Valve choice when combined with an aorta repair - does this change the equation?

[gregjohnsondsm]

Does the addition of the replacement of the ascending aorta due to aneurysm sway the choice of mechanical vs tissue in any way? I can see that there are some mechanical valves that are already coupled with a dacron sleeve. This seems like a good idea and appears to be more durable than a tissue valve coupled to the sleeve. But I have not seen any discussion about this, nor does my surgeon at NMH (Dr. McCarthy) seem to think that it makes a difference. Any comments?
My surgery is scheduled for March 2 2015 in Chicago. I have been 100% sure of which valve I would get, two or three different times now.
At first I thought the ascending aorta was repaired with a dacron mesh wrapped around the offending section, but now it appears that they are removing the aneurysm completely and replacing it with the sleeve.

 

[pellicle]

Hi

Does the addition of the replacement of the ascending aorta due to aneurysm sway the choice of mechanical vs tissue in any way? I can see that there are some mechanical valves that are already coupled with a dacron sleeve.

to me I would still say that the primary determiner is age followed by your willingness to look after yourself (and no other medical conditions which would preclude one or the other). If you are younger and if you are willing to look after yourself then to me mechanical is the way to go, especially if you are already having an aneurysm fixed, it would seem then the need for reoperation is significantly reduced. Meaning you could in all likelyhood live out your natural life without re operations. So if you are under 50 that would be attractive to me.

For instance in a recent German study involving younger people (less than 50) the cohort on advanced (self monitoring) AntiCoagulationTherapy did not have any increased significance in bleeds over the general german population of their age and condition. That to me shows that the data on anticoagulation therapy is skewed towards the past and towards the aged care cohort.

If however you are over 60 then the advantages of mechanical diminish and its really a coin toss to go tissue.

I would be tending towards mechanical, but I can't speak for you.

This seems like a good idea and appears to be more durable than a tissue valve coupled to the sleeve. But I have not seen any discussion about this, nor does my surgeon at NMH (Dr. McCarthy) seem to think that it makes a difference. Any comments?

I can't speak for durability of the dacron sock (I have one too) but the pair together is significantly an advantage (irrespective of mech or tissue) because it reduces time to implant : therefore reduces time on the pump ... a good thing if you ask any surgeon.

At first I thought the ascending aorta was repaired with a dacron mesh wrapped around the offending section, but now it appears that they are removing the aneurysm completely and replacing it with the sleeve.

to my knowledge the people who have had that done (like that fellow on the TED talks) would be far fewer than 100 globally. So its "experimental"

 

[gregjohnsondsm]

Another thought is if the combination of the dacron tube and tissue valve in some way makes 1) re-operation more difficult or dangerous and 2) chances of TAVR replacement of the tissue valve in the future more or less likely? Does anyone have any information from doctors or their own research regarding this issue? Thanks again, still grinding through the selection process. And I know that either one is going to be fine, but right now I have the freedom to choose which type of 'fine' I get to live with for the next few decades. In two weeks I will not have that choice any longer.

 

[John_MiG-19]

That's a question I asked my doctor- ask yours.

 

[gregjohnsondsm]

Of course, but a second opinion, from your doctor, couldn't hurt. From my experience these doctors need very careful oversight to ensure proper operation.

 

[neil]

Get info you require which you are doing and make your choice. Good luck

 

[MrsBray]

I chose my type of valve, then the surgeon told me he would replace a part of my aorta if needed. Didn't seem to matter to him what type of valve I was getting.

 

[gregjohnsondsm]

It doesn't seem to matter which type of valve to use with the dacron tube aortic repair. I am leaning towards the C-E Perimount Magna Ease 3300 TXF. I found it hard to find any hard evidence that lead to one over the other as being preferred. As mentioned here many times, it comes down to your idea of how you want to live the rest of your life. Mechanical : Warafin and the associated daily concerns with bleeding, eating and drinking. Tissue: the knowledge that you get to go through all of this again. Of course the future will change - possible new drugs for anticoagulation, possible TAVR procedure for valve in valve replacement. So I am going with the tissue valve and plan for 20+ years and TAVR. But one never knows. Surgery is on Monday, March 2 at Northwestern Memorial Hospital with Dr McCarthy. See you all later.

 

[neil]

Good luck and see you soon

 

[Heart Of The Sunrise]

I did my research and when my surgeon asked me which way I wanted to go...I said the On-X Valve with the attached graft.

 

[gregjohnsondsm]

Heart of the sunrise, That seems like a pretty solid choice. It was that combination or the graft with the C-E magna ease that I had narrowed the choice down to fo me. I ended up going with the tissue and the graft. But I think either would have been fine for me.

