Here is my reasoning. I would appreciate your feedback.

[JRW]

I am a new member of this website, and I have found it to be very informative. I would appreciate your thoughts about my reasoning in this post. I am a 55 year old male who is 6'3" and weighs about 300 lbs currently.

My valve-sparing aortic root replacement procedure is scheduled to take place on March 24th at the Medical University of South Carolina by Dr. John Ikonamidis.

I went to Charleston yesterday to meet the surgeon. I was extremely impressed with his discussion of the options and his down-to-earth "bedside manner." I also did a web search for information about him; he is published in several medical and research journals and appears to be higly qualified. After meeting him, I am very comfortable with him as my surgeon. If you are interested, here is a link to his bio on the MUSC website:

http://www.muschealth.com/scripts/PhysicianSearch.exe/PhysicianProfile?physician_id=742

The doctor took lots of time to explain the options for surgery. He discussed the following three methods of surgically treating my condition:

The most common involves repair of the aneurysm with a dacron tube and relacement of the aortic valve with an artifical one (The Saint Jude valve). The method has been used for a number of years and is considered the "gold standard" treatment. The downside is that the patient has to take blood thinning medication for the rest of his life to prevent blood clots.

The second method is called a homograft and involved the replacement of the patient's valve and damaged aorta with that of a human donor. The major disadvantage to this method is that after 15-20 years the donated tissue may become calcified and have to be replaced in about 25 percent of the patients. According to the doctor, that replacement is "messy" and very difficult to do.

The third method is called valve-sparing aortic root replacement. This method uses a dacron sleeve to repair both the aorta and the aortic valve, with the surgeon molding, reforming, and stitching the patient's own aortic valve back to its normal configuration. The downside is that not every patient is a candidate for this method, and it also requires a highly skilled surgeon with a high degree of surgical "art," in the words of the doctor. Dr. Ikonomidis appears to be very competent and comfortable with this procedure.

After much consideration I decided for Dr. Ikonamidis to begin with the third method. If he sees that this is not a good approach for me after he has opened my chest, then he will drop back to the homograph.

The value-sparing method would appear to be the best approach for me if it is successful. The homograph may require additional surgery in 15 years or so, but I will be 70 years old at that point. Hopefully, new methodologies will have been developed by that time as well. After my decision, the doctor said that he would have recommeded the same thing if I were his brother or dad.

 

[Ross]

Hello JRW and welcome to VR

You've been doing your homework and that is great. Choosing a procedure and valve is really a personal choice between you and the surgeon. It sounds like you've both thought out each scenario, so there's no need to get into that. The main question I would ask myself is, "How many more times do I want to go through this surgery?" Your repair may last as long as he says or it could fail as mine did, 7 years later. When that happened I had to have the valve replaced. This was done last July. I went mechanical as I do not want to have surgery ever again if it can be helped. I know that by having a mechanical valve is in no way a lifetime guarantee, but it sure beats thinking of another surgery 15 to 20 years down the road.

Any choice you make will be a good choice. So long as your getting fixed up, that's all that matters. Like I said, you've done your homework and thought things through, so you don't really have an issue with it. That's half the battle won right there.

Again, welcome to the forums and ask anything else that may be on your mind. There are a lot of very knowledgeable folks here that understand what your thinking because we've all been there.

 

[Kevin M]

Actually, I believe those homograft stats are pretty optimistic. Only 25% replacement within 15-20 years sounds pretty wonderful. Perhaps that is the case given your age, since we calcify these things less aggressively as we age.

My homograft was shot after a decade and I know that studies since the early 90's have indicated this as the norm, but only in younger patients.

I hope the homograft stats are accurate because that sounds like a nice way to go if the valve-sparing procedure doesn't go.

