Ross vs Mechanical

[exige]

Hello,

Age 34 with a bicuspid aorta valve that needs to be replaced.

I have done a lot of research on the topic, the more I do the more conflicted my decision becomes. It seems like several surgeons E.G. Mount Sinai push the ross procedure for younger people. They push this modified ross as being fantastic.

From what I understand, the ross procedure pulmonary and aortic valves have an average lifespan of 18-20 years. The benefits are you get a living valve that functions as a native aeortic valve - assuming it adapts normally to the increased pressures ect. You also do not need to be on coumidin the rest of your life.

The downside is re-operation rate, and having two valves to worry about. Also the notion that the chance of both valves failing at the same time so once procedure can fix the problems seems like a pipe dream. Everyone is saying great things about the ross in the 20 year timeframe, but what about further? I don't want to have 5+ OHS in my lifetime, and end up with a mechanical just regretting my ross decision on ruining my perfectly fine pulmonary valve. Sure they say you can use a TAVR to repair the aortic valve and probably the pulmonary in the future. But not everyone is a candidate to a TAVR and they seems to have inherited risks in themselves.

What are the studies of 20-30 year old ross patients who are now 60-70 saying? I assume there is none, especially for people with the "modified" ross procedure.

Why are surgeons against young people getting a mechnical valve such as an ON-X? Are mechanical valves more detrimental to younger people? I am reading that there is more life expectancy loss the younger you are when you get a mechanical. Is it just because of the coumdin use?

For me duribility matters most, thats why I am leaning towards a mechanical valve. Life goes on on coumidin, with the advent of at home INR testing I can dial the dose in very well and dont see it as a big deal. I do see having a lifetime of worry about two valves failing and multiple heart surgeries all throughout my life a problem. I have read that after every subsiquent OHS the risk becomes siginificatly higher of just not waking up from the surgery, and if you do the trauma your body goes through must take a big tole on you.

Thanks

 

[Buckwheat]

Hi there, I just had my operation 2 weeks ago today. I also had the option of either Ross or mechanical. I went mechanical. I'm 29 years old.

Why are surgeons against young people getting a mechnical valve such as an ON-X? Are mechanical valves more detrimental to younger people?

Mine was not. As a matter of fact, he sort of pushed for it. He's one of the few surgeons that perform the Ross procedure (frequently) in the United States. He's neither for nor against the Ross procedure. He's for what the patient wants. His own father had a mechanical valve for over 35 years. Gave me the option of either Ross or mechanical and was very pleased when I chose mechanical.

I am reading that there is more life expectancy loss the younger you are when you get a mechanical. Is it just because of the coumdin use?

I'm unsure of where you may be reading this. If it is true, odds are its patients that are not taking initiative or keeping mind to their health or use of warfarin. As with any drug, warfarin is to be respected not feared.

Mount Sinai push the ross procedure for younger people. They push this modified ross as being fantastic

According to my surgeon (Dr. Joseph Dearani if you'd like to look him up). The majority of these studies for the Ross procedure are VERY "cherry picked." According to him and even some of his team members I spoke with, those studies only really include applicants that the Ross procedure would LIKELY succeed with. He went on to further explain, although these applicants may fit the Ross procedure well, it doesn't even remotely guarantee no reintervention down the line.

For me duribility matters most

Same here. If this is true, I'd say your mind is pretty well made up.

 

[pellicle]

Hi
and welcome

I have done a lot of research on the topic, the more I do the more conflicted my decision becomes. It seems like several surgeons E.G. Mount Sinai push the ross procedure for younger people. They push this modified ross as being fantastic.

it probably is, but at the very best it leaves little room for any future errors. I've seen too many posters here say "I got endo and it stuffed the pulmonary valve that was replaced". So basically you're then left at OHS#2 with two dodgy valves when you only ever had one valve to start with.

Its worth asking "why is this so marginal when its been around for so long?"

Note that probability is not certainty

so in specific cases it is probably fine for at least 15 years (then look out).

I have zero understanding* why this "new thing" (first performed 1967 by Donald Ross) is "all the rage" while homograft (which doesn't ruin the other perfectly healthy valve) is somehow falling out of favour.

As you may be aware (if you've lurked here) I had a homograft done in 1992 and it lasted 20 years, an aneurysm developed and I needed that fixed and so I got a mechanical ... I don't want a 4th surgery. Let me know if you want more details


you say:

Why are surgeons against young people getting a mechnical valve such as an St Jude?

yes I replaced the valve for a better one, as you mentioned the marketing hype posterchild which in my view makes it the lesser choice (because you don't need to market for high quality products).

