Upcoming Surgery

[ETC908]

Hi everyone,
I am new to this forum and have read through a lot of the posts. I want to thank you all for sharing your experiences and insight, as I have found this forum to be invaluable. In summary, I am 42 years old and was found to have severe aortic stenosis and an aneurysm of the ascending aorta. Unfortunately my parameters have rapidly progressed to the point where surgery is being recommended now. I am asymptomatic, but my aortic jet velocity is about 4.9 (initial read was 5.1 but later adjusted). The aneurysm measures about 4.8. My cardiologist has recommended intervening sooner rather than later.
I have no other comorbidities. I exercise daily and fairly vigorously and consider myself to be in very good shape. I have obviously scaled down the intensity of my workouts after hearing that I've approached the very severe range.
The aneurysm obviously has to be repaired. I have gotten a couple of different opinions as far as the valve goes. A well-experienced surgeon at the hospital near me has recommended mechanical valve replacement with the On-X. The Cleveland Clinic has recommended either Ross or Ozaki. I have read the medical journal articles and lots of posts on this forum weighing out the pros and cons. I am an extreme type A personality and have no qualms about taking Coumadin, monitoring my INR, and figuring out a regimen that works well for me. The most "dangerous" thing I do is ski, and I'm a novice at best. I would very much like to avoid another surgery down the road. Hence my inclination is/was to go with the mechanical valve. What made me take pause was seeing some of the medical literature that references a shorter lifespan/higher mortality rate in patients with mechanical valves compared to the general population. Typically due to a combination of thromboembolic or bleeding events. Granted this is older data, doesn't necessarily factor in newer valves, home INR monitoring, etc. The contingent of surgeons/researchers who favor the Ross argue (based on limited data) that it improves survival rate.
I know many of you in here have done more research than I have and have better insight than I do. After many discussions, reading through the posts here, etc, I am about 98% sure I'm going to move forward with the mechanical valve. I was just curious what thoughts and insights you have on this notion of lower survival rate in people with mechanical valves. Can I expect, from a purely cardiac standpoint (as other medical issues can of course arise), to hopefully live another 40+ years or is this realistically going to shorten my lifespan?

As a completely unrelated follow-up question...as this surgery has come on more suddenly than expected, I have some family obligations/life events that I had upcoming and would still love to attend. I have 4 kids, who all have a lot going on. Recovery is obviously most important. But barring any major complications, after about 10-14 days post-op, can I expect to at least be able to stay awake and move around a bit in order to sit at a school sporting event, travel in the car (backseat of course) for a period of time?

I greatly appreciate any thoughts and insights you have. Thanks.

 

[dick0236]

Can I expect, from a purely cardiac standpoint (as other medical issues can of course arise), to hopefully live another 40+ years or is this realistically going to shorten my lifespan?

Why not? I've lived with mine for over 54 years and it is a first-generation mechanical valve. If you manage your INR and like you say, that is not a big deal..... and don't run with scissors, you should have no difficulty living a normal life span.

It's been a long time for me but I don't think I wanted to sit on sporting bleachers after 10 days post surgery. However, I had literally just graduated college when I had the surgery and I did start my career with a major company thirty days post op.....eight hours a day, five days a week.

BTW, welcome to this forum.....

 

[Chuck C]

Hi and welcome to the forum.

I'm glad that you have found the forum helpful. I found it a few months before my surgery, and it certainly was a huge help to me.

In that you will be having your aortic valve replaced and you have an aneurism to be repaired, you will be getting a Bentall procedure most likely, in which the aortic valve is replaced as well as part of your aorta. I had this same procedure done 7 months ago and went with a mechanical valve, as I was 53 years old and did not want to have repeat surgeries.

I was just curious what thoughts and insights you have on this notion of lower survival rate in people with mechanical valves.

Actually, most studies show a longer life expectancy with a mechanical valve vs a tissue valve, especially for younger folks, such as yourself- 42 is very young in the valve surgery world, with generally better outcomes for tissue valves when the patients are over 70 years old. This is why the medical guidelines around the world recommend mechanical as a reasonable choice if under 60 years old and tissue as a reasonable choice if over 70 years old and either valve a reasonable choice if between 60-70 years old. There is also at least one country that puts the lower threshold at 50 years, in which they state that between the age of 50-70 years old that it would be reasonable to choose either valve.

