Ross vs Mechanical

[tommyboy14]

And Schwarzeneggers story with his heart issues isnt over yet unfortunately. He Just got a pace maker.

Now, he would have probably had three aortic root replacements during his surgeries. One during the original Ross, then in another surgery the next day, then recently when they couldnt do TAVR and had to do OHS again. These increase the risk of a pacemaker everytime.

Obviously, he may have gotten one regardless, but one has to wonder if all of his surgeries made it more likely?


https://edition.cnn.com/2024/03/26/...negger-surgery-pacemaker-intl-scli/index.html

 

[pellicle]

other than that, you’re creating a failure story by ensuring that you will need at least two more valve replacements … at least.

It depends how long you live.

I'd like to get more information onthat Abo single centre study that gave 25year outcomes

Results This study included 108 adults (92 [85%] male) with a median age of 38 years (range, 19-66 years). Median duration of clinical follow-up was 24.1 years (IQR, 22.6-26.1 years; 2488 patient-years), with 98% follow-up completeness. Of these patients, 9 (8%) had active endocarditis and 45 (42%) underwent reoperations. The main hemodynamic lesion was stenosis in 30 (28%) and regurgitation in 49 (45%). There was 1 perioperative death (0.9%). Twenty-five year survival was 83.0% (95% CI, 75.5%-91.2%), representing a relative survival of 99.1% (95% CI, 91.8%-100%) compared with the general population (83.7%). At 25 years, freedom from any reintervention was 71.1% (95% CI, 61.6%-82.0%); from autograft reintervention, 80.3% (95% CI, 71.9%-89.6%); and from homograft reintervention, 86.3% (95% CI, 79.0%-94.3%). Thirty-day mortality after the first Ross-related reintervention was 0% and after all Ross-related reinterventions was 3.8% (n = 1); 10-year survival after reoperation was 96.2% (95% CI, 89.0%-100%)​

 

[Pixelgrowth]

It depends how long you live.

I'd like to get more information onthat Abo single centre study that gave 25year outcomes

Results This study included 108 adults (92 [85%] male) with a median age of 38 years (range, 19-66 years). Median duration of clinical follow-up was 24.1 years (IQR, 22.6-26.1 years; 2488 patient-years), with 98% follow-up completeness. Of these patients, 9 (8%) had active endocarditis and 45 (42%) underwent reoperations. The main hemodynamic lesion was stenosis in 30 (28%) and regurgitation in 49 (45%). There was 1 perioperative death (0.9%). Twenty-five year survival was 83.0% (95% CI, 75.5%-91.2%), representing a relative survival of 99.1% (95% CI, 91.8%-100%) compared with the general population (83.7%). At 25 years, freedom from any reintervention was 71.1% (95% CI, 61.6%-82.0%); from autograft reintervention, 80.3% (95% CI, 71.9%-89.6%); and from homograft reintervention, 86.3% (95% CI, 79.0%-94.3%). Thirty-day mortality after the first Ross-related reintervention was 0% and after all Ross-related reinterventions was 3.8% (n = 1); 10-year survival after reoperation was 96.2% (95% CI, 89.0%-100%)​

I'm pretty against the whole warfarin thing. If I have to go mechanical I will but for me being warfarin free for around 20 years seems worth it. And the chance of no reoperation is there. I don't plan on doing steroids or lifting like Arnold. He's been pretty hard on his body and I think that needs to be taken into consideration. Honestly I think it's impressive he's still kicking for this long.

 

[tommyboy14]

@pellicle I can give some more information. These surgeries were done by Sir Magdi Yacoub, who was seen as one of the best surgeons in the world at the time. He is behind many famous surgeries. I remember he transplanted a heart into a young girl, but leaving the old one there, believing it could recover. It did recover, and they were eventually able to take the transplant out and the girl was able to live with her own heart.

A critique of the Ross is that results arent generalisable because they can be very surgeon specific. I think given that he was an amazing surgeon (the best apparently) when he was operating, perhaps it isnt a surprise that the results are this good.

But when you look at more general registries of the Ross, it looks more like 60-70% reoperation rate


https://www.jacc.org/doi/10.1016/j.jacc.2021.01.034

 

[tommyboy14]

If you dont like warfarin, which is understandable due to your job in the Military, perhaps try the Ozaki procedure. They make an aortic valve out of your heart tissue. There is a doctor at the Cleveland clinic in the US who does this surgery.

https://www.structuralheartjournal.org/article/S2474-8706(23)00103-3/fulltext

I'm pretty against the whole warfarin thing. If I have to go mechanical I will but for me being warfarin free for around 20 years seems worth it. And the chance of no reoperation is there. I don't plan on doing steroids or lifting like Arnold. He's been pretty hard on his body and I think that needs to be taken into consideration. Honestly I think it's impressive he's still kicking for this long.

