Severe Aortic Regurgitation Leading to Second Surgery

[Superman]

OnX was developed by the same guys that designed st jude, so, if anything , OnX is a better St Jude
DUE TO the fact that:

OnX is the only mech valve that the leafs open 90 degrees,,,, and from there is the fact that it is
a better st jude,

the inr range, is not the issue, both work well at 2.0

That’s the claim. Seems adverse outcomes would be the true measure. Is there any comparative study on the various mechanical valves showing that any of them (assuming a well managed INR) has higher incidence of negative outcomes or improved physical performance by patients after installation?

I get that On-X couldn’t come into the market and say, “We’re just as good as the established product, give us a try!” So they have to create ways that they’re “better”. But are they? I’m not saying they’re worse. I just haven’t seen anything that says a persons post operative experience will be different in any meaningful way.

 

[nobog]

OnX was developed by the same guys that designed st jude, so, if anything , OnX is a better St Jude
DUE TO the fact that:

OnX is the only mech valve that the leafs open 90 degrees,,,, and from there is the fact that it is
a better st jude,

First of all, the OnX does not open to 90 deg. in-vivo, even if it did that does not make it better. The SJM valve opens to 84 degrees and if they wanted to they could make it open to 90 deg - and in-vivo it would open that far, but with a larger opening angle comes increased backflow (the leaflets arc farther) thus there is really no benefit. BTY, the OnX leaflets will flutter, the SJM's don't - so take your pick.

 

[skier]

My surgeon said the surgery could not have gone better today. I ended up with St. Jude mechanical. Already up in the chair and eating dinner. Thanks so much for all the well wishes!

 

[Chuck C]

My surgeon said the surgery could not have gone better today. I ended up with St. Jude mechanical. Already up in the chair and eating dinner. Thanks so much for all the well wishes!

Great news! Use the spirometer often and get plenty of walking in during your recovery- even in the hospital. They will give you a schedule as to how often they want you to use the spirometer- I'd suggest sticking to it like clockwork. They will help you walk from time to time, but if you feel up to it, I'd suggest asking if you can do more. As long as you feel comfortable doing so, the more you can move the better.

 

[Chuck C]

they could make it open to 90 deg - and in-vivo it would open that far, but with a larger opening angle comes increased backflow

Does the backflow increase significantly with increased heart rate? And if so, could that impede athletic performance at high HR? My athletic performance seems to be pretty close to what it was prior to surgery. However, occasionally, my HR exceeds 150+ in training and I believe that at these times my performance may be lower than it was prior to surgery. I can't say for certain, as it might just by my conditioning.

 

[Brinntache]

I guess nobody studies/evaluates these things in high-performance situations. They only take measurements on people who are lying down on a table.
The results of such a study would have altered my choice, knowing that valve A performs 10% better than valve B when hiking/riding/running.

 

[Superman]

The results of such a study would have altered my choice, knowing that valve A performs 10% better than valve B when hiking/riding/running.

Put a little turbo charger on one of them! “St. Jude. Now with extra blood flow!”

 

[nobog]

Does the backflow increase significantly with increased heart rate? And if so, could that impede athletic performance at high HR? My athletic performance seems to be pretty close to what it was prior to surgery. However, occasionally, my HR exceeds 150+ in training and I believe that at these times my performance may be lower than it was prior to surgery. I can't say for certain, as it might just by my conditioning.

First some terminology - regurgitation is the sum of leakage + backflow. All mechanical valves leak and that is pressure dependent, i.e. there is more leakage at 150mmHg vs 100mmHg. Backflow (leaflets closing) stays about constant. A 31mm valve has much more backflow than a 19mm valve. Backflow is somewhere around 30-40 ms. The tricky part is to put that into understandable terms. So it really depends on cardiac output (which could be 2 lpm to 8 lpm).

So... backflow is measured as a percentage of the total flow - this can be all over the place (same volume of backflow but different cardiac output).

Summary - mechanical:
backflow is design/valve size dependent
leakage (valve closed) is pressure dependent

As for tissue valves:
A properly functioning tissue valve will have minimal to no leakage
backflow (size for size) is typically less than a mechanical valves - think of a camera shutter

You have no control over any of this.

 

[skier]

I seem to be doing fantastic 24 hours after my surgery. I got up for a pretty long walk and it felt great!

They said I've been cleared to leave the cardiac ICU for the step down floor. Hopefully they won't have a room and I'll get another night here.

Biggest problem is nausea from the Dilaudid. Zofran is helping but not enough if I max out the Dilaudid which I really need to do to push on the incentive spirometer.

 

[Chuck C]

They said I've been cleared to leave the cardiac ICU for the step down floor.

Nice! The step down floor is where the party really gets going. Kind of like staying in a hotel with room service

 

[AZATADINE]

Getting closer to getting the catheter removed and the chest drains removed when you go to the step down ward.

