Surgery delay after pre-op testing?

[woulde]

With all of the experience in this forum has anyone had or anyone heard of valve replacement surgery being delayed after pre-operative testing? A little background on the reason I ask… Some parameters used to gauge severity have been severe for the last 18 months, all are severe per latest echo with ejection fraction below 50% and left ventricle mass size now in the severely abnormal category. I have a spreadsheet of all echo finding and see some variation in the readings (for instance AVA decrease, then increase, then decrease) which I presume is due to imaging quality, small dimensional variations in variables used in formulas to establish readings and body state at time of imaging (hydration, fatigue, anxiety level, etc.). My local cardiologist sent latest echo and records to Dr. Gillinov at the Cleveland Clinic who, after review, recommended surgery within the next three months. I am scheduled for AVR on November 11[SUP]th[/SUP]. In gaming all scenarios or possibilities the though occurred to me, what would the protocol be if pre-operative testing put the ejection fraction above 50% and some readings back to borderline moderate/severe? Maybe the left ventricle size is concerning enough to make AVR a foregone conclusion, a question I’ll ask my local cardiologist. It would be disappointing to travel from Anchorage to Cleveland only to be told watchful waiting is best at this time. Not disappointing that it was not time, disappointing in the wasted resources and time.

I am 48 years old and very active, stenosis is radiation induced as a result of radiotherapy in treatment for Hodgkin’s Lymphoma 21 years ago. Hard to reconcile and wrap my head around a still very active lifestyle with need for AVR. I average 10 – 11 hours per week of cycling moving time; August 1[SUP]st[/SUP] I completed a 109 mile mountain bike race with 10,000 feet of climbing, not superfast but a still respectable 12:25. Two weeks later echo results indicate it is probably time for AVR. I don’t think I am in denial… or maybe I am really in denial about being in denial?

As for the debate about valve type; the cardiologist I see is not much older than I am and he said were he in my position, no hesitation he would go with a tissue valve. Expectancies with latest generation valves and confidence in TAVR valve in valve re-op make it a no brainer. Dr. Gillinov’s nurse told me in our phone consult that he recommends tissue valves for a number of reason, expected TAVR advancements being one of them.

 

[McCbon]

Woulde: I have the utmost respect for the surgeons there, my experience might allay your fears. I was seen there in 2014, and my numbers were upper-end moderate, I passed the stress echo with flying colors and was asymptomatic - and they were ready to operate immediately. Your numbers may vary according to the clinicians and machines and other variables, but they consider more the range, and the inevitability of the surgery. Timing is more important with Tissue (and they favor tissue there) because the clock starts ticking to the next OHS as soon as it's placed. But the risk of doing pre-op and then saying no let's wait? Doesn't seem likely at CC in my opinion but it is just my opinion based on my experience there. I am still moferate/severe and work out 5 days a week. I am 63 in one month and do not have surgery scheduled yet. McCbon

 

[ALLBETTERNOW!]

With all of the experience in this forum has anyone had or anyone heard of valve replacement surgery being delayed after pre-operative testing? A little background on the reason I ask… Some parameters used to gauge severity have been severe for the last 18 months, all are severe per latest echo with ejection fraction below 50% and left ventricle mass size now in the severely abnormal category. I have a spreadsheet of all echo finding and see some variation in the readings (for instance AVA decrease, then increase, then decrease) which I presume is due to imaging quality, small dimensional variations in variables used in formulas to establish readings and body state at time of imaging (hydration, fatigue, anxiety level, etc.). My local cardiologist sent latest echo and records to Dr. Gillinov at the Cleveland Clinic who, after review, recommended surgery within the next three months. I am scheduled for AVR on November 11[SUP]th[/SUP]. In gaming all scenarios or possibilities the though occurred to me, what would the protocol be if pre-operative testing put the ejection fraction above 50% and some readings back to borderline moderate/severe? Maybe the left ventricle size is concerning enough to make AVR a foregone conclusion, a question I’ll ask my local cardiologist. It would be disappointing to travel from Anchorage to Cleveland only to be told watchful waiting is best at this time. Not disappointing that it was not time, disappointing in the wasted resources and time.

I am 48 years old and very active, stenosis is radiation induced as a result of radiotherapy in treatment for Hodgkin’s Lymphoma 21 years ago. Hard to reconcile and wrap my head around a still very active lifestyle with need for AVR. I average 10 – 11 hours per week of cycling moving time; August 1[SUP]st[/SUP] I completed a 109 mile mountain bike race with 10,000 feet of climbing, not superfast but a still respectable 12:25. Two weeks later echo results indicate it is probably time for AVR. I don’t think I am in denial… or maybe I am really in denial about being in denial?

