The story and concerns surrounding my AVR in 2014

[libermana]

Here's the bio I posted in my profile. I'd enjoy reading about your similar experiences and welcome your thoughts/advice:

Until my early 60's I always enjoyed great health and never experienced a hospitalization. I ran, cycled, did elliptical and weight training workouts, and practiced yoga. In 2013 while going through a department of transportation physical (a requirement for maintaining a commercial drivers license), I learned that I had a heart murmur. When inquiring about the ramifications, I was shocked to find out by the physician assistant who was examining me said that I might need an aortic valve replacement (AVR) in the future.

I immediately made an appointment with my physician who referred me to a cardiologist for evaluation and shortly thereafter, an echocardiogram was performed. While the numbers were concerning, I was told to come back in a year for a follow-up echo. Fast forward to 2014 and the results of that echo revealed that I needed an AVR within the next three months. The operation went very well, received a pig tissue valve (23 mm Magna Ease Pericardial Tissue Valve), and was released from the hospital four days later. Because of my great health and fitness, my recovery went very smoothly.

Several months later in 2015, I had laser cataract surgery for both of my eyes. In 2016, I lost vision in my right eye for about 60 seconds. Thinking it was related to my cataract surgery, I rushed myself to the eye center where I was told that I needed to immediately go to the emergency room as I might have experienced a stroke. I was admitted to the hospital and went through an exhaustive battery of tests where nothing was found related to my vision loss. The incident was labeled a TIA and I was instructed to be aware of all the warning signs of a stroke.

From that point forward, I was hyper-sensitive to anything I experienced that might be the beginning stages of a stroke. Needless to say, living in that state of mind caused me much stress and anxiety. Several months later in 2017, I started experiencing great fatigue and visited my physician on a few occasions to find the cause. Routine bloodwork came back normal and was told that my fatigue was due to stress and anxiety. I kept feeling worse over the next few weeks and eventually experienced a very high fever and chills. He finally ordered a blood culture and the results indicated that I needed to be admitted to the hospital where I was diagnosed with endocarditis. I spent six days in the hospital and was treated with Rocephin. The day I was discharged, a pic-line was placed in my arm and I spent the next six weeks self-infusing with Rocephin. Fortunately, results of a transesophageal echocardiogram showed that he vegetation that grew on my valve had receded and wouldn't need a new aortic valve. Thanks to that medication and the support/treatment of my medical team, the infection cleared and life went on!

To this day, I have no idea of the reason I got endocarditis as I always took antibiotic medication before any dental procedure. Regarding the vision loss I experienced / TIA, my infectious disease physician speculates that a tiny fragment of vegetation detached from my heart valve and was temporarily lodged in a blood vessel of my eye. Experiencing endocarditis was one of the most stressful experiences of my life as that was the first time I ever thought about my mortality. Over the next few years through the present, I've enjoyed relatively good health thanks in part to keeping fit through exercise and eating a healthy diet on most occasions. My cardiologist has been tracking my health and have echocardiograms done annually.

Most recently in May, 2022, the results of the last echo revealed that the value of the gradient was now something to monitor more closely and have another echo scheduled for November. While I really don't understand the technical aspects of the gradient value, I interpret this as the first sign the valve is failing. While my cardiologist tried to ally my concerns saying that there's no way of knowing at this time how soon I will need an AVR, the thought of having to undergo another procedure adds to my stress and anxiety. In conclusion, I joined this support group as I'm sure over the next few months and years, I will have several questions about options such as TAVR (which I much prefer) vs mini-aortic surgery, ramifications for yet another TAVR 10 years from now, latest research on prosthetic valves, etc. Thanks for taking the time to read my profile and best of luck to everyone!

 

[Chuck C]

Welcome to the forum!

That it very good news that they got the endocarditis under control in 2017 without the need for surgery. Many here have been less fortunate with endocarditis leading to another OHS and valve replacement, so good for your medical team for getting you on the anti-biotics relatively soon.

However:

Several months later in 2017, I started experiencing great fatigue and visited my physician on a few occasions to find the cause. Routine bloodwork came back normal and was told that my fatigue was due to stress and anxiety

I'm curious if they did more than blood work to try to get to the bottom of things? One thing that I have picked up from reading hundreds of stories on this forum is that when a person has a valve disease or a prosthetic valve, that signs of loss of breath, fatigue or fainting should be taken very seriously. Endocarditis and/or structural valve degeneration (SVD) should always be suspected as a possible cause and extensive testing done, including echos to rule this out. It seems that similar stories are played out often, with a physician telling a patient that their symptoms were probably just from, fill in the blank, and the true cause never discovered until typically an echo is done.

Anyway, good that the anti-biotics did the job and you didn't need surgery. However, it's certainly possible that there was some residual damage to the valve from the infection which led to earlier SVD than one would generally hope for.

the results of the last echo revealed that the value of the gradient was now something to monitor more closely and have another echo scheduled for November. While I really don't understand the technical aspects of the gradient value, I interpret this as the first sign the valve is failing.

You are likely correct. An increasing pressure gradient in usually due to the valve calcifying and narrowing, which creates greather pressure inside the left ventrical and a gradient of pressure across the aortic valve. The good news is that your medical team is on top of it and good that they moved your echos from every 12 months to every 6 months, as this is the time when close monitoring is important.

