Questions for Surgeons

[heartweave]

Hi all...I am still at the beginning of the process. I had one surgical consult who wanted to do the aortic replacement minimally invasive biological in February 2014. I am currently trying to get a second opinion with Dr. Craig Miller at Stanford. I am mostly out of denial and succumb to the fact I do need this surgery,

I will narrow down my questions.....

What questions should I be asking of my surgeon? I have asked risk, orientation, type of valve, how long is the surgery, length of time on the heart-lung machine, how long in ICU, hospital, who is in the operating room, surgeons and hospital statistics for this operation.


My valve area is 0.7cm, my gradient is 54mm/32mm, ejection fraction 60-65%. I am 57 years old in fairly good health.

Has anyone talked to their surgeon about using long acting lidocaine in the chest wall prior to closing to help with coughing, fluid build-up in the lungs. I have heard stories about people having problems with lung congestion, even pneumonia which landed them back in the hospital.

Also anyone spoken with their surgeons about different materials in closing the sterum? What are the pros and cons?

What are the pros and cons of minimally invasive surgery? Rib or sterum orientation?

Can someone tell me what is the closing team meeting? I have never heard about this.

My aortic arch is at 3.6, mild aneurysm. Dr Gaudiani doubts it will need to be repaired. What happens to the arch in the future?

I have had multiple surgeries in my life and found working with the anesthesiologist a great benefit as well as having a hospital pain control team involved in my care.

I have always had my breathing tube removed in ICU but has anyone had theirs removed prior to waking?

I have been watching the surgery I am going to have and noticed many different surgical techniques depending on the surgeons and the country of origin. Has anyone had their surgery go through the femoral artery in addition to the minimally invasive approach? Why?

I would very much like to hear from others....what questions do you have for your surgeon? What was your immediate post operative situation like? Outcome of your surgery?

How long was your surgery? Heart-Lung machine?

Will someone address blood transfusions? I have had problems with anemia, especially following my last surgery 10 months ago when I required an emergency transfusion. It is iron deficiency anemia. I was thinking of asking for an iron infusion prior. I am not sure if making a blood donation prior to surgery is good.

Thanks so much for all your info. This site is wonderful.

Leah

 

[Lynlw]

Hi leah, yes it sounds like you are really preparing well. First off have you checked the "stickies" at the top of the pre and post op forums? there is alot of really good info there, questions to ask, what surprised you etc http://www.valvereplacement.org/forums/forumdisplay.php?4-Pre-Surgery

Everyone is different and even the same person having the same surgery is different but I can answer a few of your questions, from our experience. Vent, sometimes Justin has woken on the vent, others he had it removed in the recovery room before he got to CCU and some times it was removed in ccu before he was awake. it all depends on the "numbers" from a few measurements and for the most part they will take it out as soon as it is safe. Its not uncommon to be off the vent when you wake up, or even you might be groggy so dont remember them removing it if you were awake.

Its good to get 2nd opinions but if your valve opening is .7 I probably wouldnt wait very long at all.

We never discussed lidocaine to help with coughing, and yes people can have problems, but for the most part if you work hard at doing your breathing exercises and walk as soon as much as possible in the hospital unless you have lung problems like COPD, it really shouldnt be a problem

I'm guessing for the femoral artery question you are talking about using that area to hook you up to the heart/lung machine, usually for first time OHS valve replacement the only reason they would do that is is in cases of min invasive surgery, since there pretty much isnt room in the smaller incision to fit the hook up to bypass machine and also do the work needed, they also might use an area around the clavicle for the same reason.. Sometimes for more complex REDOs they might use that if they feel it is safer to open the chest without the heart full of blood.

As for different materials to close, as far as i know wires are still the most common by far, there is some work being done w/ a bone cement, but as far as I know that hasnt been approved in the US yet, it might be possible to get in trials if your hospital is taking part and last time I was reading about it even if you used the cement they still put a couple wires in.. There also is a thing called talons, you can search here and read about them, but honestly the vast majority of people dont have any problems w/ wires and their sternum healing


Ps Blood, for the most part most people do not need any blood for valve surgery. It IS possible to donate for yourself, BUT unless you plan far enough out so have enough time to replace the blood they take, you might actually make it that you are going into surgery with a lower blood count than you would have if you did not donate, so might need to get that unit back when otherwise you would not have needed any blood.. Since you tend to be iron deficient I would probably talk to your doctor about taking iron and other things that help build your blood up, or even ask for blood work now to see what your counts are at least.