So my answer to this (which I discuss often) is that people can't be trusted, people are slack, people are inattentive, people are stupid and people are lazy. This is what happens if you are all of the above

https://www.valvereplacement.org/th...-with-an-on-x-aortic-valve.888128/post-910489

This shows two things:

1. why relying on the 'special sauce' (claims) of On-X is unwise
2. what can happen if you don't follow your ACT rigorously

However IF you follow your ACT with the enthusiasm of a vegan buying soya and animal harmless products then you'll be fine. Reach out if you want more about that.

Lastly some posts to consider:

https://www.valvereplacement.org/th...ing-to-avr-my-story.889366/page-2#post-929467

I had the same, first (normal) operation was the Ross procedure in decdmber last year.​

After the operation i felt weak and had a small fever for aboou 3 weeks.​

6 weeks later at my normal chechup the saw that my valve was leaqing a bit.​

After some more tests they decided that i needed a new operation for a repair or a replecment.​

The second operation was exactly 6 mounths after my first. When i wake up they told me a had a nad case of endocarditus and they had to do everything all over from the first operation (now a biological valve). Also had the picc for 6 weeks and now for the rest of my life 1000mg of amoxiciline (to be sure it will not hapoen again).​

Now 5 mounths later a feel fit and healthy again. Just finished the revalidation and everything is working fine. I am a non smoker 46 year old men, always a healthy life (4 x sport, healthy food).​

so he's now looking at a certainty of at least one more operation (probably two). This is what I mean by "margin of error"

https://www.valvereplacement.org/th...-soccer-dreams-on-warfarin.888515/post-915690

I think the only potentially good viable other option besides a mechanical valve is the Ross procedure. I had one at the age of 20, and the valves lasted for 20 years. No meds, no restrictions other than no repetitive heavy lifting. I recently had both my aortic and pulmonary valves replaced again at age 40 and am on warfarin.​

you may find further input in my post to this person in 2021
https://www.valvereplacement.org/th...nd-other-options-severe-ar.888126/post-911172

Finally this was the institution who did my homograft (or also called an allograft)

The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve replacements.

RESULTS:
The 30-day/hospital mortality was 3% overall, falling to 1.13 +/- 1.0% for the 352 homograft root replacements.
Actuarial late survival at 25 years of the total cohort was 19 +/- 7%.
Early endocarditis occurred in two of the 1,022 patient cohort, and freedom from late infection (34 patients) actuarially at 20 years was 89%. One-third of these patients were medically cured of their endocarditis.
Preservation methods (4 degrees C or cryopreservation) and implantation techniques displayed no difference in the overall actuarial 20-year incidence of late survival endocarditis, thromboembolism or structural degeneration requiring operation.
Thromboembolism occurred in 55 patients (35 permanent, 20 transient) with an actuarial 15-year freedom in the 861 patients having aortic valve replacement +/- CABG surgery of 92% and in the 105 patients having additional mitral valve surgery of 75% (p = 0.000).
Freedom from reoperation from all causes was 50% at 20 years and was independent of valve preservation.
Freedom from reoperation for structural deterioration was very patient age-dependent. For all cryopreserved valves, at 15 years, the freedom was
⦁ 47% (0-20-year-old patients at operation),
⦁ 85% (21-40 years),
⦁ 81% (41-60 years) and
⦁ 94% (>60 years). Root replacement versus subcoronary implantation reduced the technical causes for reoperation and re-replacement (p = 0.0098).

CONCLUSION:
This largest, longest and most complete follow up demonstrates the excellent advantages of the homograft aortic valve for the treatment of acute endocarditis and for use in the 20+ year-old patient. However, young patients (< or = 20 years) experienced only a 47% freedom from reoperation from structural degeneration at 10 years such that alternative valve devices are indicated in this age group.
The overall position of the homograft in relationship to other devices is presented.

https://pubmed.ncbi.nlm.nih.gov/11380096/

Reach out if you want to discuss warfarin and its issues, but a good start is here (lots to read, its more of a resource than a summary).
https://cjeastwd.blogspot.com/2014/09/managing-my-inr.html

Best Wishes

*note: i have theories which are dark and unsubstantiatable and revolve around the source of spare parts by the people involved
on parts see here

 

[dick0236]

I'm glad I did not have to go thru the confusing choices that younger valve patients face today. My choice at age 31 in 1967, was simple.....get a mechanical valve or die in a few years.

