Ross vs Mechanical

[MdaPA]

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)

This is the reasoning behind using the autograft PV in the AV position. It is living tissue, has living cells and can grow or reshape to it's new position. This is one of the "selling" points for the Ross.

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.

We would like to think we made the right decision but who knows. Would she had been better off if she went mechanical or with homografts?

Her issue was complex as both her AV and MV's needed intervention in 1997 and if IRRC, they were not allowed by the US FDA to use a homograft in the MV position back then (recall there was one surgeon that said he would do it anyway). If she had a good MV and just had the Ross procedure then she might still not have needed another OHS at this point (i.e. she could have been on year 27 with the Ross now).

The surgeon who did her Ross said that if her MV couldn't be repaired, then he would replace it along with the AV with mechanical valves and not do the Ross. But once he got in there, he did a quick repair of the MV valve and did the Ross procedure. The MV repair failed (actually the repair failure was noted in the ICU) but wasn't replaced until 3 years later in 2000.

Looking back at it now, skipping the Ross and going mechanical for both AV and MV would have made the most sense in 1997. This is my opinion however. It's my wife's feeling, and hers is the one that counts, is that she was free from anti-coagulation and the clicking noise for 20 years. It if was up to her, she would have a 4th OHS now and replace her St Jude MV and AV's with tissue valves so that she can come off the warfarin. She hates it. You all know, having to bridge, watch for interactions, contraindications, future medical procedures, higher risks for bleeding, etc.

The surgeon who did her MV replacement with a bovine valve in 2000 said to her, "If it was me having to decide between tissue or mechanical, I would rather have a mechanical problem than a medical problem" - meaning he would rather have a mechanical issue with a tissue valve that can he can deal with/fix in isolation than introduce other potential medical problems throughout the body as a result from being on lifetime anti-coagulation therapy with a mechanical valve (e.g. increase bleeding risk from surgeries/ falls/accidents, blood clots, diet restrictions/interactions, bridging for surgery/procedures, etc).

There is merit to this and each decision on a procedure and valve type needs to be individualized - YMMV.

 

[pellicle]

the PV autograft would last longer than a homograft in the AV position, and possibly a life-time.

This was exactly what they hoped for the homograft. As we now know it does not. Well, there were some older patients (based on the study) who passed away before the valve needed replacing, so for them it did.

 

[pellicle]

Hi

firstly I'd like to say that for your wifes situation (both physiologically and psychologically) I think that the best set of compromises were reached. And because (as I believe we agree) there being "no perfect solution" it is always a balance of factors in reaching that "best compromise" and those factors are what makes it an individual thing (more so than the physiological).

I'm hoping that in reading this discussion that any 3rd party (member in the waiting room or lurker) reaches some new understandings. I've had that happen in real life in the real waiting room with other present people in discussions I've had there.

it just made sense to put in a mechanical in the AV position at that time as well.

I would entirely agree

meaning he would rather have a mechanical issue with a tissue valve that can he can deal with/fix in isolation than introduce other potential medical problems throughout the body as a result from being on lifetime anti-coagulation therapy with a mechanical valve (e.g. increase bleeding risk from surgeries/ falls/accidents, blood clots, diet restrictions/interactions, bridging for surgery/procedures, etc).

I've seen surgeons make this case, I'm never sure if its "to put the person at ease" or if its because they fully genuinely believe it. The reality is that all things can be managed around with varying degrees of risk. Unless one is actually contra-indicated for warfarin (typically for bleeding related complications).

There is merit to this and each decision on a procedure and valve type needs to be

agreed ... and I hope that from our discussion and the various sides of this "moot" can assist others to see that and evaluate each side properly and (if possible without hate).

to use a homograft in the MV position

I personally never knew of the MV options for a mitral valve, but I found a recent evaluation of homograft in Australia and found that in the period from 2017 to 2022 that homograft was used in one MVR in Australia. No AVR's were reported in that study. No Ross either.

To my analytical view the stats of Ross vs Homograft appear to all intents and purposes "the same" ... that we have dropped the Homograft (and to all intents and purposes the Ross) in Australia suggests that medical opinion here is consistent with my expressed opinion over a decade here (that the Ross is part of history).

That CryoLife continues to promote the Ross in the Americas is interesting and to me raises a bunch of questions. Superman once stated that the difference between doing no harm and doing what is in the best interests of the patient was something worth considering. I would wonder what is going on with CryoLife and wonder if there isn't something less than ethical in their sourcing of the (totally actually) scarce resource of well harvested and well tissue evaluated human tissue. Strange that everywhere else seems to have found that trade off to not be worth it, yet they appear to be making a growth industry out of it.

