Imminent re-operation of heart valve

[sandra]

Happy New Year, I am very pleased to have recently discovered this forum. When I was 55 I collapsed on my treadmill at home and ended up in hospital where it was discovered that I had a Bicuspid Aortic Valve. I was kept in hospital for 19 days as it was deemed unsafe to let me go home. During that time most of the cardiologists I spoke to recommended that I have a mechanical valve replacement. Then one cardiologist took a long time to explain all the details and asked me if I would consider a tissue valve. I decided that would be a much better choice for me. In December 2014, I had a 19mm bovine valve put in. My average gradient after surgery was 18. Over the next six and a half years my routine echocardiograms reported a stable gradient between 18 and 22 and I was told to expect my valve to last until I was at least 70. Six months ago (now age 64) I went for my next routine echo and the average gradient came back as 58. I was totally shocked as my cardiologist said I needed a redo asap. At this stage I was extremely fit and asymptomatic. I am a keen hiker and was still racing up and down mountains. I asked for the echo to be redone, but they declined. Instead my heart team decided to treat me with blood thinners for 3 months in case it was a blood clot in the valve. I took the thinners. The next echo reported my average gradient to be 73. I then had a CT scan and a transesophogeal echo - both of them returned an average gradient reading of 63. That was about 6 weeks ago and I was then placed on the wait list for surgery. I am a public patient (in Australia) and the current wait list is about 60 days, so I am expected to go in for surgery late this month (Jan 2024). I found this website and started reading. My main questions are: has anyone gone from a gradient of 22 to 58 (or similar) in the space of two years? What could have caused this to happen? My cardio team say it is just bad luck (but they do also say that they have never seen it happen). How long should I expect from the next tissue valve I get? I know that is impossible to answer. The valve I have in now is a 19mm one. My surgeon is hoping to replace it with a 21mm one. Apparently he is looking ahead to the next time my valve could need a redo, and has told me that Open Heart Surgery for a third time is not something he will do. The alternative is to replace the valve through my groin via an angiogram, but he says that the minimum valve that can be used for this procedure is a 23mm, so not an option for me. So what is my option if this next tissue valve fails? Surgeon says I can't switch to having a mechanical valve as I have a tissue valve. I am a very young 64 year old (65 this week). I am 48 kilos and otherwise very healthy and get regularly told that I look less than 50. Does this mean that I might be young on the inside too lol? Does this mean that my next valve might not last ten years? I was reading here this morning that tissue heart valves decline faster in younger people. Two days ago I hiked 11 kilometres with an elevation gain of 514 metres (lots of up and down hills). I did this in three hours. How can I possibly do this with such a severely calcified valve? Apparently one leaflet is so calcified that it is stuck open, so my regurgitation is quite severe. My only symptoms are that I get very fatigued and I often sleep during the day. I was also feeling a little light-headed on my recent hike (not dizzy). Oh, and I forgot to mention that I was doing some research recently and came across journal articles researching the effectiveness of K2 supplementation for reducing aortic valve calcification. At the moment it is inconclusive, but studies are ongoing. I began taking K2 a month ago. Has anyone used K2 and reversed their heart valve gradient level? I have read one or two people's comments on this forum where they have stated that they are using K2 with mixed results.
Thank you for reading and listening to my story. I would welcome any replies giving me some light to my questions.
kind regards
Sandra

 

[dick0236]

Welcome to the forum Sandra. Why not switch to a mechanical valve for your upcoming surgery and eliminate the need for future surgeries?

 

[sandra]

Welcome to the forum Sandra. Why not switch to a mechanical valve for your upcoming surgery and eliminate the need for future surgeries?

Thank you Dick.
My surgeon has said that replacing my tissue valve with a mechanical valve isn't an option. Also, l don't want to have to take warfarin. Plus, l don't think l would cope very well with clicking noise.

