Visit with the Surgeon

[mainframe]

I went to see the surgeon my cardio recommended yesterday to replace a severely leaking aortic valve, Dr. Alan Hall at Virginia Mason. He was a likeable guy who was able to inspire confidence in his ability. I’m sure he'd do a fine job.

I ask about the On-X and he mentioned they have done several but because of my dilated aortic root (4.9) he thought the St. Jude with the pre-attached graph was a better choice. As a matter of fact he stated he wouldn't consider sewing a graph on the On-X, but didn't really explain his reasons.

He was concerned about my kidney (born with only 1) that was already measuring a higher creatinine level output than ideal and suggested the OHS could easily harm the kidney and result in dialysis either temporarily or permanently, though he acknowledged there the surgery should be done.

He also suggested getting another opinion or two drawing the analogy of shopping for a car at only 1 dealer. My "in-network" choices are limited, but I have signed up for "Options", a kind of insurance that pays out of network with an annual limit of 2000 so anywhere or anyplace I went, the most out of pocket would be 2000. I'm just not sure anyone else would have a better plan or do a better job.

Next step is to get a CT scan to get a better idea of the aortic dilation. The cardio wants me to get an angiogram prior to surgery, but the surgeon said he probably wouldn't need one but was willing to have me get one in deference to the cardio.

Was an interesting appointment.

 

[Lynlw]

I'm sorry things aren't more black and white. Would the function of your 1 kidney be a concern with the dye from an angiogram?

 

[mainframe]

Hi Lyn,

Yes the surgeon mentioned the dye could be an issue. He felt there needed to be time between the angiogram and the surgery to let the kidney recover.

 

[tobagotwo]

The angiogram is mostly to validate that the surgery is necessary and to determine whether there are any coronary artery blockages that should be bypassed while they are already in the chest.

I would also be concerned about the dye. The surgery itself will put stress on your kidney. It's a judgement call whether to burden it also wiith the dye. There are different dyes used for MRA (magnetic resonance angiogram) vs. cardiac catheterization, both of which can scan your coronary arteries. Is one of them significantly easier on the kidneys?

Some surgeons are fine with sewing a velour graft onto an On-X. Some are not. You kind of suspect less experience in those who won't, although it's not necessarily the case. I would seek a second surgeon's opinion, preferably one who is working regularly with aortic aneurysms or aortic root replacements. Total experience, amount of practice, and currency (recentness) of your surgery type are usually keys to the most successful surgeons.

Have you spoken to a nephrologist in terms of what issues might exist with warfarin in terms of your kidney issues, based on the possibility that you will need dialysis and may need more of it or other kidney treatments in the future? May not be an issue, but it might be good to ask.

Best wishes,

 

[mainframe]

Thanks Bob,

I've ask the question of the cardiologist about whether warfarin will have a kidney impact and he said no. I don't actually have a nephrologist, through my primary doctor has spoken with one about me.

I'll have to figure out who to talk to next. It makes sense to make to effort though at times it feels like I'm shooting in the dark.

 

[Ross]

Chris can anything ever be easy for us? I have to say, I'm really concerned for you with just one kidney. I've got two, but the likelihood of them quiting is enormously high right now. They won't even give me a catscan unless it's a life or death emergency.

 

[Lynlw]

Thanks Bob,

I've ask the question of the cardiologist about whether warfarin will have a kidney impact and he said no. I don't actually have a nephrologist, through my primary doctor has spoken with one about me.

I'll have to figure out who to talk to next. It makes sense to make to effort though at times it feels like I'm shooting in the dark.

I think it makes sense to get a neph on board now, get his thoughts on what testing to do or not to do, IF the surgeon thought he didn't need to see an angiogram, but will do one since the card wants one, that to me, personally isn't a ogood reason, given you only have 1 kidney and that has high numbers now as it is. Another reason I would get one now, is I think I'd get one that practices where (hospital) you will be having surgery , so he can follow you during the admission, especially if you run into kidney problems post op, you don't want some random Neph that just met you, to make all these important decidions, at least you could find one you trust before hand.

