Repairs vs. Replacement

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R

RandyL

I have been on this site for almost a year now and I am curious about the title I posted. It seems that a lot of people who get repairs end up having a replacement at some point some sooner than others.

I really don't understand why someone would repair a valve when they can get a brand new one. It seems like the risks are the same for the operation and if you could get a new mechanical valve that will last you the rest of your life why take the chance of repairing one and then having to get a new valve later anyways.

One operation versus two operations. Now I am not the swiftest guy on the block but in this case one seems greater than two. Maybe somebody could tell me why repairs are done when other options look better IMHO.

Let the learning begin.
 
Well it's a can of worms really. Some repairs last a lifetime and for those that do, yippee, they keep their natural valves. For those that don't, well you know the story. It's game of chance like the rest of this situation is for everyone else. We take all the info we get, try to make the best decision possible, sometimes go with gut instinct and pray for the best outcome possible.
 
I was hoping for some more replies on this one myself. Ive been told by a surgeon that he wants to repair my leaking bicuspid aortic valve. He tells me it is a probable 15 year repair? Everything he said made sense to me really, he stated that you are trying to do the best thing for your heart, not your valve.When you introduce a artificial or tissue valve then there is something that is not basically original equipment for lack of a better term. If it lasts 5 years then thats 5 years less anticoagulants, 5 years less of a foreign piece(valve) in your heart. After coming on here and reading up a bit it seems to me that this might not be all that great for me and there is a high chance of this not working for long. Im pretty much more confused than earlier really.Is the repair of an aortic valve a newer surgery with not a lot of track record or is it just a more complicated surgery than a mitral valve for instance. The surgeon told me that if it can not be repaired then it gets replaced at that time, not in another surgery. Any more input? And I hope Im not hijacking your thread Randy.
Tony
 
In my case, (had mitral stenosis), I was only 22 and we didn't have children. We had lost a set of twin boys in October, 1973. They were born premature and didn't survive. The repair (commissurotomy) was done in 1974, and I was told that it would probably last 6-10 years. Anyway, the repair bought us time to have more children. Our daughter arrived in 1976, and another set of twin boys arrived in 1978 (very healthy and only 3 weeks early). My repair lasted seven years and I had my mechanical valve implanted in 1981. I'm thankful the surgeon was able to repair the valve the first time around so we could have our children. LINDA
 
Now I'm curious....

Now I'm curious....

I had my mitral valve repaired last august. When I asked the surgeon later how long will this last, he told me it was for life. But, now that I'm reading that some repairs did not last, I'm curious...how many of you had your valve repaired and then needed a replacement? How many still have a repair and for how long? I don't know whether it is OK to ask this question here or should I start another link....if so please let me know or move it (Ross??). But, I appreciate you answers. Thanks
 
Maka, Maybe it depends on what is wrong with your mitral valve. Mine was damaged from Rheumatic Fever. I was told that the stenosis would come back after the repair. There was never a question that I would have to eventually have my valve replaced. The surgeon told me this upfront when they did the repair. LINDA
 
I don't have any sort of proof to back this up, but I would dare say (at the risk of having tomatoes thrown at me :D ), that the quality of the repair is equal to the quality of the surgeon. I've posted this on the boards before, but, at the risk of being redundant, I'll post it again, since there are always new eyeballs around. I got three opinions w/r/t my repair:

- The first surgeon said he thought I would have a 65% chance of successfully repairing the valve
- The second surgeon said he would give me an 85% chance of successfully repairing the valve
- The third surgeon said he gave me a 95% chance of successfully repairing the valve

You see, putting in a mechanical valve is a pretty straightforward procedure (well, as straightforward as open heart surgery can be :D ), but there is definitely an art to valve repair, much like there is an art to gourmet cooking. And when it comes to surgery, just like when it comes to cooking, not all surgeons (chefs) are created equal.

That was my big lesson in going through valve repair. If you are looking to get your valve repaired, you MUST do your homework and go for someone who is experienced and has a good track record.