I took the mechanical valve and still have that valve at the age 88.

I believe in the simple strategy called "KISS"......Keep It Simple Stupid. Maybe in a generation, or two, they will come up with a fail-safe, non-medicated valve that is guaranteed to last forever.......until then, the best choice is a mechanical valve that "fixes" the current problem and might last a lifetime.

 

[Timmay]

It sounds like you have a good handle on things. Kudos to doing your research.

I believe that the younger doctors aren’t as versed on Warfarin while also getting bombarded with marketing on the tissue valve side. Plus, let’s definitely not ignore the fact that the common thought by doctors here in the USA is often short-term. Emergency rooms are short term solutions. Urgent care centers are short term solutions. Our primary care doctors are often “get you in, get you out, deal with the next patient”. This mentality pollutes long-term thinking.

My cardiologist pushed tissue valves. I was 50. He knew that I was very active and non sedentary. He didn’t want to see me limited by Warfarin. Plus, they are taught that tissue valves last 15 years and often 20. So, in his eyes I could get a tissue valve and then have a TAVR at 70 and then maybe another TAVR later.

But, warfarin doesn’t limit me at all. Truly. And I prefer not to have multiple operations. I wanted to try to have a one and done which sets me up for a better future.

I went mechanical and am super happy that I did that. The ticking doesn’t bother me and I hardly hear it because of the ambient noise.

 

[exige]

Thank you for the replies everyone I appreciate it. I think a mechanical is right for me. Either way it seems like there is no "wrong" choice, there is no perfect answer.

@Chuck C I am curious your input - I read some of your posts and you were very helpful.

Thank you!

 

[pellicle]

Either way it seems like there is no "wrong" choice, there is no perfect answer.

Exactly, but there are gambles, let's look at it another way (for discussion and other readers).

What are the chances of endo? Low right? But if that puts you in a worse place because of having the Ross (vs a mechanical or a bioprosthetic) is that a worse choice (or a choice whose advantage vanished)?

Does a bio or a mechanical cause the destruction of a perfectly healthy valve (your pulmonary)?
No.

Is there a possibility that as you progress though life after this surgery that something else will drive a reoperation?
Yes.

Do you have BAV? If you do

• You are not a candidate for the Ross
• Your more likely to have an aneurysm in your future which will trigger a reoperation of the aortic valve

Do you have elevated Lp(a)?
If yes that is more likely to destroy your pulmonary valve that was placed in the aortic position leaving you up for reoperation.

As you age will something (such as an arrhythmia) likely to appear causing you to need warfarin?
Yes, up are statistically more likely to require anticoagulation therapy (which you were trying to avoid). I unexpectedly developed tachycardia a couple of years back, was I not on warfarin already I would have been quite concerned about that. Did I not have a mechanical valve (causing me to notice this) I would not have detected it as early.

Choosing a path that minimises surgery and damage caused by surgery is wiser than choosing a pathway that maximises your cumulative risks.

What are you betting on or against and why

Spread sheet it and score it.

Further listening

https://www.medscape.com/viewarticle/838221

as previously suggested by Dr Schaff of the Mayo



more current video




Best Wishes

 

[tommyboy14]

There are several studies of the modified ross procedure. The modification is usually the reinforcement of the aortic root.


The SANA clinic in Stuttgart adopted the reinforced root procedure and their own modification in 1999. Here are their results in 832 patients:

Freedom from reoperation is 80% at 20 years.
https://www.annalscts.com/article/view/16835/html

But at 25 years, it is only around 50%. See chart below. The reason that this drops so much is that before 1999 this centre used the normal ross procedure. So that cohort is different.

What do you learn from this? Even with the modified ross procedure in a very experienced centre, freedom from reoperation is around 80%.

The other big ross registry study out there is the German ross registry.

https://www.sciencedirect.com/science/article/pii/S0735109721002035?via=ihub

From that study: Estimated freedom from any Ross-related reintervention was 95.4% at 5 years, 84.7% at 15 years, 77.6% at 20 years, and 61.5% at 25 years

 

[pellicle]

The other big ross registry study out there is the German ross registry.

https://www.sciencedirect.com/science/article/pii/S0735109721002035?via=ihub

From that study: Estimated freedom from any Ross-related reintervention was 95.4% at 5 years, 84.7% at 15 years, 77.6% at 20 years, and 61.5% at 25 years

I love it when they say stuff like:

data are expressed as mean ± SD.

it gives me hope for the future of science...

