Surgical Second Opinion And And A Game Plan At Last!

[skeptic49]

This afternoon Dan and I met with a surgeon at the Temple University Heart and Cardiovascular Center in Philadelphia. This surgeon was recommended by my cardiologist. This was my second surgical opinion. I did some research on the surgeon I met with today and I was impressed with his credentials. Our meeting was intense, with a bombshell surprise: I would need a Bentall procedure, involving composite graft replacement of the aortic valve, aortic root and ascending aorta, with re-implantation of the coronary arteries into the graft. This complex and long operation is used to treat combined aortic valve and ascending aorta disease, which I have, apparently. This treatment plan was radically different from the first opinion that I got on Monday, where the surgeon suggested that my aneurysm did not need to be replaced, let alone the aortic root. The first surgeon wanted to do an isolated replacement of the aortic valve via a mini-sternotomy, and agreed to address my aortic aneurysm only after I insisted. The second surgeon today indicated that the valve and aorta needed replacement from the outset. The first surgeon suggested the need for circulatory arrest during the procedure, but the surgeon today stated that this would not be necessary. I find it interesting and a bit troubling that such divergent therapies can be suggested for the same pathology. But in fairness the first surgeon stated that he preferred a conservative approach. Today the second opinion surgeon seemed to want to correct as much as possible during open heart surgery. I come down firmly with the latter approach. I want the valve and the aneurysm taken care of, and if the aortic root needs replacement then so be it. Get it done. Therefore, I have opted to go with the approach outlined by today's surgeon and I have scheduled my procedure for February 16.

 

[pellicle]

really glad to hear you had a good meeting this time round.

Best wishes for a smooth recovery.

 

[cldlhd]

Good to hear. It is strange they have such different views but I guess they're human also . I was told my aortic root and ascending would be replaced from the get go and mine is only slightly larger than yours but I'm curious as to how they do it without circulatory arrest.

 

[ottagal]

skeptic49,

Glad that you made the decision to go for a second opinion. It sounds like you have your ducks lined up in a row and now have an official date. Will be thinking of you and sending my most positive thoughts and best wishes for a most successful surgery and smooth and speedy recovery. We will all be here awaiting your update.

 

[epstns]

Now THAT sounds like a plan! While it is a bit unnerving to hear such divergent plans from two surgeons, that precisely, is why we are advised to seek second opinions on major issues. In my case, both surgeons I interviewed recommended the same approach, so it was a different decision process. In your case, the difference in approaches made the choice clear for you.

I'm glad that you've gotten this far. Then we hope that the rest of the journey is smooth.

 

[skeptic49]

Thanks for the supportive comments, everyone. I'm still processing the information from yesterday but I remain convinced that I'm on the right path. Gotta see the dentist this morning to get surgical clearance.

 

[river-wear]

That sounds like a much better plan. I'm glad you found a surgeon you like better and that he has a good plan to address all of the issues at once. Good luck with your surgery!

Can you explain what you mean by this?
The first surgeon suggested the need for circulatory arrest during the procedure, but the surgeon today stated that this would not be necessary.

It seems impossible and I've never heard of that being done, aside from some "off bypass" CABG procedures - never for AVR or aneurysm repair.

 

[skeptic49]

That sounds like a much better plan. I'm glad you found a surgeon you like better and that he has a good plan to address all of the issues at once. Good luck with your surgery!

Can you explain what you mean by this?
The first surgeon suggested the need for circulatory arrest during the procedure, but the surgeon today stated that this would not be necessary.

It seems impossible and I've never heard of that being done, aside from some "off bypass" CABG procedures - never for AVR or aneurysm repair.

When I wrote circulatory arrest I was referring to DHCA (Deep hypothermic circulatory arrest) which is necessary for surgery on the aortic arch, but not required for procedures involving the valve, root and ascending aorta. I will be on the pump and my heart will be stopped (cardioplegia) but the rest of my body including my brain will be receiving blood.

 

[cldlhd]

I've been wondering about this. If the arch is genetically similar to the ascending,and equally likely to get an aneurysm, then is the reason they do a hemi arch and leave the top of the arch in place to avoid messing with the carotids and the supply to the brain? If so are you likely to develop an aneurysm on the remaining native material? I've seen full aortic grafts with leads coming off to supply the brain but I imagine that's a much more risky operation in terms of danger to the old grey matter.