 

[John_MiG-19]

The decision is the hardest part. I went with Mech valve with the Dacron sleeve -after they got inside, my original choice was unnecessary for my situation since the root was healthy. So they went with the former instead of the Conduit we had initially chosen.

 

[John_MiG-19]

I agree. Prayers and well wishes go with you.

 

[PJ206]

I would not even consider a mechanical valve in your situation. Given the bicuspid valve and the ascending aorta aneurysm, it is likely you have a connective tissue disorder which puts you "at high risk for aneurysms all over your body, including your brain" (in my surgeon's words). A mechanical valve requires life-long anticoagulation with warfarin. Warfarin not only makes aneurysms bleed more if they rupture, it makes them more likely to rupture in the first place. (Per the Stroke Assn, see below)

I had bicuspid valve and ascending aneurysm surgery in August 2012. Against my clear wishes and my surgeon's clear assurances, he switched me from a tissue valve to a mechanical valve during surgery. Seven months later, I had a nosebleed that put me in ICU for four days and required embolization via interventional radiology. (My INR was 2.3 upon admission to the hospital, so poor warfarin management was not the problem.) The catheter was inserted in the brachial artery in my right arm, and after the procedure my entire arm was purple from bleeding and swollen to twice its normal size. I was unable to use a mouse for three weeks and had to take short-term disability.

After returning home from the hospital, I developed an aneurysm at the site of the cath punture, so I was back in the ICU the next week for two more days for surgery on my brachial artery. This aneurysm was life threatening.

My sister has since had a berry aneurysm rupture in her brain (subarachnoid hemorrhage) , requiring clipping via craniotomy. Fortunately, she has few deficits from the stroke, but if it happens to me, it will likely be catastrophic. My cardiologist was so alarmed by this that he lowered my INR target range to 1.8-2.5.

Keeping my INR in range is not difficult for me. The problem is that, in my opinion, there is no safe level of anticoagulation for people with connective tissue disorders.
[h=4]What causes an aneurysm to bleed?[/h] [h=4]We usually don’t know why an aneurysm bleeds or exactly when it will bleed. We do know what increases the chance for bleeding:[/h]

• High blood pressure is the leading cause of subarachnoid hemorrhage. Heavy lifting or straining can cause pressure to rise in the brain and may lead to an aneurysm rupture.
• Strong emotions, such as being upset or angry, can raise blood pressure and can subsequently cause aneurysms to rupture.
• Blood “thinners” (such as warfarin), some medications and prescription drugs (including diet pills that act as stimulants such as ephedrine and amphetamines), and harmful drugs like cocaine can cause aneurysms to rupture and bleed.

http://www.strokeassociation.org/ST...out-Cerebral-Aneurysms_UCM_310103_Article.jsp

 

[gregjohnsondsm]

Is there a definite test for connective tissue disorder or is it just anecdotal based on what is happening to your valve / aorta? It seems like there are other possible causes of the enlarged aorta near the biscupid aortic valve. But if there is a conclusive test I would like to take it.

 

[pellicle]

Hi

while I appreciate your concern, and given what you have said about your own propensities for bleeding, I think its prudent to be cautious about warfarin and anti-coagulation therapy.

I'm not intending to dismiss anything you're saying but asking to get some verification on some serious points you've rasied. Regarding the risk of genaral aneurysm all over the body, I have never heard of these points and indeed have heard the opposite from my surgeon and my cardiologist as well as having heard similar (to my) reports reported here.

Given that you also say "We usually don?t know why an aneurysm bleeds", it makes me wonder if you may have the correlation the wrong way round. For instance "many people who have mental disorders smoke" , but one can not reverse that generalisation and say "If you smoke you are likely to have a mental disorder".

With respect to warfarin, I've never heard or read once yet that it contributes to reducing wall strength of blood vessels, what I have read is that when a bleed happens being on warfarin makes it take longer to stop and may require reversal of the AC therapy to stop it. For instance this journal article explores chronic use of AC
therapy (warfarin) and outcomes for aneurysm

http://www.ncbi.nlm.nih.gov/pubmed/23591187

Chronic oral anticoagulation does not appear to affect the incidence of endoleak after EVAR, nor does it impact the need for reintervention or degree of sac regression. We feel that warfarin may be safely used in post-EVAR patients. It appears that adverse long-term outcomes are more likely after emergency EVAR and in patients deemed unfit for open surgery.

