Valve Selection 1

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Hi Bob-

If your wife has any questions, I would be happy to answer them as the spouse of a man who had 5 thoracic surgeries, 3 valves and 2 lungs, plus a pacemaker.
 
Nancy, thank you for your very kind offer. I'll let her know. She has been impressed by this site, and evryone's responce to my questions.

Thanks again.

Regards

Bob B.
 
Dear Bob Bates,

Like you, I am considering the CE Perimount bovine pericardium valve. I am several weeks behind you, in that I am planning surgery for the beginning of December. Selecting a valve is the reason for delay, since I have been recommended to have surgery ASAP for severe aortic stenosis.

Have you been able to learn anything additional about this valve since beginning your inquiries?

Have you looked into minimal incision surgery? I am wondering if anyone knows the criteria for patient suitability for this procedure.

Best of luck on November 3.

Lorraine Lasker
 
Dear Lorraine;

I can't quote you the statistics or details, but I have read the summaries of two studies for this valve (CE Perimount Bovine), which show that the valve is still functioning well after 17 years (an earlier study) and 20 years ( a later study). The higher the age of the patient, the longer the valve seems to last. These studies have been referenced on this site, but I am sorry, I can't tell you exactly where to find them. Apparently a Dr. Cosgrove in Cleveland ( very well respected heart center) is a strong advocate of this valve as well. I have read nothing negative about the valve, except of course, as a tissue valve, it will not last as long as a mechanical. Also, if a second surgery is required, this valve is one which does not cause undo complications to replace it.

This valve was also the first one my surgeon ( Dr. Donald Glower- Duke Medical Center, Durham NC) mentioned when I asked him for a recommendation for a tissue valve. He did say that one's aortic root cannot be "small" with this valve, because it is a stented valve, which makes the valve opening a little smaller than a non-stented valve. I will know more about this in my case after tomorrow (10/21/03) when I undergo my Heart Cath.

My surgeon does do "port access" / minimal invasive surgery. Again, I don't know the specific criteria for patient suitabilty, as this is a topic my surgeon and I will discuss in more detail after my heart cath. He did say however, that it takes about 1 hour longer than the "normal surgery", and is a little more complicated of a procedure.

I still must discuss this with him of course, but my own feeling as of now ,is I would rather have the regular procedure. The reasons are, I want to spend as little time as possible on the heart-lung machine, and I don't want to make the surgery any more complicated for my surgeon than it has to be. This sentiment was also voiced by another doctor I asked. If there is any sort of problem, he said he would want the surgeon to have full and immediate access to my chest.

Good luck

Bob Bates
 
Excellent point that I have heard from 2 top heart surgeons. Supposedly the homograft valve requires the most cutting and pasting.



"Also, if a second surgery is required, this valve is one which does not cause undo complications to replace it."
 
Dear Bob,

Good luck on your cath tomorrow. I am on a laptop that's not mine and so have lost two responses to you. I'll write more fully when I return to my own computer at home in Westchester later in the week.

The cath is not bad at all. I had mine in July when I didn?t know much about valves so I didn?t find out if I am a candidate for the C-E Perimount.. I?ll check the cath report about aortic root size.

I feel as you do about the extra time on the HL machine and so do not want the port. We still are trying to learn more about the sternum MI but as yet do not access to the full papers , just abstracts, of the group at NYU which publishes their outcomes with this procedure.

The 17 year C-E study is by Banbury at the Cleveland Clinic who followd 268 patients, I believe, at four institutions. The VA did a 15 year outcome study. I don?t know about 20 years.

I was able to watch the monitor and converse wiith the cardiologist during the cath. The most alarming thing was the nurse approaching with the razor to prep the site. The clamp following the procedure (opt for a stitch if possible) and lying flat for four hours afterwards were the uncomfortable part. All in all, better than I would have expected.

Best,

Lorraine
 
Bob

Bob

I know you've had many opinions on both sides of the tissue/mechanical decision, but I'm viewing things for real on both sides. I was in your same situation just 1 year ago. For the same kind of reasons as you've expressed, I ended up choosing a Homograft valve for my AVR that was performed 12/20/02. I also had a bicuspid Aortic Valve.

The surgery went well and I recovered very fast, however there was bad news. My echo 2 weeks after surgery showed the valve was leaking. Turned out that one of the cusps was prolapsing and allowing the blood to leak back into the left ventricle.

I was able to get only 8 months out of this valve. Not wanting to take the chance on this happening again, I chose a St. Jude?s valve for my second AVR performed 8/26/03.

