Valve Selection 1

[Bob Bates]

Hello, I am a new member facing AVR on Nov. 3rd at Duke Medical Center (Dr. Donald Glower). I am a 58 yr. old male, and of course I am debating the choice of a valve. I am leaning towards the tissue valve, and specifically the Carpentier-Edwards Perimount Bovine . I would very much like to hear from anyone who has had this valve implanted. Why did you choose it, and of course how you are doing with this valve. I was very active, and wish to return to a very active lifestyle (running, backpacking etc.), so I want to be sure this valve will allow me to do that.

This is a great site; I've already spent many hours on it as a guest, and realize that this choice is very individuallized.

[Ross]

Welcome to the board Bob.

Until the rest of the members wake up and get going this morning, I'll take the time to welcome you.

There are some who've had your surgeon and some with that valve, so give them some time and they'll speak up. I realize your active and all, but if you don't mind my saying it, I think you'd be better off with a mechanical valve. Coumadin isn't a big deal, you can remain active, you just have to be a little more careful about cutting yourself, you won't need another surgery 12 to 20 years down the road unless something really unforseen were to occur, but the choice is yours of course. I just hate to see people having to have this surgery more then once. Each time is progressively harder and harder.

Well good morning and hang in there until the rooster crows across the country. ;)

[Bob Bates]

Dear Ross- thanks for your reply and advice. Yes that is the great dilemma isn't it; no coumadin, verus the reop. Since I haven't even been through the first surgery yet, I am afraid I may regret my choice of a tissue valve when I see how much of an ordel this surgery is. However, I alredy have some scars from mishaps in isolated places (backpacking), and I don't want to be inhibited from doing the things I want to do if I am on coumadin, hence the tissue valve. Others have expressed this rationale, but to me its not having to deal with coumadin for the next 25 years or so (I hope at least that long), versus the risk of that second operation.

[ALCapshaw2]

I understand your dilema Bob. Your goal of 25 years for a tissue valve seems 'optimistic'.

For similar reasons, I requested a Bovine Pericardial Valve which has realized 90% durability at 15 years in studies and counting. Some early placements are reaching 20 years now. Unfortunately, after 'getting in there', my surgeon decided a mechanical valve was a better option for my situation.

For someone who wants an active lifestyle, I still think a good tissue valve is a good choice with the realization that another surgery will be needed later in life.

'AL'

[Ross]

The surgery itself isn't that big of a deal anymore. Pain wise, I've had much much worse. The worst part of heart surgery is what they do to your sternum and the way they lay you out like a fillet with your shoulder blades nearly touching each other. Don't get me wrong, it's still a major surgery and your body won't like you for a couple of days afterwards. Once you get passed that initial trauma, it's not so bad.

Coumadin isn't the big ugly evil monster that alot of people make it out to be. I still can't get over how antiquated some doctors are about the stuff. The medical profession has not kept up with the advancements over the years. Unless your a lumber jack, cliff climber, sword fighter, cycle racer, or football player, I think you could deal with it. The only thing that would make me change my mind is if you do alot of tumbling and hitting your head with that backpack on. Then it might not be a good idea.

When you post, use the new thread button to start a new topic, otherwise, just use the reply button to post a reply to the existing thread. Not a big deal, I can fix these things. The forums take a little getting used to but your tough, you can handle it. hehe :D

[Bob Bates]

Thanks Ross and Al. When I mentioned the 25 years I meant that would hopefully be my total remaining lifespan, not the valve life. I understand that the CE bovine valve would probably be in the 15 to 20 yr. range at best, probably less due to my age. I do motorcycle by the way, another lifestyle issue for coumadin use, and my wife and I want to travel a lot more after I retire.

[Ross]

Your too spunky. You'll easily surpass 83 years old. :D

[Nancy]

Hi there, Bob-

Welcome to the site.

What is the reason for your needing this surgery, congenital, rheumatic fever, or something else. Not that I'm being nosy, but it might make a difference in how you view your new valve.

