Unique situation?

[s9acasl]

Greetings, I'm 31 with a bicuspid valve, currently under surveillance. Moderate/severe stenosis and regurgitation, small aortic aneurysm.

Currently looking at a Ross procedure or a TAVR into Ross procedure depending on where I am in life when something needs to be done, which hopefully won't be for a long while yet.

Currently I weightlift and do HIIT cardio 5 days a week, haven't noticed any issues thus far, and my Cardiologist confirmed that with a treadmill stress test. No issues working 40-50 hours a week either, though my work isn't particularly physically demanding.

I had an appendectomy when I was fairly young, and then a rapid case of erythrodermic psoriasis the next day that nearly killed me (some studies put the mortality rate of this psoriasis at up to 64%). Kept me bedridden in the hospital for months. I'm concerned that a sternotomy may not go very well due to this fact. There's no way to know if it will happen again, and there doesn't seem to be any consensus on what causes it, how to prevent it, when it will happen, etc... I do however have every marker for it to happen again, including unstable plaque psoriasis, male, Koebner phenomenon, and a history of either trauma or pharmaceutical induced outbreaks.

I brought this information to my Cardiologist but he didn't have much to say other than confirming the risk and to check with a Dermatologist. The Dermatologist didn't have much to say due to the rarity of that form of Psoriasis, other than I could attempt Biologics as a prophylactic treatment (which my insurance won't cover), but no guarantee it would be effective, and withdrawal of systemic treatment is a known trigger for erythrodermic Psoriasis. Not to mention the associated side effects of Biologics.

Needless to say it's a bit of a pickle, I guess it makes sense no one I've spoken to knows what to make of it as it's a 2% of 3% of 2% sort of situation. My main concern is the obvious, dying of organ failure or some horrible infection brought on by the psoriasis (the majority of my skin fell off last time). My other concern is financial, in the states FMLA only protects your job for 12 weeks, and should this happen I would likely lose my job and health insurance, which would lead to financial ruin given the cost of setting foot in a hospital.

 

[MdaPA]

I brought this information to my Cardiologist but he didn't have much to say other than confirming the risk and to check with a Dermatologist. The Dermatologist didn't have much to say due to the rarity of that form of Psoriasis,

Suggest you try to find a specialists that has experience with this condition. Maybe check-out a large research or teaching hospital?

I do however have every marker for it to happen again, including unstable plaque psoriasis

Not sure if this is the same thing or not but my wife has plaque psoriasis (controlled with Otezla) and has had no issue with her 3 OHS.

My other concern is financial, in the states FMLA only protects your job for 12 weeks, and should this happen I would likely lose my job and health insurance, which would lead to financial ruin given the cost of setting foot in a hospital.

Note that if you lose your job, you should (with some exceptions) be eligible for COBRA (Consolidated Omnibus Budget Reconciliation Act) which would continue your medical coverage for a period of 18 or 36 months but at a much higher cost than while an active employee.

 

[s9acasl]

I'm actually going to a large teaching hospital at the moment, figured it would be my best bet, although they don't offer Ross procedures so I'll probably be going elsewhere in the future for any surgery.

My normal day to day Psoriasis is well controlled by diet, coal tar, and sunlight thankfully. I've never utilized the systemic medications due to not qualifying, cost, and side effects since I've had a confirmed flare of erythrodermic Psoriasis.

The plaque psoriasis isn't really my concern, it's the flare of erythrodermic that is. This lovely form of Psoriasis (in my case) causes the majority of the body to be rapidly affected, massive loss of skin, electrolytes, and proteins through fluid, and in some cases heart rhythm disorder, or heart failure. In my case I have unstable plaque psoriasis which is a known marker for the erythrodermic variety.

I did look into COBRA but at the cost of ~~$1800 a month I don't see being able to hold onto my insurance for very long with no income.

I will continue to hunt for a dermatologist who has actually dealt with this before, but in my state it's usually a 6 month wait to see a new Dermatologist, and my experience with them hasn't been great to say the least. I'm also not really sure how to approach the issue with them since I don't have an active case of this psoriasis right now, but it was triggered by surgery, anesthesia, or the combination in the past.

 

[ValveAdmin]

Hello and welcome. Hope you'll find answers here that may help guide you with whatever decisions you make in the future. Best wishes.