I am still waiting to hear if anyone on the board has had a Cosgrove repair fail on him or her. That man has done over 10,000 surgeries, and has seen it all. If he says he can repair your valve, he can repair your valve.. .

So, when you are able to get to an experienced surgeon like Cosgrove and have surgery done at a top-notch facility like CCF, are told your repair should last a lifetime - and have reason to believe it - and you want to have children someday, and you want to keep your native valve as long as possible, and you want to postpone dealing with Coumadin. . .. you go for a repair. :)

Even if I have to have another surgery at some point down the road, I am VERY GRATEFUL for the time given to me now, with my repair. And I am grateful for the belief it will last a lifetime. For unlike tissue valves, which do have a finite life, some repairs DO last a lifetime. It was worth it (to me) to see if I might be one of the lucky ones.

Best,
Melissa
 
Well said, Melissa!

I read alot of medical research before I made my choice. The reason why people are willing to gamble repair over replace is because statistically there are less problems if you keep your own valve. Less chances of death, bleeding, infection and of course you don't have to be on blood thinners.

I got a call from a good friend last night. Her Dad is on coumiden, he fell down hit his head (not even very badly, their was hardly a lump) His brain started bleeding in three places and he died. She was a childhood friend and I knew her dad well. I know coumiden is supposed to be safe, but experienecs like this freak me out and I want to stay off it as long as possible!!

P.S. It was pointed out to me that it s unfair to link his death with his coumadin usage since I am not a doctor and I don't know for certain what killed him (I do not know what his INR was, nor do I know if the doctors found something else that contributed to his death) but these four facts I do know....he was on coumadin, he did fall and bump his head, a cat scan revealed bleeds in three areas of his brain, and he did die. I know that many people safely take coumadin, MOST people safely take coumadin, so I don't mean to create myths, I am just sharing my experience and why I think some people gladly choose the risk of repair over replacement.
 
sue943 said:
Do the insurance companies not pressurise you to have whatever surgery that is likely to be the cheapest for them in the long run?
Click to expand...
Actually no they don't. That is surprising given their track records on other things in America.
 
No Simple Answer

No Simple Answer

I think there are a number of issues here. The first is, is he patient young enough to have a choice between a mechanical or tissue valve. If this is the case the patient has to make this decision, and if there were issues that would make them choose tissue and a reoperation, would they be prepared to take the chance a repair could last longer than a tissue valve. I personally think a lot depends on your personality as Tobagotwo says, do you want a constant low level risk depending on the activities you undertake with a mechanical valve or do you want a spike in risk with reoperation with a tissue valve. Personally if they thought the repair would last as long as a tissue valve I would go with a repair. :)
 
Interesting question

Interesting question

Everybody is different. For me, I told the surgeon if the valve had to be replaced I wanted a tissue valve, even knowing that at some point it would wear out and have to be replaced. I just did not want to be on Coumadin for the rest of my life, and like Ross said sometimes we just have to go with what feels right in our gut. Mine turned out to be a pretty straightforward repair, and at my follow-ups the surgeon and cardiologists both said it could last a lifetime, although no guarantees because there always is a possibility that calcification could build up over the decades. I'm assuming that heart surgery technology will continue to advance by leaps and bounds, so if I do need another surgery I trust it will be a different ballgame.

I also read and was told what has been said in an earlier post on this thread - that the heart is happier with its own tissue. But clearly many people live long healthy lives with mechanical valves. Although even with a mechanical valve there is no absolute guarantee that the person won't need another surgery. So we all just make the choices that seem best to us at the time and see where life leads.

Everything I read validates what Melissa said about the importance of the surgeon's skill and experience when it comes to attempting a repair. Being in a high-volume heart surgery center with a surgeon who has a lot of successful repair experience seems really important for getting the best chance of a successful long-term repair.