My husband has had 3 valve surgeries, and 2 lung surgeries which are as bad, if not worse than heart surgery. I can second what Ross has said about additional operations later in life. It is not only the obvious healing which can take the body up to a year to fully finish, but the body suffers a great deal from the additional trauma of major, major surgery. Even though the surgery will go just fine, that was true in my husband's case, your body still has major issues of many natures which go on and aren't there during the first virgin surgery.

My husband had rheumatic fever as a teenager, and the aftereffects of rheumatic fever can stay in your body for a lifetime. His first surgery was for an AVR, his second was for an MVR, and the third was to repair a leak in the mitral. In addition, he has a pacemaker, and his tricuspid is leaking, but does not need surgery. He's been on Coumadin 25 years, soon to be 26, and has had no bleeding issues associated with Coumadin in all those years. He was very active as a younger man. At this point in his life (he's 72) he would be very, very high-risk surgery, if anyone would agree to do surgery on him. His body is now hyper-reactive to anything that comes his way.

So what I am getting at is that various medical conditions can have very different scenarios. With something like rheumatic fever which is ongoing and can be progressive, you might want to consider a mechanical. In that case it would be very prudent to avoid as much trauma to your body as possible.

This is the most difficult decision, as you have no doubt seen from all the debates about it.

Best wishes.

[Granbonny]

Welcome to our site. I had my mech. valve at age 61..17 months ago. Coumadin has never been an issue..other than to remember to take a pill a day....We have many members with Mech. valves that do all the things you enjoy.. Just remember. we all want to get back into our things again..but it takes 1 full year..to feel the same as before surgery....You have a wife now..who will be able to help the first few weeks..You will feelvery tired...then you can ease into a bit more activity..As far as falling, ect. you do not have to be back-packing. I fell going down steps last week.:eek:No bruises and Gina tripped over her water hose last week. :D Any valve you choose will be a good one. And btw. I'm planning on chasing the men in the Nursing home down the Halls when I'm age 95::p :p :p :p Nurses will have to remind me to take my coumadin. Bonnie

[bvdr]

Hi Bob,

I can't speak about your valve choice but Dr. Glower has been the surgeon of several of us here. He replaced my mitral valve with a St.Jude Mechanical at Duke almost a month ago. He used the heart port procedure on me and I don't have to deal with some of the sternum issues during recovery. He is a very talented surgeon. I am 55 and really didn't consider getting anything but a mechanical as if at all possible, I do not want to do this again.

[Bob Bates]

Thanks again to all that just replied. Wow, I can,t believe the responce. Frankly, I am at work and should be doing my company's business, but for reasons you all can appreciate, this is a hot topic with me right now. Happy to hear the responce about Dr. Glower at Duke,: he came highly recommended. The reason for my valve replacement is a congential bicuspid aortic valve, only discovered when I was in my mid-forties.

Yes it is a dice roll about what kind of condition I'll be in for the second surgery. It seems that most folks have no major issues with coumadin. But if you do have problems, you are going to have to live with them the rest of your life. I think I'd rather gamble with that second surgery.

Still hope to hear from folks who have had the CE Perimount bovine valve implanted: or like me are considering that valve.

Regards

[Gisele]

Welcome to this site. Here you will find that most eveyone will agree that Coumadin isn't as bad as you might think. I had been on coumadin for 21 years and would still do active things such as ski, etc. I might be the exception to the rule compared to the other members with having difficulty controlling my INR, but don't let this scare you. My INR's had always been irractic, I guess that is just how I am built.

Currently I have been off my coumadin now for approx. seven weeks due to a subdural hematoma (bleed in my head) from the coumadin. This is unusual for a patient to have a bleeding incident, so please don't go by me. I think that our resident coumadin clinic guy Alldowick has posted a study that was done regarding bleed incidents. Look under the Coumadin thread and you should find it.