As for the debate about valve type; the cardiologist I see is not much older than I am and he said were he in my position, no hesitation he would go with a tissue valve. Expectancies with latest generation valves and confidence in TAVR valve in valve re-op make it a no brainer. Dr. Gillinov’s nurse told me in our phone consult that he recommends tissue valves for a number of reason, expected TAVR advancements being one of them.

I am 49 and got a tissue for same reasons you were told. I would probably say now that I have recovered that I wish I had a mech and were done with this. Just make sure the surgeon isnt guiding you towards a tissue because of your active lifestyle and you decide. I've since found out that the fact that I play soccer caused the surgeon to steer me towards a tissue valve. I would have considered trading soccer and Coumadin for a mech. Buyers remorse I guess. Even if you get tissue and a TAVR, them what about #3??? Welcome to my dilemma. I think you will stay on track for your date, the pet op stuff is splitting hairs, the surgery is inevitable these things don't fix themselves

 

[MethodAir]

I would have considered trading soccer and Coumadin for a mech. Buyers remorse I guess.

I wouldn't hesitate playing soccer with my mechanical aortic valve. I sprained my ankle really good recently, the swelling and healing time was no different than pre op.

 

[almost_hectic]

Some doctors talk about Coumadin like its plutonium! Like one little bump and its curtains for you!!

That aside, I respect each to their own decision. But after having just gone through OHS I cant imagine anyone choosing to do it again voluntarily 10 years down the road because theyd rather not take a little pill every day. I wish Coumadin wasnt part of my future, but Ill take it over another heart surgery any day. Its kind of ironic too inst it, if a tissue valve is recommended over a mech because youre an active individual... doesnt a tissue valve fail faster in an active individual whos going to put more strain on the valve?

 

[pellicle]

Some doctors talk about Coumadin like its plutonium! Like one little bump and its curtains for you!!

I suspect this is related to the distant past (and knowledge seems to spread slowly in medicine) where they determined your dose by "are you seeing blood in your urine?" even though INR seems to date from the late 80's ... almost pathetic isnt' it.

 

[almost_hectic]

Yet they prescribe plavix like its candy, and I'd say more dangerous.

 

[honeybunny]

I was diagnosed May 29th with moderate-severe BAV stenosis based on echo and stress test. TEE then indicated it was severe and cardiologist said it would need to be replaced within a year; not an emergency. I met with Dr. Joseph Coselli at CHI St. Luke's Baylor August 3 and requested surgery this year for insurance purposes (high deductible plan with $5000 out of pocket nearly met). Had AVR 3 weeks ago today. My guess is that your doctors would proceed on schedule unless you requested otherwise and they determined it was safe to delay. Good luck~

 

[ALLBETTERNOW!]

I wouldn't hesitate playing soccer with my mechanical aortic valve. I sprained my ankle really good recently, the swelling and healing time was no different than pre op.

Yep mine is an over 40 league and most of the tiem as long as you keep yourself under control you are safe though we have seen a few knee and achilles and ankle injuries.

 

[Ske1973]

Woulde -I too am scheduled for AVR at the CC on 11/11, however, I decided to go with a mechanical valve. I am a 42 years old, active male, running 2 - 3 times a week with some light weight lifting. I had an aortic valve repair at the CC in April 2015. Unfortunately, the repair has deteriorated since the surgery. As far as the valve type, I recommend conducting some in depth research to understand the differences between the tissue and the mechanical valves. This site is full of helpful information and it was the information provided here that helped me determine the right type of valve for me. More specifically, the information that Pellicle has provided on this and his personal website have been extremely helpful to me. Good luck to you with your surgery...maybe I'll see you in recovery!

 

[almost_hectic]

Just curious for folks going to Cleveland Clinic. Are they doing minimally invasive procedures for most valve replacement surgeries?

 

[cldlhd]

I'm not looking to get in the middle of the tissue vs mechanical debate but I wonder how accurate it is when a surgeon says " if it was me I'd do this.." .It's like when I first told people about my newly discovered aneurysm last year and they'd say " I'd have the surgery as soon as possible". Advice that's easier to give than to take. My concern would be if the 1st tissue lasts 12 yrs then you get TAVR at 60 (assuming it's ready) and let's say you get 14 out of that then you're 74 and then what? I know there's the assumption that it'll last you out but that's like planning on dying. I know we're all going to die but hell my grandad made it to 87 and my Grandmom is still kicking at 86. Guess it comes down to no warfarin but likely multiple procedures or warfarin and a good chance at having only one.