For my two cents worth, I would suggest really paying close attention to any symptoms of valve disease, shortness of breath, fatigue, fainting or lightheadedness. If you have a fainting spell for example and need to go to the ER, don't let them dismiss you without getting an echo to see where your SVD is at. Once SVD has started it can progress rapidly and it is important to get surgery in a timely manner, once the time comes. As SVD progresses, our hearts adapt to the higher pressure environment, typically by enlarging. Other things can go on which affect other valves as well. For example the increased pressure can cause mitral valve regurgitation. If surgery is done in time, the structural changes to your heart will reverse after surgery. If a person waits too long, the heart may not fully recover. So, when it's time, don't delay, especially since this will be #2 for you and you already have some scar tissue in there from #1.

I think that you will find this forum a great resource- I know that I sure did. You may have choices now that you did not have in 2014. You indicated a preference for TAVR. One thing you could do now, even though it is not time yet for surgery, is get evaluated for TAVR. When my aortic stenosis was still moderate, my cardiologist referred me to be evaluated for TAVR, just so that we knew whether this choice was on the table for us when the time comes. It turned out that I was not eligible, so this consideration was completely crossed of the list as an option. Even if they do indicate that you are eligible now for TAVR, of course they will need to reevaluate you when the time comes for needing valve replacement.

One thing to consider with TAVR is that at age 69 you are still relatively young in the valve world. TAVR has advantages for the first 30 days following surgery and for the first year after surgery. However, as data is coming in for TAVR up to 5 years we are seeing that SAVR (surgical arotic valve replacement) has advantages over TAVR by the 5 year point, with lower overall mortality, even taking into account the lower risk of mortality in the first year after TAVR. Years 2-5 show SAVR having a strong survival advantage over TAVR. I would expect that that improved survival will continue in that direction as we get 5+, but data is lacking. TAVR will offer a quicker recovery and you will be back to your normal schedule before you know it, but if you expect to live more than 5 years, other than getting back to things sooner, I would question the value of going TAVR, based on the data. One of the most respected surgeons in the country, Lars Svensson, suggests that younger patients do not even consider TAVR until they have had SAVR #2, because of the low mortality for SAVR #2 and the complications that arise after the TAVR valve reaches the end of its life. See video linked below of this discussion. If you do get 10 years out of a TAVR, which is not certain at all, then you might think about what that will mean when your TAVR valve needs replacement. If things go well, you will probably be 79 to your early 80s. TAVR in TAVR may be a possibility, but that will leave you with a very small valve opening and very little cardiac output. When I ran the numbers with my cardiologist, at age 52, if I went tissue then TAVR, then TAVR in TAVR, we estimated that I would be needing TAVR in TAVR at age 70 to 75. He estimated that my cardiac output would be so limited by that point that I would not be able to do much more than walk. My dad is 79 and bikes daily and my mom is 79 and swims 5 days a week, and I hope to be active like them in my late 70s, so the TAVR in TAVR was not appeal to me at all. Now, if you end up not needing your valve procedure for another 5 years that could change things and TAVR might be given more weight as an option. However, once SVD starts on a prosthetic valve, I would say it does not seem likely that it will be more than a couple of years before it needs replacement.

I would suggest reading up on the Edwards Resilia valve and you will find threads on this forum about this valve. At age 69-70+ you would be a great candidate for another tissue valve and this valve is expected to last a little longer than previous generations. At age 70, I think it is reasonable to hope for 15 to 25 years from this valve, likely making it the last valve procedure that you will need. If you are one of those who win the genetic lottery and are still going strong by age 85 or 90, at that point TAVR would probably be an excellent option and the Resilia valve is designed to accomodate a future TAVR, with an expandable ring.

This is the valve discussion between Lars Svensson and Doug Johnson, surgeons at the Cleveland Clinic. If you go to 8:30- 9:30, Lars Svensson suggests that young patients do not consider a TAVR until having two SAVRS, due to the complications that will arise after TAVR valve wears out.



In that you are considering TAVR you may want to read this opinion piece discussing some of the inferior mortality statistics for TAVR from years 2-5, based on PARTNER-2.

“In fact, these concerns are underscored by a PARTNER-2 landmark analysis showing a higher rate of death and disabling stroke with TAVR (hazard ratio, 1.27 [95% CI, 1.06–1.53]) from 2 to 5 years.5”

“Compared with SAVR, TAVR is associated with a 3-fold higher incidence of left bundle-branch block as well as an increased incidence of need for a permanent pacemaker”

“For now, justifiable enthusiasm should be tempered by the lack of long-term follow-up data, and it is imperative that our younger patients have a realistic appreciation of the limitations of currently available data.”

https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.047874#:~:text=Multiple studies, with a mean,occurs earlier in younger patients.

The good news is that it sounds like you have some time. So, take your time and read up on your options and continue to discuss them with your cardiologist. There is a lot to take in and no need to feel pressure or rush things as you digest all of the information.

Please keep us posted and best of luck with the decisions which are ahead for you.

 

[libermana]

Welcome to the forum!

That it very good news that they got the endocarditis under control in 2017 without the need for surgery. Many here have been less fortunate with endocarditis leading to another OHS and valve replacement, so good for your medical team for getting you on the anti-biotics relatively soon.

