TAVR vs Mini-AVR...My Delema

[macdaddy]

TAVR vs Mini-AVR…My Delema.

So, in 2022, my GP didn’t like what she heard in my heart and asked to set me up with a Cardiologist for an exam. Went to the appointment, first thing, before she came in, they did an EKG. Drugs we recommended…I declined. More tests needed…okay…echocardiogram, chemical stress test, etc. Results were a “moderate” aortic stenosis. More drugs offered, once again declined. Were it not for the tests, I would have never known. I am 100% asymptomatic.

Doctor said “we will keep an eye on it, you are probably 10 years away from needing anything done. Went back 6 months later, pretty much the same…more drugs recommended, more drugs declined. Went back 8 months later, her assistant comes in the room and spouts of statistics I have never had explained to me, and summarizes I am now severe and need to schedule replacing the valve. “Who are you again?”, “I’m the doctor’s aid”.

Finally, the doctor comes in, tries to explain all the numbers to me, and comes to the same recommendation. So, I asked “what happened to 10 years?”, “It just goes that way sometimes”. “But I have no symptoms…none!” “Doesn’t matter.”

That is when the aid starts talking about TAVR, and I begin my research. A gentleman I met in the park directed me to this site; he had had a widow-maker and survived, with the insertion of a mechanical valve.

I had issues with my medical insurance that lead to some delays and I have finally been assigned my cardiac surgeon. Met with him today, great doctor (did my research) with lots of cred and experience. He introduced me to Mini-AVR, via an opening through the ribs. He is suggesting this over TAVR as I’ve got a bicuspid and, as he explained it, this makes it hard to get a “seat” for the TAVR as the larger leaf tends to push the device a little off center; leaving potential for mild leakage.

He also stated that with the TAVR, there is a 10% chance of needing a pacemaker, as there’s an electrical pathway to the heart that runs right next to where the valve will be expanded. This is much less likely with the Mini-AVR method.

He said the recovery is a little longer than TAVR, but not as involved as actually cracking the sternum. He said the valve statistically lasts longer than the TAVR, and in 15 years…if needed…they can then do a TAVR and there will be a great seat for it.

I turned 72 in April, in quite good shape (minus a few pounds) and very active. Still working 11-hour days, walking job sites, meeting with Customers, etc. I have been reading this site for well over a year; a LOT of very knowledgeable people in here, but I have never seen this procedure mentioned (at least not this exact term) and would really appreciate any helpful feedback.

 

[Chuck C]

He introduced me to Mini-AVR, via an opening through the ribs

It sounds like you are describing a mini thoracotomy. @Erwitchin is in recovery from this minimally invasive AVR technique. Hopefully she will give you her input.

I turned 72 in April, in quite good shape (minus a few pounds) and very active.

He is suggesting this over TAVR as I’ve got a bicuspid and, as he explained it, this makes it hard to get a “seat” for the TAVR as the larger leaf tends to push the device a little off center

Your surgeon is right. TAVR is not ideal for BAV. Also, you are young for TAVR. Given its relatively short life, it is better suited for those over 80 years old who are at high risk for OHS. You are still relatively young and healthy, so the short term fix is really not the way to go.

 

[Erwitchin]

Hi! Welcome to a place you never wanted to be! I am glad your friend sent you here... there is a LOT of good info from good people.
Sorry about the delivery of the news and lack of education from your cardio team... but they aren't leading you astray from what I can tell.
I have known that I had a bicuspid valve since my mid 20s, but the function was always ok so it was just "keep an eye on it.. eventually it will need replacing... probably around 75 or so. "
It was that way until suddenly last December it wasn't. "You have severe stenosis and it needs to be replaced before something else gets damaged."
Do you remember playing with a garden hose and squeezing the end? Basically, that is what your stenotic valve is doing... spraying your blood way too fast against your ascending aorta like a pressure wash. I am glad you aren't feeling it, but with the current level of surgical expertise, it is considered safer and better to fix the valve while the rest of the organ is a healthy as possible.
My cardiologist gave me some info, including his TAVR and SAVR surgeons of usual choice, but then said... you seem smart. Do some research, let me know what you want to do.
I quickly found out that TAVR was NOT am option with a bicuspid aortic valve. Blue Cross /Blue Shield specifically excludes coverage for it. (For good reason - all-cause 2 year morbidity nearly triples when TAVR is done on a bicuspid aortic valve).
I also really wanted to avoid a cracked sternum (I am 51, I teach high school, I have a 70 lb dog, and trouble sitting still) so I found a Surgeon who specializes in minimally invasive open heart surgery. After agonizing over valve choice (non issue for you - the clear recommendation after age 70 is a bio-prosthetic) I had my mini-thoracotomy on June 12. Replaced the valve, spent 4 nights in the hospital (1 full day in ICU), and am walking around, driving, and doing pretty much what I want. I am supposed to avoid straining my right arm (10 lbs or less) for 2 more weeks.
The biggest issue I have had with recovery is the chest drainage tube wound isn't healing as well as we would like, so I am seeing a wound care clinic for that.