 

[McCbon]

cldlhd; It reminds me of when I go shopping for shoes and the salesperson says "I have a pair of these, they are my favorite!" But I have become skeptical after 15 yrs in the waiting room and seeing lots of docs. CC does favor tissue, they are banking on TAVR eventually being the "new OHS" and standard re-op procedure. For my money, there are still many problems with the technology, not the least of which is that they haven't yet developed the prosthesis that would be used in the 10-20 year timeline for next ohs. Even if they did, those testing periods take 10 to 20 years to collect enough data to make predictions. Please, someone, feel free to correct me if I am wrong about that. I am truly interested in hearing as many broad ranging opinions as possible on these topics. That's what is good about this forum!
I decided not to go to CC because they were so ready to operate, even though my status did not warrant it. I found a team at Mayo and they surprised me by recommending mechanical for me, even at my age, one reason is my activity level and their feeling that the reason tissue lasts longer in elder pts is because they are less active. Because I am so active for my age, they thought I'd need the next OHS sooner that the averages. Anyway, that's just my situation. I have heard and read great things about your surgeon and as they say, any choice is a lifesaver. McCbon

 

[MethodAir]

cldlhd; It reminds me of when I go shopping for shoes and the salesperson says "I have a pair of these, they are my favorite!" But I have become skeptical after 15 yrs in the waiting room and seeing lots of docs. CC does favor tissue, they are banking on TAVR eventually being the "new OHS" and standard re-op procedure. For my money, there are still many problems with the technology, not the least of which is that they haven't yet developed the prosthesis that would be used in the 10-20 year timeline for next ohs. Even if they did, those testing periods take 10 to 20 years to collect enough data to make predictions. Please, someone, feel free to correct me if I am wrong about that. I am truly interested in hearing as many broad ranging opinions as possible on these topics. That's what is good about this forum!
I decided not to go to CC because they were so ready to operate, even though my status did not warrant it. I found a team at Mayo and they surprised me by recommending mechanical for me, even at my age, one reason is my activity level and their feeling that the reason tissue lasts longer in elder pts is because they are less active. Because I am so active for my age, they thought I'd need the next OHS sooner that the averages. Anyway, that's just my situation. I have heard and read great things about your surgeon and as they say, any choice is a lifesaver. McCbon

Your post makes a lot of sense, McCbon. I was 43 at the time of surgery this year. In the government funded Canadian health care system, tissue was not presented as a viable option by the surgeon, mainly considering my age.

 

[Paleowoman]

I found a team at Mayo and they surprised me by recommending mechanical for me, even at my age, one reason is my activity level and their feeling that the reason tissue lasts longer in elder pts is because they are less active. Because I am so active for my age, they thought I'd need the next OHS sooner that the averages.

Does the team you spoke to have references for that ? I am extremely active for my age, ha, far more active than I ever was when I was younger - yet no one ever suggested that tissue valves wouldn't last so long because of being active. Would be very interested in any studies suggesting that McCbon if you know of any that the Mayo gave you.

 

[ALLBETTERNOW!]

Does the team you spoke to have references for that ? I am extremely active for my age, ha, far more active than I ever was when I was younger - yet no one ever suggested that tissue valves wouldn't last so long because of being active. Would be very interested in any studies suggesting that McCbon if you know of any that the Mayo gave you.

I wonder if they think they know something? Edwards cant claim the new valves last 20 years but will tell you about their "therma fix" process... No surgeon will tell you or guarantee a tissue valve will last 20 years, but anectdotally they all mention seeing a patient 20 years later still with working tissue valves and CC does 80% tissue valve according to the last figures I saw. Edwards iis very close to getting valve in valve FDA approval for medium risk patients and if they can tweaked it a bit, CC may be right about that as a viable option, my surgeon agrees, but can they do round 3 via valve in a valve ina valve? i wouldnt think they could maintain a wide enough opening with 3 valves in that space? ESp for you at 19mm, atleast I started at 27mm so maybe I have a fighting chance. I also think I read that the smallest they will consider and have data for a valve in a valve in is 18mm. I am not sure how much each round of reinsertions narrrows it by?

I never knwo if they mean young is 20 or 30 or just 60 or less when they make those statements about valves wearing out sooner.All I know is that it makes a clear choice for a 50 year old impossible.....

 

[pellicle]

Hi

Does the team you spoke to have references for that ? I am extremely active for my age, ha, far more active than I ever was when I was younger - yet no one ever suggested that tissue valves wouldn't last so long because of being active.

