So the repair was to try to make the bicuspid into a trileaflet valve? I always thought that a repair consisted of fixing a leak or repairing/ modifying a cusp but I never knew they tried to separate two joined leaflets. Wouldn't have been an option for me anyway as I only had 2 leaflets of basically equal size with no raphe or sign of 2 cusps joined.pellicle;n854728 said:Hi
'm a little over 50 and have had 3 aortic valve surgeries. I had my valve "repaired" (splitting the cusp that was "bicuspid" when I was about 10. Then replacing that valve with a homograft at about 28 and then a mechanical placed at about 48. I reckon there is a fair chance you'll follow a similar pattern (especially if you have a ross or a tissue valve put in at your age).
The only time I recall being involved in the choice was at 48 but the choice to go mechanical was a no brainer because a tissue would lead to a 4th operation and that would be very unfavorable.
When I was 28 it was 1992 and the situation was quite different to now. For a start I got a transplant valve recently harvested of a dead person who was sized appropriately for me. The valve was not antibiotic preserved but may have been cryo preserved briefly. Given that we cryopreserve embryo's I am comfortable that what was implanted in me was a living tissue. That valve lasted me 20 years. The team here in Australia who did that surgery were good at homografts and one could say specialised in it. I was also part of a 20 year follow up (double the normal 10 that is common) and my personal results were better than anyone else in the age group I was in at operation for both mortality (hello, still here) and requiring reoperationv (seldom included in followups).
The surgeon who did me was unwilling to put (as he put it) a "pig valve" into me and perhaps because of his interest in homografts unwilling to put in a mechanical and have me on warfarin (which I knew little about back then).
Today I am on a mechanical and if I could time travel back to then and bring me forward to here I'd tell me to get a mechanical.
Why? Well the primary reasons are that valves are much improved and the handling of warfarin is much improved. Today we have the ability to use a compact device to measure our INR and make adjustments to our warfarin dose. That was simply not possible back in 1992. As trivial as that sounds its as important as a wheel bearing on a car as the INR is the axle that everything else rotates around in many ways.
Good outcomes on warfarin are linked to good management of INR, so just as diabetics do better with more accurate monitoring of their blood sugar and regulate their own insulin dose us valvers on warfarin can get similar good outcomes by doing that.
Additionally this means you are not tied to a patch on the ground where blood tests are made, and can travel as you wish. I for instance am living in Australia, but since my surgery have returned to Finland and done travelling around Europe and Ireland. I'm intending to go back and perhaps spend a month backpacking around Ireland next year.
People who just don't know anything (meaning they have not lived on warfarin so just don't know) will tell you that being on warfarin will do this and that and something else. Yet on this board you'll find many people on warfarin who say that self testing means its just a minor thing. You eat what you like and you do what you like (at least I do).
Some readings from my blog: here (about my views on valve choice) and here (about INR management)
yes, as it was explained to me, during embryology stages the valve is made the same way, its just the the "edge perforations" *(think perforated cardboard designed to tear when pressure is applied) didn't tear at the time circulation pushed on it. Over time the pressures on the valve strech the valve, distort it shape (squeezing it flatter) and thus further restrict blood flow. I was under the impression that in children and young adults that is now done as a valvular angioplasty but I could be mixed up.cldlhd;n854739 said:So the repair was to try to make the bicuspid into a trileaflet valve?
that's interesting, I wonder if that deformed over the decades or if the anatomy of your situation was different? I've been told before that cardiac anatomy varies in details between people (makes sense really, as so many other things do). I've been told for instance that on my arch I have two arteriers not three going up and one branches into two later ... and that this is not "uncommon".I always thought that a repair consisted of fixing a leak or repairing/ modifying a cusp but I never knew they tried to separate two joined leaflets. Wouldn't have been an option for me anyway as I only had 2 leaflets of basically equal size with no raphe or sign of 2 cusps joined.
I'm assuming,but what do I know, that the valve and aorta up to the arch in BAV are stretchier which may explain why the leaflets don't separate. My surgeon said my valve wasn't even trying to be a trileaflet and that it's 2 equal size leaflets ,kind of like a bileaflet mechanical valve I imagine. Its classified as a sievers 0.pellicle;n854752 said:Hi
yes, as it was explained to me, during embryology stages the valve is made the same way, its just the the "edge perforations" *(think perforated cardboard designed to tear when pressure is applied) didn't tear at the time circulation pushed on it. Over time the pressures on the valve strech the valve, distort it shape (squeezing it flatter) and thus further restrict blood flow. I was under the impression that in children and young adults that is now done as a valvular angioplasty but I could be mixed up.
Mine was first identified (by ear) as a murmur when I was about 5 and I had been having yearly examinations at the specialist hospital till they did the job. I had an earlier "catheter" a few months before the operation (most likely now called an angiogram) which went in through my armpit (right arm) and one after the OHS (in through the inside elbow). Back then (mid 70's) that was all ground breaking stuff.
that's interesting, I wonder if that deformed over the decades or if the anatomy of your situation was different? I've been told before that cardiac anatomy varies in details between people (makes sense really, as so many other things do). I've been told for instance that on my arch I have two arteriers not three going up and one branches into two later ... and that this is not "uncommon".
anne casey;n854697 said:Has anyone man had their valve and aorta replaced when @ 19 to early 20's? What choice of valve did you choose? And how do you feel now about that decision today?