There is actually some good news about the fact that you will be getting your aorta taken care of at the same time. When patients have their aortic valve replaced one main cause for re-operation is to have an aortic aneurism repaired, which is very common, especially if the patient is BAV. In that you are getting both taken care of during your operation, you should not face this second operation down the road. And in that you indicate that you are probably getting a mechanical valve, there is a very low likelihood of needing a re-operation at all. Also, there is data to suggest that those who have both done at one time (the Bentall) have a completely normal life expectancy, as compared to the general population and actually a little longer than those who have just their aortic valve replaced. Please see linked study below. This does make sense because many people do need to eventually get a reoperation for aneurism repair down the road, and any time you open the chest back up, it will carry some risks.

" Discharged patients enjoyed survival equivalent to a normal age- and sex-matched population and superior to survival reported for a series of patients with aortic valve replacement alone. "

https://pubmed.ncbi.nlm.nih.gov/17888968/

my aortic jet velocity is about 4.9 (initial read was 5.1 but later adjusted). The aneurysm measures about 4.8.

Your medical team is correct that those numbers suggest that it is time, and you are wise to follow their advice to get it done soon.

Some more data on age and valve choice - please see article linked below.

"The long-term mortality benefit that was associated with a mechanical prosthesis, as compared with a biologic prosthesis, persisted until 70 years of age among patients undergoing mitral-valve replacement and until 55 years of age among those undergoing aortic-valve replacement"

I find the graphs if Table 1 interesting. In the age group of 45-54, mechanical aortic valve shows a lower mortality rate compared to aortic tissue valve prosthesis. They also plot the graph for those aged 55-64, for which mortality is essentially the same for the first 12 years. But, take a look at what starts to happen after about 12 years on that second graph. Mortality for tissue starts to increase compared to mechanical, and by year 15 following surgery there is clear separation. It is not coincidence that this would be the window during which many tissue valve patients are needing re-operation.

https://www.nejm.org/doi/full/10.1056/nejmoa1613792

after about 10-14 days post-op, can I expect to at least be able to stay awake and move around a bit in order to sit at a school sporting event, travel in the car (backseat of course) for a period of time?

Personally, I was able to do a lot once I was 10-14 days out from surgery. Not allowed to lift anything over 10 pounds, not allowed to life for things high on the shelf and needed to keep exercise limited to brisk walking and some specifically prescribed exercises. But, aside from those limitations was able to do about everything else. I would not expect that sitting at a school sporting event would be a problem nor travelling in the back seat of the car.

Wishing you the best of luck with your procedure and please keep us posted.

 

[pellicle]

Good morning

What made me take pause was seeing some of the medical literature that references a shorter lifespan/higher mortality rate in patients with mechanical valves compared to the general population. Typically due to a combination of thromboembolic or bleeding events. Granted this is older data, doesn't necessarily factor in newer valves, home INR monitoring, etc. The contingent of surgeons/researchers who favor the Ross argue (based on limited data) that it improves survival rate.

research is troubling and when you read research you need to ask questions of what you are reading to yourself.

Did you see my discussion point here and here? I know that's not simple stuff, and if its too hard to grapple with then pair it back with Occam's Razor :

• separate out the points mech valve vs other valves for longevity
• the influence of INR on longevity

If you can comply with INR therapy (its really not that hard) then there is no reason why to not expect to have the "age related risk" of bleed or thromboembolism event. Meaning "welcome back to a sort of normal"

After many discussions, reading through the posts here, etc, I am about 98% sure I'm going to move forward with the mechanical valve. I was just curious what thoughts and insights you have on this notion of lower survival rate in people with mechanical valves. Can I expect, from a purely cardiac standpoint (as other medical issues can of course arise), to hopefully live another 40+ years or is this realistically going to shorten my lifespan?

just a point on the On-X its not a magic valve it is just produced by a company that knew it had no runs on the board and wanted to manufacture a market niche on those who are a little bit hysterical about INR and the threats of warfarin. I would never have imagined this as being a powerful draw, but my participation here over the years has shown me that these people exist; somehow thinking that reducing their dose from 7mg a day to 6mg a day will clear them of their fears of the possible negative outcomes of Warfarin.

If you are "impressed" by the On-X you may also interested in this thread.
https://www.valvereplacement.org/threads/aortic-valve-choices.887840/post-902334
I myself have an ATS, but if I was availed of a choice again or required to make another choice I'd go St Jude because of that actual measurement data.

