Severe Aortic Regurgitation Leading to Second Surgery

[Wiles Darkwinter]

Weighing in here.

There is evidence to suggest that sparing your native aortic valve is better if possible

https://www.sciencedirect.com/science/article/pii/S0022522306006908
My surgeon managed to spare my valve along with inserting a Dacron aortic root. Said it was the best possible outcome given my age (30) and lifestyle

 

[pellicle]

...

My surgeon managed to spare my valve along with inserting a Dacron aortic root. Said it was the best possible outcome given my age (30) and lifestyle

I think that the biggest issue here is that I have somehow mistaken the situation (for whatever reason) as being that @skier still has his native valve. Somehow I got the impression he had a bioprosthesis which had failed. I could trawl through the posts to work out how, but its not important and probably my mistake.

PS: Wiles, was your native valve fine or did it need repair.

I noted this study and interestingly Dr Lars Svensson came up ... IIRC he's also an advocate of the Ross.

https://consultqd.clevelandclinic.o...ility-demonstrated-in-largest-series-to-date/
https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC4682686/

Although there are limitations and complications of prosthetic valves, especially for younger individuals, there is ample published literature that confers strong evidence for AVR. On the contrary, aortic valve repair may be a useful option for selected patients, but there is lack of uniformity in data and absence of compelling supporting evidence.​

 

[Wiles Darkwinter]

I think that the biggest issue here is that I have somehow mistaken the situation (for whatever reason) as being that @skier still has his native valve. Somehow I got the impression he had a bioprosthesis which had failed. I could trawl through the posts to work out how, but its not important and probably my mistake.

PS: Wiles, was your native valve fine or did it need repair.

I noted this study and interestingly Dr Lars Svensson came up ... IIRC he's also an advocate of the Ross.

https://consultqd.clevelandclinic.o...ility-demonstrated-in-largest-series-to-date/
https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC4682686/

Although there are limitations and complications of prosthetic valves, especially for younger individuals, there is ample published literature that confers strong evidence for AVR. On the contrary, aortic valve repair may be a useful option for selected patients, but there is lack of uniformity in data and absence of compelling supporting evidence.​

Yeah fair one, that systematic review is a beast of a study and definitely shows that the evidence for AVR is not questionable. I suppose it’s not always a question of one or the other when thinking about AVR or a repair before the surgery - as, in a perfect world, we would all want our perfectly working native valves.

My surgeon explained that there are clear indications (once they get in there and have a look) which will make it obvious whether a repair is doable. As it says in the conclusion of that study, it may be favourable for SOME patients - I think I was lucky in that my specific pathophysiology made me an ideal candidate for my valve to be saved and re-implanted into Dacron tube. I’ve read that the enlarging of your aortic root can often cause valve failure, and sadly most people don’t notice their aneurysms until the damage to the valve is done. And then you have all the other patient profiles - bicuspid, connective tissue disorders etc. To this end, it’s hard to compare (shoulda, coulda, woulda - for the Aussies) before hand. There is nuance to every case.

My valve was working well, tri-leaflet; but my aortic root aneurysm was the problem. They were surprised to find my valve only having trivial regurgitation, which meant the repair was on.

Maybe this bicuspid valve in question is repairable? Maybe not? Tough one and I don’t know if I have any advice about what option to take, but from my experience there was resounding positivity when he found he could save the valve.

 

[Wiles Darkwinter]

Also I realise there is probably some terminology variance here which often trips people up.
AVR - different to Valve-Sparing also different to valve Repair.

 

[pellicle]

y surgeon explained that there are clear indications (once they get in there and have a look) which will make it obvious whether a repair is doable.

I have heard that from others here and from my own surgeons, although I was only a candidate for repair once when I was around ten. Since the it's been replacement (as I guess you are familiar with) a cryopreserved homograft and then a mechanical (both about 20 years apart) and an aneurysm repair.

Best Wishes

 

[Unicusp]

Weighing in here.

There is evidence to suggest that sparing your native aortic valve is better if possible

https://www.sciencedirect.com/science/article/pii/S0022522306006908
My surgeon managed to spare my valve along with inserting a Dacron aortic root. Said it was the best possible outcome given my age (30) and lifestyle

Similar experience. Ascending aorta replaced with Dacron tube. Unicuspid native valve fixed / cleaned up as best as possible and "spared". Lasted 7.5 years. Then severely stenotic and calcified.
Back in for a replacement OnX valve. Redo surgery regardless of your condition doubles your risk of death each time. One would want to minimize the frequency of such traumatic surgery. Those are my words of wisdom for today.

 

[Unicusp]

I noted this study and interestingly Dr Lars Svensson came up ... IIRC he's also an advocate of the Ross.

