Valve Repair vs. Valve Replacement

[Guest]

Hello all!

Wondering if someone could explain/refer me to studies that detail the differences between repairing and replacing valves. Had a friend recently get a repair, also read about NY Yankees coach Aaron Boone getting a repair.

As someone who was born with bav, I’ve always expected to need a replacement but was wondering how some are eligible for a repair? Does it have to do with age or the quality of the valve or both?

i know it’s unlikely, but I can hope!!

 

[libra rising]

Does it have to do with age or the quality of the valve or both?

A quick search brought me to this video :
https://www.sharecare.com/health/circulatory-system-health/what-difference-valve-repair-replacement

The answer seems to be whether the valve is 'beyond repair'. In some cases it won't be. In many cases it will e.g. a stenotic valve would need replacement.
HTH
Geoff

 

[pellicle]

Hi

Hello all!

Wondering if someone could explain/refer me to studies that detail the differences between repairing and replacing valves.
...
As someone who was born with bav, I’ve always expected to need a replacement but was wondering how some are eligible for a repair? Does it have to do with age or the quality of the valve or both?

i know it’s unlikely, but I can hope!!

ok, firstly I did a quick search like Libra and found:

https://www.ncbi.nlm.nih.gov/pubmed/24680032
[h=4]RESULTS:[/h] Hospital mortality was 0.41% (n=3), and stroke occurred in 0.27% (n=2). Freedom from aortic valve reoperation at 10 years was 78%. Risk of reoperation was highest immediately after operation and fell rapidly to approximately 2.6%/year up to 15 years. Primary reasons for reoperation were cusp prolapse (38%), aortic stenosis or regurgitation (17%), and aortic regurgitation from root aneurysm (15%). Aortic valve gradients showed an early initial peak, rapidly declined, then rose steadily, accompanied by an increase in left ventricular mass. Survival was 94% at 10 years. A risk factor for early death was greater preoperative mitral valve regurgitation, and for late death, older age at operation, more severe symptoms, and poorer left ventricular function.

and

https://www.ncbi.nlm.nih.gov/pubmed/29273323
[h=4]RESULTS:[/h] Planned repair was aborted for replacement in 115 patients (10%); risk factors included greater severity of aortic regurgitation (AR; p = 0.0002) and valve calcification (p < 0.0001). In-hospital outcomes for the remaining 1,009 patients included death (12 [1.2%]), stroke (13 [1.3%]), and reoperation for valve dysfunction (14 [1.4%]). Freedom from aortic valve reoperation at 1, 5, and 10 years was 97%, 93%, and 90%, respectively. Figure-of-8 suspension sutures, valve resuspension, and root repair and replacement were least likely to require reoperation; cusp repair with commissural sutures, plication, and commissuroplasty was most likely (p < 0.05). Survival at 1, 5, and 10 years was 96%, 92%, and 83%. Immediate postoperative AR grade was none-mild (94%), moderate (5%), and severe (1%). At 10 years after repair, AR grade was none (20%), mild (33%), moderate (26%), and severe (21%). Patients undergoing root procedures were less likely to have higher-grade postoperative AR (p < 0.0001).


both of which suggest favourable outcomes, however there is a lot missing such as what happens after 15 years and what the condition was of the valve before.

I don't know your age (or indeed anything about you) but you say "I can hope" ... may I ask hope for what?

If said repair involves an Open Heart Surgery you've done the hard yards and for what? A repair will likely last 20 years or perhaps less depending. I'm not sure I see the benefits of "a full engine rebuild" and putting in the old pistons" ... for what? To save a few bucks? Sentiment?

What?

What is the benefit of a repair to your mind?

I've had 3 OHS in my life ... sometimes I wish I could just have had one. Each successive surgery leaves you with exposure to more risks and if you're lucky (I've been pretty lucky) less damage.

