Redo valve surgery within a year

[user 18329]

Hello.. as post subject suggests I am one of the unlucky ones. Was initially elated at qualifying for valve sparing aortic root replacement surgery in January but since then my BAV (which was previously competent) has started to leak and it has reached point of severe regurgitation. Sounds weird to say but I’m almost relieved I am now getting surgery to replace it (in December) as last few weeks have been torture not being able to run properly, swim etc. I am a very active 42 yo for whom exercise is very important. Just a few questions for those in this community:

- has anyone had 2nd redo surgery within a year of first? Is it indeed very similar in terms of experience to the first?
- i am opting for Resilia tissue valve. I respect everyone’s choices so won’t comment on the alternatives but does anyone in their forties have this for 10years+ now and do you think I can be reasonably confident of getting 15 years from it? I’d love to have 15 years of enjoying life at my prime and if I need to go more conservative next time I will do that for the good of my family (I have a new 3.5mth old son!). That said I don’t fear more OHS and believe other than the BAV I am in good shape. Like many i am taking a calculated risk here that better options may be available in 10-15 years time.

Thank you!

 

[pellicle]

Hi Toffee

I'll just say the following points, you join the dots as you see fit

• the average age for AVR is over 60 (you're an outlier right there)
• you have now had one of your surgeries, redo surgeries are not infinite and come with eventually dire outcomes so I suggest you consider that carefully
• you are in your fourties, so you have to expect at least 30 years more life
• the tissue valves (such as the resillia) are designed for the average patient
• BAV is strongly correlated with aneurysm of the aorta, indeed that's what drove my 2nd redo and other members here too
• scar tissue is not just a scratch in the paint, its a wound that goes deep into your body and effects many things
• as I understand it there is absolutely no way that natural materials (what amounts to a leather wallet or a pair of leather shoes) can possibly be made with the same materials quality that fully manufactured materials (like pyrolytic carbon) can be. Thus the failure rates are more randomised
• failure rates are high in younger patients (meaning those under 60)
• each cycle of SVD and sugery to correct that contributes to permanent irreversible tissue damage of the heart muscle and nerves, this inevitably leads to arrythmias and this means you'll be on warfarin (or worse) for that over time

what do you want for your future?

Saying "pah, I'm not afraid of surgery" can be a sign of being brave or it can be something else.

I had my first surgery when I was 10, it was a repair of sorts, I had my second when I was 28, it was somebody elses (a homograft), I had my third when I was 48, it was a mechanical with a pre-attached aortic graft to fix the aneurysm. I'm nearing 60 now and that valve has already done 12 years and I see no reasons why it won't do another 20.

Well managed warfarin therapy (using INR as the guide) will see you live a long and active life; don't believe those who say otherwise and don't have actual knowledge.

Things accumulate, wisdom is grokking that in advance.

Best Wishes

 

[user 18329]

Thanks @pellicle . I'm aware mechanical valve is the more logical way to go but I think the biological valve is the way to go for me. I know 2nd / 3rd surgery is not a trivial matter at all and I'm just focused on getting it done and starting the rehab journey. The first surgery corrected a 5.5cm aneurysm with a graft and that part was successful but obviously the decision to spare the valve (which was made by the surgical team on the day) has backfired. There was a 5% chance of this happening. So next it will be AVR which I hope will be able to put me back on track after a really difficult year. Glad your valve choice is working well for you .. out of curiosity can you hear the ticking and do you get used to it, also do you have to limit what you drink in terms of alcohol? I know it must seem infuriating being asked these type of silly questions when it must seem obvious to you to go mechanical so pls forgive me..

 

[nobog]

Thanks @pellicle . I'm aware mechanical valve is the more logical way to go but I think the biological valve is the way to go for me.

At your age I highly recommend a mechanical valve.
I never thought I'd get old - I did.

 

[pellicle]

I'm aware mechanical valve is the more logical way to go but I think the biological valve is the way to go for me.

I don't need to know why you think that but just think about it in a "future projection manner".

Best Wishes

 

[pellicle]

I never thought I'd get old - I did.

for the longest time I wish I hadn't, but here I am now too.

 

[DrCooper]

Welcome Toffeelondon,

The 7-year results of Resilia might be interesting for you:
https://www.edwards.com/about-us/resilia-newsroom/commence
To pellicle's point, an interesting statement of what clinicians consider a "young" patient:
"The seven-year data from the COMMENCE aortic trial demonstrates strong clinical outcomes and excellent durability in a study of younger patients with a mean age of 65.1 years."
In any case, from the stats it seems like structural valve deterioration rate is extremely low. This is the main reason biological valves fail (due to calcification).

