Ross Procedure gone south

[ARossGuy]

Well folks, after almost 7 years my Ross procedure has officially gone south:thumbd:. The neo aortic valve has been getting progressively leaky since the aortic root opened up slightly (to 4.0cm) and is at the moderate-severe level. My LVIDd is not too bad ~ 5.44cms but is dilated none the less. My cardio referred me back to my original surgeon and we discussed a couple options. One option is to do a valve sparing procedure (aortic valve reimplantation-same as Davis procedure??) in which the valve is excised and reinserted into a Dacron ring. He has done 8 redos on Rossers using this procedure and has gotten good results so far. He recommended I google it to find out more.
During my search, I have found some studies on valve reimplantation, but only one study that documented the use on a previous rosser’s neo-aortic valve (the pulmonary valve that was moved to the aortic position) with a good outcome. The procedure appears to be relatively new and it is hard to determine the long term outcomes. However, I am not too keen on the idea since my concern is what is to prevent it from happening again since my aortic root dilation has returned to 3.7cm on last echo and the valve is still leaking. By fixing the geometry of the valve closure and preventing the root from dilating using the dacron sleeve, will the valve hold up in the long run? Seems like a gamble.
Therefore, the more I think about it, the more I am leaning to mechanical, most likely the On-X. I penciled in the re-op for September but have not decided which way to go. Either way, any fix is better than the alternative.
Back in the waiting room again and on deck for another OHS…bummer.

 

[Greg a]

So sorry to read of this new round of surgery but glad you turned to the VR family

 

[mitchner9g]

Well folks, after almost 7 years my Ross procedure has officially gone south:thumbd:. The neo aortic valve has been getting progressively leaky since the aortic root opened up slightly (to 4.0cm) and is at the moderate-severe level. My LVIDd is not too bad ~ 5.44cms but is dilated none the less. My cardio referred me back to my original surgeon and we discussed a couple options. One option is to do a valve sparing procedure (aortic valve reimplantation-same as Davis procedure??) in which the valve is excised and reinserted into a Dacron ring. He has done 8 redos on Rossers using this procedure and has gotten good results so far. He recommended I google it to find out more.
During my search, I have found some studies on valve reimplantation, but only one study that documented the use on a previous rosser’s neo-aortic valve (the pulmonary valve that was moved to the aortic position) with a good outcome. The procedure appears to be relatively new and it is hard to determine the long term outcomes. However, I am not too keen on the idea since my concern is what is to prevent it from happening again since my aortic root dilation has returned to 3.7cm on last echo and the valve is still leaking. By fixing the geometry of the valve closure and preventing the root from dilating using the dacron sleeve, will the valve hold up in the long run? Seems like a gamble.
Therefore, the more I think about it, the more I am leaning to mechanical, most likely the On-X. I penciled in the re-op for September but have not decided which way to go. Either way, any fix is better than the alternative.
Back in the waiting room again and on deck for another OHS…bummer.

Hey ARG - Sorry to hear about the Ross going south on you...I admire your sensibility to think critically about the reimplantation study without long term followup data. I can't tell you what to do but feel I should at least reach out as another ross patient and let you know what my experiences have been.

7 years is about what mine lasted, too. Do you know of a surgeon out in Cleveland, named Gosta Petterssen? He's done the "ross-redo" operation a few times where he will replace the aortic pulmonary back in the pulmonary spot, and then replace the aortic with something else...I think his decision on whether to revert the valve depends a lot on the health of the existing autograft, though.

I had my ross in 1999. reop in 2006, then another in 2007, complicated by infections, paravalvar leaks...and more. I had tried to go the bioprosthetic route to avoid coumadin (I've also got ulcerative colitis which had me worried about anticoagulation). After my 4th reop last October, (I had Petterssen above do it), I went with On-X valves for both pulmonary and aortic valves. So far, so good with the valves for me. I haven't had any trouble with the colitis and the valves certainly perform better for me than the biologic ones I had earlier (Medtronic's "mosaic" model). I've been advised to keep my INR between 2.5 and 3.5 and monitor myself with a home test kit weekly. It's not so bad compared to the hell of multiple re-ops.

fraternally,
adam

 

[texasmike]

My Ross began failing after 7-8 years, so I decided to go for a second opinion at Mayo, and at their urging (and that of my cardiologist) I elected to go with a mechanical valve. Perhaps the primary reason for this was an attempt to avoid a third surgery down the road. I know that this is still possible, but much less likely than with something other than a mechanical valve. OHS is tough, which you know already, and third and fourth operations are just that much tougher. With home testing, coumadin isn't a big deal.
My advice would be to consult with the Doctor at Cleveland and/or talk with Dr. Hartzell Schaff at Mayo (Rochester). This isn't emergency surgery and you should take the time to get input from the best doctors you can find (which, btw, includes Dr. Ryan).

 

[ARossGuy]

Thanks Greg and fellow Rossers. I did have the consult with Dr. Ryan and he recommended I at least look into reimplanting the valve but would ultimately do what ever I wanted. Since I am 49, I am probably not old enough to go the tissue route without a third OHS, therefore, opting for mechanical. The other reason I do not have a lot of faith in the re-implant method is that a CT in 2009 showed leakage in a fenestration of the aortic valve (between the two cusps) and the valve tips were not co-aptating correctly. I am really not sure about the viability of the valve but Dr. Ryan stated he would be able to tell right away if it was doable.

As far as the pulmonary homograph goes, there is some stenosis noted and while "the hood is open", would opt to replace it for a larger homograph. Doc Ryan also said he has put mechanicals in the pulmonary position which surprised me a little.

Thanks to this forum, I am not too concerned about ACT with warfarin, and will wait for the ON-X study (Plavix/ aspirin) results in 2015 with the understanding that if approved, Plavix carries its own risks.

I think it is a good idea to consult another surgeons for a group heading check, so I appreciate your advice.

 

[nngbwh]

Sorry to hear that. Wishing the best on your 2nd surgery.

 

[sylviayasgur]

hi ARG,
i'm so sorry to hear about your situation. have you considered consulting with dr. paul stelzer at mt. sinai hospital in nyc? he's another genius and those here who have used him will confirm that. you can email him all your info, questions, downloads of info, etc.
he' s a delightful man in addition to being a very talented surgeon.
you have nothing to lose...
good luck and please keep us posted.
sylvia

 

[ARossGuy]

Thanks Sylvia. I know that Dr. Stelzer is highly regarded in the RP area, so it's worth a shot soliciting his opinion also.
Regards,
Doug

 

[bdryer]

Hey ARG

I had an On-X AV implanted in the aortic position on Mar 21/11. One of the reasons I choose this valve was because of the successful PROACT study with a reduced INR of 1.5-2.0. I'm not big on the Plavix/baby aspirin therapy. At present for me, I'll stick with the warfarin for ACT.

 

[Tom F.]

What was proposed to is the "David type" valve sparring procedure. I had one done in 2002 and things still seem to be working fine.