The mean age was 44.1 ± 11.7 with 75.8% male subjects

so, quite relevant in this case. However as always:

The median follow-up time was 9.2 years

Meaning "some conjecture" about the future projections of 15 years ...

Personally I never really understood why the just didn't replace the aortic with a homograft, I mean rather than take the valve that belongs somewhere else put in the "misplace" and then put the homograft in the other place.

Just HAS to be a shorter operation too! Did I mention "extra scar tissue" for the inevitable redo-surgeon to cope with?

 

[tommyboy14]

At your age you will be guaranteed at least one other OHS if you go Ross.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8339619/

https://www.annalsthoracicsurgery.org/article/S0003-4975(22)00729-9/fulltext

The outcomes of these Ross reoperations are not that great.

Some surgeons have good outcomes
https://www.sciencedirect.com/science/article/abs/pii/S0022522322005013

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10162808/

But here is the one million USD question: How will you know in real time which surgeon has good ross procedure reoperations outcomes?

Because this is such an unusual operation you really cant know...

 

[pellicle]

But here is the one million USD question: How will you know in real time which surgeon has good ross procedure reoperations outcomes?

easy ... its one of these

 

[MdaPA]

Personally I never really understood why the just didn't replace the aortic with a homograft, I mean rather than take the valve that belongs somewhere else put in the "misplace" and then put the homograft in the other place.

Here is one explanation from an experienced Ross surgeon:

“Replacing the aortic valve with the pulmonary valve puts the best valve in the most important position,”... “Shifting the pulmonary valve to the aortic location also gives you a valve with the same-size opening, which prevents a patient-prosthetic mismatch,....

And

Ross candidates are young and, as such, reluctant to accept a mechanical valve requiring lifelong anticoagulation, and they are not well matched to a tissue valve prosthesis, which may not last that long in young people.

https://consultqd.clevelandclinic.org/the-ross-procedure-in-a-reoperative-setting-a-case-study

How will you know in real time which surgeon has good ross procedure reoperations outcomes?

They actually have a procedure for this, it's called the "Ross reversal".

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8689672/

 

[pellicle]

Here is one explanation from an experienced Ross surgeon:

thanks

however:

"Replacing the aortic valve with the pulmonary valve puts the best valve in the most important position,”​

some evidence why that would not mean that a homograft of an aortic valve would not be better or at least non-inferior would be expected IMO.

... “Shifting the pulmonary valve to the aortic location also gives you a valve with the same-size opening, which prevents a patient-prosthetic mismatch,...."

however its not a prosthesis, its a graft, seems like 'clever use of terms' and fails to address how creating two surgical sites and two diseased valves and twice the scar tissue makes up for that.

I'm seeking better quality of evidence (as it is the grade of evidence is III in the Cardio Thoracic Surgeons guidelines about the Ross.

So ultimately your surgeon "thinks it is" and the surgeons I know (who have not only started, but run state level programs on this topic) don't think it is (and prefer homograft). So I can't actually offer any meaningful input here because I'm not a surgeon.

So without that (evidence) I remain in the camp of "this is a sewing circle" preference of "medical opinion" level only.

But that's great to bring those discussions up, thank you.

 

[pellicle]

Time on cross clamp is widely noted as being an independent predictor of late survival in OHS. So if cross clamp with The Ross vs Homograft is different then that would have to count for something.

https://pubmed.ncbi.nlm.nih.gov/33491739/

Conclusions: Longer ACC time, although still within normal limits, was independently associated with decreased late survival after isolated aortic valve replacement in patients with severe aortic stenosis.​

If time on cross clamp is longer in "The Ross Reversal" (aka redo) then that would select against it even further IMO.

Again, these are questions that anyone who's contemplating this needs answered. I can't answer them because I'm not a surgeon.

Lastly I think that a good robust look and setting aside tribal sorts of positions (which aren't helpful) is needed.

 

[tommyboy14]

Here is one explanation from an experienced Ross surgeon:



And



https://consultqd.clevelandclinic.org/the-ross-procedure-in-a-reoperative-setting-a-case-study


They actually have a procedure for this, it's called the "Ross reversal".

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8689672/

So the Ross reversal article states:
During a median follow-up of 4.1 years (range, 7 months to 11 years), no patients required reoperation, 24 patients were free of pulmonary valve dysfunction, and 6 patients had clinically tolerated moderate or greater pulmonary valve regurgitation.