 

[Mentu]

Leah, I saw your note and thought I might add my own take. First, you cannot get much better advise than Lyn after all she has learned with Justin. By now you know that some of your questions cannot really be answered because every surgery is contingent upon the surgeon's experience with the individual patient. You cannot control everything and attempting to do so will only lead to frustration. Nor can you know everything; this is why we hire experts. It is important that you select a surgeon who you trust to act in your best interest. There are some things that you can discuss with your surgeon but keep in mind that he is only one element of your experience. There are nurses and hospitalists who will help manage your care and if you chose a good place, they will draw on years of experience to help you heal just as they have helped hundreds of others before you.

Again, I point out that so many things are contingent upon your condition at the moment. How long you are on the heart lung machine depends on how the surgery goes not on an arbitrary signal. Your surgeon can give you a ball park for how long the operation lasts but the specifics of your valve replacement will determine how long it takes. As Lyn told you, with modern surgical techniques, it is unlikely that there will be any need for a blood transfusion. I worried about this and went to the Red Cross to save a pint of blood should it be needed but since my bloodloss was about 6 oz it wasn't needed. The breathing tube is removed after you start breathing well on your own. I happened to be awake when this was done but you must remember at that moment one is so full of medication that it is at best a minor inconvienience and quickly over. You are not likely to be fully awake at that point.

I do have one item I can offer and that is with respect to alternatives to sternal wires. My sternum was repaired with Sternal Talons made by KLS Martin. These are clamps used usually in sets of three to hold the sternum closed after surgery. They are left in place after you heal and remain with you unless there is some reason to remove them. Here is a link should you wish to read more.

http://www.klsmartinnorthamerica.com/products/implants/sternal/sternal-talon/

The pain most people experience after heart surgery comes from the sternum not being fixed together. Talons hold the sternum firmly and do not allow for any movement of the two halves. Having read accounts here in VR that many other people had written, I didn't know quite what to expect when I awoke clear headed that first morning in my own room. I was afraid to move because I felt so good and didn't want to spoil it. When the nurse came in and suggested I get out of bed for breakfast I was surprised but he helped me manage my various tubes and wires so that I could sit in a chair at my small table. I had no chest pain. Later, one of the nurses said that without looking at charts, they could always pick out the patients with Talons because then didn't have the discomfort that some of the other patients experienced. Infact, I never had any sharp chest pains. Actually, the most uncomfortable moments in the hospital were caused by gas pains after my first meals. After I went home on day five after surgery, I did experience some aching in the evening when I went to bed but I never had any problem even when I coughed or sneezed. Once home, my number one problem was constipation not chest pain. And I do recommend that one be prepared for the constipation. My family doctor recommended one teaspoon of Miralax and one teaspoon of Benefiber at least once a day until the problem fades which may take several weeks. Of all the issues I had included in my own list of concerns before my AVR, this was not one of them.

If you hear nothing else from me and the other, however, try to keep in mind that it will almost certainly be a far better experience than you can imagine now.


Larry

 

[AZ Don]

In my conversations with the surgeon I focused on a couple things. Confirming I was a candidate for surgery now, and evaluating the surgeon by asking about his experience with the operation. I asked a couple questions about how he would do the surgery but for the most part I don't pay attention to those details. I definitely suggest that you discuss your experiences with anemia. I was quite anemic following my OHS and I never was before. I understand it is quite common following OHS.

Re. minimally invasive surgery. The recovery can be better if you are a candidate for this but I suggest that you confirm that it is not higher risk than OHS (in some cases it is, in some it is not). Whatever procedure you have you want to be sure that your surgeon is quite experienced with it.

Re. fluid in the lungs, this is also common after OHS. I had a small amount of fluid in my lungs and was on a diuretic for a week after release. Then on a follow-up the fluid came back a little and so another couple weeks on a diuretic.