Since I could not have known what would happen prior to my first decision, it's wrong to second guess the decision, but can't help wondering how I would be doing now if I had chosen a mechanical valve the first time around.

I am into cycling and understand there are some risks associated with a bad fall, but I'm willing to deal those risks and coumadin thus far in my two months has not been a big deal, although I'm starting the process for a home test system.

Good luck with your decision. I know most tissue valve choices don't end up like mine, but you do need to consider this possibility. I had not even thought about it prior to my surgery. Probably would have made the same decision, but maybe not.
 
Conk;

Thanks for your insights based upon your own experience. I do understand there are pitfalls no matter which way you go on valve choice. As I have mentioned before on other posts, it seems for every "success" story about a particular valve, someone has a story which counters it.

Most people seem to have no real problems with coumadin use, and if I was in your shoes, I too would have chosen the mechanical the second time. All I can do right now is evaluate the statistics in light of my own situation and preferences, and take a calculated risk that my choice will be right for me.


Regards,

Bob Bates
 
Chilihead;

Regarding your question about Stentless pig valves: I have not done as much research on them as I have done for the CE perimount bovine pericardial, because the bovine seems to have some good durabilty stats. Whereas I haven't come across any stats on the durabily of say, the Toronto SPV, since its a newer valve.

If you have any reasons why you think they may be a good choice in a tissue valve, especially versus the CE bovine pericardial, please pass them on.

Thanks very much.

Bob Bates
 
Hi Bob,

Dr. Glower did a mitral valve replacement by way of a heart port procedure on me in August of this year. On my Operative Note it states I was on the bypass for 198 minutes and I was cross clamped 149 minutes. I only had to be defribrillated 1 time. Total surgery time was a little under 8 hours and time I was under anesthesia was 507 minutes.

I don't know if this amount of time is about average or not.

The heart port procedure causes alot of stress to the right lung according to my cardiologist so you may want to factor that in as well.
 
Hi Bob,

I see that many people already expressed their thoughts on this very important issue, but I want to give you mine because I have my own personal story. (read in the personals)
I had two AVR's in August 2000 and my doctor made the choice for me because I was over 50 and he told me "you don't want to do this too many times, especially not at an older age". I agreed as "I NEVER WANTED TO DO THIS A SECOND TIME".
I received a Sultzer Carbomedic mechanical valve the first time and was told that this valve would last "a lifetime". Little did I know that something would go wrong and I'd be on the table again to receive a second mechanical valve within 11 days after the first surgery.
Coumadin needs to be regulated & monitered regularly by a professional, (later you learn and can do it yourself) and if you go with the mechanical I would recommend you get your own machine so you can test anytime, and not have to deal with the labs. Those are a pain in the you know what, plus scar tissue becomes an issue within the first year. That was my main concern, plus my doctor's conduct towards me was less than desirable and totally stressed me out every week. I had to fire him later.
I am fine now three years out, but two OHS do a number to your system. It took me more than a year to fully recover.
Coumadin can fluctionate quite a bit, and interferes with many things. I have my own Protime machine. Insurance didn't cover, so I paid out of pocket. I have been doing my own testing since January 2001 and I like it this way. I eat what I want and do what I want. I adjust the dosage according to my lifestyle, and not the other way around. I test once a week and call the results in to my doctor once a month. He agrees me doing it this way, so I feel free.
I've had no problems so far, but that doesn't mean I take this drug lightly. I am much more concerned with a low INR than with a high INR, so I keep my numbers higher. I can deal with a bleed (never have had one) but a clot or stroke can be fatal, so I try to stay safe.

Wishing you all the best in this difficult choice.
 
Christina;

Thank you very much for your insights. You highlighted very well the dilemma I am facing: the issues involved in taking coumadin, versus the very likely second operation. I have given this a lot of thought. There are very real risks in the second OHS, not to mention the discomfort and recoverey time.

But I want to live a very active lifestyle, as close to "normal" as possible, and I believe that a tissue valve is more compatible with that than the mechanical.

Thank you very much

Bob
 
Betty

Thank you for your comments on "port access" surgery. Since we have the same surgeon ( Dr. Glower -Duke Medical Center). its especially noteworthy.

I have not discussed this with Dr. Glower in depth yet ( I just had my Heart cath. on 10/21/03), but he told me in our initial meeting that the PA requires about an extra hr. on the heart-lung machine, and makes the surgery a little more complicated that the regular incision.