Good luck with your decision and let us know if you have any questions on recovery, etc.
Kev

 

[JRW]

More questions

More questions

Thank you Ross and Kevin for your responses, and both of you raise valid points that I have thought about. I am hopeful that the valve-sparing approach will be effective for me. I have read articles by Dr. David at the University of Toronto which seem to indicate a good success rate with this procedure. What have you guys heard about this procedure's success rate ?

If I should ever need the procedure to be redone, I had assumed that I would go with the mechanical valve as you did ,Ross, but I see that you, Kevin, had yours redone using a porcine valve. May I ask what factors influenced your decision about that? Why did you not use a mechanical valve?

I am sure that you guys have seen the following response to a question on the Cleveland Clinic website about porcine vs. human. It seems to indicate that a human donor's valve generally gives more years of service that a porcine valve. How does this factor into what you men have learned?

---------------------------------------------------------------------------------
"Dear Todd, thank you for your question. You are facing a difficult decision so I'll try to provide some information and resources to help you with that decision. Since you have decided against anticoagulation, the options you have include a porcine valve or an aortic homograft. Mechanical valves have excellent durability but require lifelong anticoagulation, as you know. Whether a mechanical valve would eventually "fail" in you is a question that
cannot be answered because the answer would only be speculative. The best chance of avoiding a reoperation would be with a mechanical valve. Otherwise, the statistics that the surgeon quoted to you are generally true. Porcine
valves usually last 10-15 years while the "free-style" porcine valve (which I take to mean a stentless valve) hasn't been used long enough to have accurate information on long-term durability. Homografts are thought to last longer than porcine valve but again, long-term data is not as extensive as with porcine valves.
The reason that porcine valves and homografts eventually fail is that the valve tissue is preserved with fixatives (porcine) or with very cold temperatures (homografts). The preservation process is thought to predispose the tissue to premature calcification and degeneration. However, the valves couldn't be used without fixation so that problem can't be avoided. The Ross Procedure (involving a pulmonary to aortic valve switch and replacement of the pulmonary valve with a homograft) is a technically demanding surgery that probably isn't appropriate for you since you may need your aneurysm repaired at the same time as valve replacement. This additional operation may influence the surgeon's choice of what type of valve to use. To gather more information, I first suggest that you look in the frequently asked questions archive of the heart forum under aortic valve disease. Second, I've listed two references that you may find helpful."

1) Aortic Valve Homografts in Adults: A Clinical Perspective. Staab, ME, et al. in Mayo Clinic Proceedings, March 1998, Vol. 73, Pages 231-238.
2) Aortic Valve Disease, Chapter in Textbook of Cardiovascular Medicine, 1st edition, Editor: EJ Topol, Publisher: Lippincott and Raven, Authors: BA Carabello, WJ Stewart, and FA Crawford Jr.
----------------------------------------------------------------------------------

--Ray

 

[Nancy]

Hi JRW-

Welcome to this terrific site. It's a treasure trove of all kinds of valve information.

Here's is a thread that is sure to keep you busy with all kinds of information about different valve choices.

http://www.valvereplacement.com/forums/showthread.php?s=&threadid=304&highlight=making+the+choice

My husband has 2 mechanical valves. His aortic has been in place for 25 years, and is still in good working order. His mitral was implanted in 1999. The aortic is a Bjork-Shiley valve and the mitral is a St. Jude.

He has also been on Coumadin for 25 years. It has not been a problem for him at all. It's just another part of his daily life.

He did have a repair on his mitral for a small leak, so he has had 3 valve surgeries. Having repeat surgeries is something you might like to think long and hard about. They are not without their own set of problems, and as you age, your body just doesn't handle heart surgery like it did when you were younger. My husband is 71 years old.

I wish you all the best with this serious choice. And I hope you will come here often and let us know how things are going.