Personally I wouldn't bet on extremely better options in 15 years; Evidence generation takes time and can fail. St Jude valve was invented almost 50 years ago. Despite it is one of the most common options still today.
In that context, RESILIA is still a pretty "new" valve; it was approved in 2016 in Europe. That means that the only patients, who could potentially be more than 10 years with it, are the ones enrolled in clinical trials such as COMMENCE, which are however targeting average age 65. There are now attempts to systematically evaluate it in patients with avg. 55 y.o. e.g. the INDURE study, but there are no long-term data yet.

I understand that in theory at your age, you are looking at OHS now at 42 and then valve-in-valve redo when you are around 60. Keep in mind valve-in-valve is still a theoretical possibility, but I haven't seen it applied extensively yet (just a few cases), especially not recommended in low-risk patients that can go through an OHS. If you need a 3rd one though that would need to be OHS again at an advanced age 75+. So it might make more sense to take the OHS at 60 for the hope of a valve-in-valve at 75+.

I believe there are quite some people in this forum who have had several OHS so I'm sure they will chime in!

All the best with the surgery and recovery!

 

[tommyboy14]

Hi Toffee,

you have to make your own decisions regarding valve choice.

I was in a similar mind set with my first AVR. I have a root replacement at in 2014 with an equine valve with superior hemodynamics. The surgeon said that it doesnt calcify as much. And he was right. It didnt calcify, but the leaflet just tore. They couldnt even do a TAVI on me.
So in 2022 I had a mechanical valve installed. Like you, I also tried a buying time strategy to get better technology in the future.

You need to be aware of a couple of things:

- You already had one root replacement. With each reop there is a 20-30% chance that they will have to re-replace the root. Re-root replacement carries a a mortality rate of 5% even in the hands of top surgeons.

- Somethings I didnt fully appreciate is that with each surgery, the side effects get worse. I sailed through the first one in my 30s. The one in 2022 was definetly a much harder recovery, despite me spending a year in specialised cardiac rehab. Turns out that heart lung machine can have some persistent effects in some people. Thank god my brain fog lifted, but it was there for quite some time.

- You should ask your surgeon, but realistically you only have 3 relatively risk free OHS attempts, before it gets messy. Now consider that sometimes a mechanical valve can need replacement after a 2-3 decades. And that there is a risk you develop other heart valve issues like mitral valve issues, which will also require OHS (there is multiple people here that has happened to). So think very carefully about whether you want to use up your second risk free attempt, knowing that there will be a third in your future.

- It is possible that there is better technology in a decade, but you will not know that. Even the Foldax valve would have only 8-9 years track record by then. That is still new in cardiac surgery terms. Also, there is a first in man trial of a tri-leafleft mechanical valve which could be warfarin free this December. So that product might come to market in 4-5 years. But then by the time you need a redo that valve will only have been on the market for 5 years. Not very long, And these new mechanical heart valves are made from new materials. We have no idea about endocarditi risks or other long-term health conseqeunces in 10 years from now. This strategy of waiting for better tech only makes sense if you can get 20 years out of the Resilia, You could get that, but that is very uncertain. We just cant know.

- Since it is your health, the decision is up to you. I wished I would have gone for a mechanical the first way around. I prefer to be conservative with ones health.

- I have bee on warfarin for a year and a half now. Managing Warfarin is no big deal, as long as you can remember to test every week and take a tablet every day.

Good luck in your decision.

 

[user 18329]

Hello @DrCooper - a great reply, many thanks! Yes, I agree, a 3rd OHS at 60 is probably the more likely scenario to avoid "running out of runway" if I do go tissue / resilia route.. and thank you @tommyboy14 for your thoughtful response. Super encouraging to hear of potential warfarin free mechanical valves.. and I will def talk to surgeon about risks of re-ops.

 

[dick0236]

I am not sure where you've gotten your info about the restrictions of a mechanical valve........but I do not agree with them. I've had my mechanical valve 56+ years (got it when I was 31 and am now almost 88)) and have raised two young men (then 6 & 8 yrs. old, now 62 & 64 yrs old). There are very few things that I haven't done that I wanted to do. I have had a successful career, built a lake house, coached little league football and basketball for my boys as they grew up, water skied and went white water river rafting......etc. You get the idea......and yes I drank (often too much when I was much younger). None of those activities posed any undo risk.

