AVR Surgery

[ITB]

  I am a 37 y.o. male, very physically active. Diagnosed with aortic stenosis at age 15. Historically asymptomatic.
  After my recent ultrasound,15 DEC 98, my cardiologist stated that my valve pressure was at 49 degrees of mercury (correct?), up from 41, 18 months ago. He stated the cut-off for AVR is 53 degrees. Cardiologist has placed me on Vasotec to see my reponse. My questions are:
  1.  Is Vasotec temporarily delaying the inevitable?
  Dr. stated he has a patient on Vasotec for 5 yrs....
  2.  After surgery, how active can I remain?
  I skydive, SCUBA, ski, run, lift, and all-around am physically pretty dynamic.
  3.  Is minimally invasive surgery a realistic possibility?

[CCF Cardio MD - MTR]

Dear ITB, thank you for your question.  I suspect that you have a bicuspid aortic valve that has caused aortic stenosis.  Generally, we rely on the pressure gradients across the aortic valve and a calculation of the valve area to determine indications for aortic valve replacement.  Vasotec may temporarily reduce the aortic valve gradient, but it will not change the underlying problem with the valve.  If you have no symptoms now, then you may be able to wait for a few years for aortic valve replacement (AVR), but the decision is best left up to your cardiologist.  I've included a paragraph on aortic valve replacement options for you.  If you receive a mechanical valve, then you would need coumadin to thin the blood.  If you are taking coumadin, you would need to avoid activities that have a high likelihood of causing you to get injured and bleed.  Thus, I imagine that skydiving and skiing may be dangerous in this regard, but only your own physician can determine what activities would need to be restricted.  Otherwise, there should be no restriction of activities with a valve prosthesis that does not require coumadin.  Minimally invasive surgery is a definite possibility for you and our cardiac surgeons at the Cleveland Clinic are international experts with minimally invasive techniques.   Thus, if you are contemplating minimally invasive surgery, you may want to come here for an evaluation.  Good luck!
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 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.
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.