Aortic Stenosis-2nd Valve Replacement

[Charles__0]

  I am a 48 year old male.  I had my aortic valve replaced in 1991.  I elected to get the porcine bioprosthesis.  I understood the likelihood that I would have to undergo valve replacement again.  However, I was hoping that there would be a better procedure and, perhaps, a mechanical replacement that would not require the blood thinning drugs.  At that time, there seemed to be talk of "defective" mechanical valves and I felt that I had better chances with the bioprothesis.  On my last checkup, my cardiologist said that my most recent echo doppler test revealed a worstening condition that would probably require valve replacement this year if the pattern  continues.  This was not expected since I have never felt better.  I have no symtoms at all.  My questions are:
  1. Would I be a candidate for the Ross Procedure?
  2. Would minimally invasive surgery be a consideration?
  3. Are there any practical options to a mechanical valve?
  4. Are the latest machancial valves less prone to clotting?
  I am not a doctor but I really need to understand.  I appreciate your help.

[CCF Cardio MD - MTR]

Dear Charles, thank you for your question.  I'll answer each of your questions individually after posting in my standard response for patients who need aortic valve replacements.
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.  
  1. Would I be a candidate for the Ross Procedure? No, a Ross procedure cannot be done after a prior aortic valve replacement and this procedure is rarely done past the age of 30 years.
  2. Would minimally invasive surgery be a consideration?  It's doubtful that minimally invasive can be done since a lot of scar tissue forms after a first open heart surgery that would make a minimally invasive approach very technically demanding.
  3. Are there any practical options to a mechanical valve?  I think you're asking if there are any alternatives to a mechanical valve.  Conceivably, you may be a candidate for an aortic valve homograft (see above) but I don't know of any cases where a homograft was inserted after a prior prosthetic valve failed.  In my opinion, the best long-term option is a mechanical valve which is durable and will not degenerate like the porcine valve.  However, coumadin is required, but you can still lead an active, productive life while taking coumadin.
  4. Are the latest machancial valves less prone to clotting?  All mechanical valves are prone to clotting and coumadin is required indefinitely.  
I hope this information is useful. Information provided in the heart forum is for general purposes only.  Only your physician can provided specific diagnoses and therapies.  Feel free to write back with further 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.