If it means the difference between one lifetime valve and facing multiple surgeries, you might want to investigate the mechancal valves and consider it as an option.

Good luck..........Gisele

[Tom]

Hi Bob,

Here's another post from a guy who went with a tissue valve. I had my AVR at age 45 and opted for a cryo-preserved homograft (cadaver valve). I'm also active and like to snow ski, mountain bike, and recently took up mountain climbing. I fall alot, especially skiing and biking. I did not want to have to worry about bleeding episodes, and realize I will have to undergo at least one more surgery in the future. But for me it was worth it and I have been doing fine with my tissue valve. As everyone has stated, it is a very personal choice. Also, different surgeons have their own preferences, so it is probably best to choose one who uses the valve you want frequently. So best of luck with your choice and welcome to the site!

[Bob Bates]

Gisele, sorry to hear about your bleeding problem. I understand that can happen, and it no doubt is very manageble.

My issue with coumadin is no one thing; its the cummulative effect of all the issues. Potential clots, testing, dealing with the Dr. to regulate dose if issues arise, potential bleeding problems, resrtictions on other drugs, and diet watching. I am sure it becomes very routine after a while. But again its a tough choice: avoid all of the above, or face a second surgery. It seems as if it is a question of having to deal with a set of risks and inconviences spread out over 25 years, or facing one big risk down the road. And as others have said before, who knows what sort of procedures and devices that may be there when the second surgery comes due.

Regards

[Gisele]

Bob, this is such a personal decision and I agree--Coumdin is a big fat pain in the butt, BUT if you have no choice it is better than nothing.

You are fortunate to have imput into your selection. I was 26 when my valve was implanted and I wasn't given a choice. They tried a tissue valve at first, but the valve I needed was too large so they went with mechanical. Things were very different back then. I don't regret having a mechanical even though I have had many complications over the years.

Go with what you and your doctor are comfortable with, and let us know what your final decision is. Good luck.

[Bob Bates]

Gisele- thanks and of couse you are 100% correct, each person's situation is very different. If I was 26 and facing this, I also would probably opt for the mechanical valve ( I am 58), or go for the Ross. I might be able to withstand one more opertion when I hit my seventies, but probably not several more, which would be the case if I was in my twenties.

Also, several folks here have said it takes about a year to get back up to speed after surgery. Is that true for most folks? I am a little surprised by that; I assumed it would be a few months, but I have not yet addressed this issue specifically with my surgeon. Of course it would depend a lot on what kind of shape you were in to begin with, which would vary greatly with age and physical condition.

Regards

[Nancy]

It'll take about 6-8 weeks for you to feel human again, and about a year to feel back to your old self. But things can vary a great deal. After 8 weeks you will be able to do a lot, but will still be sore and will tire easily.

[Bill Hall]

Bob - I have a homograft in the Aortic position and a Mitral repair, so no coumadin. I take one aspirin each day. There is definitely a trade between the mechanicals and tissue. I chose the tissue and might actually go with the mechanical if I do this again. I had my surgery at age 47 in 2001, so a re-surgery would be maybe 15 years or 2016 (or maybe longer). I would be retired (hopefully) and the coumadin would be less of an issue regarding activity. The re-surgery is definitely a concern and I am not looking forward to it. However, maybe I got lucky, but the surgery was not the worst pain I had or the worst experience. I know I could get through the few days when things are uncomfortable and then get better. Good luck with your decision, there is no easy solution.

[EVELYN]

Hello Bob and Welcome to a wonderful place!!

I'm Evelyn, whose husband, Tyce, had a mechanical AVR in June 2002. We looked at other choices and both he and the surgeon thought the St. Jude's mechanical would be the best for him. That was what we went with and haven't looked back. He, too, is extremely active....even if he does cut himself or bleed, it hasn't been prolonged or cause a problem. I do know that post surgery he said he was glad he wouldn't have to go through it again.....God willing.