 

[vitdoc]

I was 29 when I had a porcine aortic valve placed for aortic stenosis that had gotten severe. The valve lasted 5 1/2 years. Then I got a St. Jude which went 23 years until I developed a large aortic aneurysm and had aneurysm surgery with another St. Jude. That was 16 years ago. So for me nearly 40 years on warfarin.
I know nothing about your dermatological condition but it sounds like the fewest number of procedures done surgically the better.
Given your age the chance of a TAVR procedure lasting is not high. So this is probably not a good choice if you don’t want multiple procedures. You could have another TAVR but the two procedures might get you 15 years at your age. Then a third procedure which currently would be an open heart.
Using your pulmonary valve in the aortic position probably would last longer than a TAVR but will also wear out and you will need something. Maybe a TAVR through the pulmonary valve if that is feasible. By then your pulmonary valve replacement might need a redo also.
So other options would be a mechanical valve in the aortic position with anticoagulation.
Sounds like you are concerned about anticoagulation since you didn’t mention this as an option.
I am not going to say that anticoagulation is nothing, but all of your other options are not that great at your age.
I along with many on this forum can attest to the idea that one can live a pretty normal and active life on warfarin especially with home testing.
Basically everything has tradeoffs. To me multiple procedures should be minimized if possible. And trading a single valve disease for a dual valve disease (Ross) which won’t get you to the finish line is a mediocre choice.
Get another opinion about your situation.

 

[s9acasl]

TAVR would just be temporary, more or less a bridge to a Ross in my situation.

I've done quite as bit of research on mechanical valves and the Ross procedure and have come to the conclusion the Ross makes the most sense for me. The surgeon I'm working with has hundreds of patients that are 20+ and 30+ years out with no issues, I'm told it's the surgeons skill in performing the Ross that really drives the outcomes.

 

[ValveAdmin]

TAVR would just be temporary, more or less a bridge to a Ross in my situation.

I've done quite as bit of research on mechanical valves and the Ross procedure and have come to the conclusion the Ross makes the most sense for me. The surgeon I'm working with has hundreds of patients that are 20+ and 30+ years out with no issues, I'm told it's the surgeons skill in performing the Ross that really drives the outcomes.

It's great that you know what procedure is best for you, and to have a great surgeon to perform it. Best wishes to you.

 

[Timmay]

TAVR would just be temporary, more or less a bridge to a Ross in my situation.

I've done quite as bit of research on mechanical valves and the Ross procedure and have come to the conclusion the Ross makes the most sense for me. The surgeon I'm working with has hundreds of patients that are 20+ and 30+ years out with no issues, I'm told it's the surgeons skill in performing the Ross that really drives the outcomes.

We’re blessed to be able to have these types of choices. I too considered a Ross procedure. I just couldn’t justify it though. I’m 50 and very active. You can also look at the progression that Arnold Schwarzenegger took. Ultimately it will mean multiple open heart surgeries during your lifetime. That’s not a good thing. OHS is tough on the body and mind. And the older you are, the harder it is. The more you have, the harder it is.

One thing that people don’t mention is that TAVR isn’t a given. You have to be a candidate. There are those that bank of TAVR and then later find out that they MUST have another OHS.

FWIW, I’m 50 and just had OHS 2 weeks ago. I’m very active. The latest generation tissue valve would last maybe 10 years (at most). Then what? TAVR? Maybe. Get another 10-15 yrs. Then what? OHS at 70-75? Recipe for disaster. I went with mechanical.

I’m only offering perspective. Not trying to convince you. We’re all different and we all have a choice to make.

Tim

 

[s9acasl]

You're right about people thinking they are going to get TAVR but not being able to do so. In my case I've been assured that option is on the table. I'm only really considering it if I need to get things in order before OHS which potentially carries huge risks for me, just won't know until it's done.

As for the Ross I've heard wildly differing opinions. The internet is full of videos and studies pointing to it's benefits, and it being ideal for young/middle-age adults. Seems like it's making a resurgence in the aortic valve disease field.

I've noted that it appears to be based on who you speak with. The first surgeon I talked to was 100% for mechanical, but also said I would have to give up most of my hobbies due to the warfarin. The second opinion steered me towards the Ross and the guy had the data to back it up. My personal research has aligned with both of these surgeons opinions.

The Arnold story is interesting. I know a key factor for the Ross to be successful is blood pressure control for up to 6 months post-op, which allows the pulmonary valve to adapt to the increased pressure of the aortic position, and I have seen the story that mentions Arnold got on a lifecycle while still in the hospital which caused it to fail.

As for the pulmonary valve problem I've been assured that TPVR has made great strides since 2010, I know that isn't a guarantee, but it seems fairly routine at this point.