Let me know if you have any other questions for me!

 

[Juli]

Another option to consider is a mini-sternotomy. This is a procedure where only half of the sternum is opened and also the surgeon should close the sternum with Titanium plates (instead of wires) which fixates the sternum.

https://www.uchicagomedicine.org/conditions-services/heart-vascular/heart-surgery/sternal-plating

This is procedure is pretty much the standard in the major clinics for open heart surgery. I had both techniques and was back at work 2 weeks post surgery and riding my bike 6 weeks post surgery. Recovery was relatively quick, the sternum half's were stabilized and all I needed one day post surgery was just Tylenol. My surgeon told me that performing the surgery with full visibility would be his preference.

 

[macdaddy]

Hi! Welcome to a place you never wanted to be! I am glad your friend sent you here... there is a LOT of good info from good people.
Sorry about the delivery of the news and lack of education from your cardio team... but they aren't leading you astray from what I can tell.
I have known that I had a bicuspid valve since my mid 20s, but the function was always ok so it was just "keep an eye on it.. eventually it will need replacing... probably around 75 or so. "
It was that way until suddenly last December it wasn't. "You have severe stenosis and it needs to be replaced before something else gets damaged."
Do you remember playing with a garden hose and squeezing the end? Basically, that is what your stenotic valve is doing... spraying your blood way too fast against your ascending aorta like a pressure wash. I am glad you aren't feeling it, but with the current level of surgical expertise, it is considered safer and better to fix the valve while the rest of the organ is a healthy as possible.
My cardiologist gave me some info, including his TAVR and SAVR surgeons of usual choice, but then said... you seem smart. Do some research, let me know what you want to do.
I quickly found out that TAVR was NOT am option with a bicuspid aortic valve. Blue Cross /Blue Shield specifically excludes coverage for it. (For good reason - all-cause 2 year morbidity nearly triples when TAVR is done on a bicuspid aortic valve).
I also really wanted to avoid a cracked sternum (I am 51, I teach high school, I have a 70 lb dog, and trouble sitting still) so I found a Surgeon who specializes in minimally invasive open heart surgery. After agonizing over valve choice (non issue for you - the clear recommendation after age 70 is a bio-prosthetic) I had my mini-thoracotomy on June 12. Replaced the valve, spent 4 nights in the hospital (1 full day in ICU), and am walking around, driving, and doing pretty much what I want. I am supposed to avoid straining my right arm (10 lbs or less) for 2 more weeks.
The biggest issue I have had with recovery is the chest drainage tube wound isn't healing as well as we would like, so I am seeing a wound care clinic for that.

Let me know if you have any other questions for me!

Hi Erwitchin (gonna have to know about that nic sometime) and I very much appreciate your experience and insight. It was rather odd that the TAVR surgeon, never mentioned these things and I was only informed 24 hours before my appointment with the heart surgeon. The heart sugeon was very persuasive that this was the best route for me...and I grow more confident he has my best outcome in mind. Thank you.

 

[dick0236]

I turned 72 in April, in quite good shape (minus a few pounds) and very active. Still working 11-hour days, walking job sites, meeting with Customers, etc.

I was your age about 20 years ago.....with a mechanical heart valve that was 40 years old and I could do what I did in my 50s (I thought). Now I am nearly 90 with that same heart valve (thankfully). Once I hit +/- 80 things began to change, not in a good way.......it is called "old age". IMO I would look at a "bio" valve like the new Edwards Inspirus which they say could last 20 years........then you could get a TAVR.

BTW, Edwards Lifesciences also built my mechanical valve as they were the first to bring an artificial heart valve to the market. They told me, in 1967, that my valve was designed to last 50 years.......it is almost 57 years old now......and still going strong.

