Aortic insufficiency/regurgitation

[Jennie]

Hello!  I am a 33-year-old female, 5'9", with a (presumed) congenital aortic
insufficiency / regurgitation, discovered at age 12.  I have all three
leaflets of my valve - my new cardiologist commented that they appear
mis-shapen, that the tips might not be there, though I have no confirmation
of this.  My last echo, in July, reported the following:

aortic valve opening = 2.5
aortic root = 3.3
left atrium = 3.2
LV/AO ratio = .97
left ventricle (systole) = 4.2
left ventricle (diastole) = 6.1
septum = 1.6,
LV posterior wall = 1.4,
ratio = 1.14
ejection fraction = 63%.
"Severe AI, Dialated LV, no significant change from previous year.
LVH -normal sys. functioning; Mild MR; Trace TR; Ao gradient 10mm Hg (no
apprec. change from previous year); Increase in septal thickening."

In August I had my first combination stress/echo test, which I did very well
on (but had a high-speed "run" of heartbeats afterwards).  I have no numbers
for that test.  My new cardiologist said I was not a clear-cut surgery case
yet, but probably in the next few years, and said my larger LV could be
attributed to height.  He started me on a half-dose of Norvasc (2.5 mg) to
help the heart pump easier and to minimize the backwash, to try to postpone
surgery further.  He said my options for surgery might be repair, Ross,
homograph.  I would prefer not to have a mechanical so as to not rule out
future pregnancies.

In September I returned and reported that the Norvasc really quieted my
symptoms - not so short of breath (not that I was really gasping before), my
very frequent palpitations and hard glitches had smoothed out and were
virtually gone, rarely had a high-speed run, only a few sharp pains.  He was
surprised to hear this, said a small bit of Norvasc shouldn't affect my
symptoms so noticably, and said we should listen to my symptoms, and do
surgery now.  It also sounded like he talked to one surgeon at his hospital,
who said that a bovine valve was The Choice, and gave no reasons.  He waved
away the thought of repair, and said a bovine would last as long as a
homograph.  He upped the Norvasc to 5.0 mg, and said come back in three
months.

Since being on 5.0 mg, some of the symptoms have returned - palpitations and
glitches, though not as frequent or severe, and on some days some shortness
of breath and mild dizzyness, particularly during (but not limited to)
exercise (walking).

Here are my questions:

1.  It was alarming to me to have the doctor change his mind mid-visit about
when to have surgery based merely on my symptoms' response to Norvasc.  Is
there validity to his reasoning?  Does it sound like surgery is a good idea
now, even with a good ejection fraction and a good showing on my stress
echo?

2.  I am not totally opposed to a bovine or the surgeon here, but if my
doctor is still insisting on surgery come December, I would like to be seen
at the Cleveland Clinic - for at least a second opinion / discussion of
options, if not for the surgery itself.  Should I have a cath here, and
bring the results, or would it be better to have a cath there?  Or is a cath
necessary at all?  I never had one.

3.  I realize that it is impossible to confirm whether or not a valve can be
repaired until the surgeon is actually looking at it.  From what I've
mentioned regarding the leaflets of my valve, though, do you have any
thoughts on whether this type of defect is something that is generally a
good candidate for repair?

4.  Do you have any thoughts regarding the comparison of a bovine and a
homograph for people my age, particularly regarding their longevity, the
difficulty of the surgery, and the time required on a heart/lung machine?
Any articles or websites to recommend?  I've seen limited info on the web
that says the bovines are used a lot in people over age 65 with great
success, but not so with younger folk.  Seeing as I probably have several
valves in my future, I would like them to last as long as possible.

5.  Regarding "minimally invasive valve surgery" and "mini-sternectomy",
what is the difference between the two, if any, and do either of these apply
to aortic valve repair / replacement?

Thank you very much for any information, advice, or insight.  I appreciate
your time.

-Jennie

[jean]

Jennie,

Sorry, I forgot my address.  ***@****

[Jennie]

Thanks to both of you for your responses!  I hope you are both doing well.  Jean, I believe I saw you posted on another site somewhere.  I'll look around for your email address.  It'd be great to "talk".

God bless,
-Jennie

[Margitte]

Hello, I am 65 and still in recovery after repair/replacement valve cardiovascular surgery. The questions you stated in your letter were similar to mine. The prescribed medication I am on is also Norvasc amongst other daily medication such as coumadin.

I wish you well, and if you are uncertain, you are not alone in your reaction to this type of heart health condition.  

Take it easy,
Margitte.

[JEAN SISCO]

Jennie,
I had a homograft AV replacement at the Cleveland Clinic in 1-21-00 and am doing so great.  If you would like to converse with me about my experiences, you can email me.  A lot of people helped me out this time last year and I am here for those who need info and help now.
Jean

[Cleveland Clinic, MD]

Dear Jennie,
Your questions bring up an often discussed question in this forum - when is the best time for valvular surgery?  The answer to this question is more in the "art of medicine" than in the black and white areas.  I suspect you doctor was more concerned about your symptoms and not the response to the Norvasc.  Symptoms are one of the indicators that the time for surgery is near.  Ejection fraction may not be reduced and actually waiting until it is reduced could be detrimental.  It's never a bad idea to get a second opinion and we would be happy to see you here.  You can call the number below and ask to see one of the "valve cardiologists" (e.g William Stewart, Brian Griffin, etc).  You may of may not need a cath but my feeling is that you probably won't.  This would have to be determined at the time of your visit.  Do be sure to bring copies of all records and tests with you.  You're correct about repair being decided at the time of surgery.  Repair is a good option if the valve is such that it can be repaired.  The bovine vs. homograft vs. Ross debate is one that has been discussed here before and you can find those postings.  Each has its benefits and disadvantages.  The surgeons at the Cleveland Clinic perform all three depending on the individual case.  My personal bias is for the homograft but these are in limited supply.