Tissue valve failing after 6 months

[jarno1973]

I have mentioned this in another thread but i am hoping to get some more replies here. I had OHS 6 months ago and received a St jude biocor 21 mm valve. It now seems that the valve is not working properly. It is still unclear what the exact problem is but my surgeon thought the leaflets of the valve appeared to be thickened which could be caused by calcification. I knew that this was an increased risk with a tissue valve at 38 but I think at 6 months this cannot be the only issue. Another thing that was mentioned that the valve is possibly too small.

I really did not feel like receiving a mechnical valve so my choice was a tissue valve. I hoped for 20 years but expected to at least get 8-10 years out of it. In the current situation I will have re-evaluate everything and make a choice again.

I hope to get some opinions of what may have happened with my valve. Anybody heard of someones tissue valve failing after this short of a period? What could be the reason? People around me wonder if I took on too much work/excercise etc too quickly after surgery. I have pushed things a little bit at sometimes but always listened to my body and never felt I was overdoing it.

What about the size? I read of many people getting 23 mmm valves so 21 mm sounds a bit small. I am 80 kg and 184 cm heigh. The surgeon said that the size of the aorta basically determines the size of the valve they put on. If this valve fit my Aorta well i would expect it be similar in size to my original valve and should therefore be big enough. Right???

If anyone has experiences or opinions to share, I will greatly appreciate them.

Kind regards,

Jarno

 

[Mentu]

Jarno, it would be shocking for anyone to discover that a new valve appears to be failing after such a short time. As you are so well aware, without more information, it is not possible to know the circumstances of the failure. My own speculation is that it would be extremely unusual for a valve to become calcified in only six months. Whatever the cause, this must be terribly disappointing for you. Just as you, we all expect years of service from our new heart valves. Failure after a few months and so soon while you are still recovering from surgery cannot be anything but devasting to hear. As for the size of valve, like you I understand that the valve size is determined by measuring the size of oriface of one's original valve which the surgeon does during surgery. While surgeons always want to use the largest valve that is possible, they also know that using a valve that is too large creates yet other problems. Obviously, this is something only a surgeon can really address. I would encourage you to talk with your doctors as they explore these new problems because understanding the issues now will guide your decisions in the future. In the mean time, let us know how we can help support you.

Larry

 

[tprice54]

Sorry to hear your bad luck...you can be sure your activity level didn't cause this. I have heard of too small valve having this issue.

 

[Julian]

Im sorry to read this. I really do feel for you, I wish I had info to give you, I can guess and I'm afraid even doctors would be guessing as to why this could of happened. I would say valve too small would be the obvious reason. Unless you dont mind going through another surgery soon I would just choose mech at this point if possible. Maybe if you need a reop in 20 years you can try tissue again. My main concern would be if Im just the type of person that goes through tissue valves fast. If I had the same experience as you I would not want to take a second chance the last experience told me tissue might not be right for me.

 

[jarno1973]

Thanks for the answers.

I want to try and have as many tests as possible to determine the conditon of the valve. When suffering from the regurgitation before surgery one of the doctors suggested to have a look at the valve with a camera/endoscope. Does anybody have more details about this kind of procedure and is it commonly used?

Julian,

You have a good point. Even though I really prefer tissue it would be very hard to forgive myself if the second tissue valve would not have a long life either. I think the doctor will also almost certainly push for a mechanical valve.

Regards,

Jarno

 

[kfay]

The valve being too small is called patient prosthesis mismatch, and from what I have read on here and other places, it can definitely be a cause of early valve failure. You can google it or search it on here and to see if it fits what the Dr. told you about what is going on with your valve. A failure that early I think is always an indication of something going wrong, be it either ppm or just a "bad" valve.

Sorry you are having this issue.

Kim

 

[jarno1973]

Hi Kim,

Patient prosthesis mismatch surely sounds good.Could it also be described as "my doctor messed up and gave me the wrong valve" or would there be nothing to blame on the doctor?