 

[macdaddy]

Another option to consider is a mini-sternotomy. This is a procedure where only half of the sternum is opened and also the surgeon should close the sternum with Titanium plates (instead of wires) which fixates the sternum.

https://www.uchicagomedicine.org/conditions-services/heart-vascular/heart-surgery/sternal-plating

This is procedure is pretty much the standard in the major clinics for open heart surgery. I had both techniques and was back at work 2 weeks post surgery and riding my bike 6 weeks post surgery. Recovery was relatively quick, the sternum half's were stabilized and all I needed one day post surgery was just Tylenol. My surgeon told me that performing the surgery with full visibility would be his preference.

I was your age about 20 years ago.....with a mechanical heart valve that was 40 years old and I could do what I did in my 50s (I thought). Now I am nearly 90 with that same heart valve (thankfully). Once I hit +/- 80 things began to change, not in a good way.......it is called "old age". IMO I would look at a "bio" valve like the new Edwards Inspirus which they say could last 20 years........then you could get a TAVR.

BTW, Edwards Lifesciences also built my mechanical valve as they were the first to bring an artificial heart valve to the market. They told me, in 1967, that my valve was designed to last 50 years.......it is almost 57 years old now......and still going strong.

The valve shown to me for the mini was the Edwards Resillia; (bio valve) I've heard good things. I appreciate your input, keep on, keeping on sir!

 

[BGold]

Wow! Learned so much I didnt know from this thread.
Best of Luck McDaddy, I'm sure you will make the right decision.

 

[Croooser]

I was 71 when I had a Mini at CC to replace my bicuspid AV and repair an ascending AA. I assume that you don't have an AA as you did not mention it and I believe that they need a little bit more room to repair that. Valve used for me was Inspiris Resilia. Three years in and so far, so good. Resumed normal (for me) activities. Annual echo will be later this year.

HTH

 

[macdaddy]

Wow! Learned so much I didnt know from this thread.
Best of Luck McDaddy, I'm sure you will make the right decision.

Thank you BGold; interesting the TAVR nurse called trying to set an appt for surgery, but I told her I was not at that point right now. I'm getting a sense it's a competition for who gets the business, and a lot less about what's best for me. That being said, everyone has been very up front on the pluses and minuses, with full disclosure. Even with this follow up call, she repeated the downsides of the TAVR procedure. Just so much to process, based on what little information I can gather and assimilate in as little time as I have.

 

[dick0236]

Just so much to process, based on what little information I can gather and assimilate in as little time as I have.

I can only imagine your difficulty in choosing between so many options. When I had the surgery there was only one valve, mechanical, available so my choice was simple. Anything you do today can be changed if another procedure is necessary down the road. All you can do is investigate and choose what your think is best for you.

 

[macdaddy]

I can only imagine your difficulty in choosing between so many options. When I had the surgery there was only one valve, mechanical, available so my choice was simple. Anything you do today can be changed if another procedure is necessary down the road. All you can do is investigate and choose what your think is best for you.

You're right Dick0236; it's both nice and troubling to have so many choices; but I've gone through the first three stages and I'm coming to grips with it. I'm an engineer, so I still have to analyze the living daylights out of it until I feel comfortable with a decission. Thank goodness for this forum; so many nice people with so much knowledge. It's a great comfort.

 

[pellicle]

Hi

I'm an engineer

me too, but here's the thing, its not an engineering problem. Its an emotional one and a risk assessment one.

so:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6306127/

Degenerative valve disease is on the rise with greater than 100,000 valve operations performed in the US alone per year. *The majority of those procedures employ tissue bioprostheses to avoid the attendant risk of anticoagulation*, especially in the elderly. Though traditionally this approach has been considered a superior option to avoid anticoagulation, more recent analyses have demonstrated a significant incidence of previously unrecognized thrombosis associated with bioprosthetic valves, especially with the more recent advent of the transcatheter aortic valve replacement implantations. Bioprosthetic valve thrombosis is a major cause of either acute or indolent bioprosthetic valve degeneration, and often has an elusive presentation causing delayed recognition and treatment. The literature has extensively addressed the risks and benefits of anticoagulation following bioprosthetic valve replacement to prevent bioprosthetic valve thrombosis (BPVT), *without conclusive evidence-based recommendations*. The duration of anticoagulation following an episode of BPVT is unclear, *and lifelong anticoagulation has been suggested*. The increasing use of transcatheter aortic valve replacement as an alternative to surgical aortic valve replacement in various risk groups has introduced new challenges with regards to valve thrombosis, *which have been poorly studied with regards to optimal treatment and prevention*. The increasing use of valve-in-valve procedures is expected to bring on further uncharted challenges.

as previously suggested by Dr Schaff of the Mayo


a more current video


I think more than warfarin etc. This is the main issue of the valve replacement.

