Ticking Time bomb?

[ARossGuy]

I recently changed my cardiologist since my previous doctor changed practice and was no longer in my insurance network. I was overdue on my echo and got that scheduled at the new office. During the echo, as soon as the echo tech moved to the pulmonary valve I saw that there was some type of tissue extending out from the valve into the RV outflow track. I said what the heck is that??? The echo tech got flustered and said she is investigating it now and couldn’t talk about it until she conferred with the doctor. I knew right away it was either a vegetation or a PV was deteriorating since it’s the homograph from my 2004 Ross Procedure. Got a TEE done and it showed that it was a 1.1cm calcified veg, but PV was functioning normally (no stenosis or regurgitation). I did have a bout of endocarditis in 2017 and there was a small veg on my mechanical aortic valve that disappeared after 6 weeks of antibiotics. I saw the TEE report back then and nothing was mentioned about a PV veg, but I guess it was missed somehow. I know I did not have another bout after 2017 since I was very familiar with the symptoms of infective endocarditis. Recent blood culture came up negative.

My new cardiologist recommended I consult with my surgeon that did both my Ross and AVR redo (2011). I sent the TEE to him and got word back that no intervention was required since the PV is operating perfectly and the calcified veg is unlikely to detach. I am happy that another OHS isn’t required but have concerns of the veg letting go in the future. I can’t find any studies or cases out there for reference on the behavior of old vegetations. If this thing lets go, it is going to the right or left lung and will behave like a pulmonary embolism and I’m probably toast if it does.

My thoughts are if the surgeon says its fine, I should just shut up and color and go on my merry way. Any microbiology/immunology majors out there? Will the body reabsorb the veg over time? Are these things stable?

 

[pellicle]

...My thoughts are if the surgeon says its fine, I should just shut up and color and go on my merry way. Any microbiology/immunology majors out there? Will the body reabsorb the veg over time? Are these things stable?

interesting case. I'm a bit unsure that anything would "reabsorb" or even that its a vegetative mass (but equally I'm not sure they're sure either).
Calcification of valves does not follow the usual calcium cycles in the bones (https://en.wikipedia.org/wiki/Bone_resorption ) which is I understand why calcium in valves with stenosis does not get less over time either.
As to it being a vegetation I'm surprised they are taking that casually and not wondering about antibiotics (or indeed proper further analysis of if it is a vegetation).

What sort of relationship do you have with your surgeon and do you feel sufficient trust that you would be comfortable with his / her assessment?

While I am a biochem / microbiol major this sort of stuff is not "what they teach undergrads" and is actually pretty specialised (although I've had a few years since then to pick up a few side bits of data).

Dunno ... myself I'd be inclined towards looking at a 2nd opinion, I assume that you have a prosthetic in the pulmonary position now and your pulmonary is in the aortic right?

 

[ARossGuy]

Thanks Pellicle. My surgeon is highly regarded and performed many Ross Procedures when they were a more popular option (Dr. William Ryan, Plano, TX). He also did my reop when the transplanted pulmonary valve crapped out in the aortic position and I went with an On-X valve. I think the rule of thumb is that they just monitor these vegetations if they are 1.0 cm or under and are no longer growing due to active infection, and the valve function is normal. Mine is just slightly over this length and "thread-like" in appearance. My current pulmonary valve (from 2004) is a cadaver homograph. I have a F/U with my cardio in a couple months and will ask about the 2nd opinion. Thanks again.

 

[pellicle]

My current pulmonary valve (from 2004) is a cadaver homograph.

ok, well if that was cryo-preserved then you'll likely get good milage out of that. I got 20 years out of my aortic homograft and I was operated on at 28 for that one. The evidence is they lasted longer on older patients.

Freedom from reoperation for structural deterioration was very patient age-dependent. For all cryopreserved valves, at 15 years, the freedom was ​

⦁ 47% (0-20-year-old patients at operation), ​

⦁ 85% (21-40 years), ​

⦁ 81% (41-60 years) and ​

⦁ 94% (>60 years). Root replacement versus subcoronary implantation reduced the technical causes for reoperation and re-replacement (p = 0.0098). ​

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