My husband had heart surgery 6 yrs ago and chose a mechanical valve (aorta) instead of a tissue valve. He recently had an echocardiogram which shows a narrowing of the opening in the valve and leakage around the outside. Will he require open-heart surgery again to fix this defective valve? What causes the leakage and the narrowing of the opening?
If the mechanical valve fails to close completely, the blood is pumped through a smaller than normal opening. The problem causes excess work that can weaken the heart causing it to enlarge and produce various symptoms: chest pain; shortness of breath, etc. Whether the valve requires replacement depends on the underlying cause.
Sometimes a hole develops in the scar tissue around the valve, allowing blood to leak backwards around the valve whenever her heart pumped. There is an option to repair the defect with a catheter-based device that can close the hole without the need for another open-heart surgery. The procedure is placing specific designed plug in place to seal. Mayo Clinic has successfully done this procedure. Hope this helps.
Unfortunately, there generally is not any way to fix a "narrowing of the opening of the valve" without doing another valve replacement. Obstruction of the valve opening can be caused by either calcification, scar tissue (which in this situation is usually referred to as pannus), or -- in the worst case scenario -- a clot. If there is calcification or pannus, valve replacement can perhaps be postponed for a while, depending on how obstructed the valve opening is. If there is a clot, that usually has to be attended to immediately.
Leakage around the outside of the valve generally means that there is a space where the stitches have failed to hold. When there is "a hole in the scar tissue around the valve," as kenkeith puts it, that means that the stitches at that spot are holding nothing, rather than holding the aorta as they should be. Oftentimes that is due to dilation of the aortic root or other problems with the tissue that the valve was sewn into. The problem has to be very carefully evaluated, and something has to be done to prevent the whole valve from coming loose.
Occasionally, a surgeon will chose to try to resew a valve that is starting to come unsewn, but usually the valve has to be replaced. If there are also problems with the leaflets, then it would not make sense to do anything but valve replacement. Why resew the same valve around the outside when the central opening of that valve is obstructed? In that scenario, the valve needs to come out. Very often, the valve has to be replaced and other work has to be done on the aorta at the same time.
I have heard of the cath deployed device that kenkeith mentions. I knew someone who had something like that done at Johns Hopkins. It is by no means any kind of a standard solution to the problems that your husband is unfortunately having. Its use would be restricted to very specific situations and specific patients, and I doubt that it would be offered anywhere except at a few advanced centers such as Mayo or Hopkins.
The risk with using a cath-deployed device to try to plug the gap between the mechanical valve's sewing ring and the aorta is this: if it should be the case that the aortic tissue is defective, then the device might not hold, just as the mechanical valve's stitches did not hold. And there is no way to do anything to improve the site in which the valve is implanted, with just a cath. So, depending on what caused the stitches to fail in the first place, a lot of patients and a lot of doctors would want to go for the open-chest surgical fix in the first place, as it allows for a more radical and permanent solution. The surgeon can do root remodeling or aneurysm resection or whatever he thinks needs to be done go make a good seat for the valve, while he has the chest open.
The fellow I knew who had the cath procedure done was not part of a clinical trial. He was just one individual who found one surgeon who was willing to try it on him. His motivation was that he was just totally horrified at the thought of having another open-heart surgery, and he was willing to accept the risk of an alternative procedure, for that reason. He figured he would eventually have to have OHS, but he wanted to postpone it for as long as possible. Last I heard, he was doing well, and that was a couple of years after the procedure. So it worked for him, because it bought him time. But he didn't have anything else wrong with the valve, except for the bad spot where it was leaking at the circumference.
Since your husband is having problems with both the leaflets and the outside of the valve, I doubt that his doctors will want to do anything short of replacing the valve, and I don't think you should be disappointed if that is what is proposed. I would certainly ask about alternatives, but in my opinion (just my two cents), it is probably more a question of when and how the valve needs to be replaced, rather then what needs to be done.
Good luck. I was in a very similar situation, had to have the valve replaced, and came through it just fine. It's not something you want to go through if you have any choice in the matter, but sometimes you don't have any choice. You do what you have to do. The key to a good longterm outcome is correcting the basic problem that allowed this situation to arise as it did. The surgeon's experience in solving similar problems is critical.
Wow. Thank you. I really appreciate your detailed response.
You explained the problems/options very clearly and, although I'm disappointed (horrified) to realize that my husband will need OHS again, I prefer to know exactly what procedure is necessary to repair the valve so we can be prepared.
