Success Rate for 2nd OH Surgery for Older Patients?

[Mike1952]

Hi all,

I visited my surgeon on Tuesday the 17th to discuss replacing my leaking aortic valve. Because I take virtually no drugs at all (just aspirin), he suggested a Bovine tissue valve. I am sixty and will likely have to have it replaced as my family tends to live til the late 80s or even 90s. He said the success rate for a second OH surgery was very good, even for patients in their mid seventies. Does anyone have any information about this? As a surgeon, he did not see a problem with a second OH surgery, even at that age, especially if I continue a healthy lifestyle. Does anyone have any experience or thoughts on this? Surgery scheduled for August 10th! Just want to "Get er Done"!!!

Mike

 

[dick0236]

I have a neighbor who had a tissue valve implanted, first surgery, 3-4 years ago, when he was in his mid-70s, and he seems to be doing well. When my mechanical was implanted, they told me it would last 50 years. I didn't think much about that until recently. If that is true, I will need a replacement in about 5 years, when I am 81, or so. I sure hope not. It is not the valve re-op that would bother me, as docs have always told me....."the heart is just a big muscle and is easy to work on". I have more than a few family members, friends and neighbors, who have had various major surgeries, later in life, and have had trouble with recovery and returning to a good quality of life. Right now, I think I could handle a re-op well, since I have no other problems and am in good physical shape, but I ain't sure. Should I need another surgery in a few years, I will choose a tissue valve(if possible) to stay off warfan as an "old" person....and I doubt I would outlive it. You are very much in the "gray area". Make the best informed decision you can and, as you said, "git er dun".

 

[ElectLive]

If he hasn't already expanded on it, I'd certainly ask your surgeon to better define "very good" relative to not only mortality rate, but probably more importantly the complication rates and recovery process, as Dick pointed out. I have seen documented mortality stats from the Cleveland Clinic in the 70 and up age groups which you will find here: http://www.ccjm.org/content/75/11/802/T1.expansion.html. For reoperative AVR above the age of 70, the mortality rate was 2.9%. Then, above the age of 80, it was 5.6%. In comparison, primary (first surgery) AVR was 1.6% and 1.4% in the same respective age groups. Now, the disclaimer is this did not include those with coronary artery disease which is certainly a big IF at that age. These are also from the #1 rated center in the US, of course, so bear that in mind...

There is a national database that pre-surgery characteristics can be plugged into to evaluate different areas of risk (mortality, stroke, length of hospital stay, etc). It is a tool meant for professionals and not for patients, though, because the accuracy depends on a thorough understanding of the patient's condition. I wouldn't dare suggest anyone use it to try and predict future risk, but as a reference, with basic baseline characteristics, the previous surgery "toggle" has some impact on risk, but not a dramatic effect.

So, in theory, your surgeon is probably right. The "catch" with his argument, though, is that you will otherwise be the same healthy patient you are now. Risks could change dramatically with other conditions in play. But, to that point, there is also hope that the recently approved transcatheter valve replacement route will make this less of an issue in the future. As it currently stands, though, this method is basically just a tradeoff of different risk types, not necessarily a net benefit. In 10 to 15 years, though, well, certainly improvement would be expected, but how much...that's the million dollar question. It's a tough decision...it's a tough decision.

 

[Mike1952]

Thanks for two excellent responses. I'll look at the link you provided. I'll probably really know whether I would want to do it again in 15 years after I do it on Aug 10th!! Hopefully, it is like child birth, Mothers seems to forget all they went through in child birth! Right now, I am still leaning towards the tissue valve, I think. But, the doc said I could change my mind right up to the moment I go under!

 

[epstns]

Mike - There is also some statistical chance that you may not need another valve replacement, even after more than 15 years. Don't forget that the older the patient at time of implant, the slower a tissue valve tends to calcify. I had my tissue valve implanted at age 63, and based upon the projected lifespan of the particular valve I have, I may not need another. The current (third, I think) generation of tissue valves is targeted to have a lifespan of 20 years or more, but they are too new to know if these projections will hold true. I wouldn't bet the farm on it, but I was willing to bet that if I need a re-do, I will be able to tolerate it well.

 

[neil]

agree with steve, my cardio and surgeon both told me 2nd ops carry no more risks or very little compared to 1st op, of course if you are say 55 when you have the first and 75 when you have the second its gonna take a bit more out of you,

 

[Gail in Ca]

I feel that if you are a healthy person, and keep up on exercise as you age,and you have good long life genes, then you could do just fine with a redo in your late 70's. I have been pretty healthy, but have been pretty sick before my last 2 surgeries, due to nurse induced CHF with the 2nd, and bacterial endocarditis with the 3rd. However, I think because I have always been a healthy person, not overweight or having any other issues but aneurysm/valve replacements, I have come thru fine.
At 54, my surgeon felt I was on the cusp for the mechanical/tissue debate. But, since another surgery in my 60's/70's would've been my 4th, he felt mechanical was the way to go for me.
There is also the issue of scar tissue, which is really what makes the redos so risky!