Pulmonary autograft (Ross procedure) — The Ross procedure is an alternative to valve replacement with a mechanical valve or bioprosthesis. It involve replacing the aortic valve with a pulmonary valve autograft and right-sided reconstruction with an aortic or pulmonary homograft [40,41]. Use of the Ross procedure has been limited because of its technical complexity, complications with both the aortic autograft and the pulmonic homograft, and the availability of simpler and effective alternatives, ie, mechanical valves and bioprostheses including stentless bioprosthetic valves.
There are a number of potential advantages of the Ross procedure [41,42]:
Autologous tissue with documented long-term viability
Optimal hemodynamic data
Possible resistance to infection (eg, 0.2 to 0.3 percent/patient year [43,44] as compared to >0.4 percent/patient year for recipients of prosthetic valves) (see "Epidemiology, clinical manifestations, and diagnosis of prosthetic valve endocarditis").
Lack of valve noise
Freedom from anticoagulation due to rates of thromboembolic complications ranging from 0 to up to 1.2 percent per year
Strong relative contraindications to the Ross procedure include the following :
Advanced three vessel coronary disease
Other extensive valve pathology requiring replacement
Severely depressed left ventricular function
Multisystem organ failure
Pulmonary valve pathology
Marfan syndrome or other connective tissue disorders
Size mismatch between the pulmonic and aortic annulus
The Ross procedure has been used most successfully in children and adolescents, but has also been performed in adults less than 50 years of age with single valve pathology, mechanical or bioprosthetic valve failure, endocarditis limited to the aortic root, and athletes or young patients in whom anticoagulation is contraindicated and for whom optimal hemodynamics are desired (eg, a female of reproductive age). (See "Pregnancy in women with a bicuspid aortic valve".)
The pulmonary autograft in the aortic position provides excellent hemodynamics at rest and with maximum exercise; however, there may be a moderately high gradient across the homograft in the pulmonary valve position .
A number of studies have noted good short term results with the Ross procedure [46-51]. In a meta-analysis of 39 reports published from 2000 to 2008, the pooled early mortality rates for consecutive adult and pediatric series, adult series and pediatric series were 3.0, 3.2 and 4.2 percent, respectively . However early mortality rates varied from 0.3 to 6.8 percent even among these selected centers.
Selected older patients may do well with this approach, at least in the short to intermediate term. The experience with the Ross procedure was reviewed in a series of 27 patients more than 60 years of age . After a mean follow-up of 28 months, there was no mortality and only one patient required autograft replacement. When compared to 84 younger patients (mean age 44) who underwent the Ross procedure, there were no differences in hemodynamic variables for either autografts or homografts except for a slightly higher pressure gradient across the pulmonary homograft in the older patients.
Good intermediate to long term results have been reported in various pediatric and adult series. In a meta-analysis of 39 reports with one to 8.7 year follow-up, the pooled late mortality rates for consecutive adult and pediatric series, adult series and pediatric series were 0.48, 0.64 and 0.62 percent per year, respectively . In adult series, the autograft deterioration rate was 0.78 percent per year and the right ventricular outflow conduit deterioration rate was 0.55 percent per year.
Longer term results suggest a high risk of reoperation [43,44,48]:
At 20 years after operation in the pioneering series of 131 patients (age 11 to 52), survival was 61 percent, freedom from autograft reoperation was 75 percent, and freedom from pulmonary homograft reoperation was 80 percent . The mortality rate increased age.
At 16 years after operation in a series of 487 patients (age 2 days to 62 years), actuarial survival was 82 percent, freedom from autograft failure (reoperation and valve-related death) was 74 percent, and freedom from pulmonary allograft reoperation was 80 percent . Actuarial freed om from valve-related morbidity (includes autograft and pulmonary allograft failure, endocarditis, and valve-related death) was 63 percent at 16 years.
Current use — Use of the Ross procedure in adults is controversial and the procedure is only performed at a few experienced centers. There may be more perioperative complications since the surgery is longer and more complicated than simple aortic valve replacement. Dilation of the pulmonic autograft with autograft failure is a significant late complication [43,44,48,52] associated with surgical technique in some series  but not others [44,50]. Since patients with preoperative aortic regurgitation and dilated aortic annulus are at risk for future dilation and failure of the pulmonary autograft , some recommend avoidance of the Ross procedure in such patients . The pulmonary homograft is also prone to stenosis, sometimes early after surgery .
Even at experienced centers, use of this procedure has waned since the 1990s. Reasons include the postoperative prevalence of annular dilatation with aortic regurgitation, the long-term reoperation rate of 20 percent or more, and the availability of alternative stentless valve root conduit options.