 

[tommyboy14]

Hi Sandra,

you may want to get a second opinion. I find it strange that your surgeon told you that a mech valve is not an option. Is there a specific physiological reason for that?

If you are set on a tissue valve, you may want to ask for the Edwards Inspiris Resilia valve. Apparently it will last longer in someone your age and when the time comes to replace, there is a greater chance (but no guarantee) of replacement via the groin. If you go with a tissue valve now, there is always a risk that you will not be a candidate for TAVR next time.

Finally on the gradients. I would have thought that someone as fit as you would prefer a mechanical valve, since the gradients are much lower. My 25mm ON-X valve has a 5 average and 10 peak gradient. A lower gradient means that you get more out of your heart in terms cardiac fittness.

I never heard of K2 being able to reverse calcification.

 

[pellicle]

Hi Sandra

My surgeon has said that replacing my tissue valve with a mechanical valve isn't an option.

I would echo this

you may want to get a second opinion. I find it strange that your surgeon told you that a mech valve is not an option. Is there a specific physiological reason for that?

But would be cautious about such things as a genuine underlying problem with tolerating anticoagulant therapy.

On this point

, and has told me that Open Heart Surgery for a third time is not something he will do

I would agree, although I've had 3 myself, I have no desire for a fourth. I had a mechanical installed on my last surgery back in 2011.

Best Wishes

 

[sandra]

Thank you tommyboy 14 for your reply. I had not thought to ask my surgeon about the brand type of a tissue valve. I have no idea what is available and trust that my surgeon will make the best choice. Indeed, I don't actually know if I have an option to choose. I assumed that the hospital I am having the surgery at just uses what they have. I am a public patient. Maybe public patients just get what they are given here in Australia. Not sure, but maybe choices are only for private insurance patients. I will make some enquiries. I am very appreciative of your suggestion.

 

[sandra]

Hi Sandra


I would echo this


But would be cautious about such things as a genuine underlying problem with tolerating anticoagulant therapy.

On this point

I would agree, although I've had 3 myself, I have no desire for a fourth. I had a mechanical installed on my last surgery back in 2011.

Best Wishes

Thank you Pellicle. Clearly I need to educate myself more about what choices I have now, and how these will affect my future and any further treatments that I may need.

 

[pellicle]

Clearly I need to educate myself more about what choices I have now, and how these will affect my future and any further treatments that I may need.

we all have to start somewhere ... I started when I was 10 (I didn't do much self learning then I can tell ya), but I have since.

Personally I'd be looking for the actual reasons the valve failed (for instance, calcification), I'd definitely get a second opinion as to a mechanical valve, and I'd seek clarification if you would have any issues with anticoagulation.

This post is quite distuirbing and in my view verges on malpractice that she wasn't properly informed about the risks in her specific case.

https://www.valvereplacement.org/threads/up-date-re-op-has-anyone-gone-from-mech-to-tissue.884106/
Such situations are rare, but that may be what the cardiologist knows that we won't which precludes you from a mechanical valve.

More research needed I'd say ...
Best Wishes

PS; this was the thread that led to that thread
https://www.valvereplacement.org/th...-home-from-mech-to-tissue.883827/#post-883832

 

[hevishot]

Hi Sandra. You already told these people in no uncertain terms that 1. You don't want to take blood thinners and 2. You do not want to deal with the ticking sound. That is where the conversation of getting a mechanical valve should have stopped. But from past experience with this site they will not let this go. Your decision is meaningless to them.

 

[Paleowoman]

Hi Sandra - welcome to the forum. I have some similarities to you though not quite the same.

I had aortic valve replacement in January 2014 when I was 60. I too had a 19mm bovine valve, and my average gradient post surgery was 18, peak 36. Three years later in 2017 at my annual echo my average gradient had suddenly jumped to 32, peak to 58, effective orifice area was 0.76. I was immediately referred to a cardiac surgeon for a surgical reassessment.