 

[OldManEmu]

There isn't a significantly increased risk with surgery until you have had more than 3 surgeries, if there are no other co-morbidities such as kidney disease, obesity, lung disease, diabetes or you are a smoker. The increased risk of surgery is only small between 60 and 70 years compared to under 60.

 

[dtread]

Mike, there are a lot of variables in the valve choice/reoperation equation. I'm an exercise enthusiast and cyclist and I can tell you that it takes a long time to recover from the surgery. However, I probably had a more difficult recovery than most when I had my surgery at 58 as the anesthetic shut down my intestines following the operation, and I ended up having to get an enema and an endoscopy. Then a few days later I got a one pint blood transfusion. The next day I experienced heart block and had to be moved to ICU and had to get a pacemaker (which I have heard is not all that uncommon, and I still have the pacemaker five years later; to prevent bradycardia). Following the surgery I was back to around 70% - 75% conditioning within about 3 - 4 months. However, to close the gap to get that final 25% or so of conditioning to get at or near 100% of pre-op conditioning took me no less than a year. I presume a sedentary person would return to relative normal (for them) within a shorter period of time since they were not exercising prior to the surgery. The surgery is a very debilitating experience; no question about it. And the older you get, the more risk and the longer the recovery period. There is also the psychological aspect of having to deal with the knowledge that it is highly likely that a reoperation will be needed at some point with a tissue valve. Not exactly something to look forward to, particularly since you have a choice (i.e. mechanical valve) that would likely allow you to live the rest of your life without having to get a reoperation. I say likely in the previous sentence because there does exist a small percentage of mechanical valve recipients that require a reoperation for one reason or another. There is also some percentage of tissue valve recipients that are required to go on Coumadin (usually for atrial fibrillation - AFIB), which negates the advantage that they had sought by getting a tissue valve in the first place (i.e., avoidance of Coumadin). The way I see it, your choice is whether you want to look forward to probable reoperation(s) with a tissue valve with the probable freedom from taking Coumadin, or whether you would choose the probable freedom from reoperations with the certain requirement to take Coumadin with a mechanical valve. This leads to examining Coumadin and the pros and cons associated with it. This has been discussed many times on this forum. I will say that taking Coumadin has not been a problem for me, has virtually no impact on my lifestyle, and the side effects are negligible.

Good luck whatever you choose.

 

[mainframe]

Hi Mike,

The issue I rarely see pointed out on the this forum when discussing second surgeries is it's really hard to know what your physical condition will be when it's time for a the re-op. It's easy to think if your in good shape and active now that XX number of years later when it's time for the re-op you will be, but it might not be the case. I was in great shape for my first surgery, not so much for the second. Also, my bovine tissue valve failed faster than anyone expected. By the time I was on the table for the second surgery I was in pretty rough shape.

There are a few of us who suggest doing whatever you can to avoid OHS, especially a second AVR. That includes the group of a few of us who barely survived and whose time in the hospital was measured on months, not weeks or days. Fortunately it doesn't happen often but it does happen and will again to someone. Try not to be that guy.

 

[Mike1952]

Chris, thank you for the reality check. It is a gamble that's for sure. Really not a completely good option either way! I guess we are lucky they can give us an option, if we'd had a failing valve 100 years ago, we would have been toast! I"ve got two and a half weeks to make up my mind, I'll be researching and reading this forum right up to the S Day! Great info, thanks to all for the continued support!

 

[Forrest]

Mike,

The above responses represent a lot of great insights. These insights are usually derived from having gone through the surgery, and also gleaned from broad personal experiences with heart problems. It’s definitely a subject matter where a layperson would initially have difficulty grasping. This Forum really helped me understand my sudden diagnosis and surgery later that same year, and most of all, what it would mean to me. I also read a book on valve replacement and researched the Internet (e.g., Mayo Clinic, Cleveland Clinic, etc.) and I kept aware that the Internet can also offer some confusing information as well. Of course, it was very important to ask as many questions as I was able to when meeting with my doctor, cardiologist and surgeon.

As many on the Forum say, the valve choice decision is difficult and is usually a personal one, based on many factors (your medical and personal background, your cardiologist & surgeon’s recommendations, what makes you feel safe…and the list goes on). People generally report satisfaction with both types of valves. But I also appreciated how folks told their personal stories above, including their varying post-op experiences. Unfortunately, there are no automatic guarantees with any choice you make when it comes to this type of major surgery, however the operation itself has come a long way and is basically considered to be very successful for most.

It’s been almost 3 years for me since I had my aortic valve replaced and I’m doing fine, still enjoying hiking and nearly all of my sport activities. I had some bumps in the road during my recovery that I successfully navigated and I still have some Mitral valve leakage that will need to be monitored from here on out. I try not to fixate on how relatively carefree my physical life felt like before learning of my congenital heart defect, but in many ways I appreciate what I’ve learned since and how fortunate I feel to have a second chance. I usually tell people not to pay attention to my valve choice since it’s such a personal decision and individual circumstances may differ. I too live in western Washington, and hear good things about the hospitals that are experienced in valve surgery in your area. Best wishes with your surgery! After recovery, you should be fine.