Last discussion:
https://www.medscape.com/viewarticle/838221

Best Wishes

 

[dick0236]

Degenerative valve disease is on the rise with greater than 100,000 valve operations performed in the US alone per year. *The majority of those procedures employ tissue bioprostheses to avoid the attendant risk of anticoagulation*, especially in the elderly. Though traditionally this approach has been considered a superior option to avoid anticoagulation, more recent analyses have demonstrated a significant incidence of previously unrecognized thrombosis associated with bioprosthetic valves, especially with the more recent advent of the transcatheter aortic valve replacement implantations. Bioprosthetic valve thrombosis is a major cause of either acute or indolent bioprosthetic valve degeneration, and often has an elusive presentation causing delayed recognition and treatment. The literature has extensively addressed the risks and benefits of anticoagulation following bioprosthetic valve replacement to prevent bioprosthetic valve thrombosis (BPVT), *without conclusive evidence-based recommendations*. The duration of anticoagulation following an episode of BPVT is unclear, *and lifelong anticoagulation has been suggested*. The increasing use of transcatheter aortic valve replacement as an alternative to surgical aortic valve replacement in various risk groups has introduced new challenges with regards to valve thrombosis, *which have been poorly studied with regards to optimal treatment and prevention*. The increasing use of valve-in-valve procedures is expected to bring on further uncharted challenges.

Interesting study. I guess it only shows "there is no such thing as a free lunch"

 

[pellicle]

I guess it only shows "there is no such thing as a free lunch"

agreed ... and while many say "any valve is a good choice" I would not phrase it that way. I'd say "any valve is a better choice than dying of valvular disease; but you need to make an honest and true to your self choice. You need to decide in the light of:

• your age
• your medical / physical condition
• how long you reasonably expect to live
• your level of engagement your health condition in life after surgery

Most importantly, don't lie to yourself (the little stories we tell ourselves about who we are; hoping others will believe it)

From understanding all this, you can then make a more optimal choice.

If you can't then as I say "flip a coin" ... if you don't like the answer then that itself tells you something about what you really wanted.

I'm lucky, the choices were always 'obvious' to me (well, not when I was 10).

 

[macdaddy]

Hi

me too, but here's the thing, its not an engineering problem. Its an emotional one and a risk assessment one.

so:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6306127/

Degenerative valve disease is on the rise with greater than 100,000 valve operations performed in the US alone per year. *The majority of those procedures employ tissue bioprostheses to avoid the attendant risk of anticoagulation*, especially in the elderly. Though traditionally this approach has been considered a superior option to avoid anticoagulation, more recent analyses have demonstrated a significant incidence of previously unrecognized thrombosis associated with bioprosthetic valves, especially with the more recent advent of the transcatheter aortic valve replacement implantations. Bioprosthetic valve thrombosis is a major cause of either acute or indolent bioprosthetic valve degeneration, and often has an elusive presentation causing delayed recognition and treatment. The literature has extensively addressed the risks and benefits of anticoagulation following bioprosthetic valve replacement to prevent bioprosthetic valve thrombosis (BPVT), *without conclusive evidence-based recommendations*. The duration of anticoagulation following an episode of BPVT is unclear, *and lifelong anticoagulation has been suggested*. The increasing use of transcatheter aortic valve replacement as an alternative to surgical aortic valve replacement in various risk groups has introduced new challenges with regards to valve thrombosis, *which have been poorly studied with regards to optimal treatment and prevention*. The increasing use of valve-in-valve procedures is expected to bring on further uncharted challenges.

as previously suggested by Dr Schaff of the Mayo


a more current video


I think more than warfarin etc. This is the main issue of the valve replacement.

Last discussion:
https://www.medscape.com/viewarticle/838221

Best Wishes

Okay, there's 2.5 hours of looking up terminologies I never heard of. Reports like this present such a bleak picture, I’m beginning to doubt if it’s even worth it. I don’t want to walk around on eggshells worrying about the next event. I know nothing is perfect, and post-surgery, we’re playing with the house’s money, but these reports are terrifying to me. How do I go about daily routines if all I’m thinking about is BPVT et al.

Good grief! I was starting to come to peace with this…NOT ANYMORE! Now I’ve got to call my surgeon, and hit him with my next round of paranoia.