 

[Gail in Ca]

Hey,
I know Dr Ikon from when I had my surgery at Stanford!!
He is wonderful, so confident and such a caring person.
He was the Chief Cardiac Surgery Resident assisting my surgeon there, Dr. Craig Miller. I know he did many procedures there (over 150) alongside Dr. Miller, one of the best at aortic valves , grafts, etc,. also very published.
Dr I. had to leave before I got out of the hospital and begin at another hospital but I didn't know where, and now I do!
I think he will do a great job for you.
Ask if he remembers Gail , the patient that came in from another hospital ER and was near death! They gave me a carbomedics aortic valve and found that my mitral was congenitally deformed and left it alone. Mine was a 2nd AVR and they had to cut thru the graft to get to the old porcine valve which had lost a leaflet. My surgery was vidiotaped and I got to watch it. See if he remembers me or my situation. My surgery was done in the evening, poor guy, but afterwards , what a bedside manner! It would have been one of his last ones at Stanford before he left.
Best to You and to your chosen Doc. He will make a qualified decision for you and has learned from the best.

Gail , ( in Ca)

 

[mike anthony]

Hi JRW,

I had the David procedure done June of 2002. The procedure did not take and just had my aortic valve replaced 3/7/03.
My surgeon was very qualified with this procedure and I made the choice based on my active life style and his expertise. The only area I would caution is I believe the chances for reoperation are high within the first 2 years. I don't remember where I read the article from Dr. Miller, Stanford, but I believe he talks at great lengths about the risk.
My second go around I went with the Bovine. I know I'll need another operation, but I'm find with the decesion. Anyway, whatever decision you make will be right for you. Take care

 

[Kevin M]

Hi. To answer your question, I had the stentless porcine valve as a replacement to the homograft. It was a tough choice for me since I knew the likelihood of a third operation in my 50's was probable if I had another biological valve.

I almost went with the mechanical, but decided not to because of my fear of coumadin. We like to travel to places where medical care is poor. That and just general dislike of the idea of having to monitor myself with regards to diet, etc.... well, it just didn't feel right for me.

I still wonder if I made the right decision. This last operation was more difficult to recover from and once they were in there, they found my aorta was dialated, so they've got me on low dose aspirin to keep the dacron from attracting a clot.

I don't know anything about the valve sparing procedure, but it sounds quite complicated. Nowadays, they can do so much. The technology has changed a great deal even since 1990 when I had my first procedure.

From the people on this site, I have learned to have a better understanding of how coumadin affects people and it sounds a lot more tolerable than I thought. I had read all the potential negatives about it and that scared me off from the mechanical valve. That and my surgeon was pushing the stentless.

The morning of my second operation, my surgeon said, "This stentless will last you 25 years or more".

I told him, "That's what you guys said to me 11 years ago and here I am again".

I'm still happy with the porcine valve. I feel pretty good overall, but I'm not looking forward to surgery 3. The more we have, the more complications arise because of scar tissue building up. Often, the heart sticks to the chest wall and they have to carefully get rid of all the scarring that attaches it to places where it should be free.

Let me know if you have any further questions.
Kev

 

[Creed3]

Hi JRW!

Hi JRW!

I am 34 years old and I had an anuerysm/dissection repaired with the dacron and also had my aortic valve replaced with a St. Jude. What Ross has said is true. Everyone is different and valve choice is a very personal issue. It sounds like you have done your homework and discussed your options at length with your physician/surgeon. There is no wrong choice, it is what you feel the most comfortable with. The docs never really talked to me too much about the choices of valves for me, they pretty much wanted to go with the mechanical because of my age. I had done my homework before hand anyway and had come to that same conclusion myself. I didn't want to have to go through another surgery if I could help it. I have not found coumadin to be that much of a problem so far. I am almost 6 months post op. My lifestyle really hasn't changed and my eating habits are pretty much the same. It is a tough road in the beginning getting it regulated, but usually after that it levels out. But then again, everyone is different with that too. Monday I am having my first teeth and gum cleaning at the dentist. I have decided not to stop my coumadin. I will find out real soon how much I am going to bleed with the cleaning. Good luck with everything. I am sure you will get some very good advice here. Everyone here is GREAT!