However:



I'm curious if they did more than blood work to try to get to the bottom of things? One thing that I have picked up from reading hundreds of stories on this forum is that when a person has a valve disease or a prosthetic valve, that signs of loss of breath, fatigue or fainting should be taken very seriously. Endocarditis and/or structural valve degeneration (SVD) should always be suspected as a possible cause and extensive testing done, including echos to rule this out. It seems that similar stories are played out often, with a physician telling a patient that their symptoms were probably just from, fill in the blank, and the true cause never discovered until typically an echo is done.

Anyway, good that the anti-biotics did the job and you didn't need surgery. However, it's certainly possible that there was some residual damage to the valve from the infection which led to earlier SVD than one would generally hope for.



You are likely correct. An increasing pressure gradient in usually due to the valve calcifying and narrowing, which creates greather pressure inside the left ventrical and a gradient of pressure across the aortic valve. The good news is that your medical team is on top of it and good that they moved your echos from every 12 months to every 6 months, as this is the time when close monitoring is important.

For my two cents worth, I would suggest really paying close attention to any symptoms of valve disease, shortness of breath, fatigue, fainting or lightheadedness. If you have a fainting spell for example and need to go to the ER, don't let them dismiss you without getting an echo to see where your SVD is at. Once SVD has started it can progress rapidly and it is important to get surgery in a timely manner, once the time comes. As SVD progresses, our hearts adapt to the higher pressure environment, typically by enlarging. Other things can go on which affect other valves as well. For example the increased pressure can cause mitral valve regurgitation. If surgery is done in time, the structural changes to your heart will reverse after surgery. If a person waits too long, the heart may not fully recover. So, when it's time, don't delay, especially since this will be #2 for you and you already have some scar tissue in there from #1.

I think that you will find this forum a great resource- I know that I sure did. You may have choices now that you did not have in 2014. You indicated a preference for TAVR. One thing you could do now, even though it is not time yet for surgery, is get evaluated for TAVR. When my aortic stenosis was still moderate, my cardiologist referred me to be evaluated for TAVR, just so that we knew whether this choice was on the table for us when the time comes. It turned out that I was not eligible, so this consideration was completely crossed of the list as an option. Even if they do indicate that you are eligible now for TAVR, of course they will need to reevaluate you when the time comes for needing valve replacement.

One thing to consider with TAVR is that at age 69 you are still relatively young in the valve world. TAVR has advantages for the first 30 days following surgery and for the first year after surgery. However, as data is coming in for TAVR up to 5 years we are seeing that SAVR (surgical arotic valve replacement) has advantages over TAVR by the 5 year point, with lower overall mortality, even taking into account the lower risk of mortality in the first year after TAVR. Years 2-5 show SAVR having a strong survival advantage over TAVR. I would expect that that improved survival will continue in that direction as we get 5+, but data is lacking. TAVR will offer a quicker recovery and you will be back to your normal schedule before you know it, but if you expect to live more than 5 years, other than getting back to things sooner, I would question the value of going TAVR, based on the data. One of the most respected surgeons in the country, Lars Svensson, suggests that younger patients do not even consider TAVR until they have had SAVR #2, because of the low mortality for SAVR #2 and the complications that arise after the TAVR valve reaches the end of its life. See video linked below of this discussion. If you do get 10 years out of a TAVR, which is not certain at all, then you might think about what that will mean when your TAVR valve needs replacement. If things go well, you will probably be 79 to your early 80s. TAVR in TAVR may be a possibility, but that will leave you with a very small valve opening and very little cardiac output. When I ran the numbers with my cardiologist, at age 52, if I went tissue then TAVR, then TAVR in TAVR, we estimated that I would be needing TAVR in TAVR at age 70 to 75. He estimated that my cardiac output would be so limited by that point that I would not be able to do much more than walk. My dad is 79 and bikes daily and my mom is 79 and swims 5 days a week, and I hope to be active like them in my late 70s, so the TAVR in TAVR was not appeal to me at all. Now, if you end up not needing your valve procedure for another 5 years that could change things and TAVR might be given more weight as an option. However, once SVD starts on a prosthetic valve, I would say it does not seem likely that it will be more than a couple of years before it needs replacement.

I would suggest reading up on the Edwards Resilia valve and you will find threads on this forum about this valve. At age 69-70+ you would be a great candidate for another tissue valve and this valve is expected to last a little longer than previous generations. At age 70, I think it is reasonable to hope for 15 to 25 years from this valve, likely making it the last valve procedure that you will need. If you are one of those who win the genetic lottery and are still going strong by age 85 or 90, at that point TAVR would probably be an excellent option and the Resilia valve is designed to accomodate a future TAVR, with an expandable ring.

This is the valve discussion between Lars Svensson and Doug Johnson, surgeons at the Cleveland Clinic. If you go to 8:30- 9:30, Lars Svensson suggests that young patients do not consider a TAVR until having two SAVRS, due to the complications that will arise after TAVR valve wears out.



In that you are considering TAVR you may want to read this opinion piece discussing some of the inferior mortality statistics for TAVR from years 2-5, based on PARTNER-2.

“In fact, these concerns are underscored by a PARTNER-2 landmark analysis showing a higher rate of death and disabling stroke with TAVR (hazard ratio, 1.27 [95% CI, 1.06–1.53]) from 2 to 5 years.5”

“Compared with SAVR, TAVR is associated with a 3-fold higher incidence of left bundle-branch block as well as an increased incidence of need for a permanent pacemaker”

“For now, justifiable enthusiasm should be tempered by the lack of long-term follow-up data, and it is imperative that our younger patients have a realistic appreciation of the limitations of currently available data.”

https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.047874#:~:text=Multiple studies, with a mean,occurs earlier in younger patients.

