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pellicle

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Hey Pan

until the moment the surgeon mentioned a Ross for me with some ascending replacement also.

I suggest you read my first pass "critical analysis" of the Ross over here.

I checked your Bio and there was no age data there from which to make further decisions, so I of course leave that for you to do.

take your time, read what you can, try as best as you can to not put in emotional biases based on 'hope'.

Best Wishes and hope you have a great New Year

:)
 

Superman

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Oct 2, 2009
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Grand Rapids, MI, USA
Had a phone call from the hospital today.
They want me in for pre-opp next week.

Surgery will be in January or February

Aortic valve replacement , plus repair on my dilatated ascending aorta

Still feel fine, no symptoms

Just ran 7km on the treadmill a few hours ago at a decent pace (14 km/hr)...wasnt out of breathe or anything

You did a 7k in a half hour and weren’t out of breath? How fast are you when you try? 😳

Oops. Jumped in on one of the old posts in the thread. Still. If I were promised $10 million if I could just run 7k in a half hour, my financial situation would remain unchanged.
 

pekster11

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Chester, UK
You did a 7k in a half hour and weren’t out of breath? How fast are you when you try? 😳

Oops. Jumped in on one of the old posts in the thread. Still. If I were promised $10 million if I could just run 7k in a half hour, my financial situation would remain unchanged.
Actually I've since discovered my treadmill does not accurately read the speed. When I set it at 14km/hr, it's really around 10-11km/hr :LOL:
I wasn't as fit as I thought :(

All the same, I can run as well now as before the surgery (y)

Had nearly a week off beta blockers, and I've noticed my heart rate is much more responsive now.
My resting heart rate still drops to around 50bpm, as it did before surgery, but it rises much more sharply when I get up and do stuff, than when I was on B-blockers

I feel sharper and more alert....I'd say 8 months post op I am now back to the physical state I was at before surgery :)
 

PAN

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I suggest you read my first pass "critical analysis" of the Ross over here.

Hi Pellicle, thanks for taking the time to share your thoughts on that paper. I agree with quite a lot of your points, some of them could be discussed but but not going to do that here and hijack the thread. In the interest of conversation I may provide some comments in a thread of my own from some time ago. There are so many papers now indicating a survival advantage to the Ross. I find it difficult to decipher and compare them. The realities of both Ross v Mech are obvious to me now. Largely due to this incredible resource. Yet still , armed with the info I have acquired to date settling on decision is not yet possible.. I've seen that difficult choice, must be 2 valid options image so many times now :)

Anyhow, I'm 43, So 60 or so looking at Ross upgrade ?? Take the mechanical and ascending graft now, live for next 17 years, potentially not looking at another surgery again ?

Around and around we go :)

All the best for the new year everybody....

P
 

pellicle

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Hi
some of them could be discussed
as always in my view ... and nothing wrong with feeling "this needs discussion" and its entirely probably I would feel the same way if I'd read that too. As a writer its hard to express the basis and angle for everything one says in a way that's unambiguous. Not to mention "not everyone sees it the same way".

There are so many papers now indicating a survival advantage to the Ross. I find it difficult to decipher and compare them.

perhaps a thread on that? This could get not only my inputs but those of others. Or just reach out and we can get in touch and chew the fat off line. Discussion is a dish best served warm and to those who are willing to not only express a view, but receive one.

et still , armed with the info I have acquired to date settling on decision is not yet possible.. I've seen that difficult choice, must be 2 valid options image so many times now :)

I view this as meaning you see benefits in both. The question in that case becomes one of certainty vs risk. Mech valves have the certainty that they won't fail but the risk that you must manage INR properly or you'll increase your risk of harm. Can you do that? This question also depends on where you live, for in some places you can't do that because policy decisions by insurance companies may make such difficult. It is not without irony to me that the most important part of managing a mech valve is INR management, yet health care providers often want to remove that from more steady and invested hands and drag you into a world of 70% in range to make a profit and argue that they protect your health.

Ross has the risk that comes with not getting the finest craftsman to do the job as well as the risk of what happens to your other valve? Examine the case of Arnold Schwarzenegger, why did his Ross need reoperation?
 

ETC908

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Hi PAN,
I am 42 and was in the same boat you're in. I required aortic valve replacement and repair of my ascending aorta. I saw a local surgeon who had a ton of experience with AVR and aortic repair. He recommended the mechanical valve, stating that it was a "one and done". I got an opinion with the Cleveland Clinic, who recommended the Ross. The advantage being that the Ross does not require lifelong anticoagulation. I too came across some of the studies that suggested a shorter lifespan in patients with mechanical valves, and it made me dig deeper and do a lot of thought and research on the decision. I got a third opinion from Yale, who agreed with the Ross, citing the same things.