Regards,

Jarno

 

[kfay]

I have no idea what goes into making the decision of what size valve they are going to use and if it actually fits. I have never seen anyone on here who has had this ever say their surgeon admitted to making a mistake. If it were me in that situation, I would have a hard time not blaming the surgeon though.


Kim

 

[yotphix]

Anyone else feel free to correct me, but it is my understanding that a surgeon uses a 'sizing tool' to determine the size of the valve to be used. I have seen pictures of the tool which was used to size my valve. There are different, precisely sized sterile instruments which correspond to the various valve sizes. They are inserted into the Aortic annulus and checked for a good fit. The valve size is then chosen from the array kept on hand for the surgery.
http://www.youtube.com/watch?v=Qjt8wQG16NY&feature=related
Not the most instructive video, but the tool they are showing what would be inserted into the annulus to see what fits.

 

[ElectLive]

Anyone else feel free to correct me, but it is my understanding that a surgeon uses a 'sizing tool' to determine the size of the valve to be used. I have seen pictures of the tool which was used to size my valve. There are different, precisely sized sterile instruments which correspond to the various valve sizes. They are inserted into the Aortic annulus and checked for a good fit. The valve size is then chosen from the array kept on hand for the surgery.

That's exactly right. From my understanding, sizing the valve to the annulus is not where the problem usually occurs with patient-prosthetic mismatch, it's related more to the "interaction" of the effective area of the prosthetic valve in relation to body size. All prosthetic valves reduce the effective opening area of a patient's native valve to a degree, depending on the type of valve used. In most circumstances, this is not an issue, but for patients with an already small native valve (21 mm is right at the threshold) and/or a large body surface area (184 cm is fairly tall), it can lead to problems. Other factors for this "mismatch" issue are patients whose annulus size has reduced over time due to the valve disease or have small aortic roots. While there are some options to allow for a larger valve to be implanted, such as enlarging the aortic root, it is generally more complicated and higher risk, not often the preferred procedure.

There are charts that list proper valve choice based on body surface area and the effective opening of the prosthetic valve (at the patient required annulus size). It's a bit complicated for any of us to bother worrying about, but for surgeons, I would think it's pretty basic and certainly should have been done. So, Jarno, I wouldn't necessarily assume that your doctor "messed up", but that's of course impossible for any of us to guess. Unfortunately, exact annulus size is not always known until the surgery. From my understanding, pre surgery scans (such as CT) give a good estimation, but not always right. My surgeon thought I'd be either 25 mm or 27 mm pre-surgery. Now, if anything, as a patient, I don't think it's unreasonable to expect surgeons to at least discuss this potential "mismatch" issue pre-surgery if they have any reason to suspect that the valve size will be in the 21 mm range, but that's just my slightly idealistic view of it. Certainly, at this stage, ask as many questions as you need to not only get to the bottom of what happened, but what options are available moving forward. Best wishes.

 

[Lynlw]

I believe they do use a sizing tool, however about 50% of patients have PPM, maybe 10% "severe", because it isnt that cut and dry. It happens if the effective opening of the valve isn't large enough for the persons BSA. So even if the tool shows what size valve fits the best in that Aorta, it might not big large enough for you. Especially if you have a smaller Aorta.
There are a few things that help determine which valve and size if the best for someone but There is a formula they can use to see if a certain size valve will be large enough for your body. IF it isn't then there are a few options, use another kind of valve that has better hemodynamics and a larger opening for that valve size, or they might have to enlarge the Aorta so it can fit a larger size valve etc. They should do the math in the OR and that is ONE of the reasons, surgeons have several kinds of valves and different sizes in the OR. It may involve a more complex surgery so that is taken into consideration too

PPM ususally is more noticable in smaller sizes since there isnt alot of wiggle room
Of course you can cause problems if the vavle is also too large for the person.

