TAVR

[67walkon]

In 2007, my bicuspid ao valve was replaced with a bovine valve. It’s time for a new valve.

TAVR seems like the way to go. I’m working with a structural cardiac specialist group. A question is what size valve. My current valve is 25 mm but the new folks are saying the inside dimension is 23 or maybe 22. There is discussion about the size of the TAVR they can use. The open heart guy on the team suggests ohs so he can put a bigger valve in there. The TAVR doc doesn’t seem as concerned.

I‘m 74, 6’2” and weigh 160 after all the crap they have me on. I was very, very active until recently and want to return to being very, very active. The valve failure has caused some right side heart issues that should improve with replacement.

Any experience or thoughts about the TAVR, the size of the valve, or whatever related to this?

Thanks.

 

[pellicle]

Any experience or thoughts about the TAVR, the size of the valve, or whatever related to this?

There has been a lot of discussion about this here over the years, as well as development of the technology and emergence of longer term data.

I would expect you (it's statistical and biochemical) to be good out to 7 years, and perhaps 10.

After that we are finding that TAVI in TAVI , while having a reduced annular diameter may be sufficient for you.

If you are 67 there might be a good case for SAVR.

Usually I would argue that you should project on family historical basis what you anticipate that your lifespan is statistically likely to be and choose a valve which has that sort of durability.

Still relevant IMO



That should get the floor going.

 

[pellicle]

Oh, and @67walkon; when I wrote:

I would expect you (it's statistical and biochemical) to be good out to 7 years, and perhaps 10.

I think its worth looking at a recent study with a critical eye

from:
https://pubmed.ncbi.nlm.nih.gov/30732706/

Results: A total of 241 patients (79.3 ± 7.5 years of age; 46% female) with paired post-procedure and late echocardiographic follow-up (median 5.8 years, range 5 to 10 years) were included. A total of 149 patients (64%) were treated with a self-expandable valve and 80 (34.7%) with a balloon-expandable valve. Peak aortic valve gradient at follow-up was lower than post-procedure (17.1 vs. 19.1 mm Hg; p = 0.002). More patients had none/trivial aortic regurgitation (AR) (47.5% vs. 33%), and fewer had mild AR (42.5% vs. 57%) at follow-up (p = 0.02). There was 1 case (0.4%) of severe SVD 5.3 years after implantation (new severe AR). There were 21 cases (8.7%) of moderate SVD (mean 6.1 years post-implantation; range 4.9 to 8.6 years). Twelve of these (57%) were due to new AR and 9 (43%) to restenosis.​

​

Conclusions: Long-term transcatheter aortic valve function is excellent {Pellicle: if that's excellent what was your baseline for good?}. In the authors' study, 91% of patients remained free of SVD between 5 and 10 years post-implantation. The incidence of severe SVD was <1%. Moderate SVD occurred in 1 in 12 patients.​

bold mine

So if you think to yourself "based on family history" I anticipate living another 20 years, then perhaps a mechanical may be worth thinking about. After all you may just wind up on warfarin anyway.

Some points on warfarin from my blog
https://cjeastwd.blogspot.com/2014/09/managing-my-inr.html
Best Wishes

 

[morellib]

Glad you got a good 16+ years out of your tissue valve and fully understand the appeal of going TAVR this time. Several thoughts in addition to what Pellicle said. Since the one surgeon is talking about wanting to be able to put in a nice-sized valve, I assume he feels you are in good enough condition to tolerate a second OHS. If so (and I’m not trying to minimize the additional difficulties of a second OHS) you might in the long run have a better outcome, particularly if you want to get back to more rigorous activity. If they’re saying your effective diameter is 22 or 23, there will be limited valve size choices for the TAVR. The Edwards Sapien 3 TAVR comes in sizes 20, 23,26,,29 and the Medtronic Evolut PRO ranges from 23 to 29. It might be problematic to do a TAVR in a TAVR with those diameters if you need a replacement in your early 80s. OHS might get you through your lifetime, or allow for a TAVR if you need one later in life. Just some thoughts and good luck and best wishes whatever you decide…

 

[vitdoc]

The two issues you are facing are first the hemodynamic function in a valve that is significantly smaller than the current valve. I can give no advice about that but that question needs to be carefully gone over. Second, what is the life expectancy of you and your potential valve?
If you do go TAVR than you could be facing another valve in possible less than 10 yrs. If there are issues with the hemodynamics now I would expect a second TAVR would not be an option down the road. So you have a choice which to be made properly needs good input. First would a TAVR work up to your standards? If yes than what would you do if it fails and you still may be in relatively good shape say at 84? So possibly an open heart now with either a tissue valve that would probably last longer than a TAVR tissue or a mechanical. The annulus can be enlarged if you go tissue so that a TAVR in the future could be bigger.
I would carefully ask these questions especially since there is some difference in opinion between the cardiac surgeon and the cardiologist. Given your current age and the probable longevity of a surgically placed tissue that might be the best option. But I must admit doing a TAVR compared to open heart would be much nicer for you but probably not enough to overcome the limitations. Good luck.

 

[67walkon]

Ug. Now they’re telling me the valve issue has caused a liver issue. More tests.

 

[morellib]

So sorry to hear that. Keep us posted…

 

[pellicle]

Ug. Now they’re telling me the valve issue has caused a liver issue. More tests.

ugg indeed .. did they say what the liver issue was and how the valve is causal for that? (*because it seems unlikely to me)

 

[67walkon]

ugg indeed .. did they say what the liver issue was and how the valve is causal for that? (*because it seems unlikely to me)

It’s called “cardiac cirrhosis”. The aortic valve failure can cause right side heart failure which in turn causes increased venous pressures in the liver. I had never heard of it until recently. A gastrointestinal doc diagnosed it because I don’t have anything else that might cause cirrhosis. Never been overweight, tested negative for ever having hepatitis, not diabetic, haven’t abused alcohol. It may go away or at least improve when the valve is replaced.

 

[pellicle]

Wow ...

It’s called “cardiac cirrhosis”. The aortic valve failure can cause right side heart failure which in turn causes increased venous pressures in the liver. I had never heard of it until recently.

very interesting. I learn so much by being here. I'm sorry to learn at your cost.

Best Wishes