The good news is that it sounds like you have some time. So, take your time and read up on your options and continue to discuss them with your cardiologist. There is a lot to take in and no need to feel pressure or rush things as you digest all of the information.

Please keep us posted and best of luck with the decisions which are ahead for you.

Dear Chuck,
Thanks so much for the wealth of information you provided along with your analysis of my situation. There’s indeed lots to think about regarding AVR options. Hopefully, that will be a few years down the road but need to be fully informed so as to make the best decision when the time comes to consult with the surgeon. Again, thanks!

 

[pellicle]

Hi and welcome

What sort of valve did you have?

edited your quote by paragaraph breaks only:

Here's the bio I posted in my profile. I'd enjoy reading about your similar experiences and welcome your thoughts/advice:

Until my early 60's I always enjoyed great health and never experienced a hospitalization. I ran, cycled, did elliptical and weight training workouts, and practiced yoga. In 2013 while going through a department of transportation physical (a requirement for maintaining a commercial drivers license), I learned that I had a heart murmur.

When inquiring about the ramifications, I was shocked to find out by the physician assistant who was examining me said that I might need an aortic valve replacement (AVR) in the future. I immediately made an appointment with my physician who referred me to a cardiologist for evaluation and shortly thereafter, an echocardiogram was performed. While the numbers were concerning, I was told to come back in a year for a follow-up echo.

Fast forward to 2014 and the results of that echo revealed that I needed an AVR within the next three months. The operation went very well, received a pig tissue valve, and was released from the hospital four days later. Because of my great health and fitness, my recovery went very smoothly.

Several months later in 2015, I had laser cataract surgery for both of my eyes. In 2016, I lost vision in my right eye for about 60 seconds. Thinking it was related to my cataract surgery, I rushed myself to the eye center where I was told that I needed to immediately go to the emergency room as I might have experienced a stroke. I was admitted to the hospital and went through an exhaustive battery of tests where nothing was found related to my vision loss.

The incident was labeled a TIA and I was instructed to be aware of all the warning signs of a stroke. From that point forward, I was hyper-sensitive to anything I experienced that might be the beginning stages of a stroke. Needless to say, living in that state of mind caused me much stress and anxiety.

Several months later in 2017, I started experiencing great fatigue and visited my physician on a few occasions to find the cause. Routine bloodwork came back normal and was told that my fatigue was due to stress and anxiety. I kept feeling worse over the next few weeks and eventually experienced a very high fever and chills. He finally ordered a blood culture and the results indicated that I needed to be admitted to the hospital where I was diagnosed with endocarditis.

I spent six days in the hospital and was treated with Rocephin. The day I was discharged, a pic-line was placed in my arm and I spent the next six weeks self-infusing with Rocephin.

Fortunately, results of a transesophageal echocardiogram showed that he vegetation that grew on my valve had receded and wouldn't need a new aortic valve. Thanks to that medication and the support/treatment of my medical team, the infection cleared and life went on!

To this day, I have no idea of the reason I got endocarditis as I always took antibiotic medication before any dental procedure. Regarding the vision loss I experienced / TIA, my infectious disease physician speculates that a tiny fragment of vegetation detached from my heart valve and was temporarily lodged in a blood vessel of my eye.

Experiencing endocarditis was one of the most stressful experiences of my life as that was the first time I ever thought about my mortality. Over the next few years through the present, I've enjoyed relatively good health thanks in part to keeping fit through exercise and eating a healthy diet on most occasions. My cardiologist has been tracking my health and have echocardiograms done annually.

Most recently in May, 2022, the results of the last echo revealed that the value of the gradient was now something to monitor more closely and have another echo scheduled for November. While I really don't understand the technical aspects of the gradient value, I interpret this as the first sign the valve is failing. While my cardiologist tried to ally my concerns saying that there's no way of knowing at this time how soon I will need an AVR, the thought of having to undergo another procedure adds to my stress and anxiety.

In conclusion, I joined this support group as I'm sure over the next few months and years, I will have several questions about options such as TAVR (which I much prefer) vs mini-aortic surgery, ramifications for yet another TAVR 10 years from now, latest research on prosthetic valves, etc.

Thanks for taking the time to read my profile and best of luck to everyone!

Sorry to read about the endocarditis and it would seem that (as I observe is the norm) the medical system treats your body but does little (if nothing) to allay the concerns of the the mind; which can grow if not treated with a little bit of good information at the start. Nature always accompanies seeds with a store of energy to start with, perhaps medicine could do the same.

