Tissue Valve degeneration

[mitchner9g]

Hello - Have a question about the forum's experience with degeneration patterns of bioprosthetic valves, specifically Medtronic's Mosaic in the aortic position.

Previously, I understood from my surgeon that these valves tended to become fibrosed and less pliable over time. The effect presents an increasing challenge for the ventricle to push blood through the valves, thus increased ventricular hypertrophy.

Have any of you verified this effect? It's curious because at present my aortic bioprosthesis porcine valve by Medtronic seems to have developed a severe insufficiency in the past six months. This only two and one half years after implanting.

Thank you for any experience you're willing to share.

Adam

 

[Mary]

You're sure having trouble, Adam! I remembered when you posted before that you had two mosaics in the pulmonary and aortic position, and weren't those implanted after you had the Ross procedure?
I can't help; I've got an Edwards bovine, but maybe someone else will come by and offer some more information.
You might send a pm to the members who've indicated they have the same valve on this poll.
http://www.valvereplacement.com/forums/showthread.php?t=26292

 

[Lynlw]

I can't help you with that valve, but do you know where the problem is? Justin's problems tend to be on the suture lines where the scar tissue keeps growing and that happens for him in the time frame you are talking about. both times he had the problem one 6 months check up was perfect and the next it was a problem. Actualy he got a bovine valve/dacron conduit in his pulm position in 05 and in 07 the valve itself was still perfect, it was the seem where it was sewn to his rt ventricle that was the problem.

 

[mitchner9g]

Hi Lynlw - The problem is insufficiency, specifically. They have a hard time visualizing the valve proper because of the stiching ring apparently. however they can assess the regurgitation. Sorry to hear about Justin's scarring response; I've had a lot of challenges for my surgeons due to scarring in my reops, too. Not sure if it's as much an issue for the valve area, as opposed to my pericaridum sticking to my interior sternum, tho...

...the insufficiency/regurgitation is the confounding aspect of this, given the experience my surgeon's had with the medtronic valve. anyway, i'll post more to this thread as I find out more...looks like I'll be in for number 4 here in the not too distant future. My ticker is starting to look like a Microsoft product. har dee har.

Adam

 

[Lynlw]

Hi Lynlw - The problem is insufficiency, specifically. They have a hard time visualizing the valve proper because of the stiching ring apparently. however they can assess the regurgitation. Sorry to hear about Justin's scarring response; I've had a lot of challenges for my surgeons due to scarring in my reops, too. Not sure if it's as much an issue for the valve area, as opposed to my pericaridum sticking to my interior sternum, tho...

...the insufficiency/regurgitation is the confounding aspect of this, given the experience my surgeon's had with the medtronic valve. anyway, i'll post more to this thread as I find out more...looks like I'll be in for number 4 here in the not too distant future. My ticker is starting to look like a Microsoft product. har dee har.

Adam

I was just looking at your older posts and we had a similar conversation before, They usually can not see where Justin's stenosis is in echos or even the MRI because his are right on the seem so they only way they get a good look is in the cath lab. and FWIW in Justin's case at least the material being used isn't the problem because when he was 10 they made a section of conduit in the OR using bits and pieces of his own heart and his pericardial sac and THAT stenosed on the suture line. Justin ALSO has the problem, before his last 2 OHS of his heart being fused to his sternum with scar tissue, (he is an over achiever in the scar making dept)
That's interesting your heart is so close to yours sternum because technically when Justin had the section of his conduit replaced in 07 that he got in 05 the stenosis was a combination of his scarring on the suture line AND the conduit being squished by his sternum.
I saw you go to Hanley he is one of the best.

 

[tobagotwo]

That would be too soon for any normal type of valve degeneration. Your doctors need to let you know more of what's going on.

The most likely cause statistically would be a perivalvular leak, where the blood is going past the valve on the outside, due to the stitching/scar that holds the valve to the wall giving way a bit. When this happens, it's usually in someone with genetically myxomatous (weakened) tissue problems.

If it's a physical valve failure, it would sound more like a rip or other flaw, or perhaps pannus (scar tissue) or something in the way, or even an issue where it's tilted to one side enough to be hitting the wall and not closing completely.

They owe you a better explanation of what they've found and what they think may be causing it. If they don't know, they should find out, as what needs to be done about it can be highly dependent on it.

Best wishes,

 

[Lynlw]

Bob, did you see he needed both his AV and Pulm valves replaced after his Ross in a relatively short time also?