I would not even consider a biological valve at age 42 unless there was a compelling reason to do so. You have a much better chance of seeing your family grow up with a "one and done" mechanical valve.

 

[pellicle]

Yes, I agree, a 3rd OHS at 60

what if its 50?

Super encouraging to hear of potential warfarin free mechanical valves..

science fiction at this point and I suspect for your lifetime ...

here's the thing: risks of reop are measured in 30 day then 1 year ... ask about the accumulative risks involving cumulative damage to the myocardium which results in arrhythmias.

Perhaps read the literature on this risk too.

To further the point by @DrCooper

Ultimately what you do only effects you, we are just simple folk who have already walked this road.

Best Wishes.

 

[Woodcutter]

I had re-do mitral valve replacement surgery about 7 months after repair surgery. My experience was that, at a high or basic level, they were similar experiences. This is despite the details being quite different. For example: the repair was minimally invasive and the replacement opened the sternum. Different surgeons, teams, and hospitals. Recovery times were similar (probably slightly longer for the second) but the 'pains' were quite different do to the very different techniques.

A couple more comments based on my experience(s):

- I was on warfarin in my early 40's before the valve surgeries so I had no qualms about warfarin. I already knew that for me it was a non-issue. It does not impact any of the things I do (I regularly run on rough trails and fall down even though I try not to! I do a lot of woodworking starting with cutting down trees and ultimately shaping wood with all sorts of sharp pointy tools. I climb on my roof, fix my car, weld broken implements, repair my house, etc.). I did all of these things in my 40's and now that I'm retired I have time to do even more! I'll keep doing the things I enjoy as long as I can. I'm a beer drinker. Finished one before typing this and I'll have another when I hit reply!

- I also dealt with AFIB prior to the valve surgeries. Something only learned/realized after the surgeries is that every time the heart muscle tissue is cut, the future risk of electrical disturbances increases. Just a couple years ago my AFIB returned. Except that when I was in the EP lab with 25 EKG leads on (for an ablation) it became clear that it was AFlutter not AFIB. Two flutters had developed around incision scars from the mitral surgeries. I've also learned that aging endurance athletes are statistically more prone to these arrhythmias.

 

[LondonAndy]

Hi @Toffeelondon . You'll never guess where I am

You mentioned the ticking of a mechanical valve, and I just wanted to say if you want to meet in person and listen to mine sometime, to help assess if it would bother you, drop me a message.

(Now there's a pick-up line I haven't used before, though I'm gonna look a bit stupid if it's London, Canada you're in )

 

[hevishot]

Hi Toffee,
Your not going to get any positive reinforcement here. I wish I found your post sooner. I could have saved you a lot of greif.
Aortic valve replaced with a bovine tissue valve in 2005. I have a 70% ejection fraction with only minimal calcification. In addition to your swimming I would consider weight training also. Good luck.

 

[Chuck C]

Some people get very lucky in the Bell Curve of Probability. A young person could get 18 years out of a bovine valve. See the very green section below. Casinos operate the same way. I might take my annual bonus from work and put it all on 25 at the Roulette Wheel. I hit my number and make thousands. Very lucky. Now, if I then go tell all my coworkers that the casino is a great place to make a lot of money and to ignore everyone who tells you otherwise, based on my own experience, well that would be something else.

 

[vitdoc]

Testimonials are interesting but fairly worthless when it comes to decision making in medicine. We have to fall back on studies and statistics. So yes a tissue valve may last 20 years but it also could last 5.
I think an interesting thing is going on in some people’s heads when they consider valve choice. On the mechanical side for the most part you are one and done. You pretty much know your future and you know you will need anticoagulants for the rest of your days.
On the tissue side you know in your heart of hearts that the tissue will fail at some time. So another procedure will be needed. But I think that in an odd way this is looked upon as a positive. Hope that something may come along in the future that will get you to the end without significant restrictions. Say a mechanical with new materials that doesn’t require anticoagulants.
It would be unlikely that a well functioning mechanical valve would be removed if something new came along.
So in a sense putting in a tissue valve allows for hope. Putting a mechanical valve may give more assurance but limits hope.
One can speak about warfarin not being too bad - it isn’t. But it is not normal. I have been on it for 40 years. I have been very active in sports, skiing,biking,basketball but it would be nice not to have to take it or worry about it.
So I can understand the hope involved with getting a tissue even with the stats not in favor.

