Successful AVR - Info for anyone getting close to surgery, or with Acute Stenosis

[Guest]

I would like to share my recent experience to help anyone in a similar situation.

Surgery:
AVR with On-X 23mm ; 3 Nov 2017
Surgeon : Dr. V Kasirajan @ VCU Health in Richmond, VA
Complications: (1) Full heart block, due to mechanical valve installation (block still remaining as of 21 Nov) requiring Pacemaker installation on 7 Nov ; (2) A few days of Atrial fibrillation, heart naturally went back into sinus rhythm thereafter

Background:
BAV with mild aortic stenosis diagnosed Mid 2014
Mild stenosis still in Mid 2016
Actute stenosis diagnosed in Mid 2017
DOB: 1974

More information:
-Noticeable symptoms only after acute stenosis. Once symptomatic, I understand it is very very important (even more so for young/active people) to have the valve fixed ASAP. Mine went from mild to severe quickly: surgeon reported that the valve was highly calcified (meaning it was not really acting like a valve!). Please do not skip an echo if you are being monitored.
-Even with the complications (Atrial fib, Pacemaker), I felt confident along the way that there would be positive outcomes; the science is well understood and practiced at a high level.
-Chest tube, catheter, and external heart pacer wire removal are really not a big deal: 2 second of some discomfort. Breathing tube removal is not pleasant, but not terrible.
-Able to walk 100yards after 2days
-After 1 week, able to walk for 30minutes with no issues
-The standard of care at VCU was really impressive.

Any questions? Let me know and I'll do my best to answer.

 

[CazicT]

Thanks for the info, I go in tomorrow (about 13 hours, yikes)..

Pretty similar case here, 41, mild stenosis, moderate insufficiency, fairly big aneurysm (forget exact size), starting to develop pulmonary hypertension, etc.

Good to hear things went mostly well for you.

Didn't know a block was a thing with mechanical valves... Well one more thing to worry about hehe.

Anyway, hope the recovery goes speedy for you

 

[LondonAndy]

Good post, guest. I ended up with a pacemaker as well, for the same reasons, when I had my AVR done 3 years ago. Pacemaker has not been an issue, as far as I can tell. There is a useful site www.pacemakerclub.com which I now follow (and post on occasionally) to find out what issues might arise in future.

Take the recovery gently!

 

[jwinter]

Your story is a good one for all to read. Wishing you the best in your recovery. WTG on keeping an eye on things and having your check ups. i have a year old ON-X and have no experience with afib(not positive if I know how that feels) .

A few people here, like Andy, post on their pacemakers and make me feel like if that was something to deal with it can be done, Very helpful they are.

 

[epstns]

I'll agree that after the initial "tweaking the device" period, pacemakers are a big non-issue. Sometimes it takes a couple of visits to the PM clinic to get all the optional settings right for your personal activity preferences (especially is you're a gym rat as I am), and after that, the only time I am fully aware that I have a pacemaker is when I look in a mirror with my shirt off.

Even having one of my leads fail, the subsequent lead removal/replacement and device replacement was just a day in hospital and a few days of recovery. The worst part of that one was not being able to drive a car for a week after the new lead was implanted.

The potential for complete heart block is not so much related to which type of valve you have implanted as it is to the process of replacing the aortic valve itself. The nerve bundle that conducts pulses from the upper chambers of the heart (atria) to the lower chambers (ventricles) runs very close to the area around the aortic valve. Sometimes, depending upon the individual patient's physiology, the degree of calcification and the surgeon's skills, they damage the nerve bundle when the cut out the native valve. When this happens, partial or complete heart block is the result. I remember that my surgeon was a bit miffed that I required a pacemaker, as he probably felt that my situation spoke poorly of his surgical prowess. I didn't feel that way, but others asking his statistics might disagree.

Be sure that you put your device "through its paces" before you consider that project complete. Often, once the patient begins to heal, they find that they need the pacemaker to be adjusted to allow for higher max heart rate or faster acceleration, in order to keep up with the patient's increasing abilities.

