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Q: Aortic valve replacement timing
asked by: Seeff on August 17th, 2008
New User, Becoming EHEALTHy
Hi All,

I am a newbie to this forum and would appreciate some information that you might be able to provide. Many thanks in advance to all the patient responders.

I have a congenital Aortic stenosis with a bicuspid valve. A recent echo test showed a 69 peak gradient which is a considered moderate-severe aortic stenosis. In addition I have moderate regurgitation. So, a valve replacement is eminent at "some stage". Two cardiology professors see no reason for immediate surgery and suggest continuing my normal bi-annual check-ups.

I have two questions:
1. If a replacement is eminent, why wait? I am 40, lead a normal life and am classically asymptomatic - no fainting or sudden shortness of breathe. I am aware that an AS progressively deteriorates, and may cause dilation and irreversible damage to the heart muscle. I am also aware of the consequences of a replacement - Comadin etc. but cannot logically see a reason to wait for symptoms to develop. Surely it is better to be younger and healthier for surgery? I dread the idea of fainting with my small child in my arms and humbly see no reason to let my heart progressively tire itself.
2. I do find that I am somewhat more fatigued during the last year, may miss a beat or two occasionally and do get rare angina pains. Since I have been a "healthy mind-healthy body" freak, I cannot accurately associate these "symptoms" to my AS due to pure denial and living a normal life. Can a stress test pick up hidden symptoms that I am not aware of?

Any ideas, pointers will be most welcome.

Laurence
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Dr. Nikola replied on August 18th, 2008
Doctor
Management decisions in asymptomatic patients are more controversial. The combined risk of surgery and late complications of a prosthesis generally exceed the possibility of preventing sudden death and prolonging survival in all asymptomatic patients. Despite these considerations, some difference of opinion persists regarding indications for AVR in asymptomatic patients. It is reasonable to attempt to identify patients who may be at especially high risk of sudden death without surgery, although data supporting this approach are limited. Patients in this subgroup include those with an abnormal response to exercise (eg, hypotension), LV systolic dysfunction or marked/excessive LV hypertrophy, or evidence of severe AS. However, it should be recognized that such "high-risk" patients are rarely asymptomatic.

You can consult a cardiosurgeon about this.
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artdpart replied on September 3rd, 2008
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Aortic valve replacement timing
In 1966 my doctor informed me I may need my Aortic valve replaced.
In November 2007 I had my valve replaced in Paris, left hospital 5 days later, 3 weeks later cooked a Christmas dinner for my family, went hill walking in Crete during the Summer. And now the downside, I watched another younger fitter patient die following same op. same surgeon. So what your rush, I waited 41 years.
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Seeff replied on September 3rd, 2008
New User, Becoming EHEALTHy
Thanks for your replies
Some personal research and a visit to a cardiologist enlightened me with the following:

1. A controlled stress test in a hospital environment is the most accurate way to determine aortic function - I will be doing one soon.
2. The pressure gradient is not the determining factor when coupled with regurgitation.
3. Regurgitation is the primary contributor to enlargement.
4. Operative mortality outweighs the risks of sudden death in asymptomatics.
5. See a renowned cardiologist only - do not collect scraps of information from MD's - MD's deserve your respect only within their field of practice.

Thanks again, and I will certainly update you on my progress,

Laurence
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