 

[MdaPA]

I did look into COBRA but at the cost of ~~$1800 a month I don't see being able to hold onto my insurance for very long with no income.

If you lose your current insurance and don't want to continue it on COBRA due to the high cost, then you can look for a more affordable plan on the health care exchange (Affordable Care Act - ACA).

The surgeon I'm working with has hundreds of patients that are 20+ and 30+ years out with no issues

What does "no issues" mean? They have not needed re-operations or procedures 20+ and 30+ years out? Or that their PV in the aortic position and tissue valve in the pulmonary position are not showing signs of calcification/leakage yet? What is the average age of these patients compared to yours?

My wife had a ROSS procedure and both AV and PV valves were replaced after 20 years in her 3rd OHS while they were in there to replace her MV which was in worse shape (i.e. she got a complete over-hall). She was then 50 years old and can expect yet another OHS or hopefully a procedure (TPVR) to replace her porcine PV (she got mechanical for her MV and AV valves so hopefully they are good for life).

The first surgeon I talked to was 100% for mechanical, but also said I would have to give up most of my hobbies due to the warfarin.

What are the hobbies you were told you would have to give up?

As for the pulmonary valve problem I've been assured that TPVR has made great strides since 2010, I know that isn't a guarantee, but it seems fairly routine at this point.

I'm not sure if TPVR procedures are "fairly routine" yet. Maybe someone in this forum can chime-in with their experience with having one.

In your opening post you said you had an appendectomy (now that is what I would call "routine") that caused a case of erythrodermic psoriasis that nearly killed you. Given your situation, I would strongly suggest you really think though potentially being "one and done" or opening yourself up to more procedures/OHS down the road if you went with a ROSS.

 

[s9acasl]

What does "no issues" mean? They have not needed re-operations or procedures 20+ and 30+ years out? Or that their PV in the aortic position and tissue valve in the pulmonary position are not showing signs of calcification/leakage yet? What is the average age of these patients compared to yours?

I mean he has numerous patients who are over 20 years post op with no further interventions, and has a some patients who are over 30 years post op with no further interventions, I do realize 30 years or more is atypical of the Ross. He has been performing the Ross since the 1980s on patients ranging from teenagers up to 60 years old, I believe that's the cutoff.

What are the hobbies you were told you would have to give up?

Kickboxing, Jiu-Jitsu, long days at the range with large calibers (fun part of my job). Thinking about picking up rock climbing, haven't yet though.

As for mech aortic valves being one and done, the research I have seen puts them at 0.6-1% annual risk of reoperation. Some studies that stood out to me were.

https://pubmed.ncbi.nlm.nih.gov/243...vival at,matched general population in Quebec.

https://www.heart-valve-surgery.com...antages of,infections, stroke and blood clots.

A university hospital near me states that nearly 1 in 5 patients younger than 65 are either deceased or require reoperation on the aortic valve within 10 years following MAVR. Granted this is taken from an aortic valve repair page so I suppose I should expect a marketing aspect to the information they present.

I really weighed the pros and cons of the Ross vs Mech and came to the conclusion that the chance of being one and done wasn't worth being attached to Warfarin (my wife is in favor of this as well, she has some unfortunate personal history with Coumadin). However, if I wasn't fortunate enough to be working with the most decorated Ross surgeon in the world I would probably choose the mech valve over a Ross.

As for the erythrodermic psoriasis I'm not really sure what to do with that, there's no guarantee it won't happen again, and it would be easy for me to refuse intervention at all given the potential outcome. I will say that Biologics weren't available when I had that appendectomy, so I'm hopeful that could be a better option for dealing with it if it were to occur.

 

[Timmay]

You're right about people thinking they are going to get TAVR but not being able to do so. In my case I've been assured that option is on the table.

TAVR is an option until it is not. It's a gamble. You might be a candidate now but there is not guarantee that you will be in 15-20 years. Why? Changes in your aorta. Changes in the calcification of your aortic valve, etc.

I'm only really considering it if I need to get things in order before OHS which potentially carries huge risks for me, just won't know until it's done.

And THAT there is a reason to seriously consider mechanical as your valve choice. Minimize surgeries.

I've noted that it appears to be based on who you speak with. The first surgeon I talked to was 100% for mechanical, but also said I would have to give up most of my hobbies due to the warfarin.

I don't understand this comment UNLESS you're primary hobbies are all contact sports. Contact sports are the only thing that would truly be recommended to be off the table. That said, @Chuck C from this board is a martial artist that does spar routinely ... albeit with someone that he trusts not to hit him hard in the head.

