Aortic root repair, avr and clotting

[JiminMI]

Hello all.

Last December I had an echo-gram and was told I had a dilated aorta with BAV. Subsequent MRI's and a TEE revealed that I didn't have the bicuspid valve, but that I still had a 5.3 cm aneurysm at the aortic root (doc suspects I have Marfan's) and also a leaky aortic valve. They're recommending the Bentall procedure, with a root replacement with artificial conduit and mechanical valve.

Naturally, I've since been continuously reading the internet on any subject I can find relating to my condition. After reading about the not-so-pleasant prospect of lifetime Coumadin therapy, I got to reading about the On-X valve, and it's possibility of reduced anticoagulant usage. When I brought this up with the cardio-surgeon, he told me that it wasn't a question of the valve clotting as much as the conduit. Guess he meant that even if the On-X was less inclined to clot, that blood would still tend to clot on the artificial conduit that replaced my aortic root, and that I would still need the regular dosages of Coumadin. He also doesn't happen to use the On-X in any of his patients---it's either a Medtronics or St. Judes valve . . .I wonder if that fact might have affected his answer. Anyway, I've postponed any surgery until I'm satisfied I have all the necessary info. Any feedback is welcome.

Not surprisingly, this has become a very interesting site for me!

 

[Superbob]

Hi Jim. I had a Bentall's also, at age 63. Don't have answers for you on the On-X dilemma, but I'm sure others will come along with some information for you. Wanted to welcome you. Site is in the middle of a re-do so plus this is the weekend so responses are slower than usual as a result.

 

[Plumber1]

Hi Jim,

I also had bentalls but at age 52. I have an onx valve and short section of conduit, marfan tissue was diagnosed for me even though I do not have classic characteristics. I was only aware that the valve required anti coagulation, not the conduit. Others will chime in here with greater knowledge on this subject. I am 2 1/2 years after AVR and have had no problems what so ever, except the valve ticking is audible in a quiet setting.

Very best to you. Mark

 

[BDMc]

Jim, Welcome aboard. I had my surgery 25+ years ago, and while not familiar with "Bentall's" I did have part of my aorta replaced, and have a mechanical valve. The Coumadin/warfarin management seems to get easier and easier with time. There are far more resources, and technology to help with it now, than when I started. There are still mysterious things about it. My INR has been high for several days, and I can't figure out what I did, or what's going on to have changed it. Luckily I have a computer, and came here, got link to online dosing calculator, and won't worry about how much I should be taking. I will email my PC to see if he wants to check my liver, but otherwise feel very comfortable with the situation. You might consider consulting another surgeon about the valve choice. If I was doing it now, my first choices would be ATS, and On-X. All the best, Brian

 

[dick0236]

Welcome Jim...stick around, this is a great source of information. I have been on Coumadin/Warfarin for over 42 years. It is a minor hassle and takes a little getting used to, but it is NOT...I repeat NOT a drug that should be feared if you can follow a simple regimen of taking it as prescribed and testing routinely. Best wishes

 

[nngbwh]

Welcome aboard Jim !. This is a great site lots of information.

 

[Philip B]

Conduit Clots?

Conduit Clots?

Hmmmm...interesting perspective from your doctor regarding potential clots reuslting from blood flow through a dacron conduit. That's a new one on me; I've always understood that the artificial valve presented something of a concern for throwing clots.

There are a number of members here who received an On-X valve implant along with a dacron conduit. It would be interesting to hear if any of these folks are engaged in the ongoing study to determine if coumadin use for those who receive an On-X is really necessary.

While I'm not a medical professional and really don't follow much of the medical research involving valves and conduits, I wouldn't think that a conduit would present much of an opportunity for blood to stick around long enough to clot...maybe I'm wrong.

-Philip

 

[JiminMI]

While I'm not a medical professional and really don't follow much of the medical research involving valves and conduits, I wouldn't think that a conduit would present much of an opportunity for blood to stick around long enough to clot...maybe I'm wrong.

-Philip

I'm not a medical pro either, but I'd tend to agree. In reading about some valve-sparing procedures (the "David" for example), the patient has a section of the aorta replaced with the Dacron conduit without removing the AV. This supposedly negates the need for anticoagulants, from what I understand. I didn't get a full explanation from the surgeon himself actually; his nurse gave me a briefing over the phone about the valves the surgeon used.