You haven't mentioned any details about the valve you got so I'll presume that its a bio-prosthetic valve. If this is the case then the data you're getting is entirely consistent with everything known to this date about the statistics of failure of bio-prosthetice valves (sences Daniel being triggered right about here). So in the spirit of informing you I'll suggest you read this:

https://www.ahajournals.org/doi/10.1161/JAHA.120.018506
interestingly, time and time again you'll read studies saying "long term" in the abstract but saying stuff like this:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6706839/
Table 2
Selection of biological (tissue) prostheses with confirmed long term results*1

Bioprosthesis	Number of patients​	Average age of patients​	Length of follow-up; up to:​	Rates of patients without reoperation after10 years or SVD*2​	Rates of patients without reoperation after15 years or SVD*2​	Rates of patients without reoperation after20 years or SVD*2​
Perimount (e5)	2659​	70.7 ± 10.4​	24 years​	93.2 ± 0.8​	81.5 ± 1.9​	51.5 ± 4.6​
Mitroflow (e6)	1516​	75.6 (16–92)​	19 years​	79.2 ± 2.4​	63.4 ± 5.3​	Not available​
Hancock II (e7)	1134​	67 ±11​	25 years​	97.6 ± 0.6*2​	86.6 ± 1.8*2​	63.4 ± 4.2*2​
Biocor (e8)	1518​	70.8 ± 10.9​	20 years​	Not available​	Not available​	61.1 ± 8.5​
Freestyle (e9)	725​	71.7 ± 7.9​	18 years​	92.3 ± 1.8​	80.7 ± 5.0​	Not available​
Mosaic (e10)	1005​	74.7 ± 6.8​	18 years​	97.9 ± 0.6*2​	86.3 ± 3.9*2​	Not available​

I draw you attention to the after 15 year and then after 20 years.

All the data to hand shows the similar features, that for bioprosthetic valve durability:

• age at implant is the major predictor
• activitiy and metabolism is a predictor
• smoking is a predictor

Anyway, you definitely dodged a bullet with endo and I'm surprised that it didn't result in reoperation.

lastly on a communication note: I struggled to read that due to being slightly dyslexic. Such an enormous slab of unformatted text without even so much as a paragraph break is like a jungle to my eyes. I had to break it up to even be able to read it.

Paragraph breaks were invented by early writers and printers for a reason: readability. If you would be so kind as to break it up that would be lovely, if not then its ok. I'll do that to this quotation so that I can actually read it, but normally I'd have to copy and paste it into an editor to even have a chance at seeing things.

Best Wishes

 

[libermana]

Hi and welcome

What sort of valve did you have?

edited your quote by paragaraph breaks only:


Sorry to read about the endocarditis and it would seem that (as I observe is the norm) the medical system treats your body but does little (if nothing) to allay the concerns of the the mind; which can grow if not treated with a little bit of good information at the start. Nature always accompanies seeds with a store of energy to start with, perhaps medicine could do the same.

You haven't mentioned any details about the valve you got so I'll presume that its a bio-prosthetic valve. If this is the case then the data you're getting is entirely consistent with everything known to this date about the statistics of failure of bio-prosthetice valves (sences Daniel being triggered right about here). So in the spirit of informing you I'll suggest you read this:

https://www.ahajournals.org/doi/10.1161/JAHA.120.018506
interestingly, time and time again you'll read studies saying "long term" in the abstract but saying stuff like this:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6706839/
Table 2
Selection of biological (tissue) prostheses with confirmed long term results*1

Bioprosthesis	Number of patients​	Average age of patients​	Length of follow-up; up to:​	Rates of patients without reoperation after10 years or SVD*2​	Rates of patients without reoperation after15 years or SVD*2​	Rates of patients without reoperation after20 years or SVD*2​
Perimount (e5)	2659​	70.7 ± 10.4​	24 years​	93.2 ± 0.8​	81.5 ± 1.9​	51.5 ± 4.6​
Mitroflow (e6)	1516​	75.6 (16–92)​	19 years​	79.2 ± 2.4​	63.4 ± 5.3​	Not available​
Hancock II (e7)	1134​	67 ±11​	25 years​	97.6 ± 0.6*2​	86.6 ± 1.8*2​	63.4 ± 4.2*2​
Biocor (e8)	1518​	70.8 ± 10.9​	20 years​	Not available​	Not available​	61.1 ± 8.5​
Freestyle (e9)	725​	71.7 ± 7.9​	18 years​	92.3 ± 1.8​	80.7 ± 5.0​	Not available​
Mosaic (e10)	1005​	74.7 ± 6.8​	18 years​	97.9 ± 0.6*2​	86.3 ± 3.9*2​	Not available​

I draw you attention to the after 15 year and then after 20 years.

All the data to hand shows the similar features, that for bioprosthetic valve durability:

• age at implant is the major predictor
• activitiy and metabolism is a predictor
• smoking is a predictor

Anyway, you definitely dodged a bullet with endo and I'm surprised that it didn't result in reoperation.

lastly on a communication note: I struggled to read that due to being slightly dyslexic. Such an enormous slab of unformatted text without even so much as a paragraph break is like a jungle to my eyes. I had to break it up to even be able to read it.

Paragraph breaks were invented by early writers and printers for a reason: readability. If you would be so kind as to break it up that would be lovely, if not then its ok. I'll do that to this quotation so that I can actually read it, but normally I'd have to copy and paste it into an editor to even have a chance at seeing things.

Best Wishes

Dear Pellicile,
Thanks for your comments and information you provided. When I first wrote my bio, I didn't use paragraph breaks because I was concerned there might be a limit on characters allowed. I definitely understand your point and edited the text to include paragraphs.