Search through this board and you'll find tons of Warfarin people living their lives and doing whatever. From TheGymGuy who is a competitive power lifter ... to pellicle riding his scooters at like 50mph downhill ... to ?. Warfarin might be a way of life but it's nowhere as limiting as some make it seem.

The Arnold story is interesting. I know a key factor for the Ross to be successful is blood pressure control for up to 6 months post-op, which allows the pulmonary valve to adapt to the increased pressure of the aortic position, and I have seen the story that mentions Arnold got on a lifecycle while still in the hospital which caused it to fail.

Arnold also recently went in for a TAVR for his Aortic valve and guess what? They couldn't do it. He had to have another OHS. Luckily - he's Arnold. Huge team of people that treated him like a person and not a number. Huge AFTERCARE team ... which is super important too.

As for the pulmonary valve problem I've been assured that TPVR has made great strides since 2010, I know that isn't a guarantee, but it seems fairly routine at this point.

TAVR is definitely routine at this point. My grandmother in law recently had one at 85. She's doing well. Just because it is routine doesn't mean that you will magically be a candidate for it 20 years from now. Arnold wasn't ... and they didn't really figure that out until the last moment. I wonder if it was a regular person on that table if they would have just TAVR'd that person anyhow even knowing that it would not be the best option.

Tim

 

[Timmay]

Kickboxing, Jiu-Jitsu, long days at the range with large calibers (fun part of my job). Thinking about picking up rock climbing, haven't yet though.

Contact Chuck C. Seriously. Just get his experience. It's worth talking to him. Last I heard he was doing Jiu-Jitsu 5 times a week. As for large calibers, I intend to get back to my 338LM and shooting extreme long distances .

Tim

 

[Chuck C]

Kickboxing, Jiu-Jitsu,

Hi s9acasl.

Like you, before my surgery I participated in kickboxing and Jiu-Jitsu. At age 53 I was leaning tissue, due to my "active" lifestyle, but finally decided that I wanted to be one and done and chose mechanical. As @Timmay mentioned, I have gone back to Jiu-Jitsue and now train 5 days per week and do some teaching as well. I choose my training partners carefully, but I do spar and sometimes spar hard. For those who may not be awarey, BJJ does not involve striking. However, there is always the risk of getting an accidental knee or elbow to the head. So, I choose my training partners carefully and only go with people whom I trust and whom I know have good control.

At about 5 months out from surgery I did a couple days of kickboxing sparring. Again, I chose my partners carefully and agreed ahead of time that we would only go about 20% on head shots. Ultimately, I decided that BJJ was something which I felt more comfortable doing, so I decided to drop the kickboxing and commit myself to it. I've been back for 4 months now. I did 5 rounds of sparring last night, btw, with opponents much younger than me and more than held my own. I try to train smarter now, not only choosing my training partners carefully, but also forcing myself to sit out a round often. This helps me stay in the zone where I am exerting 65% to 85% max HR, which I have decided is a good idea due to my age and also due to the fact that I have a prosthetic heart valve, and I would do this whether my valve was tissue or mechanical.

Before my diagnosis, at the urging of some of my training partners, I was planning to compete for a world title in my age category, Masters 5. I've given that up as I don't want to feel pressure to push my training harder than I should. Honestly, taking the pressure off myself like this has made me enjoy BJJ more. And because I am purposely trying to keep my HR down to a level where I won't gas out, it is helping me focus more on technique. It is not just entering a sparring round trying to tap out my opponent. Sometimes I will enter a round with the goal of submitting my partner, while keeping my HR under 120. To do that you really have to think about efficiency and technique. Since you train in BJJ, I'm sure that you are aware that using less power and more technique is always good for our game.

TAVR vs SAVR

I believe that you've covered the pros and cons of the Ross well and it sounds like you have the right surgeon should you decide to go Ross. But, I wanted to address this:

You're right about people thinking they are going to get TAVR but not being able to do so. In my case I've been assured that option is on the table. I'm only really considering it if I need to get things in order before OHS which potentially carries huge risks for me, just won't know until it's done.

Prior to one of my cardiology appointments, I was briefed by the head nurse of the department. She mentioned that something which they are doing a lot of now is TAVR first, to buy a few more years, then SAVR. She indicated that this could buy me something like 5 more years and then deal with SAVR. She said that some, even younger patients, are choosing to do this now. When I looked at the numbers it made no sense to me for the following reasons.