I truly appreciate all the articles you bring in here pellicle; but I sometimes wonder if I’m not better off in my ignorance…certainly food for thought.

 

[pellicle]

Okay, there's 2.5 hours of looking up terminologies I never heard of.

excellent, since the aim is "becoming informed" I think you've started off well here ... how else can the patient make an informed decision without learning what is involved and how to discuss it?

Reports like this present such a bleak picture,

in which way? Sounds perfectly reasonable and rational to me. I've already had 3 surgeries, on the lead into the third I wanted the straight facts not some fanciful story that made me feel good then 10 years later had me actually facing a bleak picture.

I’m beginning to doubt if it’s even worth it. I don’t want to walk around on eggshells worrying about the next event.

why walk on egg shells? Do you drive a car? Far more dangerous (I ride a motorcycle too). I like to be involved in my safety.

I manage my INR to a standard way above the miserable level of clinics, so (if you'd listened carefuly to that bleak picture) you'd find that YOU TOO can do that and be in the situation of being equal to the age related general population in terms of risk.

Sounds like a bright and sunny day to me ...

I know nothing is perfect, and post-surgery, we’re playing with the house’s money, but these reports are terrifying to me. How do I go about daily routines if all I’m thinking about is BPVT et al.

do what I do ... don't make a choice knowing what the data says and take it with both hands.

My opinion is that only a mechanical valve gives me any say in the outcomes. A bio leaves me at the mercy of odds that I have no influence over ... wow ... talk about bleak right there.

I truly appreciate all the articles you bring in here pellicle; but I sometimes wonder if I’m not better off in my ignorance…certainly food for thought.

well if you say that sort of thing then you probably are better off being in ignorance.



Don't let anxiety rule you. Push it back sit on it and take charge. If you don't it will. Some great lyrics here

make sure you have good bass speakers (or headphones) and crank it up

Well you live up above my ceiling and you feed on the filth in my head​

You come down in the cool of the evening and get comfortable in my bed​

​

I had it out with you, must have been years ago and I thought that I'd left you behind​

But you've come back again to haunt me and taunt me and force me to loose my mind​

You keep pushing me down down down down down down down​

​

Now I'm seeing things and I'm hearing things​

I've let the ******* get the better of me and cast me into a well of depression​

​

Well I know that you're not a real person but I know that you're more than real​

This time I'm not going to let you screw me, so tell me how does that make you feel?​

be the captain of your own psychic parts

Best Wishes

 

[macdaddy]

Well...decision made and surgery will be 07-26-2024 @ 8AM. I'm hitching my horse to a mini-AVR with an Edwards INSPIRIS RESILIA Aortic Valve. There was a lot of ups and downs, but for the long run, if I outlive this valve, it makes it easier to do a TAVR the second time around. All things considered, I'm confident this is the route for me. I've got a mild soar throat this morning, so they asked that I do a COVID test, and if negative, they'll move forward. Scared out of my wits would be putting it mildly. If anyone here has had this procedure, I'd sure like to know what the recovery process was like...just so I know what to expect Friday after surgery.

 

[Erwitchin]

Well...decision made and surgery will be 07-26-2024 @ 8AM. I'm hitching my horse to a mini-AVR with an Edwards INSPIRIS RESILIA Aortic Valve. There was a lot of ups and downs, but for the long run, if I outlive this valve, it makes it easier to do a TAVR the second time around. All things considered, I'm confident this is the route for me. I've got a mild soar throat this morning, so they asked that I do a COVID test, and if negative, they'll move forward. Scared out of my wits would be putting it mildly. If anyone here has had this procedure, I'd sure like to know what the recovery process was like...just so I know what to expect Friday after surgery.

I just had that surgery on June 12. I was in pain for a few days because my lung didn't want to inflate back up. (I was a smoker for 40+ years and quit the day before surgery) The pain was well managed and I was able to go home 4 days after surgery. I was able to drive a week later. I am exercising now, and feel better than I have in decades (and I didn't even realize that I was feeling so bad before the stenosis was identified)

Any surgeon qualified to do the mini thoracotomy is highly skilled in an already highly skilled set of surgeons. Try not to stress! They do this all the time

 

[macdaddy]

Well, I truly, truly appreciate your feedback, and congratulations on your recovery...that's terrific. You have my best hopes, and encouragement, to not pick the habit back up again. I'd like to think it'll at several more decades to your future. Hopefully, I can check back in here again next week with the good news. Thanks again Erwitchin.