 

[Chuck C]

Testimonials are interesting but fairly worthless when it comes to decision making in medicine. We have to fall back on studies and statistics. So yes a tissue valve may last 20 years but it also could last 5.
I think an interesting thing is going on in some people’s heads when they consider valve choice. On the mechanical side for the most part you are one and done. You pretty much know your future and you know you will need anticoagulants for the rest of your days.
On the tissue side you know in your heart of hearts that the tissue will fail at some time. So another procedure will be needed. But I think that in an odd way this is looked upon as a positive. Hope that something may come along in the future that will get you to the end without significant restrictions. Say a mechanical with new materials that doesn’t require anticoagulants.
It would be unlikely that a well functioning mechanical valve would be removed if something new came along.
So in a sense putting in a tissue valve allows for hope. Putting a mechanical valve may give more assurance but limits hope.
One can speak about warfarin not being too bad - it isn’t. But it is not normal. I have been on it for 40 years. I have been very active in sports, skiing,biking,basketball but it would be nice not to have to take it or worry about it.
So I can understand the hope involved with getting a tissue even with the stats not in favor.

Very very well said.

 

[slipkid]

Regarding any ticking "noise" of a mechanical valve do not let that be a major factor in your decision. Many/most/or me at least can't hear our mechanical valves AT ALL.

I agree with the attitudes of warfarin not being a big deal but have to say I wish I wasn't on it. It does have some complications/downsides. I found having to "bridge" to Lovenox absolutely HORRIBLE in order to get certain other procedures done. Also not being "allowed" to take NSAIDs which would help greatly with some muscle & arthritis etc issues I've had is a big downside for me.

I actually said NO to a mechanical valve because I did not want to be on warfarin. I was dying at the time so my words kind of fell on deaf ears & the surgeon installed a mechanical one anyway (long story). Now that I have one I am grateful/hopeful I won't have to be opened up again like if a tissue valve failed/calcified/etc over time which is pretty inevitable IMO, assuming I would live long enough for that to happen in the interim...

 

[pellicle]

Hi
wow, succinct post which really covers the points. I hope that this stands to serve many people. I'll sure be linking to it.

Testimonials are interesting but fairly worthless when it comes to decision making in medicine. We have to fall back on studies and statistics

agreed. The problem (as I'm sure that you know) is Survivorship bias (the bio valves that failed don't post here saying how happy they are with their valve, especially if they are very sick now or dead).

Survivorship bias occurs because there's a selection process that makes it harder to collect data from the less successful members of a population. These are things like the following: Planes that didn't survive their mission. Businesses and mutual funds that fail​

So, the classic: here's where all the planes that came home from bomber missions over Germany in WW2 were damaged

an ***** would say put more armour over where the bullet holes are. A thoughtful, analytical and wise person would say "well maybe the ones that didn't come home were damaged in the places where being riddled with bullets or FLAK fragmentation, so lets reinforce the engines and cockpit"

So yes, getting testimonials from those who's bioprosthesis in a younger patient that "my valve lasted 30 years" is rather unhelpful. We need to turn to statistics (which is hard because more than 50% of the population are not smart enough to get that.

Indeed I suggest that much more than half are not smart enough to understand this

Indeed I'll say that about 80% of people aren't ...

I have one question for you however, what did you mean by this?

One can speak about warfarin not being too bad - it isn’t. But it is not normal.

Just wondering (I anticipate at this point you were trying not to write an essay ;-)

Best Wishes

PS in fighting in Europe during WW2, the Americans laid down their lives to protect world democracy; they powered D-Day and many offensives. Many lives were lost because they didn't get it right at first, but unlike (say) Russia (now) they were very quick to revise their views and put facts into the analysis.

In the second half of 1943, the USAAF continued to build up its heavy bomber forces. As it hit targets ever deeper in enemy territory, however, staggering losses threatened the entire concept of daylight strategic bombing. ... During 1943, only about 25% of Eighth Air Force bomber crewmen completed their 25-mission tours—the other 75% were killed, severely wounded, or captured. ​

https://www.nationalmuseum.af.mil/V...519640/bigger-raids-bigger-losses-and-crisis/
Lest we forget

 

[3mm]

PS in fighting in Europe during WW2, the Americans laid down their lives to protect world democracy; they powered D-Day and many offensives. Many lives were lost because they didn't get it right at first, but unlike (say) Russia (now) they were very quick to revise their views and put facts into the analysis.

Pellicle - I appreciate this shout out. Your Australian ancestors were also instrumental in many WW2 battles in Africa and in the south Pacific. As were many, many other nations.