 

[mitchner9g]

Hi, Yes, I've had 3 surgeries:

1) Ross in 1999
2) Ross re-op in 2006, implanted Mosaic aortic valve, allograph pulmonary
3) a PV re-op in 2007 due to stenotic pulmonary from '06 (likely due to infection; nobody's certain).

They wouldn't say what exactly happened during 3) but it was a complicated situation with all the scar tissue; ended up perforating my aorta and had to do an emergent catheterization via my femoral artery before they could continue taking down the adhesions between my pericarium and the sternum. When I heard about the insufficiency last week, I immediately considered them having damaged the valve during this time as the likely culprit. Much like what you are talking about above, Bob.

As for the scarring issue, before closing me up in 3) above, they placed a sheet of some sort of plastic material; between my heart and sternum. This will at least define a surgical plane that they can reference next time. Might be something to consider next time, Lyn.

Thanks for the feedback you all.

Adam

 

[pamela]

Hi Adam, My surgeon mentioned the root replacement I had as a gambit to move the incision further away from the valve leaflets (incidental to the early signs of dilation I showed as well) in order to prevent the scar tissue from interfering with the valve. The pannus outgrowth was something none of us has a lot of control over, but he's hoping that with the laminar surface of the aortic root being close to the valve that the high viscosity of my blood won't gum up the works again.

Maybe you should think about what happened to Zipper during her op. Her aortic valve was malfunctioning but as soon as the surgeon took care of the scarring and placed her heart properly, the aortic valve began to function again and now, she can look forward to a lifetime of service from it.

I pray that your situation is as fortunate but in any case, I hope the doctors find the cause and give you a solution with hopes of a lifetime of service from your replacements too.

Take Heart,
Pamela.

 

[Lynlw]

Hi, Yes, I've had 3 surgeries:

1) Ross in 1999
2) Ross re-op in 2006, implanted Mosaic aortic valve, allograph pulmonary
3) a PV re-op in 2007 due to stenotic pulmonary from '06 (likely due to infection; nobody's certain).

They wouldn't say what exactly happened during 3) but it was a complicated situation with all the scar tissue; ended up perforating my aorta and had to do an emergent catheterization via my femoral artery before they could continue taking down the adhesions between my pericarium and the sternum. When I heard about the insufficiency last week, I immediately considered them having damaged the valve during this time as the likely culprit. Much like what you are talking about above, Bob.

As for the scarring issue, before closing me up in 3) above, they placed a sheet of some sort of plastic material; between my heart and sternum. This will at least define a surgical plane that they can reference next time. Might be something to consider next time, Lyn.

Thanks for the feedback you all.

Adam

Did they hook you up to the BYPASS machine thru your fem artery in #3? That's what they did to Justin, there is like a 4in scar. I wonder if the valve itself wasn't damaged maybe where they cut is scarring inside the aorta. for Justin's pulm he has a section of conduit then the valve then another section of conduit so that 1 the valve wouldn't be right under his sternum and not get squished and , like Pam described

 

[mitchner9g]

correct, they did the bypass via the fem artery in #3. it looks like they resorted to this in their notes as an auxiliary plan, they originally tried to do the bypass via cardiac cath but ended up perforating my aortic root in the process so had to go that route. I think in USMC parlance this is what they call a "Charlie Foxtrot"

anyway, fabric conduit was used in the reconstruction of both valves, I believe. I do not know if they had to do this to the PV because they needed more room, but the aortic root was replaced in #2 because it had grown distended.

thanks for following up on this thread.

Did they hook you up to the BYPASS machine thruw your fem artery in #3? That's what they did to Justin, there is like a 4in scar. I wonder if the cvalve itself wasn't damaged maybe where they cut is scarring inside the aorta. for Justin's pulm he has a section of conduit then the valve then another section of conduit so that 1 the valve wouldn't be right under his sternum and not get squished and , like Pam described

 

[Lynlw]

correct, they did the bypass via the fem artery in #3. it looks like they resorted to this in their notes as an auxiliary plan, they originally tried to do the bypass via cardiac cath but ended up perforating my aortic root in the process so had to go that route. I think in USMC parlance this is what they call a "Charlie Foxtrot"

anyway, fabric conduit was used in the reconstruction of both valves, I believe. I do not know if they had to do this to the PV because they needed more room, but the aortic root was replaced in #2 because it had grown distended.

thanks for following up on this thread.