 

[JWalters]

OP here

I'm looking for some feedback / experience from others about getting back in athletic shape after AVR surgery. It seems like I'm struggling more than I would have anticipated. Now that I have a fully functional aortic valve, I was expecting to at least get back to where I was regarding heart function during high cardio outputs.

Specifically, when I'm exerting medium or medium heavy on the bike, say at approx 250W, my heart rate is higher than before surgery, and approaching my safe maximum rate (180max on the pacemaker!) when I could definitely push harder on my legs and lungs.

Docs don't seem to be concerned, but I'm looking for any other opinions that could help me out.

Thanks,

John

 

[pellicle]

Hi

...
I'm looking for some feedback / experience from others about getting back in athletic shape after AVR surgery. It seems like I'm struggling more than I would have anticipated. Now that I have a fully functional aortic valve, I was expecting to at least get back to where I was regarding heart function during high cardio outputs.

Specifically, when I'm exerting medium or medium heavy on the bike, say at approx 250W, my heart rate is higher than before surgery, and approaching my safe maximum rate (180max on the pacemaker!) when I could definitely push harder on my legs and lungs.

Docs don't seem to be concerned, but I'm looking for any other opinions that could help me out.

well I didn't have a pacemaker, so that may change things. However...

I asked my surgeon at my 1 month followup meeting I specifically asked about what my max target HR could be, he said "as high as you want" , so being one who knew my HR pre surgery (HR band and watch) I said what was my range and he said "sure"

The only thing he cautioned about was lifting heavy weights but as to aerobic fitness he encouraged me.

Myself I find (still) that I can do over half an hour at 140, but I burn out when going into the 160 zone. I can (for instance) skate ski on the track (with mild hills) only for a couple of minutes at 160 before I have to pull over and just breath. Same was true back in my 20's on cycling hills.

I'd get a HR monitor and plot it all and look for progress.

I was (until recently) using a Garmin Vivofit system which gave me steps / HR and training durations with an ANT+ strap. Its a good system but you may depending on needs / wants wish to get into something more. I found it being "on line" made sure I didn't forget to document things.

I'd try 45 minutes every 2 days with an average HR of 140 and see how that feels at the end of a week.

If you can, then ramp up the actual energy outputs.

there is nothing like actual data to work with and compare to determine progress.

 

[Superman]

You’re about six months out or so? Can’t speak for others, but I recall it taking quite a while for my resting pulse to come down post surgery. Didn’t keep a diary, but it seems like it must have been a good year plus. I only started spin classes recently and my last surgery was in 2009. I don’t have any before and after data. Plus, no pacemaker. I did hammer the mountain bike trails after my first surgery, but wasn’t really concerned with tracking pulse data in my late teens and twenties. Probably not much help for you, but I’m up and posting so there you go.

 

[epstns]

John - You haven't mentioned your post-op medications (if any). After my valve replacement, I was prescribed a beta blocker - to help keep my heart rate within bounds and possibly avoid afib. The beta blocker serves to limit your heart rate upper limit. In my case, after two dosage reductions (at my own request), I am still taking 25 mg/day of metoprolol, which seems to limit my practical heart rate to about 140-145. I can occasionally get up into the 150's, but it is a monumental effort.

Also, just because you have a pacemaker, that does not mean that you are necessarily paced all the time. Ask your electrophysiologist. In my case, although I need the pacemaker, I mainly need it for keeping my ventricles beating at the right rate and in sync with my atria. My atrial pacing is via my natural nerve conduction about 90-95% of the time. I do rely on ventricular pacing about 90% of the time, hence the pacer. Thus, in my case, my heart rate is actually driven by my own natural pacing within the heart. You didn't state whether yours is or not, and that will have a major impact on your possibilities.

I used to obsess about where they set my pacemaker upper limit, but once I understood my particular situation, I no longer worry. For me, it is the meds limiting my abilities, not the pacemaker.