Quick comment on this. I did not go in and read the attached so do not know the dates or how old. All I know is that I spoke with Lars about his thoughts on the Ross procedure last year. He is not a fan nor advocate and does not do the procedure.
This may be another sensitive topic where he will not criticize his colleagues publicly who perform the procedure.

 

[RPG]

Happy New Year (a bit late)! I've been ignoring cardiac things until I finished my last test today.

Thanks so much for the thoughtful responses. @Chuck C, I really appreciate your similar experience and that on-point paper I hadn't seen. Thanks!

Good news from my tests, I think. At least better than I expected.

CT Coronary
1. No coronary artery plaque or stenosis.
2. Calcium score of 0; placing this patient at the 0th percentile for age, gender and ethnicity.
3. Normal left ventricular wall motion with preserved ejection fraction.
4. Cardiac chambers: Normal sized cardiac chambers. No evidence of LVH
--------------------------------------------------------------------------------------------------------

Echocardiogram: Transesophageal (TEE)
Mildly dilated left ventricle with normal systolic function, 3D LVEF 67%.

Normal right ventricular size and systolic function.

Moderate-to-severe aortic regurgitation across the entire coaptation plane of the bicuspid
aortic valve and culminates in an eccentric jet towards the anterior leaflet of the mitral
valve. Eccentric nature of AR jet limits accuracy of pressure half time and several
quantitative metrics. Likely diastolic flow reversal in the descending thoracic aorta
although alignment was difficult.

Otherwise normal valvular structures and function

Unable to estimate pulmonary artery systolic pressure due to insufficient tricuspid
regurgitation.

No pericardial effusion.

Ascending aortic graft limits assessment of proximal ascending aorta. Aortic root measures
3.7cm at the level of the sinus of Valsalva.

No significant change noted in comparison to transthoracic study dated 7/27/2021.
--------------------------------------------------------------------------------------------------------

I'm meeting with my cardiologist tomorrow to discuss. No appointment scheduled with my surgeon yet.

I'm guessing that I'm not yet a candidate for surgery yet, based on moderate-to-severe aortic regurgitation, normal left ventricle size, and no progression over five months. Does anyone see it differently?

We'll see about ongoing activity restrictions. No skiing is rough for me. It's been snowing here a bunch.

I had severe aortic regurgitation and my cardio and surgeon recommended surgery ASAP. I was also asymptomatic, but my EF was down around 15-20% and my LV was severely dilated. Wall thickness was good. The docs were very, very surprised that I was still asymptomatic given my EF. I'm relatively young (36) and otherwise healthy. I was going to need a replacement regardless, so they suggested doing the surgery now--while I'm feeling good--rather than waiting for things to go south.

Went under the knife in December 2021. I'm about 6 weeks out now and feeling pretty good. Hope all goes well, Skier.

 

[AZATADINE]

I could be wrong but I have the impression that repairs buy a bit of time but I don't get the impression that it buys more than a few years at most. Again, it's just an impression that I have from browsing forums rather than fact of course.

From a personal point of view, if I was to undergo OHS, given my experience of it having gone through it now, I'd be opting for either tissue or mechanical rather than take the risk of a repair which might/might not not buy much time.

 

[Chuck C]

I had severe aortic regurgitation and my cardio and surgeon recommended surgery ASAP. I was also asymptomatic, but my EF was down around 15-20% and my LV was severely dilated. Wall thickness was good. The docs were very, very surprised that I was still asymptomatic given my EF. I'm relatively young (36) and otherwise healthy. I was going to need a replacement regardless, so they suggested doing the surgery now--while I'm feeling good--rather than waiting for things to go south.

Went under the knife in December 2021. I'm about 6 weeks out now and feeling pretty good. Hope all goes well, Skier.

Welcome to the forum RPG.

Thanks for sharing your experience. A 15-20% EF is about the lowest I've heard of. Glad things went well for you and that you're feeling good at just 6 weeks out. It will be interesting to see how quickly your EF bounces back. I would expect that youth would be in your favor in this regard. Please keep us posted.

 

[pellicle]

Hey
Welcome aboard

Went under the knife in December 2021. I'm about 6 weeks out now and feeling pretty good.

I hope you continue to have a reasonable recovery

Best Wishes

 

[skier]

Is sternal healing after a second open heart surgery worse or takes longer than after a first surgery?

For the category of man makes plans, and God laughs: I'm thinking about scheduling my surgery at the end of ski season but allowing enough time for me to heal enough for a family beach vacation before the kiddos go back to school in August.