Be cautious of following the Lower INR protocol without:

1. weekly INR testing
2. co-administration of Aspirin
3. aversion of any INR number below 1.6

Best Wishes

 

[ETC908]

Thank you so much for the detailed responses. Both are extremely helpful. My preference this entire time has been to go with the mechanical valve. But I didn't want to completely blow off the Ross as an option and potentially short-change myself over the long term. Pellicle, I had read through your prior posts/threads and that was a large reason why I felt more comfortable with passing on the Ross and sticking with the mechanical valve. I don't think I have a choice of valve, as my surgeon uses the On-X. I had read through prior posts here expressing some skepticism over the lower INR range. So I'm inclined to keep it closer to 2.5 despite the company's recommendation. I'll have better peace of mind knowing I'm less likely to throw a clot at that level.
Chuck C, I greatly appreciate that reference and insight. I had not come across that article. The info you provided is tremendously reassuring. Thank you.
I have a phone call pending with the surgeon from Cleveland Clinic just to pick his brain, but again I'm 98% sure I'll be going with the mechanical valve. Other than the ability to avoid anti-coagulation, is there any other reason why these centers are recommending the Ross? I would think more people would rather take a blood-thinner than risk a more complicated re-operation down the line, so I'm curious if there are any other advantages.
I'm obviously dreading the surgery and am nervous about it all...even the cardiac cath leading up to it. But I at least want to go in comfortable with my decision and ready to handle the life adjustment afterward. Thanks to you all and this forum, I think I'm at that point.
Thanks again for the good wishes.

 

[CarolM]

Thank you so much for the detailed responses. Both are extremely helpful. My preference this entire time has been to go with the mechanical valve. But I didn't want to completely blow off the Ross as an option and potentially short-change myself over the long term. Pellicle, I had read through your prior posts/threads and that was a large reason why I felt more comfortable with passing on the Ross and sticking with the mechanical valve. I don't think I have a choice of valve, as my surgeon uses the On-X. I had read through prior posts here expressing some skepticism over the lower INR range. So I'm inclined to keep it closer to 2.5 despite the company's recommendation. I'll have better peace of mind knowing I'm less likely to throw a clot at that level.
Chuck C, I greatly appreciate that reference and insight. I had not come across that article. The info you provided is tremendously reassuring. Thank you.
I have a phone call pending with the surgeon from Cleveland Clinic just to pick his brain, but again I'm 98% sure I'll be going with the mechanical valve. Other than the ability to avoid anti-coagulation, is there any other reason why these centers are recommending the Ross? I would think more people would rather take a blood-thinner than risk a more complicated re-operation down the line, so I'm curious if there are any other advantages.
I'm obviously dreading the surgery and am nervous about it all...even the cardiac cath leading up to it. But I at least want to go in comfortable with my decision and ready to handle the life adjustment afterward. Thanks to you all and this forum, I think I'm at that point.
Thanks again for the good wishes.

Good luck with your surgery. Don't be concerned about the cath; it is really a breeze in comparison to everything else. It provides good data to your team, so not to worry, in my opinion. Regarding 10-14 days after surgery, personally I was still feeling every bump in the road when traveling, but doable with a pillow over my incision. I found myself fatigued easily in the early weeks, primarily because sleep was challenging. We are all different though. Best of luck!

 

[Chuck C]

I find the graphs if Table 1 interesting.

Correction- I meant to say the graphs for Figure 1

 

[pellicle]

My preference this entire time has been to go with the mechanical valve. But I didn't want to completely blow off the Ross as an option and potentially short-change myself over the long term.

that's wise and its always good to do due dilligence in researching what you are not inclined towards, that's actually proper research (rather than just feeding in confirmation to your existing bias)

Thanks again for the good wishes.

Your welcome.

A little surprised that a surgeon wouldn't give you a choice in valve brand, however I don't think there are any significant down sides to any current bileaflet valves.

Anyway, when it comes time and you are doing your INR yourself (or not) I recommend you toddle over to my pages on INR (this is all of them in most recent first order) and use that as a reference or guide.

Best Wishes

 

[AZATADINE]

I'm 52 male and I'm opting for the Magna Ease bovine tissue in 2 weeks time. This is my own preference due to activity levels such as horse riding. I want to avoid warfarin (due to the management and risks) plus I really don't think I could stand the ticking of On-X.

I'm in that gray area of 50 to 65 where either choice is ok though.

 

[paul donnelly]

im in for my AVR 28th Oct 2021 opting for a tissue valve. Im 65.

