BAVR Replacement 2nd time around.

[Bad Mad]

Having underwent an echo last week, i am due to be reviewed by my cardiologist next week.

My aortic valve was replaced (age 23) in 2001 and replaced with a homograft.
Since then my ascending aorta has dilated further to 4.5cm currently.
My valve, I suspect is now at the moderate to severe regurgitation stage, perhaps more severe.

I want to be sure at this next appointment, I ask all the right questions and make any correct decisions that need to be made.

Here are some of the things I intend to quiz him on. Are there other questions that perhaps I should be asking him??

Current Measurements/condition -

1. Ascending aorta?

2. Rest of aorta?

3.Velocity across valve?

4. Left ventricle size?

5. Inter-ventricle septum hypertrophy?? Was at 14mms at last echo. Significance?

Much/any deterioration since last echo?

Timing for surgery??


Type of mechanical valve surgeons have experience with??
Best surgeons??

Which mechanical? I will be asking him to research the ON-X and I will provide him with info. that I have gathered through Catheran Burnett and on this site.

Home INR testing??

Whilst given my current well-being I am not an obvious candidate for surgery just yet, I have the feeling (after our last review) he may give me an option of scheduling surgery sooner rather than later. I would know him fairly well.

Given that fact that the On-X is becoming more popular by the day, one half of me says to:
"wait until it is introduced in Ireland first, and until the surgeons begin using it more readily; and at that stage hopefully their will be more compounding evidence to go for it."

The other half of me says: "why wait, put your life on hold, restrict yourself physically and run the risk of permanent damage being done, when you could get it done while you are fit and well."

Answers on a post card?? BM

 

[Cooker]

The other half of me says: "why wait, put your life on hold, restrict yourself physically and run the risk of permanent damage being done, when you could get it done while you are fit and well."

Answers on a post card?? BM

Sounds like your other half is pretty smart......usually the case with us guys Good luck.

 

[Karlynn]

The big question is - when will the On-x be introduced in N. Ireland? Perhaps your contact can help with that question.

It would seem that then your answer may be easier - if there's ball park date to look to, there may be one answer. If there is no earthly clue - there's your other.

 

[OldManEmu]

Questions

Questions

Bad Mad there are a couple of other questions, what is the pressure across the valve.
Most importantly as you sound like you are getting a Bentall Procedure (replacement of valve and ascending aorta), it the surgeon prepared to make a manually an On-X and ascending aorta manually.
I say this because to my knowledge On-X does not yet make a factory manufactured valve with pre-attached aortic graft.
If the surgeon will not make one up for you what is the fall back choice?

 

[Bad Mad]

Thanks for the replies so far guys.

Very good cooker...and I thought us shovenists were a dying breed!

Not sure if or when it will be introduced Karylnn. My cardiologist didn't seem to be aware of it at all. But as i've argued on here before, I don't think it's case of him having the old head buried in the sand, but that:
1. More conservative approach here.
2. Market Forces and affordabilty/practacality issues i.e. Public |Health Sector.

OME: I see a few of those young Irish recruits are doing well down under?!
Have you heard of Martin Clarke (Collingwood I think)?

Now that's interesting. I've came across this term 'Bentall' before but didn't release that it was the double whammy op!
Pressure across the valve. Is that the same thing as velocity??
If so, I know at the last echo it measured 2.5 metres per second, but strangely at the one before, 3.5m per second. If accurate, I suspect the BP med combined with the less hectic physical activity to be the reason. I think 4.5m per sec is usually the threshold for surgery??

 

[OldManEmu]

Bad Mad I have thought of another question to ask what is the surface area of the valve (the opening). In answer to your question Velocity is different to pressure across the valve.
As for valve cost in Australia the cost of all valves is in the AUD 4k-5k range, the price is very similar between tissue and mechanical. The mechanicals are all similarly priced, not the same but with a few hundred dollars.
I can't see why it would be any different in the UK with the NHS buying them in under contract.
It is different in the US they appear to charge what they can get away with. I recall one guy posting on VR about a year ago how he was charged USD 25k for an On-X valve that sells in Australia for <5k AUD, and they are not selling them in Australia for a loss.
Some one is getting nice and rich with that type of mark up.
As for the football I had heard that Collingwood was having an Irish guy come out and train with them for 2 months before they make a decision to sign him up.
Speaking of football Aussie rules players that are long kicks are now going to the US at the end of their careers and trying out as specialist punters, another one just got signed on by an NFL club last week.

 

[Bad Mad]

Would the surface area of the valve be a standard measurement recorded on an echo OME? What does it determine?

I'm just looking at my last echo report and under the MMode/2D measurements and calculations it gives:

Left Ventricle values: LVIDs, Diastolic and systolic volume, septum and IVS wall movement, posterior wall/posterior wall movement, frac shortening, cardiac output and EF.

left Atrium: Diastolic dimension

Right cavities

Vessels: Aortic Root (I wasn't happy as on the echo there seemed to be no measurtement taken for the ascending aorta)

Then under Doppler Measurements 7 Calculations
Aortic valve: Tri-cuspid valve (same kind of measurements)
Peak velocity
Peak gradient
Mean velocity
Mean gradient
P1/2 time

Are any of these things: pressure across the valve or surface area of valve??

That's interesting about the kickers OME. I remember them trying to sign a few of our guys a while back. Nice easy way to make a few bucks!!

