if you have a biological valve you can put it up with tavi to 2-3 times. because each one is smaller like the babushkas Russian dolls .

Twice with a TAVI (in a stented tissue valve) is a long shot - 3X is just nuts.

 

[iren_999]

No damage has been detected from numerous tests. Even this surgeon who just examined my documents said the heart itself is very healthy, however, its just the inner part of the aortic valve that is small (18mm).

Sorry, please forgive me, but I don't understand these medical terms so I may be writing some things that are nonsense when it comes to medical terminology...

 

[dick0236]

[QUOTE="iren_999, post: 898713, member: 16205]
Sorry, please forgive me, but I don't understand these medical terms so I may be writing some things that are nonsense when it comes to medical terminology...
[/QUOTE]

No need to apologize. I don't understand a lot of what I read here. I think some of the people on this forum know more than several; doctors I have seen over the years.

My only advice, at your age of 76, is try to pick a solution that will minimize future procedures.

 

[Paleowoman]

No damage has been detected from numerous tests. Even this surgeon who just examined my documents said the heart itself is very healthy, however, its just the inner part of the aortic valve that is small (18mm).

Hi @iren_999 - If there's no damage and your heart is "very healthy" then you need to seriously think whether to wait and have repeat echos like I do. My valve is smaller than yours (inner part 17mm), and although I have symptoms, ie never got back to the fitness I had pre-surgery, my heart is still working fine and so is the valve that is too small. Annual expert echos are the way my cardiac surgeon is monitoring this so as to do surgery at the right time (see my earlier post).

 

[Johan]

Hi iren_999. I received an Edwards Bovine Pericardium valve 11 years ago. The valve is 21mm dia, I presume that is the outer metal ring, so the inner part could be smaller. I am now 77 and have an echo every 6 months.

So far all the reports indicate a healthy heart. I lead an active life (for a 77year old ) and have never given my valve size any thought. When my valve needs replacement due to wear and tear, we'll decide on the best way forward. I can't give you any advice, but if I were you, I would make very sure that the "small" valve is indeed detrimental for your heart.

 

[iren_999]

Thank you for all your support.

@Pauleowomen - may I ask how old you are? Because I am 76 yrs old, and I can keep going to echo exams like you do to make sure the heart is still in good condition, but what happens if the time comes for a redo operation and the risk of mortality rate goes up due to my age?

Or, what if they say they cannot even redo due to my age?

 

[Paleowoman]

H @iren_999 - I'm now 67. I'm aware that the mortality risk my cardiac surgeon spoke of will rise the older I get, but he obviously didn't feel the risk was worth taking now while the valve and my heart are still okay. And I prefer it that way, I don't want surgery before it's absolutley necessary.

I believe they can do surgery at greater ages these days. Before TAVR was available, people were given surgery when they were very elderly - yes it carries more risk than when they're young, but it was still done with success.

The stress of knowing that redo will be coming sooner rather than later isn't good but the longer time has passed since I knew this was on the cards, and the more often I have echos to check things, I get used to the idea.

 

[Paleowoman]

PS - thinking about it, it might be an idea to get a second opinion from another cardiac surgeon at a different hospital. If they also recommend redo surgery now than you need to know exactly what type of surgery they would propose - they can't just take out the current valve and put in a larger one.

The space where the valve goes has no give as it is very fibrous and only allows a particular size, that's why pre aortic valve replacement no one can know for sure what size valve they're going to get before surgery as the surgeon doesn't know until they have access to the aortic valve space after taking out the old valve and measuring it with a 'sizer'. That's why they have a selection of valves available. It would be great if they knew beforehand the size of replacement valve as then, if the space is small and only a too small valve would fit (like you or me) they could do the different type of surgery at that point when there is less 'risk'. The 'risk' now, at least for me, is the scar tissue from the first surgery added to the complications of a different type of surgery, ie supra-annular replacement or aortic root enlargement.

 

[iren_999]

So basically, the surgeon who I had seen this time is keeping his silence. Its been noted on his diagnosis paper which I have that there are going to overview my situation with another senior professor surgeon (who did my first surgery). No call, nothing. And I am sick and tired of waiting and I am being constantly ignored...Maybe to them, my situation is not that serious at all. They always do this to me. I see the surgeons for another consulting session but no word for weeks and months...(same hospital)

Anyways, what leads to a surgeon to insert a smaller valve? I don't understand it. Do they not measure the valve before the surgery?

At the moment, I am feeling fine. And also I have the urge to swim. Also, I have this stepping machine that I do almost everyday about 100 steps and I feel fine.

I

 

[Paleowoman]

Anyways, what leads to a surgeon to insert a smaller valve? I don't understand it. Do they not measure the valve before the surgery?

They cannot accurately measure the space where the replacement valve is going to go before surgery. It is only during surgery when the bicuspid or diseased valve has been taken out that the surgeon can measure the space where the replacement valve is going to be inserted - they use an instrument called a “sizer” to measure the space and so pick the valve size which will fit - that’s why they have several different size valves available in the operating theatre.

The mismatch occurs when the size of the replacement valve is too small in relation to the patient’s body size. During surgery, after the size of the replacement valve has been worked out the surgeon should be able to work out with a simple mathematical formula if there will be a mismatch between it and the patient’s body size. I do not know why this does not appear to be done. I had my weight and height taken the evening before surgery which would have given the surgeon my Body Surface Area which should have alerted her to the fact that the valve I was going to be given was going to be too small. She could therefore have inserted a different type of valve or put a bigger valve in a different position which would be a better option for me.

Here’s a technical paper on patient prosthesis mismatch: Prosthesis‐patient mismatch: definition, clinical impact, and prevention.

At the moment, I am feeling fine. And also I have the urge to swim. Also, I have this stepping machine that I do almost everyday about 100 steps and I feel fine.

You need to find out the degree of mismatch that you have from your new surgeon. What are your pressure gradients on echo ? What is the 'Effective Orifice Area' of your replacement valve ? Those should both be calculated during echo and given on your echo report. The degree of mismatch is dependent on the efective orific area and will affect the new surgeon's decision on when to do a redo, especially if you feel fine and there is no indication that your heart or valve are being damaged.

I've got "moderate" mismatch so that's why they are doing annual echos rather than immediate redo which carries high mortality risk for me. My valve may deteriorate more quickly than it otherwise would have as there are high pressure gradients across the valve but otherwise there is no damage.