 

[pellicle]

@jlcsn2015

First of all, the OnX does not open to 90 deg. in-vivo, even if it did that does not make it better. The SJM valve opens to 84 degrees and if they wanted to they could make it open to 90 deg - and in-

some data to back this up
https://www.valvereplacement.org/threads/aortic-valve-choices.887840/page-2#post-902334
make sure you are actually informed not just "boned up with the glossy brochure produced by the sales team"

Better to find this out before it goes in

Best Wishes

 

[pellicle]

think of a camera shutter

I'm quite sure that the differences between an in lens leaf shutter and a focal plane shutter curtain will be lost on most people ... so with that in mind (I use both)
Leaf shutter will at higher speeds give vignetting (darkening) on the outer parts of the film because of how it operates:

focal plane shutter will give movement artifacts as it moves a slit across the film plane at higher speeds

both produce different "issues" at higher speed (so neither is perfect) and the photographer should know about this (or face confusing issues)

https://www.analog.cafe/r/focal-plane-shutter-vs-leaf-shutter-za9i
enjoy

 

[BillDaThrill]

I seem to be doing fantastic 24 hours after my surgery. I got up for a pretty long walk and it felt great!

Skier - great to hear you are doing so well with your shiny new mechanical valve. And excellent timing getting the most outta the ski season until surgery. I had my surgery this time last year, and I was skinning up the mountain in early winter. You'll be on first chair in '22! Keep us posted on your recovery!

 

[d333gs]

I seem to be doing fantastic 24 hours after my surgery. I got up for a pretty long walk and it felt great!

They said I've been cleared to leave the cardiac ICU for the step down floor. Hopefully they won't have a room and I'll get another night here.

Biggest problem is nausea from the Dilaudid. Zofran is helping but not enough if I max out the Dilaudid which I really need to do to push on the incentive spirometer.

I've only had one AVR but 24hrs seems pretty quick....doesn't it ?

 

[Woodcutter]

I guess nobody studies/evaluates these things in high-performance situations. They only take measurements on people who are lying down on a table.
The results of such a study would have altered my choice, knowing that valve A performs 10% better than valve B when hiking/riding/running.

My experience is with the mitral valve. There are some major differences between the valve positions that are less frequently discussed. For simplicity, I like to think of the mitral valve as the pump inlet and the aortic as the pump outlet. In my case I first had a leaky mitral valve repaired. As a pretty active runner, I found this made it "effectively stenotic" during exertion (hence a few months later I had a redo, the ring was removed and replaced with a mechanical valve). The natural/normal mitral valve tends to have an area of 4-6 cm^2. The effective area of (any) replacement valve tends to be meaningfully less. Replacement valves are round and the mitral position is anything but. More significant (in my estimation) however, is the natural pumping action which physically opens (enlarges) the pump inlet. It is not just leaflets moving but the size of the valve changes. Current technology simply does not replicate this phenomena. Replacement valves are contained within a rigid ring.

If the mitral valve is too small (generally considered 1.0 cm^2), pressure is higher in the atrium and this will 'back up' to the lungs. Pulmonary Hypertension. In my case, all was fine during normal operation but if I exerted myself I could feel the pressure in my chest. I was strong enough aerobically that when I would attempt to push through, I'd be coughing up blood.

All they could do to test this activity phenomena was put me on a treadmill right next to ultrasound equipment. I ran until my heart rhythm concerned the tech and they had me quickly lie down for an echo. As expected (by the cardiologist and surgeon) this showed extremely high pressure drops across the repair and they quickly decided I needed to have a mechanical valve (instead of what I like to call the o-ring . . . annuloplasty ring used for a valve repair to 'tighten things up').

So that is my take on why there's not an abundance of data during high cardiac demand/output. The body wants/needs flow. Valve area is a very critical parameter but in the natural valve it is variable. Then current technology is to use ultrasound to measure velocities and then back-calculate an effective area or diameter of something that is not round. Perhaps an infinitely small flowmeter would do the trick!

 

[AZATADINE]

I've only had one AVR but 24hrs seems pretty quick....doesn't it ?

Thought that myself. I was in ICU for 24 hrs and I don't remember much about that really. After that, I was in step down but I wasn't sitting in a chair the same day or even the following day post op. Think it might have been the third day post op in my case. Soon after that, the dreaded chest drains came out....

 

[skier]

I'm doing fantastic, thankfully!

Quick summary:
Wed: Surgery day, extubated and woke up reasonably lucid in the ER, sat up in the chair for a couple of hours.
Thurs: Spent most of the day in the chair, long walk, swans catheter removed.
Friday: 2 of 4 chest tubes removed, pacer wires removed, foley catheter removed, BM (finally, with some help).
Saturday (today): Last two chest tubes were removed. Xray looks good. Nothing hooked up to IV lines. I'm still on 1 liter of oxygen.

The final thing is getting my anti coag right before I can go home. I started Coumiden yesterday. INR was 1.1 this morning. It might take a couple of days.

 

[skier]

A few details from my chart about my operation.
Operation: 1. Redo Sternotomy 2. Aortic Valve Replacement 25mm St Jude Regent Aortic valve
Aortic Cross Clamp Time:72"
Cardiopulmonary Bypass Time: 54"
Findings: bicuspid repair failure, sievers type 1, failure of the plication stitch on fused leaflet causing prolapse
Complications: none

 

[skier]

INR was 1.2 this morning.

Yesterday was 1.1. The docs increased my warfarin to 7.5 mg today, up from 5 mg the last two days.

Any reason I shouldn't push to go home tomorrow, promising to go to the clinic every day to get tested until I get into the therapeutic range. It sounds like that might be an option.