Some readings of relevance
https://openheart.bmj.com/content/7/1/e001209

Surgical Complexity and Outcome of Patients Undergoing Re-do Aortic Valve Surgery​

Abstract​

Objectives Re-do aortic valve surgery carries a higher mortality and morbidity compared with first time aortic valve replacement (AVR) and often requires concomitant complex procedures. Transcatheter aortic valve replacement (TAVR) is an option for selective patients. The aim of this study is to present our experience with re-do aortic valve procedures and give an insight into the characteristics of these patients and their outcomes.
...
Conclusions A significant proportion of patients were young (61%<60 y), required complex aortic procedures (49%) or presented with contraindications for TAVR (mechanical valve, AR, IE, proximal aortic disease, need for concomitant surgery). Re-do aortic surgery remains the only treatment for such challenging cases and can be performed with acceptable mortality and morbidity in a specialised aortic centre.
... TAVR and V-in-V procedures are a very attractive alternative to conventional high-risk re-do aortic surgery, but the number of patients that would be eligible for such procedures is probably overestimated. Re-do aortic surgery currently remains the only realistic treatment option for such challenging cases.​

underline mine

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853167/

Transplantation of cryopreserved human heart valves in Europe: 30 years of banking in Brussels and future perspectives​

that has so much information in it on so many levels (and by extension applies equally to and raises questions about what CryoLife are doing with their human tissue).

Best Wishes

 

[Nesphito]

I’m 33 and going mechanical. Personally, I wouldn’t do a Ross unless I was 70. Arnold Schwarzenegger had a Ross at 50. It lasted 20 years and he’s had 2 more heart surgeries since then. I believe he now has a mechanical.

For me I was more worried about surgery than I was about taking warfarin.

 

[Chuck C]

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.

That sounds like a very reasonable decision. Left in place, it would have meant another future intevention. As she was getting mechanical for her MV and would be on ACT for that anyway, no reason to leave the tissue valve in place waiting for another future OHS to deal with SVD of her aortic valve.

 

[Chuck C]

Arnold Schwarzenegger had a Ross at 50. It lasted 20 years and he’s had 2 more heart surgeries since then.

Good point. This is considered a Ross success story. Ross at about age 50, then by about age 72 he has his third OHS, one to replace the pumonary and one to replace his aortic valve, due to SVD. He was promised TAVR for the next round for each, but ended up waking up both times with a big bandage on his chest to learn that they were unable to do TAVR or TPVR. So much for the promise of "next time we'll just go through your groin and no OHS". They intended to, but it does not always work out.

And, actually, if Arnold is telling his story correctly, he has had 4 OHS. After his Ross there was a problem and they had to open him back up within a few days. So, that was #2 and when he was about 70 he got OHS #3 and then #4 at about 72. This is one reason to choose a plan that involves as few procedures as possible. Planning for 1 often becomes 2, due to unexpected circumstances. Planning for 2 can easily become 3. In Arnold's case, planning for 3 has already led to 4 and he is still relatively young in the valve world. I think he may have gone tissue again, though I'm not sure. So, he may or may not be done with procedures, depending on how long he lives and other factors.

Along the lines of planning for 3 and ending up with 4, when you involve 2 valves, instead of leaving the healthy pulmonary valve alone, you are almost doubling the chances that something will not go as planned adding to +1 or +2 unplanned future procedures. By way of example, we have had members get the Ross then need reintervention on one of the two valves failing after only about 8 or 10 years, instead of the +/- 20 years that one hopes for with the Ross. And, then there are always the cases where something goes wrong, like with Arnold, and they need to go back in to fix one of the valves immediately.

In my view, it is a reasonable strategy to plan for as few procedures as possible.

 

[pellicle]

This is considered a Ross success story.

we've read about some of the failures here ... its not pretty.

Informed consent ... as long as you've properly been informed of both advantages and the disadvantages then its all up to the patient ¯\_(ツ)_/¯

to reiterate my view on this "go mainstream" not cult.

 

[Pixelgrowth]

we've read about some of the failures here ... its not pretty.

Informed consent ... as long as you've properly been informed of both advantages and the disadvantages then its all up to the patient ¯\_(ツ)_/¯

to reiterate my view on this "go mainstream" not cult.

I'm 26. I have a consultation with my surgeon on Tuesday. I'm going to ask about Ross. My cardiologist suggested a mechanical valve. But I have no prior heart problems, I have/had infective endocarditis and it's cause valve regurgitation of my aortic valve. And from my understanding that should make me a decent participant. Obviously being so young I would also like longevity.

 

[Chuck C]

I'm 26. I have a consultation with my surgeon on Tuesday

My cardiologist suggested a mechanical valve.