I had TOE (TEE) and further echos. There was nothing wrong with my valve - the surgeon explained that I had “moderate patient prosthesis mismatch” - my valve is effectively too small for my body size - I’m slim, I’m 5ft 4ins (162cm) and 46 kilos. My pressure gradients on annual echos have remained in the 30’s average and 50’s peak, always the effective orifice area is at 0.76. I have a very loud murmur which sounds like the murmur of aortic stenosis but it isn’t. I have no symptoms. I’ve learned that pressure gradients on echo and orifice areas do not appear to have the same significance or meaning as with a native valve on echo. For example, the real orifice area of the 19mm valve is clearly not just 0.76 but that is the "effective area”, and with me it’s due to the mismatch between my body size and the valve. The cardiac surgeon would not have been able to put in a larger valve because the size implanted is due to the size of the annulus which is accurately measured during surgery. The annulus is very fibrous and tough and cannot take a larger valve than it’s measured size (I believe a valve can be implanted supra-annularly which means a bigger valve can be put in).

The surgeon I saw in 2017 said he would recommend a mechanical valve when I need the valve replacing…I would not want that due to the ticking noise and warfarin. The surgeon wouldn’t do a redo back then as he said my mortality risk was "too high” - well I think that gets higher with age but once the valve is degenerated then that over rides the risk. When my valve goes wrong then I will go for a tissue valve again..

You wrote that one of your leaflets is severely calcified - would that be the cause of your increased pressure gradients ?

I take vitamin K2, been taking it since 2008, I started taking it after reading on a cardiologist’s blog about it and also because it helps with osteoporosis. I had some calcification on my native bicuspid valve…though I don’t think the calcification on it was too bad, it was only “moderate” when I had the valve replaced. I begin to question whether I should have had surgery originally when I did as I had felt very fit and well then…but the original surgeon said I could have “sudden death” - I wonder about that, but can’t go back in time LOL

All the very best to you, do let us know how things go.

 

[Timmay]

What hevishot above failed to see is that you pointed out that your surgeon said that a mechanical valve was not an option. So - the conversation is NOT over. Why? Because you, as the patient, need to understand why. That is supremely important. Everyone here has your best interests at heart. Some people (hevishot) don’t want to hear facts and just want to follow feelings. However, facts are facts. You don’t want to get a 3rd open heart surgery. You just don’t. In fact, as your doctor already pointed out, he won’t even do it. That there should speak volumes to you. It ultimately means that your very next surgery should probably be your last one. Please think about that.

I am not against tissue valves. I think they’re pretty cool. AND - If I was 65 when I had my operation then I probably would would have got one. Definitely ask about the Edwards Resilia Tissue Valve (in addition to why your doctor indicated that you can’t go mechanical).

Keep in mind that if you go with a tissue valve, you’ll need at least one more intervention before you part this world (and maybe 2). Your doctor will tell you that you can get a TAVR (aka TAVI) if your tissue valve fails but take that with a grain of salt because you cannot qualify for a TAVR until you are evaluated in the moment that you need one. There are plenty of people that don’t qualify even though they were told a decade ago that they can get one once the tissue valve fails.

Given how active you are, you might be able to get 15 years from the Edwards Resilia Valve ,,, but it could be 10. So figure on another intervention between 74-80.

Good luck and God bless.

 

[treichert0312]

I did not want a mechanical valve on my 3rd OHS but my tissue valve from 2014 failed - broke a leaflet so it was stuck open / ineffective. All the docs I spoke with were in accord with mechanical valve and I went with that. TAVR through the femoral was not an option even though that had been my plan.
From my experience only, the ticking is less noticeable than the previous murmur. Less sloshing/wooshing sound. Also, blood thinner management is very important of course. Mechanical valve can develop clots that get launched to the brain and cause a stroke. My aunt suffered a stroke that way around 1995.

I did get a mechanical valve in 2022 and I am curious why the docs say no mv for you.

Happy new year to y’all!