In regards to your question and comments, I went through all the discharge paperwork in October, 2014 and found more information related to my replacement valve: 23 mm Magna Ease Pericardial Tissue Valve. That's all the information I could find. Regarding the bullet points you included regarding durability of valves, mine was replaced at age 62 (I had a bicuspid valve due to stenosis). I was not a smoker and my lifestyle since my late 20s has been very active. Since receiving the replacement valve, I ran about 12 miles a week and just recently stopped this past November following the advice of my medical team as I had a total left hip replacement. I've continued to do weights regularly at the gym three times a week along with cardo activities four to five times a week: walking, elliptical and cycling. I'm not sure about my metabolic rate but my weight is good for my height (5', 3" and 131 lbs.).

I definitely dodged a bullet regarding my endocarditis and the medical team told me about how lucky I was that I didn't lose vision in my right eye.

In summary, I guess I'll know a bit more about when I will need a replacement valve when I get my next echocardiogram (currently scheduled for November 2022). The results of my previous echo indicated that my gradient value (if that's the correct way to state it) was 17.

Again, thanks for writing!

 

[pellicle]

Hi
and good evening (about to hit the hay here in the land of down under)

...I went through all the discharge paperwork in October, 2014 and found more information related to my replacement valve: 23 mm Magna Ease Pericardial Tissue Valve.

that's a well regarded valve from a good company and getting 8 years is on the low end but I suspect that the average time is closer to 10 ... if you're active (exersize wise) then that will also as I understand, contribute to it lasting less.

... and my lifestyle since my late 20s has been very active.

yep. As it happens a good (life time) friend of mine who does marathons (and is the same age as me) had his valve done last year. He picked a tissue prosthetic (I forget which) for reasons such as "after all the problems you've had with managing warfarin" ... which bamboozled me and was like he'd been gathering data from a Pellicle in the alternate universe with Walternate (via a IBM golfball typewriter).

...stopped this past November following the advice of my medical team as I had a total left hip replacement.

oh my, that's bad news ...

I definitely dodged a bullet regarding my endocarditis and the medical team told me about how lucky I was that I didn't lose vision in my right eye.

don't buy a lottery ticket ... you've already used up your quota for a bit ;-)

In summary, I guess I'll know a bit more about when I will need a replacement valve when I get my next echocardiogram (currently scheduled for November 2022).

That is indeed how it goes (me included).

The results of my previous echo indicated that my gradient value (if that's the correct way to state it) was 17.

this is an aspect which I've never bothered schooling myself on because frankly I put credence in the opinions of my surgeon and cardiologist. In my own case I had a surprise aneurysm discovery in 2011 which was (IIRC) about 5.6cm and surgery was to be done based on that. So I never got to stretch out the limits of my valve (of that time) which was a homograft.

So in Nov 2011 I had my 3rd surgery and they put in an ATS and a dacron graft for the aorta.

I've been ticking along fine since then, with perhaps a recent occurrence of atrioventricular tachycardia (with a few ectopic beats chucked in for good measure). Seems to be currently well managed with drugs and I go about my life as usual. Doing my usual projects

https://cjeastwd.blogspot.com/2022/03/over-paneled.html
and self entertainment on my electric scooter *(caution on authentic Australian regional language)



Lastly I'd say that take it all in slowly, get your head around the choices and read up on what you can. I know that warfarin gets a bum rapp but if you're interested I've published a lot of stuff on my blog about that under the Tag INR
https://cjeastwd.blogspot.com/search/label/INR

Best wishes

 

[Chuck C]

The results of my previous echo indicated that my gradient value (if that's the correct way to state it) was 17.

Ok, that is helpful. I assume that by having a value of 17 that you are referring to the mean pressure gradient across your aortic valve, which is given more attention than the max pressure gradient to evaluate the severity of aortic stenosis.

17 is not that bad. This would classify you as only having mild aortic stenosis. Keeping in mind that there are a couple of other metrics that they evaluate as well, it is generally time for surgery once the pressure gradient reaches 40mmHG, which is the threshold for severe aortic stenosis. This could mean that you are many years away from needing surgery. Hopefully this is the case. At the same time, once SVD starts it is hard to predict how quickly it will progress and this is probably even more so for a prosthetic valve, so it is good that they are giving you an echo evaluation every 6 months.

So, keep getting those evaluations every 6 months and don't hesitate to contact them should you experience any symptoms such as shortness of breath, fatigue, light headedness or fainting. You really don't want to dismiss any of these symptoms, so please take them seriously if they occur. The good news is that it sounds like you have a medical team that is on top of things and knew when it was time to switch from evaluations every 12 months to evaluations every 6 months.

 

[Croooser]

Much good info from Chuck and Pellicle here. I would add that in my experience (WHICH MAY NOT BE APPICABLE TO YOU), the key metric from the echo, that the Doctors looked at for the valve, was AVA (aortic valve area). When it goes below 1.0, they tend to consider some patients as ready to go to the OR. Once my AVA went slightly below 1.0, they took a much harder look at the other measures from the echo as well as symptoms and other health issues. In my case, a borderline moderate to severe valve combined with a borderline aortic aneurysm = time for surgery.

As noted above, valve deterioration is not linear or predictable. I hit a plateau with little or no change for about 7 years, but then in another 3 years or so, I was much worse.

