Homograph -> Mechanical?

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In considering a valve for a person of my age (36) who would not want to have two or more surgeries, it would make sense for me to go with at Mechanical valve if I had to have AVR tomorrow. However, the CryoLife SG sounds very promising. From the posts I have read from Steve and Peter, it sounds like it is pretty much a "roll of the dice" at this stage.

Here is my question. Lets use this scenario, say I opted for a CryoLife SG Homograph and 8 years later I found out I would need another operation. Also, lets say I wouldn't want to press my luck with another surgery. How hard is it to replace a previous Homograph with a Mechanical valve? I know that part of the Aortic root is replaced when a person opts for a Homograph. Does this stay and the Mechanical is sewed onto the old Homograph Aortic root?

If there is anyone who experienced going from a Homograph to a Mechanical who could explain this process, please feel free to share your knowledge.

This is a really good question. I thought I saw something related to this when I was reading some stuff today, but instead it was kind of generic:

From the American Heart Association:
"In patients undergoing repeat valve replacement, dysfunction of a biological valve may be a consideration for a mechanical valve, and a previously thrombosed mechanical valve is a consideration for a biological valve. "

Replacing a "biological with a mechanical" is pretty generic statement, since porcine/bovine valves are so different than homografts in design/procedure, etc.

Since calcification/deterioration affects all of the foreign tissue, I would suggest that they would pull the homograft root and use a conduit of non-biological material. I am not a medical professional, so I don't know for sure.

Sorry I couldn't be more helpful. I'm afraid my reply only hints at answers.
Hi Jim

This is a good question you pose and obviously you are thinking through a whole-of-life strategy here.

My surgeon (who is a Homograft specialist) told me that he usually puts in a mechanical valve when he re-does Homografts. However, that's not to say that he can't or doesn't do a Homograft re-do. I think it becomes a bit more complex the second time round (scar tissue etc) to do a Homograft re-do, although I have read an article from Prof Yacoub in UK who says how it is done.

It's probably also a case as to the state of your aorta and general health, age and other variables which may affect the choice.

Anyway, it's probably all academic, because it will be Year 2015 + technology that will determine what is possible at the time.

Just my thoughts....

Homograft or mechanical

Homograft or mechanical

Hi, I always wonder about how long my mechanical valve will last and then I realize that I am 57 years old. I add up the math and it dawns on me that I am getting old. Should I really worry about this at all...... ?

The doctor recommended the st judes because he said I was young...... Now I wonder about the procedures here versus the procedures in UK, Aus or Canada/ do they opt more for the homografts and porcine valves? I think, I should be happy with what I have, and I should stop thinking about it. Recently at a wake, I talked to someone who had a mechanical valve for over 20 years and he is still ticking good....so? The coumadin seems like a nonpluss thing but I think it does wonders. :confused:

All in all a really interesting question brought up and good to ponder just for awhile.:confused: Now I should go to the coumadin thread....:)
Hi Mikesan-

Hi Mikesan-

Husband Joe has had a mechanical AVR for 24 years. Still going strong. On a scale of 1-10, I think he would rate Coumadin a 1 as far as it bothering him. Of course he isn't a skier or motorcycle rider, but he prefers to be active.
Michael, your mechanical valve will likely outlast you. My surgeon told me that if I had opted for a mechanical valve, it would outlast my lifetime and I'm 35. Even many of the the older style mechanicals have proven very durable and should last a lifetime.

I wouldn't worry about it unless there are other medical considerations that suggest another surgery.

Depending on the size of the valve, other medical factors and overall health, they often recommend tissue valves in the 60+ age group these days. They have proven to have good durability in this age group (not as good in younger folks) and do not require coumadin.
Replacing a Homograft w/ a Mechanical

Replacing a Homograft w/ a Mechanical


Thanks for sharing the opinions of your surgeon. From him, it sounds pretty routine to replace a homograft with a mechanical.

It would be interesting to find out whether any of the aortic root needs to be replaced at the same time a mechanical is inserted. I would assume that if the homograft aortic root is OK, then it wouldn't be any problem sewing the mechanical in place. However, my assumptions about the various topics in valve replacement has been wrong in the past.
Roll of the dice

Roll of the dice

Thanks, Jim, for introducing this thread.

I wanted to take issue a little bit with the characterization of getting a SynerGraft valve as 'rolling the dice'. Of course, I don't question that entirely, since some increased risk and uncertainty is surely involved, even more than there is to some extent with all types of valve surgeries.

However, the producer of the SynerGraft valves (CryoLife) is not a new fly-by-night, similar to a flash in the pan dot.com, outfit. They essentially are to tissue valve supply what St. Jude is to mechanical valve supply, those who have owned the lion's share of their respective market for quite some time. Also, it's not like the SynerGraft valves are at the initial stages of experiementation. They have already undergone extensive animal and human testing and have earned commercial market approval of both US and European regulatory agencies.

My surgeons assured me before surgery that what I was risking beyond the normal risk of homograft valve replacement surgery is only fulfillment of the promise that the valve might last my lifetime, or at least longer than normal.

I also think that perhaps more than necessary is being made of the issue that the current CryoValve-SG homograft is a pulmonary valve rather than an aortic one. While some further risk of less durability is there, it is again not risking everything, but rather just some years less than might otherwise be expected.

Increased risk there is. If someone wants to absolutely minimize the risk of valve replacement surgery as much as possible, by all means go with the most tried and true. But, many of us are quite comfortable with a well calculated risk of only part of our investment, which I believe is truly the case with the SynerGraft valve or other new developments that haven't had 15-20 years of track record yet to guarantee us of a reliable actuarial projection of our possible outcome.