Thanks for an interesting question!
Liz
 
The surgeons judgement is critical. My surgeon learned repair from Alain Carpentier himself ( the inventor of the " French Correction" ). I went into surgery expecting to come out with a repair. I woke up with a mechanical St. Jude. My surgeon told me two of my three valve leaflets were badly shredded and several of the chordae tenedinae were ruptured. He said if he attempted a repair he would guarantee I would be back on the table inside two years. The decision to install a mechanical rather than a tissue he said was more controversial. Most of his tissue valves at that time were lasting only 7 to 10 years. He had one that lasted only two years so he finally went with mechanical. I've had a good eight years and warfarin has been no problem. I've been lucky and havn't been in an accident or needed other surgery. It's good to be lucky and .... to have an experienced mitral surgeon.
 
MelissaM said:
I am still waiting to hear if anyone on the board has had a Cosgrove repair fail on him or her. That man has done over 10,000 surgeries, and has seen it all. If he says he can repair your valve, he can repair your valve.. .
Click to expand...

I have a friend (not on this board) who had his BAV repaired by Dr. Cosgrove, and the repair failed a little over a year later. However, he went back to Dr. Cosgrove for his second surgery (mechanical replacement) and still thinks highly of him. In any case, BAV repairs are more likely to fail than other types of repairs, from what I understand.
 
Tony -

Have you consulted, or at least contacted, a recognized Bi-Cuspid Aortic Valve Surgeon with a long history of good outcomes? I really believe you need a second opinion from such an experienced surgeon.

I ask this because I've never even heard of anyone even trying to REPAIR a defective Bicuspid Aortic Valve. It seems that all the posts I remember about Bicuspid Valves lead to the same conclusion: Replacment or Death.

As everyone has stated, the outcome depends highly on the skill of the surgeon, and for more complex cases, (such as Bicuspid Aortic Valves and Aneurisms), surgeons who specialize in these procedures have the best outcomes.

'AL Capshaw'
 
Another case where replacement the first time could of elliminated a lot of pain and agony. I am still not convinced that repair > replacement

Non-Invasive Valve Replacement

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

Hello everyone! It's good to be "back" again! Four years ago, I was here at this forum searching for answers for my then-upcoming Mitral Valve Surgery. I was able to get tremendous support from all the members here & had so much comfort knowing that when I went to the operating table, "everyone" here was with me. For that I thank you all from the bottom of my heart for being here. The people that run this forum is not only very informative & knowledgeable, but more importantly truly concerned for everyone undergoing the same experience.

At that time, my surgeon did not know whether he would repair the valve, or simply replace it. He mentioned that the only time he could make an informed decision was when he opened me up. Bless his heart he was able to repair it, albeit a time-consuming surgery.

Before the surgery, my wife & I asked him how long would the repair last. He looked us in both our eyes & answered matter-of-factly that he didn't know. 10 years hopefully, maybe 5, maybe less. Almost a month & half ago I started to feel very fatigued without doing anything strenuous, 2 trips to the ER, an echo that showed the valve was now leaking in 2 places, but no real damage to the heart. It turns out that this time, my surgeon said it was time for a mitral valve replacement. So we were able, at least, to get 4 years out of the repair. Although we wanted more mileage to it, unfortunately, that did not turn out to be the case.

Back to the same surgeon's office & we make an informed decision to do a mitral valve replacement this time with a mechanical one. I just can't see myself being opened up again for the third time. Now, here is where my question comes: My surgeon mentioned about a non-invasive procedure. He told me that he could do the replacement without having to open my sternum. Instead, he will go thru my left side &, I am assuming, break one of my ribs so that he can have access to the heart & then replace the mitral valve. Has anyone here at this forum experienced this kind of procedure? As far as I have learned through research on the internet, this procedure is being done only for repairs. But, of course, who am I to know? My surgeon told me that he is one of the pioneering doctors to do this procedure here in the West Coast. By the way, I implicitly trust my surgeon & I know of his reputation. His name is Dr. Hon Lee. But all I would like to know is if some of the members of this forum have undergone this same procedure & what are their experiences. I've heard that the recovery process is a whole lot faster than Open Heart Surgery. I am also hoping that this will now be the norm for all valve replacements.