 

[scuba_898]

I don't know if i can offer any true advice. I am young 29 yrs, BAV diagnosed 6mo ago, recently told of a small aortic aneurysm. I have seen three different surgeons and two different cardiologist in 1 mo. time. Two of the surgeons had similar recomendations and suggested a mechanical valve. One suggested st. jude another suggested carbomedic, I too was wanting an on-x. the third surgeon who i saw on tuesday thought i should go a valve-sparring / repair route but if i wanted a mechanical valve, would put any kind in me that i wanted. So a lot of different opinions. when i asked the last surgeon what his reasoning was, he said that overall he saw no defining difference in the mech valves. he prefers to use and make his conduit graphs vs. use the pre-made ones and believes that hand made ones are more friendly to the risk of re-operations. he said that if a conduit graph or valve were to fail, a premade graph would mean that all would have to be replaced again. where as a custom one would allow either part or all to be replaced as needed. his recomendation for me was different based on a few things and my age. I know that everyones situation is unique to them, I recommend going what with a doctor tells you, but 1st, be sure to get second oppinions, as in my case i got three uniquely different opinions.

My new and for the time permanant cardiologist told me to use the time i have now before surgery to seek out different opinions. For when it comes to surgery you want to be confident that you did everything you can at the time to get what is best for you. So that there are no regrets.

One last thing make sure you see a confident surgeon that performs many of the type specific surgeries that apply to you. the first two surgeons i saw are both really good surgeons and perform roughly 200 surgeries a year, the second i think performed a few more AVR than the 1st did, the third said he performed over 350 surgeries last year, with a large focus on the aorta as its his area of interest.

I didn't mean to preach or talk to much if i did. If this helps at all then great. I believe that if you want the on-x valve, you can get it, just find the surgeon that agrees to use it.

 

[Lynlw]

I don't know if i can offer any true advice. I am young 29 yrs, BAV diagnosed 6mo ago, recently told of a small aortic aneurysm. I have seen three different surgeons and two different cardiologist in 1 mo. time. Two of the surgeons had similar recomendations and suggested a mechanical valve. One suggested st. jude another suggested carbomedic, I too was wanting an on-x. the third surgeon who i saw on tuesday thought i should go a valve-sparring / repair route but if i wanted a mechanical valve, would put any kind in me that i wanted. So a lot of different opinions. when i asked the last surgeon what his reasoning was, he said that overall he saw no defining difference in the mech valves. he prefers to use and make his conduit graphs vs. use the pre-made ones and believes that hand made ones are more friendly to the risk of re-operations. he said that if a conduit graph or valve were to fail, a premade graph would mean that all would have to be replaced again. where as a custom one would allow either part or all to be replaced as needed. his recomendation for me was different based on a few things and my age. I know that everyones situation is unique to them, I recommend going what with a doctor tells you, but 1st, be sure to get second oppinions, as in my case i got three uniquely different opinions.

My new and for the time permanant cardiologist told me to use the time i have now before surgery to seek out different opinions. For when it comes to surgery you want to be confident that you did everything you can at the time to get what is best for you. So that there are no regrets.

One last thing make sure you see a confident surgeon that performs many of the type specific surgeries that apply to you. the first two surgeons i saw are both really good surgeons and perform roughly 200 surgeries a year, the second i think performed a few more AVR than the 1st did, the third said he performed over 350 surgeries last year, with a large focus on the aorta as its his area of interest.

I didn't mean to preach or talk to much if i did. If this helps at all then great. I believe that if you want the on-x valve, you can get it, just find the surgeon that agrees to use it.

To your one point, Justin's last surgery was to replace just 1 part of his conduit/valve/conduit the surgeon made in the Or. Since the rest looked good he left the rest alone didn't have to sew both ends to Justin's tissue.

 

[mainframe]

Ross, if things were easy we probably wouldn't be here. For some, they seem to be a bit more difficult.

I've emailed my primary care doctor with the surgeons concerns who at this point seems most likely to bring a nephrologist on board. That seems to be the way the insurance works. Referrals from someone, anyone but me.

 

[Lynlw]

Ross, if things were easy we probably wouldn't be here. For some, they seem to be a bit more difficult.

I've emailed my primary care doctor with the surgeons concerns who at this point seems most likely to bring a nephrologist on board. That seems to be the way the insurance works. Referrals from someone, anyone but me.

AH do you have a HMO? Luckily we (PPO)don't need referals so can just call who we want for an appt.