I have edited my post because I failed to focus on the "being active" and I'd been under the impression that being active was the other primary linkage (after being younger). However I'm unable to be sure that is not a "bias" I've received from listening to surgeons who promote "young and active" in the same breath. Perhaps this is not correct ...

As I understood it you had your valve less than 2 years ago, so that you are not having any issues with the valve is entirely expectable. I hope you will be able to report your experiences and thoughts in 20 years from now.

Here is one paper for you which uses it as a well known fact upon which to begin exploring a mechanism for activity being linked it (with an eye towards planning to combat it).

http://www.ncbi.nlm.nih.gov/pubmed/1...?dopt=Abstract

Calcification is accelerated by young recipient age, valve factors such as glutaraldehyde fixation, and increased mechanical stress

that "increased mechanical stress" to me implies athletic style exersize.

From http://circ.ahajournals.org/content/119/7/1034.full

Recent studies suggest that bioprosthetic valves are not in fact completely “immunologically inert” (Figure 8).[SUP]73[/SUP] Hence, residual animal antigens could elicit humoral and cellular immune responses, leading to tissue mineralization and/or disruption. A more robust immune system might also explain the more rapid SVD usually observed in younger patients.

Best Wishes

 

[pellicle]

Hi

I never knwo if they mean young is 20 or 30 or just 60 or less when they make those statements about valves wearing out sooner.All I know is that it makes a clear choice for a 50 year old impossible.....

I would agree, it is so well known among surgeons that for years the guidelines were clear , less than 50 and you got a mechanical, greater than 50 it was choice. Now (perhaps in responce to patient complaints about ticking and compliance concerns with anticoagulation therapy) they (in some countries) give anyone who pushes for a tissue prosthesis what they want.

My wife used to always say to me "be careful what you ask for, you may just get it"

There is enough evidence however to my reading that at 50 with no other issues (co-morbidities) that you will be better off (statistically) with a mechanical valve. That Mayo Clinic link produces some clear points about that too.

Ask your sugreon this question : in a 30 year follow up of patients who were under 50 at time of surgery, what percentage remained free of reoperation.

If you find a single study I'll be surprised ... nobody studies against the obvious.

I can however point you to studies done on homografts where 29 year followups were done. There were zero free of reoperation who were under 50 at time of initial surgery.


In this journal http://www.hindawi.com/journals/iji/2011/263870/

I found the following interesting. It provides a clue to support why tissue prosthesis degrade faster in athletic people.

[FONT=Minion W08 Regular_1167271]As evident now, native heart valves—the aortic and mitral valves in particular—function in a high-magnitude and complex surrounding hemodynamic environment to which the valvular structure constantly responds. The mechanical environment varies spatially and temporally over the cardiac cycle. Close correlations between mechanical stresses and heart valve biology have long been documented by clinical observations and animal studies [26–30]. The cellular and molecular events involved in these processes, however, still remain unclear. Moreover, the biological response and the mechanotransductive signaling pathways appear to be different from the extensively studied vascular cell counterparts [19, 31].[/FONT] [FONT=Minion W08 Regular_1167271]According to various early studies, the structural components of the aortic valve undergo constant renewal in response to mechanical loading [26], and the sites of protein and glycosaminoglycan synthesis in the leaflets correlate with the areas of functional stress [27]. Changes in mechanical loading in turn alter the biosynthetic behavior of valve cells. For example, collagen synthesis in mitral valve leaflets was enhanced as a result of altered stress distribution due to left ventricular infarctions [32]. [/FONT]

so essentially a tissue prosthesis can not undergo any renewal in response to mechanical loading stresses. Just like any "leather hinge" of old it will begin to fray, and be calcified. The mechanical valves avoid this.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2696738/table/T1/

 

[Fundy]

Your post makes a lot of sense, McCbon. I was 43 at the time of surgery this year. In the government funded Canadian health care system, tissue was not presented as a viable option by the surgeon, mainly considering my age.

I was 45 in the same system, cardiologist told me she thought tissue would be preferable, and surgeon told me he would be about 50/50 if it were him choosing.

 

[McCbon]

Paleogirl: Nope, the docs did not site a study but in subsequent discussions here, Pellicle sent me some links. He's included them above.
Both the surgeon and the cardio made the same recommendation and the surgeon said it was up to me that if I wanted tissue he would implant a tissue valve. He said implanting tissue valves is a slightly easier procedure. Every choice has it's trade-offs. McCbon