I understand the appeal, because who wants to get OHS if there is an alternative. But, going TAVR, for someone in their 40s or 50s does not avoid OHS, it just kicks the can down the road. Also, and this is critically important, while TAVR does have better mortality statistics during the first month and first year, when this is taken out further this advantage goes away. In fact, the few studies that have been done on SAVR vs TAVR show that mortality becomes equal after a couple of years and by 5 years SAVR is somewhat superior. Sometimes, depending on where their funding is coming from, they will word the results "the same", or "no statistical difference", but when you actually get in and look at the numbers you'll see a survival benefit to SAVR by 5 years. See study linked below:

In this study, patients were randomly assigned to either TAVR or SAVR. I find the results eye opening:

"Patients were stratified according to intended transfemoral or transthoracic access (76.3% and 23.7%, respectively) and were randomly assigned to undergo either TAVR or surgical replacement."

The results, the bold is mine:

" At 5 years, there was no significant difference in the incidence of death from any cause or disabling stroke between the TAVR group and the surgery group (47.9% and 43.4%, respectively; hazard ratio, 1.09; 95% confidence interval [CI], 0.95 to 1.25; P=0.21). "

No "significant difference", but there is a difference and the rate of death or disabling stroke is higher for TAVR after 5 years.

Also:

" Results were similar for the transfemoral-access cohort (44.5% and 42.0%, respectively; hazard ratio, 1.02; 95% CI, 0.87 to 1.20), but the incidence of death or disabling stroke was higher after TAVR than after surgery in the transthoracic-access cohort (59.3% vs. 48.3%; hazard ratio, 1.32; 95% CI, 1.02 to 1.71). "

Again, SAVR outperformed TAVR in both cohorts.

And more:

" At 5 years, more patients in the TAVR group than in the surgery group had at least mild paravalvular aortic regurgitation (33.3% vs. 6.3%). Repeat hospitalizations were more frequent after TAVR than after surgery (33.3% vs. 25.2%), as were aortic-valve reinterventions (3.2% vs. 0.8%). "

And yet they conclude: " Among patients with aortic stenosis who were at intermediate surgical risk, there was no significant difference in the incidence of death or disabling stroke at 5 years after TAVR as compared with surgical aortic-valve replacement. "

Oh, but wait: "Funded by Edwards Lifesciences " Edwards is the leading TAVR valve manufacturer. So, you can decide for yourself whether or not that conclusion fits with the results from the data.

https://www.nejm.org/doi/full/10.10...xt=or disabling stroke.-,Results,1.25; P=0.21).

In one of our consultations, my cardiologist pulled up a study in Japan which found similar results- TAVR better after one year, but SAVR outperforming by 5 years.

So, personally, it made no sense to choose TAVR to buy myself approximately 5 years before OHS. Although my risk of a bad outcome would be better for the first year with TAVR, at 5 years I would likely have a better outlook if I had gone SAVR. And, then if I had chosen TAVR, I would get to have my OHS anyway at about the 5 year point. It made no sense to me no matter how I sliced it. To be clear, I believe that TAVR remains a very good option for some, for example if someone is 85 years old and would be high risk for OHS. But for younger patients who are low risk, it would appear to only put off the inevitable, at the cost of repeat surgery and higher mortality. Also, it was determined that I was not a candidate for TAVR anyway, so it was completely off the table. Very true that not all will be eligible.

Anyway, I applaud you for your analsysis and for considering all your options. I really like that you are getting 2nd opinions as well. That is the way to do it.

Best of luck with your decision.

 

[MdaPA]

I really weighed the pros and cons of the Ross vs Mech and came to the conclusion that the chance of being one and done wasn't worth being attached to Warfarin (my wife is in favor of this as well, she has some unfortunate personal history with Coumadin). However, if I wasn't fortunate enough to be working with the most decorated Ross surgeon in the world I would probably choose the mech valve over a Ross.

ok, so it looks like you gave this some series thought and research along with finding an experienced surgeon.

long days at the range with large calibers (fun part of my job). Thinking about picking up rock climbing, haven't yet though.

If you think you might be on the receiving end of any bullet, on or off the range, then yeah, wise decision to avoid anti-coagulants (BTW, if you are a police officer/SWAT or in the military, then thanks for your service!). Although with rock climbing I figure if you take a high fall, it wouldn't matter much one way or the other.

 

[pellicle]

TAVR would just be temporary, more or less a bridge to a Ross in my situation.

myself I'd call a Ross a bridge to the next surgery at your age. Just ask Arnold. Basically you start with one defective valve before the Ross and end up with two after it. You can trust stats or surgeons (and their curated stats). It seems to me people go bonkers chasing after choices that allow them to avoid warfarin therapy as if its some sort of monster.