Take Care!
Gail

 

[JRW]

Thanks to all of you.

Thanks to all of you.

The knowledge that you all have acquired from your own experinces has been very helpful to me. I am continuing to reseach the options, but so far I feel pretty comfortable with the valve sparing aortic replacement as the first option. I have included an abstract of an article by Dr. David from Toronto about the long term results of this relatively new procedure, and they would seem to indicate that it is very promising.

This is day 6 of the countdown before surgery which will take place next Monday. The past few days have been somewhat difficult because of the nervousness about what awaits me, but I am more relaxed (and resigned?) about the surgery at this point.

Thank you again for all the information, and please keep me in your prayers.


ARTICLE ABSTRACT:
--------------------------------------------------------------------------------
Ann Thorac Surg 2002;74:S1758-S1761
© 2002 The Society of Thoracic Surgeons

--------------------------------------------------------------------------------

Session 1: Ascending Aorta

Aortic valve-sparing operations in patients with aneurysms of the aortic root or ascending aorta
Tirone E. David, MDa*, Joan Ivanov, PhDa, Susan Armstrong, MSa, Christopher M. Feindel, MDa, Gary D. Webb, MDa
a Divisions of Cardiovascular Surgery and Cardiology, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada

* Address reprint requests to Dr David, 200 Elizabeth St, 13EN219, Toronto, Ontario, Canada M5G 2C4
e-mail: [email protected]


Presented at the Aortic Surgery Symposium VIII, May 2?3, 2002, New York, NY.

Abstract

BACKGROUND: Aortic valve-sparing operations are an alternative to aortic root replacement in patients with aortic root aneurysms, or aortic valve replacement and supracoronary replacement of the ascending aorta in patients with ascending aorta aneurysms and dilated sinotubular junctions with consequent aortic insufficiency.

METHODS: From 1988 to 2001, 230 patients underwent aortic valve-sparing operations for aortic root aneurysms (151 patients) or ascending aortic aneurysms with aortic insufficiency (79 patients). Two types of aortic valve-sparing operations were performed in patients with aortic root aneurysms: reimplantation of the aortic valve and remodeling of the aortic root. Mean follow-up was 3.8 ± 2.8 years.

RESULTS: Patients with aortic root aneurysms were younger, had less severe aortic insufficiency, less extensive vascular disease, and better left ventricular function than patients with ascending aorta aneurysms. The 8-year survival was 83% ± 5% for the first group and 36% ± 14% for the second. The freedom from aortic valve reoperation at 8 years was 99% ± 1% for the first group and 97% ± 2% for the second. In patients who had aortic root aneurysms, 3 developed severe aortic insufficiency (AI), and 15 developed moderate AI, for an 8-year freedom from significant AI of 67% ± 7%. But freedom from AI was 90% ± 3% after the technique of reimplantation, and 55% ± 6% after the technique of remodeling (p = 0.02). In patients with ascending aortic aneurysms, the freedom from AI greater than 2+ at 8 years was 67% ± 11%.

CONCLUSIONS: The long-term results of aortic valve sparing for aortic root aneurysms are excellent, and reimplantation of the aortic valve may provide a more stable repair of the aortic valve than remodeling of the aortic root.

 

[Nancy]

Hi JRW-

The week leading up to surgery is certainly one of the most difficult. But you will be very busy getting all kinds of things done, and many have found that the day or two before surgery, a calm feeling comes over them.

You will be fine, and I wish you well during this week.

 

[Creed3]

JRW,
I just wanted to let you know that I will be thinking of you on Monday. This right now is the toughest time. Believe me, I am not making light of the surgery, but since having it, it boggles my mind how almost routine this has become for some doctors. I am sure everything will go just fine for you. I hope you can have someone post for you after the surgery to let us all know how you are doing. If you have any anxious moments, just use us all here. We will help you through.

Take Care & Good Luck!
Gail

 

[mike anthony]

JRW,

Good luck with your surgery. You will be amazed at how fast you recover. Prayers will be with you.

