when is it too late??

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kevin21

When is it too late or have you gone past the point of permanant damage as far as aortic surgery goes?

I had some lv size gain on my last visit (according to my dr) and he put me on the ace's. I'm just worried about going to far. I have a 2nd opinion appt. in 2 wks, we'll see what he says.

I still exercise (cardio) and feel fine. I'm not sure what to look for as far as symptoms (I know like light headed and short of breath are some).

I had a spell about 2 months ago where when I layed on my left side I could feel "hard" or "thumping" type beats and wondered if that had anything to do with it. It really doesn't do that anymore, except when I dwell on it.

just asking
 
M

Mara

Hi Kevin
In my opinion, determining when it's too late to do the surgery is what you pay your cardiologist for.
It was always explained to me that there was no question that I would need valve replacement surgery (I had congential aortic valve defect), the trickier part was determining when I was sick enough to need the surgery, but no so sick that the surgery would be a waste of time. Only your docs can answer that. The echo, ekg, x-rays, tee, etc give them the info they need to determine the time periods.

My only real symptom was fatigue. I could do the exercise bike, and treadmill, but after playing soccer with the dog I was more winded than I wanted to admit. Others on here have experienced a lot of symptoms - dizziness, fainting, black-outs, shortness of breath, etc.

I think its better to get it done sooner rather than later because you bounce back more quickly from the surgery.

-Mara
 
B

Bill Hall

Kevin,

I have an opinion on this one. I think when you have leakage, your heart has to work harder than it should. Since your heart is a strong muscle, it doesn't matter much until it starts leaking badly. The cardios have thresholds where they will suggest surgery. They have to trade-off the risk of surgery versus the risk of deterioration. My heart was enlarged for more than 20 years before surgery. After surgery, it reduced in size, more than I would have thought. Anyway, my opinion is the risk of surgery is pretty low. Good luck with your decision.
 

BillCobit

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Timing of surgery for AS

Timing of surgery for AS

http://www.acc.org/clinical/guidelines/valvular/jac5929fla16.htm

Kevin - I agree w/ Mara that determining the time of surgery is what you pay your cardiologist for... but just in case you want to make sure s/he is on the job, the above link provides some (hopefully useful) info regarding your question.

Some excerpts below discuss some of the key determinants for pulling the trigger on surgery for aortic stenosis (I believe that's your condition in question?):

-valve area
-trans-valvular pressure gradient
-anatomic changes to the heart
-status of left ventricular function
-symptoms
-trade-offs between surgical risks and benefits

There's no crystal clear right answer, but general consensus among experts on what the key decision criteria are.


Aortic Stenosis

a. Grading the Degree of Stenosis. The aortic valve area must be reduced to one fourth its normal size before significant changes in the circulation occur. Because the orifice area of the normal adult valve is ~3.0 to 4.0 cm2, an area >0.75 to 1.0 cm2 is usually not considered severe AS (44,45). Historically, the definition of severe AS is based on the hydraulic orifice-area formulae developed by Gorlin and Gorlin, which indicate that large pressure gradients accompany only modest increments in flow when the valve area is <0.75 cm2 (46). However, in large patients, a valve area of 1.0 cm2 may be severely stenotic, whereas a valve area of 0.7 cm2 may be adequate for a smaller patient.

On the basis of a variety of hemodynamic and natural history data, in these guidelines we graded the degree of AS as mild (area >1.5 cm2), moderate (area >1.0 to 1.5 cm2), or severe (area <1.0 cm2) (46a). When stenosis is severe and cardiac output is normal, the mean transvalvular pressure gradient is generally >50 mm Hg. Some patients with severe AS remain asymptomatic, whereas others with only moderate stenosis develop symptoms. Therapeutic decisions, particularly those related to corrective surgery, are based largely on the presence or absence of symptoms. Thus, the absolute valve area (or transvalvular pressure gradient) is not usually the primary determinant of the need for aortic valve replacement (AVR).