I actually spoke with an On-X rep by phone last Thursday and he referred me to a surgeon in Ann Arbor who worked with their valves (can't believe he's the only one in Michigan). I couldn't find a lot of info about the surgeon, but he doesn't appear to have the same level of experience or medical background as the one up here. It would be kind of a long drive for me, living in northern MI. Perhaps the On-X is more hype than legit---could be that there won't be any significant difference in Coumadin requirements for the patients that have it. I guess right now that's just a personal decision I'll have to make. Anyway, thanks to all of you for your comments and advice.

 

[Philip B]

No Hype!

No Hype!

No, there's no hype with the On-X. It's a good product and many here can comment positively about it based upon their personal experiences. Research clearly shows that the On-X does less damage to red blood cells that other valves.

There are a number of great valves out there and many have been around for a good period of time. I suspect many surgeons simply prefer to use the reliable products they have used successfully rather than look at different products.

As far as the coumadin thing goes, odds are pretty good that any kind of approval for those with an On-X to stop using coumadin is not going to happen any time really soon. Studies take a long time.

If I had chosen an On-X rather than a St. Jude, I'd still be taking coumadin. As others have noted, coumadin hasn't been a big deal for many of us. From my perspective, there seems to be a lot of hype related to misconceptions about the drug. Some of those misconceptions are genuinely stupid, but it's an exercise in frustration to convince those who believe those misconceptions to change their minds. The only alteration I've made to my life style during the three years I've been on the drug is to test my blood at least once a week to check my INR.

-Philip

 

[tobagotwo]

The confusion may be in the timing. When the dacron sleeve first goes in, there is enhanced risk of clotting, as well as of infectious endocarditis. Over the course of three to six months, your own cells (endothelium) grow into the material and make it "yours." Once those cells are fully established, the risk of clotting and IE returns to normal.

The same thing happens to all the cut and sutured areas around a new valve (of any type) or a valve repair, although that part is usually reestablished by three months post surgery.

During the first three to six months, most valve recipients receive some form of anticoagulation therapy, such as Coumadin or Plavix. I am not aware of any protocol that anticipates a need for anticoagulation therapy after six months for an aortic root replacement. So the coumadin discussion may relate to the period shortly after the OHS, not long term.

Is there some special concern that your root sleeve won't populate with your cells, due to an unusual type of Marfan's or something similar? To be honest, your surgeon sounds a bit limiting. You may want a second surgical opinion.

Best wishes,

 

[ALCapshaw2]

Surgery of the Aorta is another step up in complexity over 'mere' Valve Replacement Surgery.

My recommendation for anyone needing surgery of the Aorta is to find a Surgeon with Considerable Experience doing Surgery of the Aorta. These are typically found at Major Heart Hospitals. I have no knowledge about Aorta Specialists in Michigan.

The head of the Aorta Surgery group at Cleveland Clinic is Dr. Svensson
The Aorta Specialist at Mayo Clinic is Dr. Sundt

The most prolific user of On-X Valves at Cleveland Clinic is Dr. Petersson (sp?)

'AL Capshaw'

 

[karen14]

Hi Jim, welcome! I had what you do, a dilated aorta; and do have Marfans, only they found a BAV and no aneurysm. Can't make any suggestions on the On-X, as I did not have what you're doing there...

But... I went with the St. Jude mechanical & have been on Coumadin ever since with no major problems. Being on it for a year and a half now, my INR has been low on a few occasions, but I've learned to just be more consistent from this (taking it around same time every day, try to stay away from dark green, leafy veggies (like spinach, although I do still indulge now & again), and I do take an Ibuprophen for migraines- and learned it messes with Coumadin UNLESS taken every day). At first I dreaded the thought of being tied down to taking this drug, but have found it's not so bad at all. I mean like, I take vitamins every day right? And other medications every day...

Good luck on your decision, hope this helps! Luv, ~Karen

 

[tobagotwo]

Just a thought...

There are a number of members who've had the Bentall procedure with a tissue valve and a dacron (or similar) conduit. They don't take coumadin after their six months is up. It wouldn't make sense that the conduit would be considered an independent risk when used with a mechanical valve, but not when used with a tissue valve. The sleeves are used for both types of valve interchangeably.

He's a surgeon. He replaces them. It's not really his job to take care of them after they've grown in. This is a better question for a cardiologist, who manages them over time. Still, his notions seem disturbing.

Best wishes,

 

[buncle]

I had the "David procedure" with dacron and have only been on asprin (except during a bout of a-fib). There was no mention of possible clotting.
Maybe there was no concern for clotting because my original valve was reimplanted.