 

[skeptic49]

I've been wondering about this. If the arch is genetically similar to the ascending,and equally likely to get and aneurysm, then is the reason they do a hemi arch and leave the top of the arch in place to avoid messing with the carotids and the supply to the brain? If so are you likely to develop an aneurysm on the remaining native material? I've seen full aortic grafts with leads coming off to supply the brain but I imagine that's a much more risky operation in terms of danger to the old grey matter.

As I understand it, in the case of my aneurysm, the lesion extends from the root to the ascending aorta, however, the arch and descending aorta are normal. There is no reason to do surgery on the arch, which is riskier.

 

[cldlhd]

That's good to hear. I was talking about in general though. Mine is the root,ascending and the beginning of the arch. From what I've read,and was confirmed by my surgeon,is that the descending is usually normal with BAV but the arch and ascending are different if you're one of the ones likely to get an aneurysm. So I guess the question is once the root,ascending and bottom of the arch are replaced how likely is the rest if the arch to stay within tolerances.

 

[skeptic49]

That's good to hear. I was talking about in general though. Mine is the root,ascending and the beginning of the arch. From what I've read,and was confirmed by my surgeon,is that the descending is usually normal with BAV but the arch and ascending are different if you're one of the ones likely to get an aneurysm. So I guess the question is once the root,ascending and bottom of the arch are replaced how likely is the rest if the arch to stay within tolerances.

Well, I think that they must feel fairly confident that there will be no more tissue pathologies post re-sectioning of the aorta. I asked my surgeon to carefully evaluate the proximal (underside of) my arch. In the final analysis, you have to trust your surgeon.

 

[cldlhd]

Ya I guess that's why they get the big bucks. I told mine I want him to do everything that needs done while he has the wheels off. Getting ready to look into hotels in center city .Surgery is on Feb 6th so figure it'll be easier rather than the family schlepping back and forth from Bucks County.

 

[skeptic49]

Ya I guess that's why they get the big bucks. I told mine I want him to do everything that needs done while he has the wheels off. Getting ready to look into hotels in center city .Surgery is on Feb 6th so figure it'll be easier rather than the family schlepping back and forth from Bucks County.

I live in center city. My surgery isn't until the 16th. Want a visitor (me) with similar problems? You're at HUP with Bavaria?

Look at this web site. I think you will find it interesting if you haven't seen it yet:

http://valleyheartandvascular.com/T...ortic-Arch-and-Re-operative-Aneurysm-Sur.aspx

 

[cldlhd]

Sure if you want to visit that'd be good. Ya Bavaria at HUP. Thanks for the link, any hotel recommendations??

 

[cldlhd]

I suspected the proximal arch was being stretched by my ascending and that article seems to confirm it and makes me happier that I chose to get it over with before it spreads further

 

[skeptic49]

I suspected the proximal arch was being stretched by my ascending and that article seems to confirm it and makes me happier that I chose to get it over with before it spreads further

Sent you a PM...

 

[AZ Don]

My understanding is that those with Bicuspid valves are at an increased risk (vs. the general population) of having an aneurysm in the root or ascending aorta. I don't think that there is any clear connection to increased risk in the arch, and just based on what I've read on this site, aneurysms of the arch seem to be much more rare. I had aneurysms in both my root and ascending aorta and my Cardiologist basically said that we should assume that my artery walls are not as strong as those of the average person and so I could be at risk of another aneurysm elsewhere (and that is why I take metoprolol and losartan). Separately I saw discussion of a study that for those with BAV and abnormal blood flow into the aorta, aneurysm formation was more likely in the specific area of the abnormal blood flow (my view of this is that rather than blood flowing smoothly into the aorta it may be spraying towards the aorta wall). Bottom line is that there may be some increased risk of an aneurysm in another location but from all I've read I think it is very small. Definitely surgery on the arch to the point the other arteries branch off is more complicated.

 

[cldlhd]

From what I've read and also heard from my surgeon the flow characteristics contribute but the formation of the aneurysm is more down to the stretchiness of the arterial walls. It's funny how different the professional opinions are , my cardiologist wants me to stay on a beta blocker in perpetuity but my surgeon says that unless I have high blood pressure, which I don't, it's not necessary.