We Have Game Plan For Surgery!

This afternoon Dan and I met with a surgeon at the Temple University Heart and Cardiovascular Center in Philadelphia. This surgeon was recommended by my cardiologist. This was my second surgical opinion. I did some research on the surgeon I met with today and I was impressed with his credentials. Our meeting was intense, with a bombshell surprise: I would need a Bentall procedure, involving composite graft replacement of the aortic valve, aortic root and ascending aorta, with re-implantation of the coronary arteries into the graft. This complex and long operation is used to treat combined aortic valve and ascending aorta disease, which I have, apparently. This treatment plan was radically different from the first opinion that I got on Monday, where the surgeon suggested that my aneurysm did not need to be replaced, let alone the aortic root. The first surgeon wanted to do an isolated replacement of the aortic valve via a mini-sternotomy, and agreed to address my aortic aneurysm only after I insisted. The second surgeon today indicated that the valve and aorta needed replacement from the outset. The first surgeon suggested the need for circulatory arrest during the procedure, but the surgeon today stated that this would not be necessary. I find it interesting and a bit troubling that such divergent therapies can be suggested for the same pathology. But in fairness the first surgeon stated that he preferred a conservative approach. Today the second opinion surgeon seemed to want to correct as much as possible during open heart surgery. I come down firmly with the latter approach. I want the valve and the aneurysm taken care of, and if the aortic root needs replacement then so be it. Get it done. Therefore, I have opted to go with the approach outlined by today's surgeon and I have scheduled my procedure for February 16.

Mini-Sternotomy for Ascending Aortic Aneurysm and Bicuspid Aortic Valve ...

This is exactly the procedure that I need, with the exception that I need a replacement aortic valve rather than a repair. I would think that replacing the aortic valve would be even easier than repairing the native valve.

Surgical Consultation No. 1

On Monday, January 5, I met with a cardio-thoracic surgeon at Penn Presbyterian Hospital, a branch of the Penn Medicine health care system in Philadelphia. Unfortunately, my husband and I were forced to wait over two hours past our appointment time before we finally got a chance to talk to the doctor himself. While the consultation was valuable in terms of adding to the information we need to make decisions about my surgery, we both felt that this particular surgeon would not be the best choice for me, and we were disappointed in the way we were treated at the facility. Unlike my meeting with another surgeon back in 2009 at a different branch of Penn Medicine, this doctor was at least personable, honest and sincere. He was also willing to listen to our concerns and to try to accommodate my wishes in terms of how I view the procedure I need. In particular, while he initially indicated that his conservative approach would be to not address my 4.6 cm aortic aneurysm at the time of AVR, he agreed to replace it after I indicated that I wanted it addressed. At first he told me "I don't think it will give you any problems." Perhaps not, but who wants to have open heart surgery and not see the surgeon correct an aneurysm that could potentially dissect in the future or require another operation? This captures the difference between the approach of this surgeon and the approach that I need. I don't want a conservative approach. I want a surgeon with a proactive approach willing to fix as much as possible as long as he is in there. So Wednesday we meet with another surgeon at a different facility. Hopefully, the experience will be better and the surgeon will prove to be more in line with my needs and expectations.

Tomorrow It Starts

Photo: Holiday greeting from my friend Wolfgang in Leipzig.

Tomorrow Dan and I meet with the first of two surgeons that we will see this week. We'll see how it goes.

Two Surgical Consultations Next Week

Photo: Philadelphia's Newly Re-designed Dilworth Park at City Hall

I'm meeting with two different surgeons next week. One is associated with the University of Pennsylvania hospital and the other with Temple University hospital, where my cardiologist works. I'm compiling a list of questions to ask. But first I will give each physician a chance to propose a course of treatment. I think I have to listen closely first before peppering them with a lot of questions. I've sent my records to both so they should have a pretty good idea of what they would do before I get there. I'm taking my husband Dan with me so we'll have four ears and two heads to process the information. The obvious questions are about AVR, (prosthesis type, etc.) and what to do about my aneurysm. Also, how quickly can surgery be scheduled? Other questions have to do with the surgery itself, but I don't want to get too far out ahead of things, like I was six years ago when I first met with a surgeon. It wasn't time then I was told, but I think it is time now. How many more heart attacks and strokes do I have to have?

The Risk Of "Smaller" Aortic Aneurysms

CT scan of my aortic aneurysm

Aortic dissection is a medical emergency. Those of us with BAV have to be concerned if we have an accompanying aortic aneurysm, even if the aneurysm is relatively small. Consider the results of this research:

IRAD (International Registry of Acute Aortic Dissection) produced a paper entitled: “Aortic Diameter > 5.5 cm Is Not a Good Predictor of Aortic Dissection” in the journal Circulation in 2008...investigators found that an astounding 60% of acute aortic dissections occurred in aneurysms that measured less than 5.5 cm at the time of diagnosis, 40 % in those that measured less than 5 cm, and approximately 25% at sizes less than 4.5 cm... investigators do not give us guidance on why thoracic aneurysms can and do rupture or dissect at these 'smaller' sizes, but it is important to recognize that they can and that we take them seriously in terms of risk stratification and counseling.

The new 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease acknowledges the risk. Here is the recommendation for patients with BAV undergoing AVR:

Class IIa2.Replacement of the ascending aorta is reasonable in patients with a bicuspid aortic valve who are undergoing aortic valve surgery because of severe AS or AR (4.2.3and5.3.3) if the diameter of the ascending aorta is greater than 4.5 cm. (Level of Evidence: C)

TEE Bicuspid Valve

The images from a TEE (trans-esophageal echocardiogram) are rich in detail. I can see why the TEE is the gold standard for evaluating heart valve disease. This is a video that I made from my TEE and it shows my stenotic bicuspid aortic valve.