The bottom line was that I agree with my cardiologist, who said "There is not a wrong answer". The Ross procedure is more complex, involves two valves, and carries a SLIGHTLY increased mortality rate relative to a mechanical valve replacement. However, lifelong warfarin is not needed.
The mechanical valve requires lifelong warfarin. However, it should last a lifetime. Having an aneurysm repaired at the same time further decreases the chance of any further open heart surgeries in the future.
I'm not saying my assessment is correct, but what I found was that the cardiothoracic surgery world is entrenched into two camps on this: The pro-mechanical valve surgeons will tell you it's "one and done" and that the Ross creates a "two valve issue", and that complications with it can be very challenging to fix.
The pro-Ross surgeons will tell you that you won't need warfarin, and that if one of the valves require re-intervention in the future that it can be done minimally invasively (ie a TAVR approach). They will also cite the survival rates.
I was leaning towards the mechanical valve but was concerned about the survival data. Thanks in large part to this forum, along with my own analysis, I decided that there were way too many variables to make any definitive conclusions. The studies on decreased survival typically cite complications from the warfarin, both bleeding and thromboembolic events. Most of that data is older. Do we know what other comorbidities the patients had, and how well they regulated their INR? Have we factored in the impact of home testing?
Unfortunately there will be no guarantees. Even with the Ross, there is no guarantee that a future intervention could be done without having to open things up again. And at my age, it was pretty much a guarantee that one of the valves would go should I live to my 70s and beyond.
In the end I went with the mechanical valve, and had it done on November 10th of this year.
I think it comes down to personal preference and knowing yourself. I'm anxious, type A, and neurotic about most things in my life. I had little doubt that I'd be diligent with tracking my INR and managing my warfarin. In fact I bought a home kit before my surgery even happened, so that I had it in place when I got home. I am still in the early stages of managing it and have gotten a lot of help from the folks on this forum. I knew I did not want to have another open heart surgery if I could avoid it, and that I'd be worrying all the time about the status of my repaired valves should I go with the Ross.
Now that I'm on the other side of it, having dealt with some small bumps in the road post-surgically, I'm currently content with my decision. The additional variables the Ross brought would have caused my anxious self to worry about even more bumps or complications.
This is all assuming the Ross is done by a highly experienced surgeon who is well-versed in the Ross, working at a center that is well-experienced in it. Things can go terribly wrong with it in inexperienced hands, and having to re-operate on a Ross that goes wrong is very difficult.

So I guess to summarize...do you want a more established, "simpler" (I use that term very lightly of course) surgery that hopefully will not require reintervention in the future, but subjects you to lifelong warfarin management (which potentially carries a survival risk, but I think that's very debatable)....or do you want a slightly more involved surgery that will allow you to avoid lifelong warfarin, but will likely require re-intervention on a valve later in life, which could be done minimally invasively but is not a guarantee?
Again, I don't think there's a wrong answer.

There are others on this forum that are much more well-read on things than I am and have great resources, so that's just my two cents. I wish you all the best!

P.S.- If you don't mind, I'd love to see the papers you're referencing as well
 

Astro

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Thanks ETC908 for your careful summary of this complex topic.

I agree that it is choosing between two good options (no surgery is very bad).

I feel that Arnold Schwarzenegger is a good example of a Ross procedure. Avoiding warfarin allowed him to continue his action movie career - fantastic. However, twenty years later, he has had two open heart operations to replace worn out pulmonary and aortic valves.

Ross procedures tend to be performed in fitter patients who wish to remain very active. You would expect the "average" Ross patient to live longer than the "average" mechanical patient based upon this difference in baseline. Also, I would expect mechanical's benefits to take 20-30 years to become apparent (when the Ross procedures wear out) - this is beyond the length of current studies. Hence the survival differences are difficult to interpret.

My best wishes to anyone who is deciding between these two options. I feel that it comes down personal choice.
 
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pellicle

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I agree that it is choosing between two good options (no surgery is very bad).
hey good to see you mate.

someone here the other day asked if there were any papers or researches showing that having OHS earlier rather than waiting till the classical "last minute" were available. I had thought this was a research topic of yours. Can you make any suggestions?

Best Wishes and Happy New year mate
 

Astro

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Adelaide, Australia
Hi Pellicle,

Happy New Year to you . 🎄🎅😄

The optimum timing for valve replacement surgery is a complex issue. Surgery has its obvious risks. This needs to balanced against permanent heart scarring from letting a heart start to fail. For aortic stenosis there has been only two randomised controlled trials looking at early surgery:

1) Kang DH, Park SJ, Lee SA, et al. Early Surgery or Conservative Care for Asymptomatic Aortic Stenosis. N Engl J Med 2020; 382: 111-9.

2) Banovic M, Putnik S, Penicka M, et al. Aortic Valve ReplAcemenT versus Conservative Treatment in A symptomatic SeveRe Aortic Stenosis: The AVATAR Trial. Circulation 2021.

Both are small (145 and 157 patients). All the patients had severe aortic stenosis, had no symptoms and had good heart function on echo. Patients were randomly allocated to either early surgery or usual management. Both studies showed a clear survival benefit for early surgery.

Larger studies are in the pipeline which will hopefully give us a more definitive answer.

There have been no randomised controlled trials (RCTs) for aortic regurgitation but I suspect that earlier surgery may also have similar benefits.

I hope that I have given the right balance. The current American Heart Association guidelines do not support early surgery. However, there is emerging evidence that earlier surgery (when aortic stenosis is severe but the person has no symptoms) may be of benefit. Further studies are being undertaken which will give us a clearer picture.

I personally made the decision to proceed with aortic valve replacement before symptoms developed but I actually developed symptoms during the 5 months wait before surgery.
 

Chuck C

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Patients were randomly allocated to either early surgery or usual management. Both studies showed a clear survival benefit for early surgery.

This was probably the biggest factor which I weighted in deciding to get my surgery before symptoms, rather than wait for symptoms, once I crossed the line into severe stenosis. The November 2021 study had not yet been published, but the Kang et al study from 2020 had. The mortality rate was 3x as high for those who waited for symptoms. In my view, very little to be gained by waiting for symptoms and potentially a whole lot to lose.

There have been no randomised controlled trials (RCTs) for aortic regurgitation but I suspect that earlier surgery may also have similar benefits.

I would expect this as well.
 

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