 

[markp66]

I initially read your post and thought you said it had failed after 6 years and thought that was bad enough. How rubbish. Mine failed after 4 years and my surgeon said he had seen many valves failing in younger patients (I was 23..). However, lots of young patients get 10 years out of a tissue valve so I guess it's all to do with how your body reacts to the valve. I had mine replaced with a mechanical. This was an obvious choice for me as a 3rd reop is more risky and lets be honest, OHS isn't the nicest of experiences. My surgeon told me my mechanical valve + root should get at least 50 years and said they are pretty much indestructible. I've spoken to many surgeons who all agree and well managed anticoagulation in younger patients has a death rate of less than 0.5% per year in some studies.. Not far off the average population. I was dreading warfarin but I can honestly say it has been so easy to manage and keep stable (I know there are a few people who have had bad experiences).

I doubt they will be able to say what is wrong with the valve until they do surgery so it's a tough choice to make. PPM is not a huge problem in most cases and can't be helped. Some surgeons just put the wrong valve size in by error although v uncommon.

Good luck and sorry about the awful news. Good to know though that 2nd OHS is very safe and not much more, if any riskier than the first.

 

[tobagotwo]

It's a real shame you are going through this.

Even an old-fashioned, standard pig valve from 30 years ago with no anticalcification treatments would not calcify in six months, unless it was very much too small. Something is wrong here. And yes, 21mm does seem small for someone who is about six feet tall and 176 lbs, although not impossibly so.

You need an opinion from a different cardiologist, who doesn't have any skin in the game (who isn't worried he or his surgeon friend might be sued or have his reputation damaged).

It could be an issue with a radically defective valve, a patient/prosthesis mismatch, or (something?) missed or done incorrectly during the surgery.

Best wishes,

 

[jarno1973]

Thanks for sharing everyone.

Today I have visited my surgeon. I went there basically just to discuss my options and ask questions as the last time I was a bit too shocked to ask the right questions. I really like my surgeon and I chose him over another very experienced surgeon because he really explains everyhting very well, seems to be very knowledgable and has an aswer to everything. People may be sceptical of the quality of health care in Thailand. I was sceptical as well but it really seems to be at a very decent level. Off course this situation makes you doubt but if it wasn't for this I would have been so happy. All has been great so far and looking at everyhting I cannot actually conclude whether anyone made mistakes or not.

I will have another echo in 2 weeks to see if things are further degrading. According to the surgeon there is a minor chance that there was a bit of inflammation at the valve the last time in which case the next result could be better. I dont expect this to be the case though. I learned a little bit more about the echo results as now flow restriction is the problem as where before surgery leakage was the problem. From leakage the heart itself gets larger but from the restriction the wall of the heart becomes thicker (muscle gets stronger because of the additional work it has to perform). There is quite a difference between the thicknes before surgery (8 mm) and now (14 mm). So this seems to confirm that there is really something wrong.

I may never get the exact answer to what is wrong and what has caused it but I also dont want to focus on that as it will not change the fact that I will have to go for another surgery. I am slowly starting to accept that this time it will almost certainly have to be a mechanical valve. No doctor would take the risk of recommending another tissue and the possibility to end up with a 3th surgery in short time. Neither would I like to make that choice as I pushed so hard for tissue instead of mechanical last time that I am almost starting to blame myself for what is happening.

I had quite a big discussion about size with the surgeon. It seems to be correct that size is determined during the surgery and that the valve that fits the aorta is installed. The actual capacity of the valve is however determined by the internal diameter of the valve. Tissue valves may in this case have a bigger restriction than mechanical ones which have a very thin body. He said that in a re operation he would definitely try to get a bigger one in but if possible without aortic root widening as this brings additional risk and requires a more extensive procedure. All of this seems to indicate that there is a real chance that my current valve is on the small side or really too small. The question remains should the surgeon have known better. I can imagine that there are no golden guidelines, that the choice was between the 21 mm or a bigger valve and aortic root enlargment with increased risk of complications. Maybe an easy call to make afterwards but a lot more difficult at the moment.

regards,

Jarno