Anyway ... I hope that helps

 

[dornole]

I'm with Pellicle, I would ask about the durability of the proposed repair before going that route. I had a balloon-based repair that they said would probably last 10-15 years, sparing me OHS, so that was pretty clear Yes to that Repair for me. (On year 16, woo)

However, if I had been told I'd only get 10-15 out of an OHS repair (I was 34 then), I would have told them to put in a mechanical valve if they were cutting me open anyway. I was done having kids and I'd rather manage warfarin than guarantee myself another (probably multiple other, given my age) open heart surgery .

 

[pellicle]

... I had a balloon-based repair that they said would probably last 10-15 years, sparing me OHS, so that was pretty clear Yes to that Repair for me. (On year 16, woo)

good point, I'd overlooked catheter based repairs. If that is on the table then its an obvious first choice

 

[DJM 18]

I have been following BAV repairs and have read many studies. While there are not yet significant long term results, the good news is that this is a rapidly developing field with significant improvements. If you compare repairs pre 2000 to post 2000 the results are significantly better and they continue to get better as there is more data on why these repairs fail.

As long as the valve is in relatively good shape and does not have calcification, then the probability of a repair is actually not that low. Svenson of Cleveland puts it at 70% but they can really only tell once they have eyes on the valve.

As far as durability of a repair, Cleveland in their latest studies is at 10% failure within the first ten years. Which is quite good and they argue that most failures happen early and thereafter it seems to flat line so a durability of 20 years or more is not entirely out of the question. Other high specialty centers are also demonstrating very good results (Tirone Toronto, Bavaria Penn, Stanford, a few centers in Europe).

This procedure continues to grow in popularity as more and more centers are offering as an alternative to a bio prosthetic valve. And as I said previously the results continue to improve as they gain more experience, for example results have shown marked improvement since they started measuring the cusps more carefully or as they worried more about stabilizing the root. Currently there is a ring being used (Lansac ring) similar to mitral valve repairs which is quite promising.

In any case, I agree that the last thing one wants is multiple OHS but I also feel that this has gotten to the point where it makes lots of sense for many patients. Certainly much better than a bio prosthetic valve that may only have 8 to 12 year durability in a younger patient. In any case an exciting and evolving field with great progress being made every year.

There is in this forum a firefighter from Colorado who had his repaired last summer, for him being on coumadin meant not being on active duty. He has a blog which is well worth reading. And there is also a marine jet fighter pilot who also had his repaired at Stanford and is again flying. And there is also a young athlete that wanted to continue his football career, he had been recruited by the Jets. Not to mention women who are looking to get pregnant.

I understand Pellicle's point but this field started as more and more surgeons were asking themselves a different question: "why are we throwing out native valves that are still in very good shape?"

 

[DJM 18]

If you want a long detailed explanation, here is a good video to watch from Dr. Stewart at Mt Sinai on BAV repair...

https://www.youtube.com/watch?v=x4G_P7JqF4k

 

[DJM 18]

And here is a link to eric's blog...the fire fighter from Colorado who had his valve repaired.

https://captaintinman.blogspot.com/2017/06/welcome.html

 

[pellicle]

Hi

I have been following BAV repairs and have read many studies. While there are not yet significant long term results, the good news is that this is a rapidly developing field with significant improvements. If you compare repairs pre 2000 to post 2000 the results are significantly better and they continue to get better as there is more data on why these repairs fail.

thanks for that ... could you post (or PM me) with a couple of studies (saves me searching) which clarify the differences between the decision reasons for repair VS replace and with outcomes?

Its also not clear (although it seemed to be regular OHS in the case of CaptainMan's) if this is broken down into catheter delivered vs regular OHS delivered.

I understand Pellicle's point but this field started as more and more surgeons were asking themselves a different question: "why are we throwing out native valves that are still in very good shape?"

