Newbie: Replacing with oversized bioprosthetic

[Gail in Ca]

We talk about OHS as if it were a tonsilectemy. My surgeon, any great surgeon, is concerned when facing a 3rd surgery for a valve redo. If you could read the detailed notes on my 3rd surgery, you wouldn't give tissue much consideration. I was told at Stanford Hospital, a top heart hospital, that any tissue would give me about 10 yrs. I was 54 a yr ago when I had my 3rd surgery. My surgeon did give me a larger mech valve inside a larger graft, placing the valve in a different position. He wanted to provide me with the largest valve possible. ALSO, repeat surgeries have the risk of cutting thru scar tissue, which can add 4 hrs to the procedure. Risks also include, but are not limited to:bleeding,infection,anesthetic complications,renal insufficiency, renal failure,myocardial infarction, stroke, and even death. I was told this before my surgery. I know tissue is tempting, but at what cost?

 

[fischje]

Dr. Sabik did my first surgery in 2003 --Bovine Aortic and Mitral Valves - I had a redo in ten weeks ago ( Mechanical) . At the time I thought I was making the right choice being a 27 year old woman with the wish of having children one day--I remember Dr. Sabik saying there really wasn't a good choice for me at the time. I also was told best case scenerio was 18 years and worse 5 years with the tissue valves. Mine lasted only less than seven. I guess there is no going back now --luckily now I am done with OHS --but coumadin can be frustating.
But as a surgeon my family and I were happy with him at the time

 

[mwkentner]

Thanks all for posting. I'm here at Cleve Clinic waiting to see Dr. Sabik. 5hrs passing since my actual appt. I'm not sure which way to go yet, All options have + or - Hopefully some light will come on as the best option for me, scarey not to know yet.

 

[Bradley White]

Hi Mk,

I just wanted to say that I have had two OHSs and will undoubtedly have a third (unless I'm hit by a bus or something before then) and the second was easier than the first, believe it or not. The really good surgeons at Mayo or Cleveland Clinic are so skilled at reoperations these days that the risk is very low even for second and third surgeries if you are otherwise healthy. My surgeon at Mayo told me that he doesn't think my third surgery will carry any more risk than my second did.

Good luck.

 

[mwkentner]

Thats is good to hear, I am healthy otherwise, and blessed with having the chance to even have a second OHS. Its hard to plan what might happen tomorrow, let alone ten years down the road

 

[mitchner9g]

Hello everyone,
[...]
With McCarthy gone I have been referred to Dr Sabik for surgery. I have yet to meet him but will in the next few weeks.
My question is, has anybody else picked the use of a oversized bioprosthetic ? How have you felt? Any problems with placing a large valve into smaller plumbing? Does this cause your heart to overwork to compensate for the nonrestrictive blood flow that you now have? Or are you feeling like superman who could run a marathon? Of course any input or help would be appreciated.
[...]
Mk from Columbus

Hello Mk - You raise a question that I've had for quite some time, although our situations are a bit different. In my case, I underwent a pulmonary valve replacement (my 3rd) a couple years ago, and they implanted what my cardiologist considers too narrow of a bioprosthesis. This is a Medtronic Mosaic valve -- you heard that right: Pulmonary position[1]. My symptoms include SOB and right side hypertrophy. Along with A-fib/flutter likely caused by right side enlargement.

Now I've read that surgeons err on the side of small and I cannot explain why haemodynamically (I suppose too little pressure to open the leaflets could be a bummer), but for very active people, a narrow valve hits it's threshold much earlier than either side of the valve would like. You end up with a severe gradient, ergo upstream constipation and downstream starvation.