HTH

 

[Paleowoman]

Fast forward to 2014 and the results of that echo revealed that I needed an AVR within the next three months. The operation went very well, received a pig tissue valve (23 mm Magna Ease Pericardial Tissue Valve),

Hi libermana ! I too had my AVR in 2014 and got a Magna Ease Pericardial Tissue Valve (I think you'll find it's bovine tissue not pig tissue). Mine is 19mm which is too small for me so I have 'moderate patient prosthesis mismatch' and I am monitored with echos every year as the pressure gradients across my valve are high, they've been around 56 mmHg peak and 35 mmHg mean since soon after AVR. I don't have any symptoms at the moment.

If, or rather, when, my valve fails I will go for the Inspiris Relsila valve or the Foldax one which is still being 'tested' as far as I know. The Inspiris Resilia should have a much longer life than the Magna Ease which was the preceeding model in the Edwards range. The Foldax one if it's works will have an even longer life apparently.

You are so lucky that your endocarditis was caught and cured.

 

[mecretired]

After making it through two rounds of endocarditis, I learned to ask my doctor to do labs—get my CRP and do blood cultures.

 

[pellicle]

Hey @libermana
just reading this post I'd say that (not being specifically expert myself in this area but knowing that Chuck is) this sounds about right

17 is not that bad. This would classify you as only having mild aortic stenosis. ... This could mean that you are many years away from needing surgery.... At the same time, once SVD starts it is hard to predict how quickly it will progress and this is probably even more so for a prosthetic valve...

on this bit I'll comment that SVD is well documented at having a non-linear progression, which has a final stage asymptote. This is exactly why (as Chuck rightly observes) an increase in frequency of monitoring is regarded as the norm. It may well be that it fails to progress rapidly in which case they may drop you back to yearly echo measurements, but that remains to be seen.

Its my anecdotal observation that as you age and as your activity levels reduce (in a natural way) that can taper out how long it lasts. So it becomes a "competition" for does the valve become incompetent before you die of something else?

I'd be aware (very) during the coming times of the possibility of a misunderstanding of (possible) symptoms as being indicative of valve failure and would be guided by the pressures and gradients and what your Cardio says, but I'd interject if something gets labelled as "heart failure" with the question of "could this be valve thrombosis" and ask "should I perhaps start ACT". Be wary of people saying "tissue valves don't require ACT, as this is not born out in the literature nor in well experienced clinical practice.

I'd also explore if you are or are not a candidate for TAVR, because if you are a candidate for that then there is a benefit to extracting the greatest longevity out of that valve you currently have. If you get into your early 70's without needing it replaced then a TAVR will probably do you for the rest of your life (lets leave my natural tendency to black humour out of this for the moment). I say that from the web I see that current estimates of the average life expectancy U.S. male 2022 to be 78.18 years from birth.

This would be the low hanging fruit IMO rather than facing a surgery now (or even less favourably further down the aging track).

Time will reveal the answers and so my advice to you is this:

Marcus Aurelius

Best Wishes

 

[libermana]

Hi
and good evening (about to hit the hay here in the land of down under)



that's a well regarded valve from a good company and getting 8 years is on the low end but I suspect that the average time is closer to 10 ... if you're active (exersize wise) then that will also as I understand, contribute to it lasting less.



yep. As it happens a good (life time) friend of mine who does marathons (and is the same age as me) had his valve done last year. He picked a tissue prosthetic (I forget which) for reasons such as "after all the problems you've had with managing warfarin" ... which bamboozled me and was like he'd been gathering data from a Pellicle in the alternate universe with Walternate (via a IBM golfball typewriter).



oh my, that's bad news ...



don't buy a lottery ticket ... you've already used up your quota for a bit ;-)



That is indeed how it goes (me included).



this is an aspect which I've never bothered schooling myself on because frankly I put credence in the opinions of my surgeon and cardiologist. In my own case I had a surprise aneurysm discovery in 2011 which was (IIRC) about 5.6cm and surgery was to be done based on that. So I never got to stretch out the limits of my valve (of that time) which was a homograft.

So in Nov 2011 I had my 3rd surgery and they put in an ATS and a dacron graft for the aorta.

I've been ticking along fine since then, with perhaps a recent occurrence of atrioventricular tachycardia (with a few ectopic beats chucked in for good measure). Seems to be currently well managed with drugs and I go about my life as usual. Doing my usual projects

https://cjeastwd.blogspot.com/2022/03/over-paneled.html
and self entertainment on my electric scooter *(caution on authentic Australian regional language)



Lastly I'd say that take it all in slowly, get your head around the choices and read up on what you can. I know that warfarin gets a bum rapp but if you're interested I've published a lot of stuff on my blog about that under the Tag INR
https://cjeastwd.blogspot.com/search/label/INR
View attachment 888640

Best wishes

Thanks so much for your reply to my updates. Wishing you all the best!

 

[libermana]

Ok, that is helpful. I assume that by having a value of 17 that you are referring to the mean pressure gradient across your aortic valve, which is given more attention than the max pressure gradient to evaluate the severity of aortic stenosis.

17 is not that bad. This would classify you as only having mild aortic stenosis. Keeping in mind that there are a couple of other metrics that they evaluate as well, it is generally time for surgery once the pressure gradient reaches 40mmHG, which is the threshold for severe aortic stenosis. This could mean that you are many years away from needing surgery. Hopefully this is the case. At the same time, once SVD starts it is hard to predict how quickly it will progress and this is probably even more so for a prosthetic valve, so it is good that they are giving you an echo evaluation every 6 months.