 

[pellicle]

Is sternal healing after a second open heart surgery worse or takes longer than after a first surgery?

seemed about the same to me.

the issues of which I speak are typically nothing which you the patient notice, but are things which

• impede the surgeon and block access (scar tissue for instance makes reoperation much harder and requires more pre-surgical imaging) {note: few people have done what was once ordinary (and still is in places) such as skinning and "dressing" an animal for cooking and eating. People who have will likely have encountered scar tissue in an injured animal and it makes (for instance) separating tissues from each other. Why does this matter? Well "oops" nicked the AV node, well, the electrocardiologist will put you on a pacemaker post surgery anyway}
• increased time on the "pump" and quite likely increases in recovery time for mental processing
• greater risks of infections (not least due to increased surgical times)
• injuries to places like shoulders and rib cartilage (you can search here for that) which makes post surgical life difficult (my shoulder is still iffy and I know of another two people who are going through "Frozen Shoulder")

Surgeons typically only care about the exact specifics of their work (the valve and the surgical site).

 

[slipkid]

Welcome to the forum RPG.

Thanks for sharing your experience. A 15-20% EF is about the lowest I've heard of. ....

I was interpreting his comment of "my EF was down around 15-20%" to mean that it was 15-20% LOWER than what the value should be or was for him (say for example his EF was 70%, then 20% of 70 is a drop of 14 points which would take him down to say EF value of 56% which wouldn't really have any noticeable symptoms) OR more likely NOT interpreting the "%" part of the comment as a percentage dropoff of his normal baseline and instead just applying a 20 point drop of his ejection fraction (which semantically is expressed as a % of how much blood is flowing out vs in rather than in relation to a previous measurement thus causing me to interpret it 2 diff ways) to be 70-20 giving him an ejection fraction measured as about 50% (also good enough to be asymptomatic).

I believe that if someone's EF is 35% or below you would be in heart failure territory and out of breath severely on exercise. Mine was supposedly only 33% when I collapsed with a heart attack (coronary artery disease starving the heart muscle, plus bad aortic inefficient bicuspid valve on top of that). At 15-20% I don't even know if you could live like that, so many things would be going wrong. But I am NOT a Dr so take this with a grain of salt obviously.

 

[Eva]

I've probably said this up here b4, and I say it all the time to people dealing with some type of medical illness/situation, which is "if you blindly listen to your Dr then you are a fool". Sometimes you don't have that option, in an emergency situation or whatever but if you do...

...then it pays to be somewhat educated and ask intelligent questions. I have caught numerous mistakes by Drs in the past only by my asking questions. The #1 thing I have learned from those exercises is that the competence of the Dr is inversely proportional to how mad and disrespectful they behave towards you because you simply dared to ask questions and wanted to understand what the options were or brought something to their attention which they either were wrong about or flat out just did not know themselves but acted like they did. I could write a book about my mindblowing experiences over the years.

I can’t understand how such doctors don’t realize that we are their employers…they are not our bosses nor entitled to intimidate the patient. Many of us are very alert about what’s happening with our bodies more than they do! One endocrinologist (complementing me) told me that doctors are taught to be cautious around smart patients! But I had seen some who het get upset!

 

[Chuck C]

At 15-20% I don't even know if you could live like that, so many things would be going wrong.

I agree this would be extremely low. Perhaps he will clarify the context of the 15-20%, whether the EF value, or drop from baseline. If EF was truly 15-20%, I would think that a person would be fainting (syncope) constantly.

 

[Chuck C]

I was interpreting his comment of "my EF was down around 15-20%" to mean that it was 15-20% LOWER than what the value should be or was for him (say for example his EF was 70%, then 20% of 70 is a drop of 14 points which would take him down to say EF value of 56% which wouldn't really have any noticeable symptoms) OR more likely NOT interpreting the "%" part of the comment as a percentage dropoff of his normal baseline and instead just applying a 20 point drop of his ejection fraction (which semantically is expressed as a % of how much blood is flowing out vs in rather than in relation to a previous measurement thus causing me to interpret it 2 diff ways) to be 70-20 giving him an ejection fraction measured as about 50% (also good enough to be asymptomatic).

I believe that if someone's EF is 35% or below you would be in heart failure territory and out of breath severely on exercise. Mine was supposedly only 33% when I collapsed with a heart attack (coronary artery disease starving the heart muscle, plus bad aortic inefficient bicuspid valve on top of that). At 15-20% I don't even know if you could live like that, so many things would be going wrong. But I am NOT a Dr so take this with a grain of salt obviously.

How's the Covid recovery coming along?

 

[pellicle]

But I am NOT a Dr so take this with a grain of salt obviously.

 

[pellicle]

Yes, @slipkid

How's the Covid recovery coming along?

I hope its not only on the wane, but that you don't become a long covid sufferer.

 

[Unicusp]

Yes, @slipkid

I hope its not only on the wane, but that you don't become a long covid sufferer.

I'm starting to wonder if I'm in that category now. Significantly more fatigue since getting over Covid last early October. Need more sleep now than before.
How are you feeling @slipkid ?