(Regarding myocardial hypertrophy)

The development of concentric hypertrophy appears to be an appropriate and beneficial adaptation to compensate for high intracavitary pressures. Unfortunately, this adaptation often carries adverse consequences. The hypertrophied heart may have reduced coronary blood flow per gram of muscle and also exhibit a limited coronary vasodilator reserve, even in the absence of epicardial CAD (61,62). The hemodynamic stress of exercise or tachycardia can produce a maldistribution of coronary blood flow and subendocardial ischemia, which can contribute to systolic or diastolic dysfunction of the left ventricle.

(progression of condition)

Eventually, symptoms of angina, syncope, or heart failure develop after a long latent period, and the outlook changes dramatically. After the onset of symptoms, average survival is less than 2 to 3 years (85-90). Thus, the development of symptoms identifies a critical point in the natural history of AS. Management decisions are based largely on these natural history data; many clinicians treat asymptomatic patients conservatively, whereas corrective surgery is generally recommended in patients with symptoms thought to be due to AS.

(indications for surgery)

6. Indications for Aortic Valve Replacement. In the vast majority of adults, AVR is the only effective treatment for severe AS. However, younger patients may be candidates for valvotomy (see section VI.A. of these guidelines). Although there is some lack of agreement about the optimal timing of surgery, particularly in asymptomatic patients, it is possible to develop rational guidelines for most patients. Particular consideration should be given to the natural history of symptomatic and asymptomatic patients and to operative risks and outcomes after surgery.

a. Symptomatic Patients. Patients with angina, dyspnea, or syncope exhibit symptomatic improvement and an increase in survival after AVR (86,112-116). These salutary results of surgery are partly dependent on the state of LV function. The outcome is similar in patients with normal LV function and in those with moderate depression of contractile function. The depressed ejection fraction in many of the patients in this latter group is caused by excessive afterload (afterload mismatch [52]), and LV function improves after AVR in such patients. If LV dysfunction is not caused by afterload mismatch, then improvement in LV function and resolution of symptoms may not be complete after valve replacement (116). Survival is still improved in this setting (112), with the possible exception of patients with severe LV dysfunction caused by CAD (116). Therefore, in the absence of serious comorbid conditions, AVR is indicated in virtually all symptomatic patients with severe AS. However, patients with severe LV dysfunction, particularly those with so-called low gradient AS, create a difficult management decision (117) (see above). AVR should not be performed in such patients if they do not have anatomically severe AS. In patients who do have severe AS, even those with a low transvalvular pressure gradient, AVR results in hemodynamic improvement and better functional status.

b. Asymptomatic Patients. Many clinicians are reluctant to proceed with AVR in an asymptomatic patient (118), whereas others are concerned about following a patient with severe AS. Although insertion of a prosthetic aortic valve is associated with low perioperative morbidity and mortality, long-term morbidity and mortality can be appreciable for mechanical and bioprosthetic valves. Significant complications occur at the rate of at least 2% to 3% per year, and death due directly to the prosthesis occurs at the rate of ~1% per year (119-124). Thus, even if surgical mortality can be minimized, the combined risk of surgery and the late complications of a prosthesis exceed the possibility of preventing sudden death and prolonging survival in all asymptomatic patients, as discussed previously. Despite these considerations, some difference of opinion persists among clinicians regarding the indications for corrective surgery in asymptomatic patients. Some argue that irreversible myocardial depression and/or fibrosis may develop during a prolonged asymptomatic stage and that this may preclude an optimal outcome. Such irreversibility has not been proved, but this concept has been used to support early surgery (114,125). Still others attempt to identify patients who may be at especially high risk of sudden death without surgery, although data supporting this approach are limited. Patients in this subgroup include those who have an abnormal response to exercise (eg, hypotension), those with LV systolic dysfunction or marked/excessive LV hypertrophy, or those with evidence of very severe AS. However, it should be recognized that such "high-risk" patients are rarely asymptomatic.

