Ascending Aorta Aneurysm, Aortic Valve

[Tod-Wiliams]

  I'I'm 33 years old with an aneurysm of the ascending aorta (non-Marfan's) and moderate regurgitation.  I have decided against using anticoagulants at this point in my life.  Neither surgeon believes that I am a good candidate for the "Ross Procedure."  I have received some different information regarding different types of tissue valves.  One surgeon believes a homograft may last 15-20 and porcine about 10-15 years, another says it would likely be 10-12.  The second surgeon beleives that the new "Free-style" porcine valve would likely give me service comparable to a homograft without the availability problems (again about 10-12 yrs).  What do you believe would be a likely range (Please include any other pros and cons for each type)?  Where can I find statistics for these options?  Also, the one surgeon mentioned that surgeons say that mechanical valves last "forever" they mean, greater that 20 years and there would still be a very good chance that it would need to be replaced before I reach 70 - do you agree?

[CCF Cardio MD - MTR]

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Dear Todd, thank you for your question.  You are facing a difficult decision
so I'll try to provide some information and resources to help you with that
decision.  Since you have decided against anticoagulation, the options you
have include a porcine valve or an aortic homograft.  Mechanical valves
have excellent durability but require lifelong anticoagulation, as you know.
Whether a mechanical valve would eventually "fail" in you is a question that
cannot be answered because the answer would only be speculative. The best chance
of avoiding a reoperation would be with a mechanical valve.  Otherwise, the
statistics that the surgeon quoted to you are generally true.  Porcine
valves usually last 10-15 years while the "free-style" porcine valve (which I
take to mean a stentless valve) hasn't been used long enough to have accurate
information on long-term durability.  Homografts are thought to last longer than
porcine valve but again, long-term data is not as extensive as with porcine valves.
The reason that porcine valves and homografts eventually fail is that the valve
tissue is preserved with fixatives (porcine) or with very cold temperatures
(homografts).  The preservation process is thought to predispose the tissue to
premature calcification and degeneration.  However, the valves couldn't be used
without fixation so that problem can't be avoided.  The Ross Procedure (involving
a pulmonary to aortic valve switch and replacement of the pulmonary valve
with a homograft) is a technically demanding surgery that probably isn't
appropriate for you since you may need your aneurysm repaired at the same time
as valve replacement.  This additional operation may influence the surgeon's choic
of what type of valve to use.  To gather more information, I first suggest that you
look in the frequently asked questions archive of the heart forum under aortic
valve disease.  Second, I've listed two references that you may find helpful.
1) Aortic Valve Homografts in Adults: A Clinical Perspective.  Staab, ME, et al.
in Mayo Clinic Proceedings, March 1998, Vol. 73, Pages 231-238.
2) Aortic Valve Disease, Chapter in Textbook of Cardiovascular Medicine, 1st
edition, Editor: EJ Topol, Publisher: Lippincott and Raven, Authors: BA Carabello,
WJ Stewart, and FA Crawford Jr.
I hope you find this information useful.  Our cardiac surgeons at Cleveland Clinic
are very experienced with aortic valve and aneurysm surgery.  If you would like
to be seen here, please call 800-CCF-CARE for an appointment with a cardiologist
at Desk F15 who could do an evaluation and consult with a cardiac surgeon.
Information provided in the heart forum is for general purposes only.  Specific
diagnoses and therapies can only be provided by your physician.