Surgery

[DottyCece]

A followup to my situation.  I had mitral valve replacement 5/21/03 and pacemaker insertion. I had a normal EF, coronary arteries etc. After surgery, I had heart failure, atr fib/flutter requiring 7 cardioversions. Followup echos showed a tissue mass at the posterior ventricular border but echos show MV functioning well at rest. I complained but never got anywhere except adding drugs etc.  So, I sought a second opinion from a cardiologist with an expertise in pulm HTN. On stress echo, I had high PA pressures and a drop in pulse ox. A cardiac catheterization showed high PA pressures, high wedge (41 with arm exercise) and a very high v wave.  She recommmended a redo of the mitral valve, ring on the TV and biatrial ablations.  This was done 4/27/04.  I already feel much better. Pacemaker is a backup and I am on my own intrinsic rhythm.When the surgeon (a different one who is a valve expert) opened the heart, he noted a soft tissue mass in 1/3 to 1/2 of the mitral valve opening and when the valve was removed, he noted a very poor suturing job under that valve.  So all along it was the MV and no one really went there for the cause of all my problems. It took fresh eyes etc.

1. Why was this soft tissue problem not picked up on echo, either TEE or TTE?
2. I was discharged on aspirin with the coumadin and Levonox.  Is aspirin commonly used with coumadin? What are the pros and cons of this approach?  Prior to this surgery I only took coumadin.  
3. How long does it take for the ablations to heal?  I have a lot of bigeminal PVCs with any activity right now, less with rest.

[Cleveland Clinic]

Dotty,

I'm glad you feel better.

1. A TEE or ECHO is a 2 dimensional representation of anatomy and can't show all of the fine details of the structures that are imaged.  Alot of echo is inference. For example, even though they remarked on pulmonary pressures on your echo, they never really measure the pressure. They measures the flow in the heart and extrapolated pressure based on those measurements. Further complicating things, artificial valves and pacemakers lend artifact to images which could interfere even more with the images.

2.  Some will prescribe both. If a patient has coronary disease, some physicians will add low dose aspirin to the coumadin.

3.  I would give the ablations 6 months to get back toward a baseline.

Dotty, I know this has been frustrating for you.  It will be a natural tendancy to want to point fingers and try to figure out why the first surgery went awry and why noone picked it up sooner. Truth is, that a small percentage of patients in even the most skilled hands have complications. Sometimes, we as physicians do not help matters by critiquing others. I would imagine that all of the physicans involved in your care wanted to get you better.  You did the right thing by seeking another opinion. A fresh set of eyes is sometimes the best route. The most important thing is your feeling better.  

good luck

[2manytears]

Im very curious about valve replacement. How many times should a surgeon try to repair a valve before using a machanical valve? I hear the longer on a bypass machine the more risks involed, especially when the patient is a senoir.

[DottyCece]

Hi

It is my understanding that surgeons try to repair valves if they are able to do so.  About 80% of valves are repaired.  In my case, it was 50/50 so they elected to replace.  There are some surgeons who replace more readily because they are finding that with a repair, there is often a need to go back in and replace.  Age is a factor.  Regarding the pump: the less pump time the less complications.  I am not sure how replace vs. repair stacks up in terms of time on pump.  I have been on the pump for both surgeries and have had not complications.  This time I notice some short term memory issues but that could be from drugs.

[2manytears]

Dotty,  Thank you for your response. I am glad you are doing well. It seems you really educated yourself as we all should, thats why Im trying to get as much information as i can. I dont know your age, I know the younger a person is the less complications. No one will tell me the complications for a senior for being on bypass longer than expected or how many times a doctor should try to repair a valve before going with a machanical valve. Like how many times is safe, verses staying on bypass too long and having things go wrong. Thank you again and take care...

[Momto3]

Have you checked out www.valvereplacement.com?  It has a lot of great information for "valvers."  Good luck!

[DottyCece]

I am not sure that the pump time would be greater or less for a repair versus replacement.  The big issue is whether the valve can be repaired. As I said, there are surgeons who believe that repairs don't last and that eventually a replacement will be needed.  You never want to go back in for surgery if you don't absolutely need to. (My experience a second redo is no fun.)  The other issue is with a prosthetic valve, you need to take coumadin. If there is some contraindication for that they may want to do a tissue valve or repair.  There is always a risk with pumps, but I have been on them twice and did fine.  This time I noted some short term memory issues but that may be more from all the pain meds and anesthesia than anything else. How old are you?  There are so many factors the surgeons will weigh  before proceeding.  Just make sure you have a surgeon who is a valve expert.  They call my surgeon the "master" when it comes to valves and that he is.  So, I have learned a lot and this site and the Doctors here have really helped me. I also have had very excellent and supportive physicians.