Yep Plan B, we knew going in because during the pre op tests, beside the normal echo they did a ultrasound of both his femorals and neck incase they needed them for bypass. the simple explanation is not as much blood in the heart while they are getting to it is safer.
Normally in the PVR they use a conduit as part of the pulm artery right after the valve so most people are right ventricle/valve then conduit, Justin has an extra section so he is rt vent/conduit/valve/conduit

 

[luvsgod]

Adam - I had my aortic valve replaced with an Edwards Bovine Pericardium Tissue valve 11/01/07. I began to notice a difference as I became more breathless after 4 months, and in less than year it malfunctioned and began leaking "severely". I am scheduled to have surgery in 2 wks and will go with a mechanical valve this time. I am still pressing on to find out why my valve malfunctioned so soon. The surgeons advisedme I would get about 20 years out of it. Ha! When I went back I told my Thoracic Surgeon "that was a short 20 years." Anyone else had the same experience?

 

[Debbie]

Wow, this is the first time I've heard of an Edwards bovine failing so quickly. I also have the same valve as you and my surgery was just 2 months after yours. If it were me I'd be contacting Edwards and tracking down that valve to see what the problem was. You know they keep very detailed records of all the valves they produce. Take care and good luck with your up coming surgery. Debbie

 

[Mary]

Adam - I had my aortic valve replaced with an Edwards Bovine Pericardium Tissue valve 11/01/07. I began to notice a difference as I became more breathless after 4 months, and in less than year it malfunctioned and began leaking "severely". I am scheduled to have surgery in 2 wks and will go with a mechanical valve this time. I am still pressing on to find out why my valve malfunctioned so soon. The surgeons advisedme I would get about 20 years out of it. Ha! When I went back I told my Thoracic Surgeon "that was a short 20 years." Anyone else had the same experience?

I can't think of anyone else right off hand, but there's probably someone out there who's had a similar experience. I noticed that your profile says you had replacement in 2008, but this post says 2007? Where did you have your replacement performed? Will you use the same surgeon for your next re-op?
I wish you the best and hope you get some answers as to why the first valve failed.

 

[Karlynn]

Given the chronology reported - I'm guessing the replacement was in 11/07 not 11/08.

 

[ChouDoufu]

Adam - I had my aortic valve replaced with an Edwards Bovine Pericardium Tissue valve 11/01/07. I began to notice a difference as I became more breathless after 4 months, and in less than year it malfunctioned and began leaking "severely".

was it the valve leaflets leaking, or was it leaking around the stitching?
did they tell you how exactly it was leaking and why?

 

[ALCapshaw2]

Adam - I had my aortic valve replaced with an Edwards Bovine Pericardium Tissue valve 11/01/07. I began to notice a difference as I became more breathless after 4 months, and in less than year it malfunctioned and began leaking "severely". I am scheduled to have surgery in 2 wks and will go with a mechanical valve this time. I am still pressing on to find out why my valve malfunctioned so soon. The surgeons advisedme I would get about 20 years out of it. Ha! When I went back I told my Thoracic Surgeon "that was a short 20 years." Anyone else had the same experience?

Luvsgod -

I can't help but wonder what Hospital (and what Surgeon) performed your AVR.

'AL Capshaw' (also in Alabama)

 

[mitchner9g]

As TobagoTwo mentions above, I'm betting high it's a paravalvular leak as opposed to a malfunction of the valve proper; one thing I'm going to twist my surgeon's arm about is reserving the old valve if it cannot be repaired. Since I won't be going back to the sawbones who did this valve, I don't think that will be too much a problem.

sorry to hear about your own misfortune. Suerte.

Adam - I had my aortic valve replaced with an Edwards Bovine Pericardium Tissue valve 11/01/07. I began to notice a difference as I became more breathless after 4 months, and in less than year it malfunctioned and began leaking "severely". I am scheduled to have surgery in 2 wks and will go with a mechanical valve this time. I am still pressing on to find out why my valve malfunctioned so soon. The surgeons advisedme I would get about 20 years out of it. Ha! When I went back I told my Thoracic Surgeon "that was a short 20 years." Anyone else had the same experience?

 

[luvsgod]

You are corrrect. The first surgery was 11/07. I will update my profile. The TEE I had in 11/08 revealed valve was seated correctly, no calcium deposits but one of the leaflets was frozen in the open position creating severe insufficiency. Edwards did a study of my TEE but did not have a concrete answer. In fact their report stated valve was malfunctioning. Wow! I could have told them that. I had my 1st surgery at EAMC near Auburn, AL. My redo will be done at UAB, Birmingham, AL. Thanks for all the input!