Unless you are medically contra-indicated for Warfarin, the best bet you have for less procedures (and the consequent erosion of health each cycle) is a mechanical. If you search here almost everyone who starts warfarin says "it was nowhere near as difficult as I expected".

my most sincere advice would be to get a mechanical

 

[s9acasl]

Appreciate the perspective but as I mentioned I spent many months and received numerous opinions on options, I'm happy with my choice. I don't think Arnold is a good representative of the Ross procedure, seeing as how he ruined it almost immediately.

As for continuing my hobbies, I think it's awesome that people here have continued contact sports while on warfarin, I wouldn't. I would feel terrible for someone if by some chance they caused damage far in excess of what should have happened. I could probably find agreement with some people I spar with, but I can't justify putting them at risk of potentially hospitalizing me because I chose to continue with something I shouldn't have.

Further I can't put my wife through the stress of Warfarin, she lost her best friend to an IC bleed which was caused by it, and has subsequently developed a very dim (putting it mildly) view of the drug.

We were both elated to come across the Ross procedure as an alternative, and again as I have mentioned are very fortunate to be working with a surgeon who has performed hundreds of said procedure. I guess his enthusiasm has rubbed off on me, and he has the data to back up his claims.

 

[Timmay]

... I'm happy with my choice. ...

... I would feel terrible for someone if by some chance they caused damage far in excess of what should have happened. ...

... I can't put my wife through the stress of Warfarin, she lost her best friend to an IC bleed ...

... We were both elated to come across the Ross procedure as an alternative ...

This is all really good. You have come to a final choice based on a lot of factors that you are comfortable with. Additionally, you accept that you will need multiple open heart surgeries in the future AND you accept the ramifications of that (and that, truly, is the key factor here).

Like you, I considered the Ross. I ruled it out because ...

• I didn't want to have another OHS at ~70.
• And I didn't want to turn a 1 valve problem into a 2 valve problem.
• I didn't want my history of sporadic auto-immune stuff to cause my body to attack the new pulmonary.

That said, I didn't have the complications that you do: Wife against Warfarin, contact sports (I'm not gonna count high caliber rifles).

This is one of the videos that steered me toward the Ross. I will post it here for you as a pat on the back for the Ross.

 

[s9acasl]

The high caliber rifle thing is pretty niche. I work in advanced optical systems as an electro-optic engineer.

Occasionally...(whenever I get the chance, it's to much fun) I get to take prototypes I've been working on out to the range and put hundreds of rounds through (purely scientific). Anything from 9mm to 50bmg, even without warfarin on board I can walk away pretty bruised, in the name of science. We have a number of contracts with the US military and Police departments.

This is one of the videos that steered me toward the Ross. I will post it here for you as a pat on the back for the Ross.

I appreciate Dr. El-Hamamsy's passion for the Ross. I believe he's working on a national training program to reintroduce it into mainstream AVR options, but making sure it's done correctly, Ross centers of excellence or something like that.

 

[Chuck C]

I don't think Arnold is a good representative of the Ross procedure, seeing as how he ruined it almost immediately.

Could you clarify how you believe that he ruined his valve almost immediately? That is the first I've heard of this. I searched for additional information on this, but found nothing. Perhaps I missed part of his story, but from all accounts which I have seen, his Ross Procedure was very typical.

In 1997 he underwent a Ross procedure.

2018 he had OHS #2 to have his pulmonary valve replaced. As this is a donor valve in the Ross procedure it is not expected to last forever and he actually did good to have it last 21 years.

In 2020 he had his aortic valve replaced. In the Ross, as you know, the pulmonary valve is moved to the aortic position. It is common for the pulmonary valve to not last forever in the aortic position.

So, his experience was what I believe one would probably expect if things go well with the Ross. 21 years until OHS #2 is a good run. Ideally, the pulmonary and aortic valve give out at the same time and can both be replaced in OHS #2, but, as with Arnold, this is not always the case. As such, in 2020 he needed OHS #3. I believe that he hoped to have a transcatheter for the 2018 operation, but learned when he woke up that it had to be surgical replacement.

I am doubtful about the story that he immediately ruined his valve after his 1997 operation. I don't believe that either of his valves could have lasted 21 years had he done so. But, if you have a source for this information about him ruining his valve it would be much appreciated so that we can better understand his story. Thanks.

https://www.heart-valve-surgery.com/arnold-schwarzenegger.php