Aortic Valve Regurgitation

[TWR]

Son of a friend, an adopted 26 y/o dx with aortic valve regurgitation.  surgery coming next month.  Choice of Pig valve replacement with Coumadin for life or mechanical valve replacement good for 10 years.  What would you recommend for an active 26 y/o ???  Thanks

[Vg993]

54 minutes ago, TWR said:

Son of a friend, an adopted 26 y/o dx with aortic valve regurgitation.  surgery coming next month.  Choice of Pig valve replacement with Coumadin for life or mechanical valve replacement good for 10 years.  What would you recommend for an active 26 y/o ???  Thanks

I am by no means a PA or MD, I currently work in a CVICU so I will just state my understandings and the data from notable sources so you can advocate for your son’s friend in the best position.

From my understanding coumadin is typically used for the mechanical valves, since they have a higher likelihood of forming blood clots. But they last the lifetime. However these are typically suggested for younger patients with life expectancies of several decades. Being active will collide with this patient being on a blood thinner so there may have to be a change in lifestyle. 

The tissue valves are recommended for older patients since they will need to be replaced in 10-15 years and don’t require warfarin or coudamin. 

I would suggest that you ask if it’s feasible to get a donor valve or ask the surgeon about a Ross procedure(find a surgeon who still practices, rapidly declining practice) seems like the best option for a young adult and it’s the use of his own tissue from pulmonary valve.

Ross Procedure : 

http://columbiasurgery.org/conditions-and-treatments/aortic-valve-repair-and-ross-procedure

stats:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5395476/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4632330/

i don’t know how many hospitals across the nation do TAVRs (transcatheter aortic valve replacement) but we see many patients come in with severe aortic stenosis and discharge 24 hours post op. They are mostly older patients (70-99) and no data yet for how long the valves will actually last since they just superimpose a new valve on the existing one. 

TAVR:  https://www.edwards.com/devices/heart-valves/transcatheter-Sapien-3

https://www.health.harvard.edu/heart-health/aortic-valve-disease-surgical-or-transcatheter-replacement

 

[sas5814]

I'm a little surprised they would even offer the pig valve to someone so young knowing it's life span. That is a tough call.

[SHU-CH]

I used to work in open heart. If it was me, I'd go mechanical. Tissue valves don't last very long in younger patients. You'd be guaranteeing another surgery  about every 10 years and each time you go in is more complicated than the last time.

There are always risks with anticoagulation, but the meds are getting pretty sophisticated.

I was in a couple Ross procedures. It's an option, but you'd need to find a center that has a lot of experience. Almost anyone can do a run of the mill aortic valve replacement without much trouble. 

[ventana]

depends on patient

 

if he is a desk jockey and doesn't do much active would think mechanical with life long anticoag

 

if he is adrenaline nut and loves doing mountabiking, climbing, surfing, skate boarding, ice hockey and the like might consider porcine

 

need to know the patients goals......

 

Anticoag has it's risks....  

repeat surgery has it's risks.....

[TheDude]

Im current CV Surgery, have been whole career.  With his age, I'd go with mechanical.  Now here is the devil's advocate part, can he be trusted taking his "thinners" and maintain good iNR's?  This is always a conundrum with younger patients because no matter how well they have their head screwed on, there is always a concern.

[TheDude]

On 10/17/2018 at 1:07 PM, SHU-CH said:

I used to work in open heart. If it was me, I'd go mechanical. Tissue valves don't last very long in younger patients. You'd be guaranteeing another surgery  about every 10 years and each time you go in is more complicated than the last time.

There are always risks with anticoagulation, but the meds are getting pretty sophisticated.

I was in a couple Ross procedures. It's an option, but you'd need to find a center that has a lot of experience. Almost anyone can do a run of the mill aortic valve replacement without much trouble. 

@SHU-CH the ROSS is a great option but you have to find a surgeon who's been trained in them and as you stated, experienced.  They are becoming more rare due to other techniques chosen and lack of training unfortunately.

[jayzee]

Ross, but then you potentially have 2 valve disease. A Peds cardiac surgeon (they also does adults) would have working knowledge of this procedure. You can also do a double Ross depending on severity of the AI, and the neo-pulmonary valve can easily be addressed with percitaneous valves... until you run out of functional internal diameter. 

The On-X mechanical valve has a lower INR recommendation in the mitral position and this has also been used in the aortic position, using an INR of 2-3 after the first 3-6months (not a to. Of data to support this in aortic position). While tissue valves are great, it’s is guaranteed to wear out, and not every institution is doing TAVR on you patients hat are still good surgical candidates. 

[TWR]

Post op  f/u   Minimally invasive procedure was performed and upon entering the chest on the right side between the ribs, he determined that repair was viable rather than replacement.  All went well.

Addendum  The surgeon is leaving Houston to become head of cardio in Miami.  I think crackerjack specialists get traded to the highest bidder like a football or baseball player.

Thanks for the great input prior to surgery.  They did decide to go with mechanical and not pig.