 

[Pixelgrowth]

If you dont like warfarin, which is understandable due to your job in the Military, perhaps try the Ozaki procedure. They make an aortic valve out of your heart tissue. There is a doctor at the Cleveland clinic in the US who does this surgery.

https://www.structuralheartjournal.org/article/S2474-8706(23)00103-3/fulltext

I will also ask the surgeon his opinions on this. It does look to be harder to get in than the Ross would be.

 

[Teapotimus]

A critique of the Ross is that results arent generalisable because they can be very surgeon specific. I think given that he was an amazing surgeon (the best apparently) when he was operating, perhaps it isnt a surprise that the results are this good.

This is very true and probably the biggest weakness of the Ross procedure. While I believe the modern Ross to be an excellent option the huge caveat is it's only a good option when done by one of a few surgeons worldwide.

Some surgeons such as Dr. Starnes have been utilizing what is effectively a 'bio bentall' type procedure with the Ross to make it more reproducible, but I believe that technique to be inferior to the inclusion technique.

Dr. Skillington has a series of Ross patients where the reoperation rate on the autograft is shaping up to be directly comparable the reoperation rate of mechanical valves. Apparently presizing the annulus and paying incredibly close attention to valve commissures translates to an exceptionally durable procedure. I believe that series shows a reoperation rate on the autograft of 3.4% at 20 years which is quite impressive.

 

[pellicle]

If I have to go mechanical I will but for me being warfarin free for around 20 years seems worth it.

could you clarify why you think that tradeoff is worth it ...

And the chance of no reoperation is there.

I'm not sure your age, but unless you are 45 with a statistically long life span there is virtually zero chance of remaining operation free (if you mean indefinitely). What's more likely is you'll require an operation in the weakest time of your life and it won't just be the aortic because the pulmonary valve will perhaps need replacing too.

The only actual shot you have at remaining one and done is a mechanical and manage INR ... which isn't what its blown up to be by those with another product to sell you.

 

[Pixelgrowth]

could you clarify why you think that tradeoff is worth it ...


I'm not sure your age, but unless you are 45 with a statistically long life span there is virtually zero chance of remaining operation free (if you mean indefinitely). What's more likely is you'll require an operation in the weakest time of your life and it won't just be the aortic because the pulmonary valve will perhaps need replacing too.

The only actual shot you have at remaining one and done is a mechanical and manage INR ... which isn't what its blown up to be by those with another product to sell you.

Well I'd say statistically the most likely way I would die would be in a car crash and warfarin makes those odds go up. Id be restricted on what I can do, no alcohol, no tattoos, no cranberry or grapefruit juice or green tea, no thc, antibiotics before any procedure, I'd have to change my antidepressants, constant worry about my inr being out of whack and having some sort of heart related accident. Constant monitoring of anything that contains vitamin k so that I don't eat too much or too little of it. I'm not afraid of the surgery I'm afraid of being chained to a drug forever.
Or alternatively in 2045, if I'm lucky enough to make it that far. I may need a surgery that has a statically high success rate.

 

[pellicle]

Well I'd say statistically the most likely way I would die would be in a car crash and warfarin makes those odds go up

I'm not sure of that, and the second part is false ... you having any heart valve will make a car trauma more likely to die, not the warfarin.

Its not like this:

because one is on warfarin ... so I think you have a misunderstanding about the risks.

Id be restricted on what I can do, no alcohol, no tattoos, no cranberry or grapefruit juice or green tea, no thc, antibiotics before any procedure,

so most of that is wrong (except grapefruit) and the antibiotics applies equally to a bioprosthetic (perhaps more so) and the antibiotics do not require any intervention in managing your INR. I drink alcohol (until recently, when developing tachycardia got in the way. Although tenative testing is revealing I can have a beer again now). I also drink green tea 2 or three times daily AND have a coffee (espresso) in the morning. There are many posts here about tattoos and people on warfarin who've had them.

So its good that we clear these things up (which is how "informing" happens when you read about "informed patient consent"

Constant monitoring of anything that contains vitamin k so that I don't eat too much or too little of it.

again, that's somewhere between wrong and overblown beyond recognition.

https://journals.lww.com/md-journal..._between_dietary_vitamin_k_intake_and.23.aspx

however I personally don't mind what you choose, if I'm making a mistake and you've already written mech off completely please just say so ... but even if you have I can't let lurkers read stuff which is flat out wrong and perpetuate misapprehensions (to give them the nicest possible name).

