Subject: Re: Advances in Aortic Valve Replacenents
Forum: The Heart Forum

Topic Area: Heart Disease

I am 48 with progressive aortic stenosis (calcification)
My valve area has gone from 1.7 to 1.4 in 2 years.
I am asymptommatic as of yet and remain very active. When the time comes for a valve replacement, I would much prefer not to be chronically anticoagulated. I am very active and have 2 young children who like to play hard.
When is the "right" time to have a valve replaced?
Most importantly, are there any major advances in valves which would nor require chronic anticoagulation? I have read about a newer valve from medtronic.
What valve would you most commonly use in someone like me?

Thanx,

Eric

Dear Eric, thank you for your question. With an aortic valve area of 1.4 cm2, you are still a long way from needing an aortic valve replacement (AVR). Typically, the valve area needs to be < 1.0 cm2 to even begin considering an AVR, you have to have symptoms like chest pain, passing out, or shortness of breath, or the pressure gradient across your valve has to be progressively increasing. Thus, there is no specific "right" time for AVR because it's an individual decision for each patient and their physician. There are no mechanical valves that do not require anticoagulation, but you may be a candidate for an aortic valve homograft that does not require anticoagulation and is more durable than a porcine valve. I've listed the typical AVR options below for your information, but you should speak with your own physician (in the future) before making such an important decision.

Aortic Valve Replacment Options:

There are four basic options for aortic valve replacement (AVR). First, a mechanical AVR involves a prosthetic valve (usually a St. Jude's or Carbomedics valve) that has excellent long-term durability but requires coumadin - a blood thinner. Coumadin can be harmful to fetal development so women who expect to become pregnant after an AVR should investigate options that do not require coumadin. Second, a bioprosthetic AVR is made from porcine tissue and doesn't require coumadin. However, a bioprosthetic valve only lasts 10-15 years so it's not appropriate for a young person. Third, an aortic valve homograft is a cryopreserved cadaveric aortic valve that is self-contained in the overlapping aortic tissues and is inserted as a whole conduit. The native coronary arteries are reimplanted just above the valve. While homografts have only been used for 10-15 years, results are good and coumadin is not needed. However, there are unanswered questions regarding long-term (> 15 years)durability with homografts. Fourth, there is a unique form of AVR called the Ross Procedure that involves switching the native pulmonic valve to the aortic position and replacing the pulmonic valve with an aortic homograft. This surgery is very technically demanding and should only be done by a surgeon with good experience since there is a high rate of perioperative and postpoerative complications. The benefit of a successful procedure is, however, no need for coumadin and probably the most durable aortic valve prosthesis that doesn't require coumadin. There is a website for the Ross Procedure and the URL is http://www1.primenet.com/~carym/. Finally, AVR can be performed via a minimally invasive approach with a 4-5 inch incision and postoperative pain and recuperation are reduced. Our surgeons at Cleveland Clinic have pioneered minimally invasive valve replacement, so you may want to consider coming to Cleveland for an evaluation.

I hope you find this information useful. Information provided in the heart forum is for general purposes only. Only your physician can provide specific diagnoses and therapies. Please feel free to write back with additional questions. Good luck!

If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter. The Heart
Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.

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