 

[JWalters]

Hi All, Some clarifications:

>Meds : 7.5mg Warfarin, Low Statin & Baby aspirin x Daily
>Fully Paced on the Ventricle due to 100% heart block
>I've been lifting and biking quite a bit : 4x / wk , total of 3hr/wk of exercise, since February
>My perception (missing solid data...) is I have lost ~20-30% power output capability. I have a road bike course that I could do in 13.5minutes (~20mph) before surgery, and it took me 15.5 minutes this weekend. So I think there is something real here to understand more.

More data makes sense to me. I will attempt to build a HR vs Power Output correlation , and trend over time, this summer.

John W

 

[JWalters]

Hi All, Some clarifications:

>Meds : 7.5mg Warfarin, Low Statin & Baby aspirin x Daily
>Pacemaker is actuating the Ventricle due to heart block, with natural Pacing from the Atria
>I've been lifting and biking quite a bit : 4x / wk , total of 3hr/wk of exercise, since February
>My perception (missing solid data...) is I have lost ~20-30% power output capability. I have a road bike course that I could do in 13.5minutes (~20mph) before surgery, and it took me 15.5 minutes this weekend. So I think there is something real here to understand more.

More data makes sense to me. I will attempt to build a HR vs Power Output correlation , and trend over time, this summer.

John W

 

[pellicle]

...is I have lost ~20-30% power output capability. I have a road bike course that I could do in 13.5minutes (~20mph) before surgery, and it took me 15.5 minutes this weekend. So I think there is something real here to understand more.

well I'd call that reasonably solid data ;-)

My view is that's about "on track" given you are less than a year post op AND given that you had some other complications which are treated with stuff like a pacemaker. I mean its good, but its not "back to elite athlete" stuff. I'm not sure about the effect of statins (if any).

IIRC it was a good couple of years before I'd recovered my (well pre-surgery) levels of fitness. Mainly because I was in the middle of doing another degree at Uni when I had the OHS at 28 years old and the sedentary aspects sort of enforced by the study workload meant it wasn't until I was back working and settled in that I started pursuing fitness again. Then it took me about a year of cycling to be at what I think is close to my personal peak.

I was riding to work (17km each way) and then after a few months was throwing in a "loop around the city" on the way home (with hills) bringing my homeward journey up to 30Km.

Somehow I'm sure that now at 54 I'm not at that level (my own causes).

But gather data and chart it and see ... I'd expect to see a modest but continuous development over the following months. Just don't over train ;-)

Best Wishes

 

[JWalters]

Just an update if anyone is following this thread. I've been training steadily over the fall/winter/spring with a resting HR reduction and increased power output, but still with a noticeable reduction vs prior surgery in Nov 2017. CPAC / VO2 max test, charted my HR vs power output over the last months.....

So, I'm convinced the pacemaker is not as effective in stimulating the Ventricle as Mother Nature's method, and my blood flow isn't as good as prior surgery. Seems the Electo physiologist believes it, too, and offered to place a new wire into a more effective position in the ventricle when I get my pacemaker replaced in 10 years. It is not really an issue, and I'll worry about the new wire option later !

All is well and I'm healthy

John

 

[epstns]

Hi, John,

Glad you've stopped back to see us.

Since you've been to the electrophysiologist, did he/she look into things like your A-V delay? IIRC, you have (or had) 100% heart block, being paced in the ventricle 100% of the time. This does not (or may not) mean that you are in atrial pacing much at all. I have the same situation -- atrial pacing about 10-15% of the time, with ventricular pacing more like 90% of the time. In my case, the time delay between the atrial pulse and the ventricular pulse makes a major difference in my athletic performance. If they lengthen the delay (the amount of time the pacer "waits" to see if your ventricle is going to pace naturally) to try to save battery life, my exercise tolerance takes a negative hit. We tried that for a bit, then went back to allowing the pacer to control ventricular pacing more of the time because I just felt better under exercise load.

I don't know all the specifics of your heart's condition, but it may be worth a quick call to the E-P doc to see if it is worth trying for you.

 

[JWalters]

Thanks for the feedback Steve. I'm 100% blocked ; I'll bring it up with the EP next time !