Re: valve choices and considerations

[Ted-Cotrel]

Posted By Ted Cottrell on April 18, 1999 at 13:56:41
I have some questions and concerns before making a decision on what type of valve to use to replace my stenosed aortic valve.
It is down to 1.1sq cm.  now .. I have relatively few symptoms.. my heart appears to be tolerating this well .  my ejection fraction is above 55 and I am 53 yrs old..
A surgeon I have been talking with suggests using a porcine valve.. I am confident in his ability to do this but I wonder if the homo graft is not liable to last longer.. or is this purely speculation?? I have heard a lot of positive stuff about the homo graft lately..  this doctor seems to think the porcine will last as long..
I am also wondering about subsequent surgerys.. is it easier to redo a homo graft or a porcine..  and are the flow characteristics of both equal.. ...?
and is endocarditus a  likely problem after surgery even if I do not have it now? I have heard a lot about this and wonder if just the act of replacing the valve adds to this possibility?
I am thinking that I do not want the mechanical valve for most of the obvious reasons but I worry about the longevity of these natural valves..
in an otherwise young healthy person like myself .. is there an average valve life..?
and when they fail .. do they just wear out and not seal tightly or do they stenose as the birth valve did...?
thats enough questions for now.. sorry there are so many

Thanks
Ted

[CCF Cardio MD - MTR]

Posted By CCF CARDIO MD - MTR on April 19, 1999 at 22:52:44
Dear Ted, thank you for your question.  I've detailed the options for aortic valve replacement below.   For someone your age,  a porcine valve would be expected to last 10-15 years and a homograft 15-20 years. Mechanical valves can last indefinitely if proper blood thinning medications are always taken.  Generally, a mechanical valve is most durable, a homograft next, and porcine valve last.  Thus, you may want to reconsider a mechanical valve - taking coumadin to thin your blood isn't that bad. Endocarditis is a possibility with your stenosed native valve and any valve replacement.  Thus, you need antibiotics before dental and other invasive procedures.  Redo valve replacement is more difficult than the initial surgery, but can be accomplished with good outcomes in experienced hands.  
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.  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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