So, keep getting those evaluations every 6 months and don't hesitate to contact them should you experience any symptoms such as shortness of breath, fatigue, light headedness or fainting. You really don't want to dismiss any of these symptoms, so please take them seriously if they occur. The good news is that it sounds like you have a medical team that is on top of things and knew when it was time to switch from evaluations every 12 months to evaluations every 6 months.

Thanks so much for your reply. Your comments about my gradient pressure was comforting. While there's no way of knowing how much longer my valve will last, your thoughts that I have mild stenosis gives me hope that the valve will continue to work satisfactorily for a few more years. Please know that I'm not a procrastinator... once I get word by my cardiologist that I need surgery, I will get it done asap! I'm not sure how others on this portal handle the psychological/emotional aspects related to the reality of knowing that they will likely need a 2nd surgery down the road, but stress/anxiety is something that I've been trying to cope with since my initial surgery. I exercise regularly, practice yoga, meditate twice daily (transcendental meditation), and remind myself regularly about all I have to be grateful for regarding my current health compared to others... I'm independent regarding daily living, don't have terminal cancer, I'm not paralyzed, etc.

 

[libermana]

Much good info from Chuck and Pellicle here. I would add that in my experience (WHICH MAY NOT BE APPICABLE TO YOU), the key metric from the echo, that the Doctors looked at for the valve, was AVA (aortic valve area). When it goes below 1.0, they tend to consider some patients as ready to go to the OR. Once my AVA went slightly below 1.0, they took a much harder look at the other measures from the echo as well as symptoms and other health issues. In my case, a borderline moderate to severe valve combined with a borderline aortic aneurysm = time for surgery.

As noted above, valve deterioration is not linear or predictable. I hit a plateau with little or no change for about 7 years, but then in another 3 years or so, I was much worse.

HTH

Thanks so much for this great information regarding echo data and in particular, AVA area. Wishing you all the best!

 

[libermana]

Hi libermana ! I too had my AVR in 2014 and got a Magna Ease Pericardial Tissue Valve (I think you'll find it's bovine tissue not pig tissue). Mine is 19mm which is too small for me so I have 'moderate patient prosthesis mismatch' and I am monitored with echos every year as the pressure gradients across my valve are high, they've been around 56 mmHg peak and 35 mmHg mean since soon after AVR. I don't have any symptoms at the moment.

If, or rather, when, my valve fails I will go for the Inspiris Relsila valve or the Foldax one which is still being 'tested' as far as I know. The Inspiris Resilia should have a much longer life than the Magna Ease which was the preceeding model in the Edwards range. The Foldax one if it's works will have an even longer life apparently.

You are so lucky that your endocarditis was caught and cured.

Thanks so much for your reply Paleowoman and sharing information about your valve and current condition. Very cool and coincidental that our surgeries were the same year and with the same valve type! Wishing you all the best :0

 

[libermana]

Hey @libermana
just reading this post I'd say that (not being specifically expert myself in this area but knowing that Chuck is) this sounds about right



on this bit I'll comment that SVD is well documented at having a non-linear progression, which has a final stage asymptote. This is exactly why (as Chuck rightly observes) an increase in frequency of monitoring is regarded as the norm. It may well be that it fails to progress rapidly in which case they may drop you back to yearly echo measurements, but that remains to be seen.

Its my anecdotal observation that as you age and as your activity levels reduce (in a natural way) that can taper out how long it lasts. So it becomes a "competition" for does the valve become incompetent before you die of something else?

I'd be aware (very) during the coming times of the possibility of a misunderstanding of (possible) symptoms as being indicative of valve failure and would be guided by the pressures and gradients and what your Cardio says, but I'd interject if something gets labelled as "heart failure" with the question of "could this be valve thrombosis" and ask "should I perhaps start ACT". Be wary of people saying "tissue valves don't require ACT, as this is not born out in the literature nor in well experienced clinical practice.

I'd also explore if you are or are not a candidate for TAVR, because if you are a candidate for that then there is a benefit to extracting the greatest longevity out of that valve you currently have. If you get into your early 70's without needing it replaced then a TAVR will probably do you for the rest of your life (lets leave my natural tendency to black humour out of this for the moment). I say that from the web I see that current estimates of the average life expectancy U.S. male 2022 to be 78.18 years from birth.

This would be the low hanging fruit IMO rather than facing a surgery now (or even less favourably further down the aging track).

Time will reveal the answers and so my advice to you is this:

View attachment 888641

Marcus Aurelius

Best Wishes

Great words of wisdom both regarding the monitoring of the valve along with the emotional/psychological coping... easier said than done for me but as they say in yoga, "It's a practice". Your comments are much appreciated!

 

[pellicle]

but as they say in yoga, "It's a practice".

life is a journey that continues as long as we keep walking.

I've certainly had some practice at the need to sit down and rest from time to time.

If I can keep moving, you can too. The thing is to focus on what you can do and let the rest take care of itself.

Best Wishes

 

[libermana]

Thanks, great advice!

 

[Wiles Darkwinter]

Thanks, great advice!

Another good one I’ve heard about this - “if you can’t do 5 minutes of yoga, you need to do 10”

 

[libermana]

Another good one I’ve heard about this - “if you can’t do 5 minutes of yoga, you need to do 10”

Indeed!