Talking to freinds who have OHS, recovery times have differed, so to use a phrase we in the UK use too often "it is was it is"

You'll be fine and wish you a speedy recovery

 

[pellicle]

im in for my AVR 28th Oct 2021 opting for a tissue valve. Im 65.

here's hoping for a smooth and uneventful recovery.

Best Wishes

 

[Croooser]

One advantage of the cath procedure is that you get a definitive evaluation of any blockage. That's good to know if you have ever tested high on cholesterol.

FWIW, my recent experience at the CC was excellent.

If you are willing to say, who is your surgeon?

Best wishes for a successful surgery and a complete recovery.

 

[Chuck C]

I'm 52 male and I'm opting for the Magna Ease bovine tissue in 2 weeks time. This is my own preference due to activity levels such as horse riding. I want to avoid warfarin (due to the management and risks) plus I really don't think I could stand the ticking of On-X.

I'm in that gray area of 50 to 65 where either choice is ok though.

Best wishes with your procedure! Please keep us posted on your recovery if you feel up to it.

 

[Chuck C]

im in for my AVR 28th Oct 2021 opting for a tissue valve. Im 65.

Talking to freinds who have OHS, recovery times have differed, so to use a phrase we in the UK use too often "it is was it is"

You'll be fine and wish you a speedy recovery

Good luck Paul! Please keep us posted on your recovery.

 

[BillDaThrill]

I don't think I have a choice of valve, as my surgeon uses the On-X. I had read through prior posts here expressing some skepticism over the lower INR range. So I'm inclined to keep it closer to 2.5 despite the company's recommendation. I'll have better peace of mind knowing I'm less likely to throw a clot at that level.
Chuck C, I greatly appreciate that reference and insight. I had not come across that article. The info you provided is tremendously reassuring. Thank you.
I have a phone call pending with the surgeon from Cleveland Clinic just to pick his brain, but again I'm 98% sure I'll be going with the mechanical valve.

Wishing you the best ETC. Was thrilled with my care and outcome at the Cleveland Clinic and, 4 months later, am loving life with my On-X valve!

 

[ETC908]

One advantage of the cath procedure is that you get a definitive evaluation of any blockage. That's good to know if you have ever tested high on cholesterol.

FWIW, my recent experience at the CC was excellent.

If you are willing to say, who is your surgeon?

Best wishes for a successful surgery and a complete recovery.

Thank you. The surgeon at CC is Dr. Weiss. He is recommending the Ross procedure and would be operating with Dr. Pettersson, who just retired but is coming back in a few weeks to do some cases. I have a surgeon in my local area at the hospital I'm affiliated with (I work in health care) who would be doing the mechanical valve/On-X. He is well-versed in aortic valve replacement and aortic aneurysm repair, and I'd be in an environment where they know me and would (hopefully) take good care of me. I would travel to CC for the Ross if it was my preferred option, but as I am favoring the mechanical valve I'd rather stay local if I can. I'm awaiting one more conversation with each surgeon to solidify my decision. But I'm fairly certain I'll be going with the mechanical valve.
Thank you again for the good wishes, and I will be sure to let you know how it goes.

 

[MdaPA]

The surgeon at CC is Dr. Weiss. He is recommending the Ross procedure and would be operating with Dr. Pettersson, who just retired but is coming back in a few weeks to do some cases.

I would press CC as to why they recommend Ross over a mechanical in your situation. Nonetheless, I'm sure they would honor your wishes and do a mechanical (although I'm curious to know if Dr. Pettersson would come back out of retirement to assist if you are not having a Ross procedure).

 

[ETC908]

Thank you, I did speak with them. Their rationale for the Ross was the ability to avoid anticoagulation, coupled with the fact that the reoperation rates for the Ross are similar to those with mechanical valves (according to the literature they use). When I asked about my risk of reoperation with a mechanical valve after having the ascending aortic aneurysm also repaired (which I would assume based on Chuck C's info above would be lower given that the aneurysm is being addressed?), I didn't really get a straight answer. They also cited better hemodynamics with the valves used in a Ross vs. mechanical valve.

 

[drleng]

1) Just 1 comment about choice of valve - my surgeon chose St Jude for me (over all the newer ones available) because it's tried and tested and he was comfortable with the consistency and reliability. New does not necessarily equate to better.

2) Post-op, you are young and fit, so you'll definitely be walking around as soon as you're out of ICU. But, I would be worried about catching Covid (breakthrough infections are common in fully vaccinated) in a crowded event more than any problem related to open heart surgery!