I'm afraid of being chained to a drug forever.

what about your antidepressants? Go ask anyone over 60 if they take:

• any medication which is needed
• if as they age they get more on that list
• take a regular suppliment

face it, medicine makes our lives better. The people I know who are on a drug forever are usually on alcohol and tobacco ... which isn't good for you and few ever quit.


Best wishes

 

[Pixelgrowth]

I'm not sure of that, and the second part is false ... you having any heart valve will make a car trauma more likely to die, not the warfarin.

Its not like this:
View attachment 890109

because one is on warfarin ... so I think you have a misunderstanding about the risks.


so most of that is wrong (except grapefruit) and the antibiotics applies equally to a bioprosthetic (perhaps more so) and the antibiotics do not require any intervention in managing your INR. I drink alcohol (until recently, when developing tachycardia got in the way. Although tenative testing is revealing I can have a beer again now). I also drink green tea 2 or three times daily AND have a coffee (espresso) in the morning. There are many posts here about tattoos and people on warfarin who've had them.

So its good that we clear these things up (which is how "informing" happens when you read about "informed patient consent"


again, that's somewhere between wrong and overblown beyond recognition.

https://journals.lww.com/md-journal..._between_dietary_vitamin_k_intake_and.23.aspx

however I personally don't mind what you choose, if I'm making a mistake and you've already written mech off completely please just say so ... but even if you have I can't let lurkers read stuff which is flat out wrong and perpetuate misapprehensions (to give them the nicest possible name).


what about your antidepressants? Go ask anyone over 60 if they take:

• any medication which is needed
• if as they age they get more on that list
• take a regular suppliment

face it, medicine makes our lives better. The people I know who are on a drug forever are usually on alcohol and tobacco ... which isn't good for you and few ever quit.


Best wishes

I haven't written it off. I may decide to go with a different hospital though but that's for personal reasons. Mainly the stats look better at the other one. I appreciate you helping out and clearing some things up. I can live without grapefruit juice. I like it but can't remember the last time I had it. But I love green tea and I'm glad to hear it doesn't have to go. You make a good point about the antidepressants. I was pretty worried about the side effects when I first started. I'm on Wellbutrin and a major side effect is seizures. But now it's great. I sleep better and am way more productive throughout the day. Other then the lifestyle changes I am also worried about the chance of blood clots or stroke or whatnot happening. How hard is it to maintain a proper inr if you can monitor it at home? Which I fully plan on doing its a small price to pay for my mental and physical well being.

 

[pellicle]

Hi

Glad it's useful, I'm not really wanting to persuade anyone of anything

I love green tea and I'm glad to hear it doesn't have to go.

You can still have a glass now and then. Like all things (except US politics) it's not a polar opposite of binary position if yes or no.

Drinking a gallon in a daily succession of large glasses of grapefruit juice. It's more like a small glass of freshly squeezed or an actual fresh fruit will cause little harm.

It's like playingin a swimming pool some splashingof the concreteis inevitable, but that's not what they mean when the management say "no splashing"

 

[V__]

I can live without grapefruit juice. I like it but can't remember the last time I had it.

It seems grapefruit is not recommended when you are on Wellbutrin either. Although it could be a matter of dose...

 

[pellicle]

It seems grapefruit is not recommended when you are on Wellbutrin either. Although it could be a matter of dose...

there are a few phrases which have come to mean more to me over the years, such as:

• "do no harm" does not mean "do what's in the patients best interests"
• "...may interact with..." does not mean "will interact with"

it seems that something not even as as substantial as a chalk mark on the concrete is enough to make an impenetrable barrier which must not be crossed; yet completely forgetting to take your medication for weeks at a time is all ok because "you don't need that stuff anyway".

¯\_(ツ)_/¯

 

[carolinemc]

I’ll be a bit more up front about it.

Schwarzenegger’s story is one of failure. pure and simple. The dude has had at least 3 open heart surgeries when he only needed one. If he would have just gotten a mechanical during his first surgery then he would have been done with it. But nope. He went Ross … thereby creating a situation that absolutely guaranteed additional surgeries. He turned his one valve problem into a future two valve problem. I doubt that I will ever understand why people do this. If you’re contraindicated for Warfarin - sure. If you’re a woman and you’re dedicated to having children - sure. But other than that, you’re creating a failure story by ensuring that you will need at least two more valve replacements … at least.