I'm 38, and cannot go past 12 minutes following the standard treadmill protocol. This after being a multi time state champion cyclist in the chrono, is a fair number of steps down. And while I can set aside the vanity of needing to keep up with grandmas on my morning constitutional jog (they kick my arse every time), the fact that I'm experiencing other potentially damaging side effects means I'm getting down to brass tacks with my sawbones about what to do. To wit: My cardiologist is right now corresponding with Cleveland Clinic (and UCSF) about what to do with my case. I would not be surprised at all if the doctors you named overlap with the ones on my cardiologist's rolodex, or at the very least the ones she is communicating with might have opinions coinciding with Sabic et. al. given they are all under the same roof.

I will be sure to bring this up with her during our meeting Tuesday 5/4 next week and report back if there's anything to share. Valve selection is a tough choice. Suerte, amigo.

[1] Pulmonary and aortic valves are similar enough that this can work -- my first surgery was a Ross procedure.

 

[Bob in Colorado]

Dr. Sabik implanted a homograft in me in 2000

Dr. Sabik implanted a homograft in me in 2000

He was trained directly by Delos Cosgrove and he is an excellent surgeon. I have had two OHS at CC and both were good experiences. A homograft in 2000 and a mechanical valve in 2009. Like you, the homograft was touted as the tissue valve of choice then and thought to last for many, many years. In retrospect, I would have been much better off in having had a mechanical valve with the original surgery and not have had to have the re-operation. Now I have an artificial aorta which would not have been necessary with the first surgery, and a big scar, and me and my family had to go through the trauma of the surgery two times (so far). And my heart had to suffer less than optimal conditions as the tissue valve deteriorated.

Another tissue valve was out of the question for me - or for my cardiologist. As others have said, I would not count on an oversized tissue valve setting you up for a less-invasive replacement in 10 years. And I do think CC is biased towards tissue valves. My reop was done by Dr. Pettersen with an On-X. I feel terrific, even though I have a vacuum cleaner hose for an aorta an take warfarin each day. The outcome just feels much better!

Best to you in your decision!

 

[mwkentner]

Now I've read that surgeons err on the side of small and I cannot explain why haemodynamically (I suppose too little pressure to open the leaflets could be a bummer), but for very active people, a narrow valve hits it's threshold much earlier than either side of the valve would like. You end up with a severe gradient, ergo upstream constipation and downstream starvation.

[/URL].

The Way it was explainded to me me is that they will replace my valve with the largest reasonable sized valve possible. Its not like they are going to squeeze in some type of supersize valve. The larger the better though, Included in the thinking was a "Possibility" of replacing down the road with less advasive techniques. But as we know we cannot count on any of this speculation.

 

[mwkentner]

And I do think CC is biased towards tissue valves. My reop was done by Dr. Pettersen with an On-X.

I asked Dr Sabik while doing my pre surjury at Cleveland Clinic about On-X valve. He stated to me that he does not do any replacemnts wtih that type of valve, which at the time I thought to be funny, but recommended the st jude mech if I was intetrested in it. So is the ON-X valve a option at Cleveland Clinic?? I've heard good things about it, but wasn't given that option, my thinking was that I wiould have to start the process all over at a another Hosp. Cleve Clinic was my second opinion hosp already. Riverside Hosp in Cols my first. Maybe a third opinion is needed?

MK

 

[ottagal]

I

The Way it was explainded to me me is that they will replace my valve with the largest reasonable sized valve possible. Its not like they are going to squeeze in some type of supersize valve. The larger the better though, Included in the thinking was a "Possibility" of replacing down the road with less advasive techniques. But as we know we cannot count on any of this speculation.

For what is' worth, my surgeon said that he put in a 'good sized' bioprosthic valve (bovine) . I never asked if he 'oversized' it or not. It would have been worth asking.

 

[Bob in Colorado]

MW, I had planned to have Dr. Sabik do my re-operation since he had done my initial surgery. But I wanted full consideration of the On-X. I learned that the CC surgeon most familiar with the On-X was Gustav Pettersen. Check him on line at CC.

Dr. Sabik did not have any direct experience with the On-X, just the Saint Jude. Hence, I went with Dr. Pettersen there who did a great job.

