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Heart Disease (Expert Forum)
Re: confused after second opinion
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Re: confused after second opinion
by Janele, Jan 01, 1995 12:00AM
Posted By Janelle on November 21, 1998 at 12:27:27:
In Reply to: Re: confused after second opinion posted by CCF CARDIO MD - MTR on November 21, 1998 at 11:17:25:
I am a thirty year old female with a congenital bicuspid aortic valve. I have aortic insufficiency, no stenosis. I have been followed annually since I was 14 years old. Last April my echo showed that my left ventricle had begun to dilate (6.6 from 5.9 the previous year) At that time he stated that I would probably need valve replacement surgery in the near future. I was unable to have the cath. right away because I have had to wait 6 months for insurance (pre-existing condition). I decided to get a second opinion at a hospital closer to home, and have just come from that appointment.
The second opinion cardiologist thinks that I should wait for surgery because my heart is still pumping efficiently, and because of my young age. I will need a tissue valve because I have a bleeding tendency, so a mechanical valve is not an option.
I have been anticipating having surgery soon. My original cardiologist said before Christmas. Now, I am not sure what to do. I have become increasingly fatigued over the last year, and experience other symptoms that I assumed were part of the valve problem. From everything I have read, including answers to previous posts on this form, I understood that once your left ventricle begins to dilate, and you have symptoms, it is time for surgery.
I realize that you cannot offer my a diagnosis, and any feedback will be general opinion, but if you could shed some light as to where I should go from here, I would greatly appreciate it! I hope this isn't too long, I tried to include only the very basics. Thank-you for this service.
Janelle
I
Dear Janelle, thank you for your question. I think that now is the time for you to have an aortic valve replacement (AVR) since your ventricle is indeed beginning to dilate. Despite your present normal left ventricular function, your ventricle may be permanently damaged if you wait much longer for AVR. Thus, I encourage you to have your cardiac cath done soon and to speak with your cardiologist again about valve replacement. Since you have a tendency to bleed, a mechanical valve is not the best option for you, but it would offer you the best long-term durability of any of the valve replacement options. I've detailed the options for different types of aortic valve replacements below.
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 wouldn't be 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 with reimplantation of the native coronary arteries 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.
In your case, an aortic valve homograft or the Ross procedure would be the best options.
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.
In Reply to: Re: confused after second opinion posted by CCF CARDIO MD - MTR on November 21, 1998 at 11:17:25:
I am a thirty year old female with a congenital bicuspid aortic valve. I have aortic insufficiency, no stenosis. I have been followed annually since I was 14 years old. Last April my echo showed that my left ventricle had begun to dilate (6.6 from 5.9 the previous year) At that time he stated that I would probably need valve replacement surgery in the near future. I was unable to have the cath. right away because I have had to wait 6 months for insurance (pre-existing condition). I decided to get a second opinion at a hospital closer to home, and have just come from that appointment.
The second opinion cardiologist thinks that I should wait for surgery because my heart is still pumping efficiently, and because of my young age. I will need a tissue valve because I have a bleeding tendency, so a mechanical valve is not an option.
I have been anticipating having surgery soon. My original cardiologist said before Christmas. Now, I am not sure what to do. I have become increasingly fatigued over the last year, and experience other symptoms that I assumed were part of the valve problem. From everything I have read, including answers to previous posts on this form, I understood that once your left ventricle begins to dilate, and you have symptoms, it is time for surgery.
I realize that you cannot offer my a diagnosis, and any feedback will be general opinion, but if you could shed some light as to where I should go from here, I would greatly appreciate it! I hope this isn't too long, I tried to include only the very basics. Thank-you for this service.
Janelle
I
Dear Janelle, thank you for your question. I think that now is the time for you to have an aortic valve replacement (AVR) since your ventricle is indeed beginning to dilate. Despite your present normal left ventricular function, your ventricle may be permanently damaged if you wait much longer for AVR. Thus, I encourage you to have your cardiac cath done soon and to speak with your cardiologist again about valve replacement. Since you have a tendency to bleed, a mechanical valve is not the best option for you, but it would offer you the best long-term durability of any of the valve replacement options. I've detailed the options for different types of aortic valve replacements below.
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 wouldn't be 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 with reimplantation of the native coronary arteries 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.
In your case, an aortic valve homograft or the Ross procedure would be the best options.
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.