Arnold is not a story of failure, for sure he had two repairs and a then a valve replacement of the aortic valve. You got the message mixed up, for getting a mechanic valve and warfarin is not a failure at all. And women have had children while on warfarin. I do not know where you are getting your information, but many of us have had repairs before getting a valve replaced, wither it is a tissue or mechanical. It a choice we can live with, not a failure.

 

[carolinemc]

I'm not sure of that, and the second part is false ... you having any heart valve will make a car trauma more likely to die, not the warfarin.

Its not like this:
View attachment 890109

because one is on warfarin ... so I think you have a misunderstanding about the risks.


so most of that is wrong (except grapefruit) and the antibiotics applies equally to a bioprosthetic (perhaps more so) and the antibiotics do not require any intervention in managing your INR. I drink alcohol (until recently, when developing tachycardia got in the way. Although tenative testing is revealing I can have a beer again now). I also drink green tea 2 or three times daily AND have a coffee (espresso) in the morning. There are many posts here about tattoos and people on warfarin who've had them.

So its good that we clear these things up (which is how "informing" happens when you read about "informed patient consent"


again, that's somewhere between wrong and overblown beyond recognition.

https://journals.lww.com/md-journal..._between_dietary_vitamin_k_intake_and.23.aspx

however I personally don't mind what you choose, if I'm making a mistake and you've already written mech off completely please just say so ... but even if you have I can't let lurkers read stuff which is flat out wrong and perpetuate misapprehensions (to give them the nicest possible name).


what about your antidepressants? Go ask anyone over 60 if they take:

• any medication which is needed
• if as they age they get more on that list
• take a regular suppliment

face it, medicine makes our lives better. The people I know who are on a drug forever are usually on alcohol and tobacco ... which isn't good for you and few ever quit.


Best wishes

I hardly drink and gave up smoking 22 years ago.

 

[3mm]

the most likely way I would die would be in a car crash and warfarin makes those odds go up

I've 33 years of law enforcement experience in the USA, so I've worked at a lot of auto accidents. I've never heard a paramedic say an auto accident victim died from bleeding out.

 

[pellicle]

I've never heard a paramedic say an auto accident victim died from bleeding out.

as tempting as it is, lets not do 'horror stories' here ;-)

(no career in law or fire dept on my side, I just happen to know a lot of them)

 

[tom in MO]

Well I'd say statistically the most likely way I would die would be in a car crash and warfarin makes those odds go up. Id be restricted on what I can do, no alcohol, no tattoos, no cranberry or grapefruit juice or green tea, no thc, antibiotics before any procedure, I'd have to change my antidepressants, constant worry about my inr being out of whack and having some sort of heart related accident. Constant monitoring of anything that contains vitamin k so that I don't eat too much or too little of it. I'm not afraid of the surgery I'm afraid of being chained to a drug forever.
Or alternatively in 2045, if I'm lucky enough to make it that far. I may need a surgery that has a statically high success rate.

I am not sure where you got your info, but alcohol, cranberry juice, green tea and thc are not contraindicated if you are on warfarin. You can have grapefruit, but in moderation. Antibiotics are not required before "any procedure" just some. There is no need for "constant monitoring anything that contains vitamin K." You only need to check your INR every 2-3 weeks. You've seem to have twisted reality to support your gut decision that tissue is the path for you. That's OK since it's you, but maybe not for others...

 

[Chuck C]

Other then the lifestyle changes I am also worried about the chance of blood clots or stroke or whatnot happening.

There is a common misconception that you are more susceptible to strokes if you have a mechanical valve. In a sense you could say yes, this is true, but that is why those with a mechanical valve take warfarin. When one takes warfarin the increased risk of stroke of mechanical vs tissue disappears.

Please see the meta analysis linked below, looking at a total of 17,000 patients with both mechanical and biological valves.

I quote: “Stroke rates did not differ between the two groups.”

Keep in mind, this is among the average mechanical patient. Please note the following:

1) The vast majority do not self test, but test at the lab about every 4 weeks.
2) The amount of people that don't take their warfarin management seriously and are noncompliant is remarkably high.

Studies have shown that those who self test have far fewer events and spend a higher % of time in their therapeutic range. Even given my points #1 and #2 above, this study and others found that the stroke risk is the same with mechanical vs bioprosthetic. If one is committed to 1) self testing and 2) being serious about warfarin management and being compliant, then it is likely that the stroke risk of having a mechanical valve would be even lower than having a tissue valve.

See 2021 meta analysis linked below:

https://cdn2.imagearchive.com/valve...chanical-AVR-in-Patients-younger-than-70-.pdf