**********

Hope this helps.

Bill
 

Ross

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Bill C, why don't you put a copy of that in the reference section?
I know I'll want it and won't be able to find it someday. :)
 

Ross

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Thanks Bill C!

As often as I try software that has bugs and I end up formatting, I stopped saving really important links and try to remember where they are. Now I know. :)
 

Mentu

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My surgery was performed at Oklahoma Heart Institu
Hi, Kevin, I have been away from this site for several years and now find myself preparing for a repair or replacement of my own AV. The first time, 9 years ago, I sort of let the doctors work out the timing. Hey, I didn't know any better and felt they were doing their job. In retrospect, I realized that by delaying surgery my cardiologist caused me a lot of discomfort that wasn't necessary. He was waiting for more symptoms to appear. In fact, not everyone develops all the classic symptoms of valve failure until very late in the process. I came to think that I should have pushed them towards surgery earlier.

This time, I began my conversation by being very upfront about not wanting to wait until I feel as ill as I did the first time. My cardiologist agreed that with a valve area reduced to 1 cm2 and a significant pressure gradient (45-70 mm Hg) it was time get things moving despite that my only symptom is shortness of breath. Even in the past few weeks since our meeting, I've also become dizzy when I stand and walk.

What I'm trying to say is that you can let things move on "autopilot" or you can become more involved with the decision making. After all, you are the customer and they work for you. The days should be gone of doctors being regarded as special beings. Sometimes, they are wrong. What I am finding in this second iteration, however, is that they have responded to my conversation in a very positive way. They also respond well to knowledgeable patients who take the time to become familiar with the issues and to understand the most common test results such as echocardiogram, TEE & heart cath.

Being more involved will help you formulate your questions and, yes, always take a written list of questions with you when you see your Cardio or Surgeon.

Larry.
 

pellicle

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Wow,
Larry, 2003

Mentu;n886737 said:
Hi, Kevin, I have been away from this site for several years and
...
Being more involved will help you formulate your questions and, yes, always take a written list of questions with you when you see your Cardio or Surgeon.

Larry.
Quite the zombie thread revival.
 

ottagal

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Mentu;n886737 said:
Hi, Kevin, I have been away from this site for several years and now find myself preparing for a repair or replacement of my own AV. The first time, 9 years ago, I sort of let the doctors work out the timing. Hey, I didn't know any better and felt they were doing their job. In retrospect, I realized that by delaying surgery my cardiologist caused me a lot of discomfort that wasn't necessary. He was waiting for more symptoms to appear. In fact, not everyone develops all the classic symptoms of valve failure until very late in the process. I came to think that I should have pushed them towards surgery earlier.

This time, I began my conversation by being very upfront about not wanting to wait until I feel as ill as I did the first time. My cardiologist agreed that with a valve area reduced to 1 cm2 and a significant pressure gradient (45-70 mm Hg) it was time get things moving despite that my only symptom is shortness of breath. Even in the past few weeks since our meeting, I've also become dizzy when I stand and walk.

What I'm trying to say is that you can let things move on "autopilot" or you can become more involved with the decision making. After all, you are the customer and they work for you. The days should be gone of doctors being regarded as special beings. Sometimes, they are wrong. What I am finding in this second iteration, however, is that they have responded to my conversation in a very positive way. They also respond well to knowledgeable patients who take the time to become familiar with the issues and to understand the most common test results such as echocardiogram, TEE & heart cath.

Being more involved will help you formulate your questions and, yes, always take a written list of questions with you when you see your Cardio or Surgeon.

Larry.
Hi Mentu! Nice to see you post, but very surprised about your news in needing a second surgery. You and I underwent our AVR's around the same time. Thinking of you and sending positive thoughts and very best wishes. You may want to post a new thread on your news (only if you wants to). I apologize if another post shows up after this. For some reason, my first post showed up as 'spam'. It said it needs to be reviewed by a moderator.
We are here for you! :)
 
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