I'm actually in a casual information gathering about this (I say casual because it has no pertinence to me) , but for the life of me I'm yet to see any basic reason to do this as OHS (vs a catheter delivered version which I do see advantages in) other than to allow the surgeon to have themselves some "point of difference" in a marketplace and an appeal to the illogical sentiment of the (vulnerable) patient. It has an emotional appeal.

To me there must be a clear and obvious reason for the approach or its just "fluff", for instance perivalvular leaks will be a non issue, but what about endo? (just to start the ball rolling)

So sure you can make a bicycle out of bamboo, but Alluminium is the standard for light and strong and durable.

Best Wishes

 

[pellicle]

oh, and DJM 18 , I don't believe that surgeons are all Angles of Humanity Savior, many are strictly ego driven and money motivated. Perhaps the cohort is slightly more skewed towards altruism than the general population, perhaps not. So there doesn't have to be a reason that's scientifically based to them.

I look towards the reasons for calcification which are usually tissue damage of the valve leaflet, so I would need to get sound and solid medical imaging that there is enough viable tissue in the leaflet (which is a living sheet of tissue by the way, not just dead skin like your fingernails or hair) there to continue operating and that the "repair" actually contributes to its longevity.

I suspect that the choices being made for candidates may indeed err on "more work for me" rather than "certainty of a better outcome for you"

call me cyinical, but if one is to go through this surgery one needs to really really understand what you're doing and why.

Or your just meat on the table...

 

[pellicle]

DJM 18
some of the ones I've already read:

https://www.evernote.com/shard/s223/...valve%20tissue

Some of the things which bothered me in that study were even plain in the conclusions:
The presence of severe aortic regurgitation (HR, 2.2; 95% CI, 1.1-5.06; P ¼ .02) and more than mild regurgitation at discharge (HR, 5.87; 95% CI, 2.67-12.68; P .0001) were predictors of late reoperation. Freedom from other valve-related events was 94% and 91% at 5 and 10 years, respectively. Forty-seven patients (21%) with intact valve repair were using warfarin at the last follow-up visit.


and this one shows the important aspect of the anatomy / morphology of the valve leaflet tissue:
http://circres.ahajournals.org/content/113/2/186

(in case they overlap with your readings)

 

[DJM 18]

this has some good data on the topic...Aciher has some good studies and this one is in slide format. I found slide 22 quite surprising, I would have thought mechanical was much higher. And perhaps repair is gaining favor quickly as it is a better option than bio-prosthetic at present.

http://www.uniklinikum-saarland.de/...aesentationen/2015_05/Aicher_Why_and_when.pdf

 

[DJM 18]

This is a good piece by Tirone form Toronto who in many ways has been a pioneer of this procedure, a fantastic surgeon who put together this piece on the AVRepair...

http://www.onlinejacc.org/content/accj/68/6/654.full.pdf

 

[DJM 18]

One last piece which is also interesting...

http://circ.ahajournals.org/content/128/8/854

 

[pellicle]

Hi

thanks for the readings ...

this has some good data on the topic...Aciher has some good studies and this one is in slide format. I found slide 22 quite surprising, I would have thought mechanical was much higher. And perhaps repair is gaining favor quickly as it is a better option than bio-prosthetic at present.

actually I'm not surprised, many factors are selecting against mechanical these days. I'm undecided if its rational choice or fears driven...

i will give them a good read this evening

 

[DJM 18]

I was actually shocked by the slide, of course it does not comment on the age of patients. But based on all I have learned in the past year I am surprised that mechanical valves are not more popular given the advances that have been made in INR self testing. I think a repair that could potentially last 20 years (or more) is a rational choice but selecting a bio prosthetic when young seems like the equivalent of putting yourself back in the waiting room the day after you are discharged from the hospital.

 

[carolinemc]

Guest, my experience, I was eight years old when I had repair on aortic valve and replacement when I was 36 years old. So I wish I could help you on your information journey. After replacement, my heart health was better. There are good studies on both sides. Good luck in your information journey. Hugs for today.