I am not concerned too much with the cosmetics of the cut.
My thought right now is I want to minimize my time on the HL machine, and make the surgery as easy as possible for Glower. So if I had to make the choice now, I would opt for the regular procedure.

I welcome any additional comments from you, or anyone else for that matter, regarding my thinking on this issue.

Thanks

Bob
 
Bob,

I agree with you on this - I'd rather make the surgery as easy as possible on the surgeon. Sure, he could probably do the port access, but why make it more challenging for him? It's like giving Michael Jordan a layup instead of a foul shot!

I also didn't care about the cosmetics. For my second AVR, the surgeon told me the incision wouldn't be as long as my first one 14 years earlier. The 2 inch shorter scar - well - I could care less at this point.

As for the tissue vs mechanical, well, I already tried to address that tactfully but some still get their feathers ruffled. You know the issues and will make an informed decision. You seem to have done a good job separating the facts from the opinions. Having had both tissue and now mechanical, I can understand both sides of the issue.

The big day is approaching fast. Good luck!

Rob
 
Rob;

Thanks for your comments, and the compliment about separating fact and fiction. The problem is however, as you are well aware, there are facts, and then there are emotional / subjective issues to consider which are quite different for each person. Even the so called "facts' can be interpreted different ways depending on your point of view.

I have enjoyed reading your posts due to your somewhat unique perspective on both the mechanical and tissue valves. Also ,as someone who will probably face two OHS, I have to admire your apparent "coolness under fire" so to speak, in facing the two you have undergone.

But frankly, I am almost tired of thinking about it now. I have made my decision to go with the tissue valve, and now as I face my AVR on Nov. 3rd ,I just want to get it over with.

My only concern now (other than the fear factor !), is that the surgeon will get in there and find some reason why my valve choice can't be implanted. My heart cath. on 10/21/03 was good however, no blockages other that the valve. Of course, I will be discussing a backup plan with my surgeon before the big day.

Regards,

Bob
 
I had a great sense of relief when the decision was made, though I still had a few months prior to surgery. I even refused to re-evaluate it, as some tried to get me to do. Like you, I was tired of thinking about it.

I think you made a sound, reasonable decision.

I never even thought about a back up plan. Good idea, at least the surgeon will know what your input is. Of course, at that point, its all up to his judgement.

You've covered all the bases, sleep well knowing your cath was 'clean' and your surgical team is one of the best in the country. OK - try to sleep well...

Rob
 
Rob;

Thanks again. At the risk of getting too emotional here, I want to say to you and to all on this site how much the words of encouragement have meant to me.

Most of us are strangers to one another, but there is a bond here due to the obvious shared experiences. Its one thing for someone who has never been through this to say "it will be alright / heart surgery is almost a routine thing", etc., and quite another to hear good things from someone who has been there.

Bob
 
Dear Bob , Congratulations on your decision. I felt a big weight was lifted when I made my choice. I think all along in your heart you knew you wanted, a tissue valve, you just had to look , listen , and you now know it feels right for you. I am happy for you and hope you surgery goes well. HFK
 
Bob,

I well remember that "I just wish this was over with" feeling. I had a leaky bicuspid aortic valve replaced with a CE perimount bovine valve in January 2002 at Cleveland Clinic. I believe that is the preferred tissue valve at Cleveland. I was 52 at the time. I did not do much research on valves except to decide I wanted a tissue one rather than a mechanical. My reasons were similar to yours.

They did a traditonal operation on me, cracking my chest and all, and I must say it was MUCH LESS traumatic than I had anticipated. I flew home to South Florida five days after surgery. The operation has had no effect on the routines of my daily life; I quickly returned to the lifestyle I enjoyed before the surgery. I hardly ever think about it now.

I don't have a pre-op fitness baseline to compare to, because although I had been an exerciser in my younger years, I had not been very active in the years leading up to the surgery (lazy-related, not cardiac). Nevetheless, I have exercised some since the operation, and when I'm puffing hard I get a sense that the artificial valve does not function as well as the original, but the difference (if there really is one) is insignificant for a person of my age and athletic prowess.

Sometimes I think about the fact that someday I will need another operation, and it is not a pleasing thought, even though my experience was about as benign as it could be. On the other hand, it is not an unsettling thought either, or something I worry about. It seems like a distant challenge, and I feel sort of how I felt 12 years ago when I was first told that someday I probably would need the first AVR.

Good luck. I'm sure things will go very well for you. We will be thinking of you.

Landon

AVR - January 2002
 
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