I do think that either valve would be a fine choice. I just wanted to try the On-X as all of the things I had read about it I found compelling. I have to say that I feel terrific now, but I would imagine that I would also feel just fine with the Saint Jude.

Take your time and make the choice that you feel best about. CC is a great place but do not let it run you!

 

[Gail in Ca]

I found out before my 3rd avr, that my 2nd valve, mechanical, was placed inside my 1st valve, a porcine, that had worn out.
During my 3rd surgery, it was found that my aortic opening where the new valve would've gone was only 19mm. Dr. Miller wanted to use a 25mm and so he placed it farther up the aorta and created his own valve+graft, and that was placed, removing all the old valve mess, & the old graft. This larger mech valve has been wonderful so far. I feel like my old self when I had porcine.
My point? When your surgeon gets in there, he has to have the expertise to be creative if his original plan won't work! I am living proof of this.
Good Luck on your decision.

 

[mitchner9g]

[...]
Dr. Miller wanted to use a 25mm and so he placed it farther up the aorta and created his own valve+graft, and that was placed, removing all the old valve mess, & the old graft. This larger mech valve has been wonderful so far. I feel like my old self when I had porcine.
[...]

Gail is this Dr. Miller at Stanford?

Thanks,

 

[Gail in Ca]

Yes, Dr. Craig Miller at Stanford. According to one of my nurses, people come from all over the world to him, because they have been told something couldn't be done, and he says he can do it. My 3rd surgery was 12 hours, and I recovered as well as I did from my 1st surgery.

 

[mwkentner]

Its been some time since I last posted so I thought I'd share. I am now almost 8 months post op and recovery has gone very well. I did have a small set back a week after surgery. After 5 days in at Cleveland Clinic they released me to finish recovery at home. Within Two days of being home I went into Atrial Fib and had to be admited to a local Hosp (Riversides McConnel Heart). The care there was excellent and was back to recovering at home within 4days. Since then I have been on a steady course to normal life. Within 3 months I was back to work doing clerical work and have recently finished 12 weeks of cardio rehab. Rehab has definitly given me more energy and tollerance to exercise. Before surgery I was walking once around the block and became tired, Now I can go 6 trips around and still have energy. Spent this past Thanksgiving in New york city walking the city and seeing the sites without much difficulty. So looking back I'm glad I went through with surgery and I'm sure better days are to come. My medication list is much smaller now, basicly Vitiams, asprin, accupril, topral. My pain was minimal, steady and but tolerable. Since this was my second OH, I can compare. this was a little more difficult but I believe I feel better now than I did at the same time after my first surgery.
I hope this will help anyone who is searching pre-op and looking for some peace of mind. Its only my story and everybody has a different one. I believe mine to be a positive experience. You'll find many opinions on this board and you find it to be a god send of information. It helped me, I hope it will help you find the information you are looking for.

 

[Lynlw]

What a great update. Glad things are going so well.

 

[ALCapshaw2]

Glad to hear you are doing well.
Yep, A-Fib is a COMMON after-effect of OHS.

Out of Curiosity, what kind of valve did you decide upon?

 

[Lily]

Glad you're doing so well. Thanks for the update and take care

 

[normofthenorth]

I'm curious about something else, and I'm surprised nobody asked you pre-op: Is your "original" AV and Aorta way smaller than average? Sizes vary, and not always in proportion to body size. In an average person, even at high levels of CV activity, a slight decrease in AV area is unlikely to have any noticeable affect. But in (say) a person of average size with a 19mm valve, every mm might count, and oversizing might have clinical benefits.

A chain is only as strong as its weakest link, and a pump's (or a hose's) flow rate tends to depend on its narrowest opening, and not so much on the others. . .

 

[mwkentner]

Well I’m not sure what the size was of my original AV and aorta. But I do not remember them ever saying that it was too small or small for my size. Just that it was a bicuspid valve with severe stenosis. Sorry I don’t have a answer.
And thanks to everyone.