Thanks so much for your time & I am glad to be back home.

Missed you all,

Benny
 
Which valve?

Which valve?

Please be very careful when discussing repairs not to mix stories of mitral valve repairs in with those of aortic valves. Mitral valve repairs have a much higher success rate than aortic repairs, and tend to last much longer.

The mitral valve is much more complex than the aortic. Yet paradoxically, that allows a number of options for repair that the aortic valve just doesn't have.

The difference in odds for success is so great, they really shouldn't be discussed in the same thread.

Best wishes,
 
For what it's worth...just throwing this out... the one surgeon we have spoken to thus far would attempt a repair first for my son's bicuspid aortic valve. He said that success partly depends on the anatomy of the faulty valve. In Matt's case, one leaflet is lower than the other and prolapsing--he would pull it up and sew it into place. He says this will stop the regurg. in many cases (they give it a trial during the surgery by taking the patient off the pump to see if it holds). This surgeon--we liked him but will go with someone more experienced when the time comes--has done 12 BAV repairs. Two required reop in two years, the rest are holding at 4+ years. Given the young age of our patient, he saw the repair as "buying some time" before moving to replacement. Again, just wanted to throw out his opinion... I don't know if it is shared by more experienced surgeons in the field, but I guess we will be eventually finding out!
 
Thank you to all for your answers. Allow me to tell more about my case. I was told I had a ?murmur? since I was a teenager due to a mitral valve prolapse. Most likely congenital. Doctors never really gave it any worry although I had EKG during regular checkups. Around 1999 my oncologist recommended my seeing a cardio as he thought the ?murmur? sounded different. When I went to see her (after an EKG and Doppler) she told me I should get OHS within 6 months. I freak out and went for another opinion. The new cardio told me to monitor it (he did it) and see whether there?ll be any changes. In 2004 my oncologist suggested that I see a cardio again as he was listening like ?skip? beats. And sure enough, he recommended me the same cardio as the first time without his remembering I had already seen her. I really respect his opinion and told him that last time she scared the he...... out of me. He then called her and made the appointment and told her my comments. Went to see her and she was really nice and after the exam told me again that although she could see no mayor changes since last time she still recommended OHS. Told her I?ll think about (I was not symptomatic) About a year later and a couple of more exams and same comments from her I decided to consider the operation. Again my oncologist recommended the surgeon (Dr. Krieger of NY Presbyterian-Cornell) and suggested I see him just for an opinion. When I went to see Dr Krieger, he thought I was better informed than the majority ( I had not found this forum and I can tell you that I did not know as much as I know now...you are a wealth of knowledge).
Dr Krieger was very sympathetic and spent more than an hour talking to me. I told him my concern about coumedin and asked whether he could repair the mitral. He told me ?I can repair any valve but there are some no worth doing it and the decision will be mine.? To end the story, he repaired it , but I was told by his assistance that any other without his skill and experience would not have done it. I?m 69 and hope the repair lasts as he said ?for ever?.
Thanks for listening
 
RandyL said:
It seems like the risks are the same for the operation and if you could get a new mechanical valve that will last you the rest of your life why take the chance of repairing one and then having to get a new valve later anyways.
Click to expand...

I highlighted the magic word on which the "mechanical=1, repair=2" math is based. All procedures run risk of re-op. You may be interested in the following article:

http://circ.ahajournals.org/cgi/content/full/104/suppl_1/I-1

This study is for mitral valve operations (Bob makes an important point about not comparing MV repair to AV repair), and is limited to MVP as a surgical indication. What I found interesting is the observation that long-term success rates were significantly better after the 1980s - suggesting that improved technique and pre/intra-op valve assessement were responsible, and serving to emphasize Melissa's point about skill of the surgeon.

There's an element of dice rolling for any option a patient chooses; may we all roll successfully!
 
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