I'm sorry you had to go through this procedure twice but am grateful that you're willing to share your knowledge and experience with us. Thank you so much. ida
Information that helps and prepares the patient for replacement of a mechanical heart valve. Before Heart Valve Surgery
After Heart Valve Surgery
You and Your Physician
Stuck leaflets (impingement) - Leaflets in mechanical heart valves can become trapped by pressure on the valve orifice.Tissue from underneath the valve in the mitral position or pannus tissue can cause leaflets to stick. This has been reported in professional literature for other mechanical heart valves, but has not been reported postoperatively with the On-X valve in more than 70,000 patients in 12 years.
Mayo Clinic: 2009
To plug or to sew may depend on the underlying cause of the blood leakage. There may be some creativity involved, but that is the hallmark of good medical ingenuity represented by the Cleveland Clinic and Mayo Clinic.
"Drs. Cabalka and Hagler and their medical team threaded a thin tube (catheter) through Schroder's blood vessels into her heart and inserted a specially designed plug into the hole. "Once we had the plug in place, it took a matter of minutes for the device to seal the hole and stop the leaking around her heart valve," says Dr.Cabalka".
I'm sorry your husband is in this situation, too. I can't say what he is going to have to do or not have to do, but I wanted to let you know that if he does have to have the valve replaced, he shouldn't feel like his surgeon is overdoing the solution. Sometimes you just have to "go there."
Again, it takes a very, very experienced surgeon to handle a situation like this and get you to a place where you can have confidence that the new implant is going to last. With another valve replacement, the main thing is to make sure the new valve is sewn into good, healthy tissue, so it doesn't come loose again. The surgeon has to have the skill to identify and remove any bad tissue that is going to cause the same problem. The surgery will be complex and is not something that your average heart surgeon necessarily has the experience to handle.
I went to Dr. Joseph Cosellli in Houston for my re-op. I had to travel, and it was hard -- but I figured I might not get a chance for a third bite at the apple if the re-op didn't work, so I wanted to maximize my chances of a good outcome. I didn't want to be part of anyone's learning curve, and Dr. Coselli is one of the world's foremost specialists in aortic surgery. It is now six years later, and I am doing well. If I had not had a surgeon of Dr. Coselli's skill, I don't know that I would even be here.
If at all possible, I would suggest that your husband consider being treated at one of the country's major heart centers that has a thoracic aortic surgery program. You want a surgeon who can handle anything that needs to be done, and in this situation the best candidate would be someone who specializes in aortic surgery.
Good luck in working through this. There are doctors out there who can help. Your husband just has to find one of them.
Your welcome, Ida. I find it very helpful to gather as much information availabe about a subject as you are doing. Six years ago I updated my Will, and today my heart is normal size and functioning normally, and obtaining as much informtion about heart failure has served me well..
I do have severe mitral valve regurgitation and looking at valve repair or
replacement so I can identify with the anxiety you and your husband may have. I am bias for Mayo Clinic in Rochester, Mn, and the renown surgeon (thousands of valve operations) there has stated the biggest problem he sees is that the patient has waited too long...the heart can enlarge and the reduced EF as a result of MVR and an operation at that time may not ever restore normal EF functionality.
Your doctor has probably explained to you that valve stenosis can enlarge the heart chamber due to the gradient pressure across the valve opening. Also, there is less blood pumped with each heartbeat, and that can add to dilate the chamber.
Mayo Clinic has an excellent aortic specialist surgeon named Dr. Thoralf Sundt. He trained with Dr. Nicholas Kouchoukos of St. Louis, who is one of the pioneers of aortic surgery. I'm pretty sure Dr. Kouchoukos is still practicing, too.
I'll be happy to let you know. I really appreciate the information I've received from you and kenkeith and I realize how important this forum is for those who are in distress and trying to find answers. Thanks so much. ida
I had a mechanical vavle replacement a year ago yesterday. Last night I chocked on some popcorn husks which was a lot of coaching and this morning I noticed I am not hearing the tick tick no more as it was very loud, should I be cobcerened I can hear my heart beating it sounds fine, please help me tell me what to do.
It's not really possible for a coughing fit to damage a mechanical heart valve. One year out from surgery is within the time range that many people stop being able to hear the valve noise, though. I don't know why, exactly, but a lot of people don't hear their valve nearly as much after the first year or two. If you're really worried about it, just have your doctor put a stethoscope on your chest and listen. An experienced doctor can tell if the valve is making the right sound. If there is still any question at that point, an echocardiogram can be ordered, but I bet you won't need that. Good luck.
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