Your cardiologist is spot on, in terms of which valve is recommended for you, given your age.

Obviously being so young I would also like longevity.

The guidelines call for a mechanical valve for young folks, such as yourself, for this very reason, based on decades of evidence.

One caution I would give is that there are some financial interests which heavily promote the Ross. They will cite 14 year studies and claim that it is the valve that will give you the best long term survival. However, the multiple surgeries with Ross generally start coming into play after about 18 or 20 years. In my view, a person who is 26 years old should be looking 50 or 60 years ahead, and not just a 14 year study, which does not accurately reflect the long term risks posed by the Ross, due to creating two valves on the pathway for multiple repeat surgeries during the patient's lifetime.

The evidence based guidelines are very clear for someone your age, but, it is a personal choice, and you will need to do your own due diligence to determine which choice is best for you. Actually getting your procedure done when the time comes and not delaying is probably the most important aspect.

Wishing you all the best of luck in the choice before you and success in your journey.

 

[pellicle]

I'm going to ask about Ross.

seems reasonable, one does need to inform ones self.

Firstly I want to say that if you pick a mechanical, you must be prepared to be like a diabetic (except its about 28 times easier) test your blood to check your INR level and take your pills.

There is a LOT written here about the Ross, so rather than repeat it, I suggest you try this link
https://www.valvereplacement.org/threads/ross-vs-mechanical.889507/post-931542

which results in about 20 more replies

Then searching here as many people in your age group have said things like:

https://www.valvereplacement.org/th...-who-had-a-ross-procedure.888820/#post-920892

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

https://www.valvereplacement.org/th...edure-and-life-expectancy.887753/#post-900741

theres more ... so far everyone who's liked it has been one of:

• elderly
• psychologically bent against warfarin therapy
• female and wanting pregnancy (which is made complex by warfarin)
• still in the first 20 years since their surgery (and haven't yet faced the other issues)

Do not underplay the significance of doubling your valve disease and massively increasing future surgeries complexity and time on the cross clamp (which is an independent marker for mortality) on redos (yes, at your age plural).

Then maybe this essay
https://docs.google.com/document/d/1p3e74bFolm-Fj-GuFb0V9sJ8M9xDTHKsVNp6xbVojzM/edit?usp=sharing

Best Wishes

 

[tommyboy14]

On these survival claims, this is all based on observational studies. But only the healthiest and fittest patients are offered a Ross. These also tend to be patients thst have congenital heart disease, ie not due to lifestyle. to a degree, this patient selection aspect are why the ross results are so good.

if you try to find fit and healthy mech valve patients, their survival is actually the same as ross patients. A number of studies have shown that....

 

[Pixelgrowth]

On these survival claims, this is all based on observational studies. But only the healthiest and fittest patients are offered a Ross. These also tend to be patients thst have congenital heart disease, ie not due to lifestyle. to a degree, this patient selection aspect are why the ross results are so good.

if you try to find fit and healthy mech valve patients, their survival is actually the same as ross patients. A number of studies have shown that....

That is completely valid. I agree that for the most part mortality rate statistics are skewed. Most statistics really. At the same time though. I am fit and healthy. I'm active duty military and I'm quite active. The only reason I have valve regurgitation is from getting an infection in my hip joint, which led to endocarditis. I got it from physical therapy when they dry needled me. I think what seems so appealing is the lack of warfarin as well as a potential for not having another surgery ideally. But at the same time. Technology will be better in 20 years time. If surgery isn't fully robotic by then I will be mildly disappointed.

 

[pellicle]

Technology will be better in 20 years time

don't hold your breath, the focus is on TAVI and the elderly, not the less than 1% of the market which constitutes those under 50.

Just trying to be realistic, because looking at the last 20 years I'm not seeing any staggering change except the move towards Patient Self Testing with Point of Care machines.

All other stuff (not including ICU) remains about the same (yes, statistically I don't see any change in the longevity data for 20 year old bovine or porcine valves). One thing has changed, homograft has fallen out of favour (I had a homograft done when I was 28 and got 20 years out it, no buggadup pulmonary valve or additional time on the cross clamp needed).

 

[Teapotimus]

On these survival claims, this is all based on observational studies.

There is one Randomized trial on the Ross vs homografts though it's not free.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60828-8/abstract

I believe it's discussed in some detail in this video.