Beyond the normal risk of all valve replacement surgery, the main increased risk that I truly believe that I have incurred is that I may have another surgery in this lifetime. If I have to have another, it doesn't really bother me that I would have it a few years earlier because the replacement was a pulmonary rather than an aortic valve. In fact, earlier might be better since I will be younger and presumably better able to tolerate the reoperation. In any case, with a regular homograft I am risking virtually 100% that I will face another surgery and with a mechanical I start with the Coumadin inconvenience and risk right away.

In any case, just as some of those on Coumadin have complained that the inconvenience and risk associate with it may be somewhat exaggerated, I think we may also be risking exaggerating the risk of some of the new developments like the SynerGraft as well (not to minimize it either, of course).

So, let's calculate our risks accordingly and consider whether or not to roll the dice on the calculated part, not the whole shabbang! That way, we won't miss any really good opportunities, either.

Thanks for your indulgence with this. Hope others will chime in on this issue.
Roll of the dice

Roll of the dice

Couldn't agree with you more Steve. I think "roll of the dice" is a term that can be used quite loosely when venturing into technological advances.

My point in using the Cryolife SG as an example was not to question the technology. Personally, from what you have mentioned in your experiences and from my limited research, I think this is the greatest thing in valve replacement surgery today.

However, for anyone of us making a choice, we have to hope for the best and be prepared for dissapointment. In preparing for dissapointment, you need to know what "plan B" is and how easy it is to make a transition. In clarifying my question, for those of us who are young and want to get a homograft, any homograft, how difficult is it for the surgeon to replace a homograft with a mechanical if a second surgery is needed?

Steve, I'm glad my mention of "roll of the dice" has got you fired up to support this new innovation. Your comments and continued support to this group on your experiences w/ the CryoLife SG makes me feel a lot more comfortable about my future options.

Thanks, Jim, for your kind reception of my 'fired up' defense (tirade?!) of new developments like the SynerGraft valves. Indeed, your question about the followup replacement of a homograft replacement is something that I must pay close heed to, since what I have risked by choosing a homograft of any type is precisely that. We must be able to endure the failure of our gamble, however calculated it is, or we certainly should not choose it. Plan B must be an outcome we can also live with.

It is true too that most of us have had to make these choices without being fully informed, as many questions and issues come to our attention post-surgery, especially with new stuff like the SynerGraft. For this reason, the web in general and this website in particular is such a Godsend for us. Surely those who still have time to decide are profiting from all this discussion. That's why I feel that I can't lose in the larger view of things, because even if my relative risk-taking with the SynerGraft proves bad for me, it will still be instructive for the rest of you. Not that I am so altruistic, but in this case that will have to serve as the consolation prize!

I am not normally a gambler; I have honestly never even bought a lottery ticket in my life. The only lottery I ever one was one that I did not enter voluntarily (for those who remember about it, my birthday was drawn as a very high number, in the 300's, in the first lottery for the military draft during the Vietnam War era, circa 1969-70; translation, bingo, one night while in college I was exempted from military service while at the same time my brother and many of my close friends learned they had no legitimate escape). But, this business of choosing valves is not one of choosing between risk and no risk, but rather between various estimates of risks for various types of outcome. The better we can estimate the risks that are most pertinent to our own interests and objectives, the better of a choice we can make.

God, I'm glad I didn't get this far in thinking about all this before my surgery!:D
Bio vs. mechanical

Bio vs. mechanical

I was 72 three years ago when I had mitral valve replacement with a mechanical St. Jude. My native valve was shot and couldn't be repaired. I'm glad I have a mechanical. Heck ,I'm too old to have another operation. Coumadin? Its not much trouble and there is some evidence it is good for old guys, decreases chance of stroke, vein thrombosis, etc.


well.... this is an area I have been trying to read up on but still feel very much in the dark. My dad will be 80 next Fri. and when he had his "episode" the cardiologist in the ER said he would recommend a "mechanical valve" and then he could "live another 30 years!" He is in (otherwise) good health and is very fit.
But some have said that tissue valves are more often recommended for older patients because of the "risk" of coumadin. My dad's thoughts are - he plans to live as long as his uncle (100) and he doesn't want to think of re-doing this surgery - especially in his 90's!!
I have had so many other things to think about I haven't been too stressed over this. I want to be well informed - but I feel we have found the best surgeon and the best hospital we could find. So I want to hear his recommendation about which valve.
Do they really let you choose? Or do they just take your preferences into consideration but once they look at your heart make the best choice for your situation???
I will continue to read every word anyone writes here on this topic. Thank you all for your combined knowledge!!! Cindy
Longevity seems to run in your dad's family. Having another valve replacement at 90 is frightening and the surgeon might not be willing to do that. Assuming your dad lives a good long life like people in his family, a mechanical would seem appropriate, at least in my opinion.

It would be awful to get to that length of years and find out you have an insufficient valve and there aren't any options. He would live out his life in misery.
Tissue valves typically do not require lifetime anti-coagulent (coumadin) therapy. There is lots of data showing that tissue valves last longer in older (over 65) people than in younger people.

The Carpentier Edwards Bovine Pericardial valve looks very promising with good longevity results at 15 years and counting. This valve is highly regarded at the Cleveland Clinic which is the #1 rated heart center. Another advantage is that it has a low profile and can be installed quickly which minimizes undesired side effects of surgery such as memory loss and cognitive problems. Even at age 57, this is my favored choice.

To learn more about the potential impacts of Coumadin, see the Coumadin Forum and the Coumadin section under Heart Links.

Thanks Al!

Thanks Al!

Thanks Al!
I will do some research on the Carpentier Edwards Bovine Pericardial valve since my dad's surgery will be at the Cleveland Clinic. I want to hear what they recommend after looking at his tests.... but I also want to be prepared with questions - and have some preferences in mind before we go up there... All the great information here is SO helpful! Cindy