http://www.ncbi.nlm.nih.gov/pubmed/15683272

After EVAR, anticoagulation appears safe and does not significantly alter mortality, risk for rupture, or the incidence of reintervention. Early endoleaks appear more common in anticoagulated patients, but anticoagulation does not preclude spontaneous endoleak resolution nor does it increase late endoleak rates.

this study seems to find a linkage between aneurysm and warfarin:
http://www.sciencedirect.com/science/article/pii/S0741521410006798

but a quick read shows two points of interest:

During a 7-year period, 127 consecutive patients with infrarenal AAAs who underwent EVAR were monitored for a mean of 2.14 years. The average age at the time of EVAR was 73.8 years.

the cohort of study was small and their average age was 73 years old and they had all had aneurysm recently... To me this would raise questions about the transferrability of their observations to the broader (younger) community.

I had bicuspid valve and ascending aneurysm surgery in August 2012.

... me too ... although I had my bicuspid aorta replaced in 1992 with homograft , then my homograft replaced and a aneurysm cut out in 2011.

Against my clear wishes and my surgeon's clear assurances, he switched me from a tissue valve to a mechanical valve during surgery.

did he ever provide reasons for that?

Seven months later, I had a nosebleed that put me in ICU for four days and required embolization via interventional radiology. (My INR was 2.3 upon admission to the hospital, so poor warfarin management was not the problem.)

it definately sounds like you have a propensity for bleeds, did you have this before?

I'm very sorry to read of all your medical woes with respct to your circulatory system, and while your cautions are good to consider there remains a bulk of evidence to suggest that your situation is not the 'normal' one.

So my point here is not to diminish your situation or dismiss it, but to advise gregjohnsondsm that while he should take into account your experience, that it does not represent the most likely outcome for him.

Greg is (in my non medical view) at about the age where a mechanical or a tissue would be of equal benefit trade off. Were he 30 (instead of 50) I would feel differently. Being 51 and having had now 3 OHS myself I am happy to have a mechanical valve as I don't want more surgery. Gregs and your cases are different to mine in that respect.

Anyway sorry to inject so much here, I hope its beneficial to Greg

 

[pellicle]

Hi

Is there a definite test for connective tissue disorder or is it just anecdotal based on what is happening to your valve / aorta? It seems like there are other possible causes of the enlarged aorta near the biscupid aortic valve. But if there is a conclusive test I would like to take it.

not that I know of, but I'd be keen to hear. To my knowledge its just 'statistical' likelyhoods.

 

[skeptic49]

I opted for a tissue valve (S.t Jude "Trifecta") in combination with a dacron graft all the way up to the underneath of the arch (hemiarch). My surgeon recommended this for me (age 66.) I also had two CABG grafts sewn into the dacron. I think it is correct that the choice of valve type is largely age dependent. These complicated plumbing repairs (my procedure lasted 7 hours with 2 hours 15 minutes on the pump) seem to be routine for surgeons at high volume heart centers of excellence. I ran your exact question by my surgeon in advance, namely: wouldn't it be better to use a pre-made conduit with the mechanical valve pre-installed? The answer was, no, not if a tissue valve is more advisable for your situation. (Conduits with pre-installed valves are NOT available with tissue valves, only mechanical valves.) Bottom line for me: pick a heart center of excellence for your surgery and select the valve type that is appropriate and that you are comfortable with and let the surgeon worry about the rest. Six weeks post surgery I feel great with a tissue valve sewn into a graft in the OR plus two native buttons (coronary arteries) plus two extra buttons - CABG grafts also sewn into the dacron. That's a lot of work but hey, it worked for me. Good luck with your decision.

 

[cldlhd]

I heard the opposite from my surgeon . He said other connective tissue disorders put you at a higher risk for aneurysm in other areas of your body but with a bicuspid valve the aneurysm risk is strictly from the aortic root to the beginning of the arch. I saw the geneticist at the same place I ad the surgery ( Univ. of Penn ) and he didn't run any specific tests . He did some general measurements of my head- vaguely reminded me of early 20th century eugenics- asked how flexible I was and that was that.

 

[W. Carter]

Back to the original op question about choice of valve. I am 58 and not a heart surgeon so I just left it up to my surgeon to decide what I needed rather than reading on the internet from wanna be doc's what I needed. My surgeon said that at my age I needed a mechanical valve. He said I was too young for a tissue valve. I didn't even know what kind he installed until after the surgery. Again i'm not a surgeon so I just trusted his decision. As it all worked out, it worked out perfect. My surgeon installed a one piece graft/valve that is working great.