 

[JRW]

The Big Day Approaches

The Big Day Approaches

I would like to thank all of you for being part of this wonderful resource. I have learned a lot and met a number of great people.

I report to the Medical University of South Carolina hospital in Charleston on Monday at 5:30 am for my procedure. I have spent the last several days preparing for the big event and the recovery period afterward. The advice you all have shared has been a wonderful guide to me as I prepare. Thank you once again.

I have learned that Bonnie (Granbonny) lives fairly close to me, and she has sent several kind emails. The plan is that she will post my progress as soon as she gets the news from my friend Helen or Jimmy after the surgery.

As a single guy I have had to rely on my family and friends as I plan for the recovery period. As an extremely independent sort of fellow, it has been somewhat diffcult for me to have to depend on others, but I have handled the task pretty well.

Thank you once again for your advice, your kind words, and your prayers.


Ray

 

[Ross]

No problem. We've all been there and know what you mean.

I'll be thinking and sending a few prayers your way Monday and will await hearing the good news of the outcome.

See ya soon!

 

[ALCapshaw2]

Hello Ray,

I understand your thinking and choices.

For completeness, there is another option which you (and your surgeon) did not mention, namely the Bovine Pericardial Tissue Valve. It is highly regarded at the Cleveland Clinic (#1 Heart Hospital) and has a fairly long and successful history. Durability statistics are 90% at 15 years and counting. The valve is made from the pericardium of a cow's heart and shaped to be similar to a human valve.

Another issue you did not address is Valve Hemodynamics. I suspect most doctors don't say much about this issue which relates to the size of the valve opening and therefore the maximum amount of blood flow during exertion. Being a BIG GUY, I suspect this may be of contern / interest to you. Stentless valves have a larger opening than stented valves. The St. Jude Mechanical Valves come in different sizes, depending on the size of your aorta, but typically have smaller openings.

FWIW, I asked for a Bovine Pericardial Valve and my surgeon agreed but after opening me up, he decided the St. Jude Mechanical was a better / safer choice for me and my situation, even though the effective opening is only 1.2 sq.cm. (low end of
normal range).

I've learned to live with Coumadin (no problems) and exercise regularly. I DO bump up against my maximum heart rate and exercise tolerance level at what I consider a moderate level which means that I probably can't engage in competitive sports or activities. I'm pushing 60 and weigh around 200+.

'AL'

 

[Rain]

ya gotta watch that Bonnie lady.....

ya gotta watch that Bonnie lady.....

Ray,

?Valve-sparing? ....... that?s what they want to do to my son. Its my understanding that if the valve is in good shape this procedure should last forever? But then he?s only 19... gotta watch those cardios... when he was talking to me about valves one minute he would say ... ?forever? and the next it was ?twenty years?....... That would put an end to my lifetime at 59!!!! Grrrr.... gotta watch those docs.

Best wishes for a speedy recovery!!

 

[Enudely]

homograft followed by mechanical???

homograft followed by mechanical???

JRW....well, from what I've read, today's the day! I pray for you and hope that it is going well! I'm a new member to this site also and I can't BELIEVE the amount of support I've recieved already. It's amazing.!!
I look forward to hearing about your surgury.
One thing that JRW said that I have a question about is this....
He said that his doctor said that replacing the homograft with the mechanical is "messy and difficult".....I'm just in the very preliminary stages of valve replacement (knowing that I'll have to have it sometime soon, but I don't know when) and I've been thinking that because I want to have children, the homograft is the best choice.....because I'm only 23 years old, however, I think they'll have to put in a mechanical valve after that.....is this really that difficult???

 

[Ross]

To be honest Enudely, you'd be better off asking your surgeon. I don't think any of us are qualified to answer that one.

 

[Enudely]

Yeah, I know the final decision is with a surgeon and I guess I'll just have to wait until the time comes and I find a surgeon.