 

[Mary]

Sounds like your other half is pretty smart......usually the case with us guys Good luck.

Scoot over, fellas, and make room for another smartie, because I concur.
I wouldn't wait; I'd get on with my life.

 

[Bad Mad]

We've just made room Mary
Thanks for ur tupence worth

 

[Bad Mad]

Just back from my review with my cardiologist.
Have to say, I feel quite frustrated and unsatisfied

I had my echo done two weeks ago - where I found myself telling the radiologist to make sure he checks out the entire aorta, as I wasn;t comfortable that he had been instructed to do this.

When I arrived this morning, the Cardiologist asked me if I had an echo done yet?? So, that annoyed me straight off, because he obviously hadn't looked at the results. So, he brought them up on computer and as I fired way with questions about valve deterioration, aorta measurements etc. I got general answers but some were quite evasive.

At my last echo in Feb. he told me that the AV hadn't deteriorated much (moderate - severe) so he would see me in a years time. However, after a dizzy spell during exercise, i emailed him asking to be seen in 6 months.
He told me today, that he wasn't totally upfront with me the last time about my situation and that the valve was worse than he had said??
So why was he happy enough to review me again in a year??
I think that he didn't read the echo thoroughly the last time.

In summary, the ascending aorta is much the same at 4.5cm.
The aortic valve is both leaking and regurgitating a good bit.
Velocity across the valve is about 3.4 m/s.
The valve has a bit of stenosis.

So he thinks (taking into account the dizzy spell also) that there is an argument for seeing a surgeon to discuss if it is time for an operation. I am going back to see the surgeon who did my original AVR with a homograft (almost 7 years ago). If he thinks its time, then I will be getting it done within a year If not, then I will see my cardio again in 6 months.
He says that they give the surgeon who did the original op first refusal unless there is some reason not to. That suits me as I know he is a very good aortic valve specialist. (and graft)

As regards the type of mechanical valve, his recommendation is the St. Judes, becasue of its 30/40 year track record. He did admit that the On-X could be a good choice, but that too often he has seen "New Valves" recalled.
As regards potential for reduced Clot formation, he did say that it's so unlikely anyway.

He wasn't keen nor did he have the time to look at my literature on the ON-X, but he said I should discuss it with the surgeon.

Although I know my Cardio fairly well, I think he felt a little uncomfortable with my file of info and list of typed questions. Also time was a constraint as there were other patients waiting. Good old Public Health

When I quizzed him about screening of family members, he first of all quoted a 1-2% chance, and when at looked at him strangely, he corrected himself, and said that was the chances of som-one having a bi-cuspid valve. He then quoted a 10% chance. I did show him the printout of the study of the 13 families where 1 person had diagnosed BAV. But as I say time ws ticking, so I needed to get the basics out of the way.

I'm sure he felt that I was tring to catch him out on things.
He cited the fact of my high level of activity/sporting career being the main reason why the valve has worn out so quickly . I responded by saying that I thought it was more to do with your age/metabolism rather than your level of activity.
Well that's what some people on here were saying, when i argued before that your activitly levels were a factor. I still think he may be right to a certain degree....any-one care to argue?!

I don't want this to come across that I have no confidence in my Cardio, but I do feel a little annoyed that we didn't get more time to thrash out other things. To be fair to him, he had spoken to my original (and more experienced cardiologist) cardio, to get his opinion. (He is on the verge of retiring, that is why I changed over).

 

[Magic8Ball]

Most importantly as you sound like you are getting a Bentall Procedure (replacement of valve and ascending aorta), it the surgeon prepared to make a manually an On-X and ascending aorta manually.
I say this because to my knowledge On-X does not yet make a factory manufactured valve with pre-attached aortic graft.
If the surgeon will not make one up for you what is the fall back choice?

That was also my understanding as of november last year.

If you are getting the valve and the ascending aorta replaced it is possible to keep the aortic root as original if it is ok. so the separate valve and graft would be ok.

My root was enlarged and as that whole area was knackered i decided on a bentalls to replace the whole lot.

I opted for the one piece st jude as i didnt fancy waiting on getting the on-x stitched to a graft during surgery...the shorter time cracked open the better and the less amount of human stiches to fail later on the better.

Good luck.

 

[Susan BAV]

It sure sounds like your cardio was "winging it." It almost sounds to me like he had your case confused a bit with someone else's.

So you do have an appointment with the surgeon now? He should be able to answer your questions. Hopefully others will respond here also. I believe I recall another member here saying that her son's graft with the On-X only took the surgeon an extra 5 minutes of operative time; but I'm not positive it was a similar graft as to what you are describing. I think I've also read that the stitches are the important thing though. Take care and post again.

 

[Bad Mad]

He might have been winging a little, but we know each other from long before I became his patient, so I suspect he wasn't mixing me up with anyone else.

That's right about the extra 5 mins, but not all surgeons would be necessarliy compliant to that. ON-X hope to have Valve/Graft conduit in the next year.

My operation will be an aortic valve re-do and ascending aorta repair.
I had wondered though about the root??

Was looking at previous echos compared to my last one, and they seem to quote the root as 3.5cm. Surley this isn't a case for an entire root replacement??

My appt. with the surgeon is TBA. I suppose on the up side, hopefully he will remember where he put the stitches the last time!! I know he's verging on retirement also, but hopefully he's still as sharp. He does have polio though!!