 

[V__]

In December 2014, I had a 19mm bovine valve put in.

Surgeon says I can't switch to having a mechanical valve as I have a tissue valve.

I wonder if the statements above might be related. If the hospital only has On-X valves (which are bigger than others by design, requiring more room), then maybe the small diameter is a limitation/restriction. Could be worth asking, if you want to consider the mechanical version. There are other types of mechanicals that are smaller in size (St. Judes seem to be also popular).

My only symptoms are that I get very fatigued and I often sleep during the day. I was also feeling a little light-headed on my recent hike (not dizzy).

I would take them seriously. These are real symptoms. Many of the heart issues appear as non-specific issues. Even a heart attack, that can show up as a "heartburn", a jaw pain, arm numbness, etc.

 

[V__]

already told these people in no uncertain terms.... Your decision ...

I would not be so categorical. Maybe it was just a current opinion, based on the current understanding. Rather than a final decision.

Certainly seemed like Sandra was looking for information on the people's experiences. Some of it may not look relevant to her, but she can always disregard it.

 

[pellicle]

But from past experience with this site they will not let this go.

do not suggest that the entire site is homogenous. You have your view others have theirs. Why not just make it clear that you think its "some members". Why presume to know what the OP actually needs to hear?

 

[MdaPA]

l don't think l would cope very well with clicking noise.

How about searching this forum to see how others with mechanical valves cope with the clicking? Some are bothered by it, some are not, and others don't even hear it.

Here is one recent thread:

Mechanical valves ... but what about the ticking?

FWIW, my wife has 2 mechanical valves, one in mitral and the other in the aortic position. Her heart sounds like a symphony and it does bother her, mostly when trying to sleep (so she listens to radio, white noise, etc.). However, she has had 3 OHS and doesn't want to have a 4th.

Do read what folks here have to say and then make the best decision for your situation.

Good luck!

 

[MdaPA]

Instead my heart team decided to treat me with blood thinners for 3 months in case it was a blood clot in the valve. I took the thinners.

l don't want to have to take warfarin.

Did you encounter any issues with taking anticoagulation medication for 3 months?
If it was warfarin, what are your concerns with taking it?

 

[pellicle]

with the clicking?

something I mention now and then is hypnosis and its possibilities ...

https://www.valvereplacement.org/th...-and-quality-of-life-study.888754/post-920126

 

[tom in MO]

...I am 48 kilos and otherwise very healthy and get regularly told that I look less than 50. Does this mean that I might be young on the inside too lol? Does this mean that my next valve might not last ten years? I was reading here this morning that tissue heart valves decline faster in younger people. Two days ago I hiked 11 kilometres with an elevation gain of 514 metres (lots of up and down hills). I did this in three hours. How can I possibly do this with such a severely calcified valve? Apparently one leaflet is so calcified that it is stuck open, so my regurgitation is quite severe. My only symptoms are that I get very fatigued and I often sleep during the day. I was also feeling a little light-headed on my recent hike (not dizzy)...

Your symptoms of fatigue, daytime sleeping and light-headed are fairly acute. Don't wait too much longer. In a review of autopsies of Italians who died of BAV, the age range was 17-80 with the median being 55. These people had no warnings. To me it sounds like a second opinion is what you need to help guide you to the best path.

 

[Gail in Ca]

These people??
I have experienced 3 open heart surgeries and only recommend whatever valve keeps people from having repeat surgeries. My surgeon was one of the world’s best and he was concerned about my 3rd surgery.
He’s retired now, and I’m having severe mitral valve leakage. I’ve spoken with a
Renowned robotic surgeon and an interventional cardiologist. I’m due for a TEE and CT w contrast. BOTH doctors are VERY concerned about a potential 4 th surgery.
Do not take redo’s lightly. Plus, other stuff can happen causing a redo surgery, like bacterial endocarditis or a cardiac test gone wrong and ending up in congestive heart failure.
Please do not put people down, for their experiences are real.