There will likely be much more Ross related material and innovation in the coming years as well. Dr Hamamsy was recently named president of the heart valve society. There was also a recent publication looking at a series of Ross patients in their third postoperative decade, impressive reoperation numbers compared to previous series.

https://www.mountsinai.org/about/ne...hd-named-president-of-the-heart-valve-society

 

[pellicle]

@Pixelgrowth

some thoughts

There is one Randomized trial on the Ross vs homografts though it's not free.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60828-8/abstract

its interesting ... from that:

Male and female patients (<69 years) requiring aortic valve surgery were randomly assigned in a one-to-one ratio to receive an autograft or a homograft aortic root replacement in one centre in the UK. ​

...​

Actuarial survival at 10 years was 97% (SD 2) in the autograft group versus 83% (4) in the homograft group. Hazard ratio for death in the homograft group was 4·61 (95% CI 1·71–16·03; p=0·0060). Survival of patients in the autograft group was similar to that in an age-matched and ***-matched British population (96%).​

wow ... so:

• need to know average age and standard deviation of that age
• one-to-one ratio of randomly assigned ... right ... so how did consent work there? Seems strange
• actuarial survival at 10 years of the autograft group was 97% (and similar to the age and *** matched general population) but yet somehow the homograft group was 83% that's very interesting.
• as a less than 30 year old I'd really want to see that data set for 20 year (funny we never get that) and also want to see the data set for reoperation (rather than assuming that the surgery is an end point (which wouldn't be correct unless you died, and you wouldn't expect that at under 30)

another "publication" of that study is here
https://pubmed.ncbi.nlm.nih.gov/20684981/

with slightly different data

I note this study
https://www.ahajournals.org/doi/full/10.1161/circ.100.suppl_2.Ii-42

Homograft valves offer many advantages; however, there is concern about their use in second aortic valve replacement because of the complexity of the procedure and the possibility of accelerated degeneration.​

so here they are studying homograft as a redo and still got

The actuarial survival rate was 93% and 82% at 5 and 10 years, respectively. Freedom from tissue degeneration was 96% and 80% at 5 and 10 years, respectively, and freedom from reoperation was 97% and 82% at 5 and 10 years, respectively.​

to be clear I am not advocating you go homograft as while that's what I had done back in 1992 at 28 years of age, its not what I'd recommend now.

 

[Teapotimus]

I didn't realize this earlier but I believe this recent publication is the third decade followup of the Ross portion of that randomized clinical trial.

Median follow up of 24.1 years, median age of 38 at time of operation, and 71.1% free of reoperation at 25 years. Seeing as these operations took place primarily in the 90's I wonder what the newer iterations/refinements of the Ross procedure will look like in another decade.

https://jamanetwork.com/journals/jamacardiology/article-abstract/2811496?resultClick=1

 

[Pixelgrowth]

I didn't realize this earlier but I believe this recent publication is the third decade followup of the Ross portion of that randomized clinical trial.

Median follow up of 24.1 years, median age of 38 at time of operation, and 71.1% free of reoperation at 25 years. Seeing as these operations took place primarily in the 90's I wonder what the newer iterations/refinements of the Ross procedure will look like in another decade.

https://jamanetwork.com/journals/jamacardiology/article-abstract/2811496?resultClick=1

The new studies look promising. There's definitely a chance for reop. But at the same time you don't have to take warfarin. Like I said before. I plan to talk to my surgeon about it. I don't think he can actually do the Ross. I believe Duke hospital is the closest to me for it. But he should be able to tell me at least his advice and whether or not I'd even be a candidate.

 

[pellicle]

I didn't realize this earlier but I believe this recent publication is the third decade followup of the Ross portion of that randomized clinical trial.

Median follow up of 24.1 years, median age of 38 at time of operation, and 71.1% free of reoperation at 25 years. Seeing as these operations took place primarily in the 90's I wonder what the newer iterations/refinements of the Ross procedure will look like in another decade.

https://jamanetwork.com/journals/jamacardiology/article-abstract/2811496?resultClick=1

Impressive

 

[Buck83]

My surgeon is a big proponent of the On-X, especially in younger patients. Warfarin is not the end of the world. You just have to be mindful. I talked to him about the Ross and he was against it because of me being so active. He said the aortic valve is the valve that handles the most pressure in the heart and it gets replaced with a valve that is used to significantly less pressure. Not to mention what everyone else has already said about reoperation.

 

[Timmay]

This is considered a Ross success story. .

I’ll be a bit more up front about it.

Schwarzenegger’s story is one of failure. pure and simple. The dude has had at least 3 open heart surgeries when he only needed one. If he would have just gotten a mechanical during his first surgery then he would have been done with it. But nope. He went Ross … thereby creating a situation that absolutely guaranteed additional surgeries. He turned his one valve problem into a future two valve problem. I doubt that I will ever understand why people do this. If you’re contraindicated for Warfarin - sure. If you’re a woman and you’re dedicated to having children - sure. But other than that, you’re creating a failure story by ensuring that you will need at least two more valve replacements … at least.