24 out of 30 success rate. and this is in a very small sample of patients. So 80% success at 4 years really isnt that great if you think about it.
The other interesting quote is:

it remains to be seen if our results can be replicated by others outside our institution, with recent published case reports demonstrating acceptance of the procedure

So yes you can have a Ross reversal, but given the science and knowledge today, it is totally unclear is that operations is a good idea relative to another pulmunary homograft on the RHS.

 

[pellicle]

morning

it remains to be seen if our results can be replicated by others outside our institution, with recent published case reports demonstrating acceptance of the procedure

well, as you know my view is that Surgeons With Opinions will slant their views of the evidence. Researchers with (hopefully only) the goal of understanding from an impartial position try to gather data. I've personally never seen a well constructed study comparing just Aortic Homograft and The Ross, but occasionally there are meta-analysis of studies. This one exemplifies my views on the matter

https://pubmed.ncbi.nlm.nih.gov/30084899/

Results: Thirteen observational studies and 2 randomized controlled trials (RCTs) were identified (n = 5346). No observational study was rated as having low risk of bias. The Ross procedure was associated with decreased late mortality in observational and RCT data [mean length of follow-up 2.6 years, relative risk (RR) 0.56, 95% confidence interval (CI) 0.38-0.84, I2 = 58%, very low quality]. The RCT estimate of effect was similar (mean length of follow-up 8.8 years, RR 0.33, 95% CI 0.11-0.96, I2 = 66%, very low quality). No difference was observed in mortality <30 days after surgery. All-site reintervention was similar between groups in cohorts and significantly reduced by the Ross procedure in RCTs (RR 1.41, 95% CI 0.89-2.24, I2 = 55%, very low quality and RR 0.41, 95% CI 0.22-0.78, I2 = 68%, high quality, respectively).

emphasis mine

Further few studies exist where they actually spend much time discussing The Ross vs the Aortic Homograft when that is in the title, instead they seem to include bio-prosthesis and mechanical and focus on them. Seems a bit 'bait and switch' to me (I guess the authors of that one felt the same).

So without actual quality studies I can only rely on the basic facts from which to make an assessment

1. the thing which does the least destructive stuff done the better (note: surgeons destroy stuff, that's what cutting does, the body in turn heals itself around the cutting, because that's what the body does.) A good design is when there is nothing left to remove, not when you can't add more stuff.
2. more damage = more scar tissue = harder and more problematic redos (but, meh, that's for someone else later)
3. all studies on The Ross seem to cherry pick, and you seldom (I've never found) a 99% complete 29 year follow up on The Ross that had a statistically valid number of patients
4. despite all this time The Ross wasn't ever really picked up and was flagging in popularity (until some company supplying needed harvested body parts from other humans came along). How can one be sure there is no ethical issue at work here?

So I remain of the conservative view (that just like the homograft) its falling out of favour (for valid reasons) and in my opinion (without evidence to the contrary) there must be "some other reason" why a small selection of surgeons love it.

Finally the OP is 34, and so (IIRC) no younger member here who has had "The Ross" has said it got me to 60 ... IIRC (and please do let me know @MdaPA) MdaPA had his Ross in 1997 (placing it 26 years ago). That's a great result but as its not statistically presented in the literature we can not discount that result being an outlier (perhaps facilited by genitic / lifestyle factors).

In my own institutions study, freedom for reoperation at 15 years for my own age group was 85%, making my 20 years without reoperation (probably quite) an outlier too.

Best Wishes

 

[MdaPA]

IIRC (and please do let me know @MdaPA) MdaPA had his Ross in 1997 (placing it 26 years ago).

My wife had a ROSS procedure, along with a MV commissurotomy (repair), in 1997. Her AV and PV's were then replaced in 2017 (so she got 20 years) but it was her failing MV that necessitated this surgery, not her AV or PV. The surgeon said "while I'm in there I might as well do an over-hall of all her valves" but that the AV and PV valves could have gone on longer. She choose ROSS versus mechanical because of child bearing reasons.

 

[pellicle]

Hi

My wife had a ROSS procedure

ahh, I checked your bio and it said:

Diagnosed with Aortic and Mitral valve stenosis and regurgitation as a teenager. Have had 3 open heart surgeries for valve repair and replacements:​

​

1997: ROSS procedure with MV commissurotomy (Dr. Paul Addonizio/Temple Univ Hosp)​

2000: MVR with pericardial bovine valve (Dr. Delos Cosgrove/Cleveland Clinic)​

2017: AVR and MVR with St. Jude (Master series) valves, PVR with porcine valve, and repair of TV (Dr. Gosta Pettersson/Cleveland Clinic)​

​

but I had a suspicion that you were the one who's posting on behalf of his wife (but don't totally trust my memory on most things and there was another possible candidate).

So given the above I would argue that for the OP being male who is:

"Age 34 with a bicuspid aorta valve that needs to be replaced."​

That a more durable solution would have advantages. Twenty years puts him up for reoperation at 54, which while not "risky" isn't as good a choice as

• mechanical and paying attention to ACT
• bioprosthesis (if you can't do the above) and a reoperation with just one valve replacement at that time

I would still argue that for childbearing (a valid avoidance of warfarin) a homograft would be a non-inferior (IMO superior) option. Of course that pre-supposes that you have a center of excellence for Aortic Homograft (or same for The Ross)

, along with a MV commissurotomy (repair), in 1997. Her AV and PV's were then replaced in 2017 (so she got 20 years)

a good duration IMO ... (and this sounds familiar, so thanks for reminding me)

but it was her failing MV that necessitated this surgery, not her AV or PV.

similar to my situation with my aneurysm driving my #3 OHS, seemed prudent to do it (and the AV wasn't in tip top shape anyway) rather than have another OHS in (say 3 or 4 years).

In my case the other valves were (by dint of not having a Ross done) operating fine (still are).

Thanks for the added data.

Best Wishes (and also to your lovely wife).

PS: I wonder why you keep capitalising all the letters when its not an acronym but named after a man called Donald Ross?

https://en.wikipedia.org/wiki/Ross_procedure

The procedure was first performed using the subcoronary method in 1967 by Donald Ross, for who the procedure is named for.​

Its my non-medical specialist opinion that we've moved on a long way since 1967 and that there exist better alternatives now.

 

[pellicle]

Oh and @MdaPA I just wanted to clarify two points

1
I'm not recommending anyone get a homograft, just as I feel about the Ross it has had its time and it is demonstrated to not be superior (statistically) in long term outcomes to the existing alternatives (bioprostheis and mechanical prosthesis).
Back when I have my valve done (1992), to the best of my understanding it was thought that the homograft may provide a more durable solution because it was living tissue. I don't know, but I conjecture that early emergence of evidence that it wasn't may have been attributed to 'preservation methods' (and eventually cryopreservation was the norm)

2
Decisions made in the past were exactly that; in the past. With information available to us in the past. Accordingly (to be clear) I am in no way intending to suggest that you or your wife did not make the best decision with all the information and advice available to you at the time.

My purpose in this discussion is to say that now things are different, the body of knowledge has increased and we have more data. I want the OP to read and understand the valve replacement landscape as it exists now, with the information we have now.

On that topic I'll mention that my institution basically no longer does homografts unless the patient requests it. Indeed the tissue bank for that hospital is decomissioned and to the best of my knowledge only one exists in Australia and its in New South Wales (the state immediately to the south of here).

Part of the "why" of this can be found in the costs of maintaining that tissue bank as well as the "barely better" than modern bioprosthesis and mechanical valves for the vast majority of AVR patients (which would be people over 60).

I'm pretty sure that statistically you'll find that TAVR is the new groundswell for AVR in that age group in the USA too.

Best Wishes

 

[MdaPA]

PS: I wonder why you keep capitalising all the letters when its not an acronym but named after a man called Donald Ross?

Not sure why I capitalize "ROSS"- bad habit I guess.

but I had a suspicion that you were the one who's posting on behalf of his wife (but don't totally trust my memory on most things and there was another possible candidate).

Yes, this is my account and I post to get and communicate information for my wife (no valve surgeries for me but may need some form of intervention in future for CAD if med's and diet don't pan out).

I would still argue that for childbearing (a valid avoidance of warfarin) a homograft would be a non-inferior (IMO superior) option.

Replacing the AV with a homograft instead of the PV autograft from the Ross was an option in 1997 but the expectation was that the PV autograft would last longer than a homograft in the AV position, and possibly a life-time.

a good duration IMO ... (and this sounds familiar, so thanks for reminding me)

The surgeon said if he left the PV autograft in the AV position at year 20 she would have gotten more milage out of it but since her MV was being replaced with a mechanical (i.e. the reason for the OHS), it just made sense to put in a mechanical in the AV position at that time as well.