The coumadin has NOT been any problem. We do have our Protime machine to thank for that. I don't think there's any food you can't incorporate into your regime....it's only an adjustment on the coumadin. Once you get that in your brain, it's fairly easy. Of course, vacations and summers surely seem to raise that level up, but we like to blame it on RAIN'S DOG.....it works!!

I wish you much luck in your search. You will certainly get many opinions on this site....you just have to be comfortable with your choice. The more you know, the more comfortable you will become with one.
Good luck and again welcome.

Evelyn

[Bob Bates]

Thank you Evelyn and Bill. Unfortuanately, your responces seem to be an example of what I am finding on the site. For every satisfied tissue valve recipient, there are mechanical valve people on coumadin who are also not having any problems or issues.

Even though I am leaning very much toward the tissue (CE Perimount Bovine), I admit to doubts , since at age 58 I will need the reop. After the tissue valve implant operation, i may think that that is the last thing in the world I want to go through again. But that is part of the decision making process, i.e. gathering as much information from all sources before making that final decision.

Thanks again for your thoughts.

Bob B.

[MelissaM]

Hi Bob,

You might want to do some research on the cutting edge surgical techniques that are being honed. There is a robotic operating system called The Da Vinci System that got approved by the FDA last November for fixing mitral valve stuff. They are working on approving it for other heart surgeries as well. Fifiteen years from now, heart surgery might look very different! It might weigh into your decision making process

Also, one thing you will read again and again on this forum is that people's pain levels post-surgery were surprising less than they expected. Recovery takes a while, but - in my opinion - it is more related to building stamina rather than dealing with pain.

Melissa

[Bob Bates]

Melissa-thanks for those words of encouragement. I am kind of a wuss when it come to pain and discomfort, which you would think would make me a candidate for the "one operation" mechanical valve. As you suggested however, I hope that medical advances will make future surgeries less risky with less discomfort. That is a factor in my almost sealed decision to go with a tissue valve.

Regards

Bob B.

[JAMES W]

Bob....

I had my AVR in January of this year. I am 50yo, having had Rheumatic Fever as a child. Because I'm in law enforcement, I chose a Medtronic porcine over the mechanical. Like you, I would rather endure a 2nd surgury down the road. I was asymptomatic before the surgury, so I think it made the recovery easier.
I had a gall bladder removed in July that was far more painful than the OHS ever was...Remember, it is your decesion...become informed...this site is wonderful...only wished I'd found it before my surgury, rather than after...
Good luck my friend....
:)

[Bob Bates]

Thanks James

I am trying to validate my decision about coumadin use. I assume for some reason you thoughjt your work was incompatible with a blood thinner, e.g. getting cut, shot etc? Or were there other considerations? I hope these questions are not too intrusive.
Everyone seems to be pretty laid back about coumadin , but there has to be some downsides to it?

Thanks

Bob B.

[Ross]

Bob I'm telling you coumadin is not a big deal. There is a whole world of hoopla about it, but it's not a big thing. The downsides--Frequent testing of your INR is probably the tops, then followed by not being able to totally engorge yourself with dark leafy greens, most energy drinks and supplements, etc, that contain Vitamin K. For the most part, you maintain eating the way you normally do and allow the coumadin adjustment for that diet. As long as your consistent with your diet, you can still have all the things you love.

I'm trying to say that alot of the garbage you hear about it is myth or old school thinking from those that have not kept up with the advancements over the years. It's really not that bad. I'm sure others will point a few things out too.

[ShezaGirlie]

Hi Bob,
Well, I'm kinda known for being an opinionated person, so here goes!

Coumadin is a BIG deal. Your INR will have to be monitored regularly [at least once a month] for the rest of your life. This means a trip to a Coumadin Clinic or to a Lab if you don't have your own hometest equipment. Then a wait for a phone call from the doctor or nurse to see if you're in range or if you need to adjust the dose.

If you have your blood drawn at the Lab you will develop scar tissue over time from numerous sticks. It's very convenient to have your own hometest machine. They cost around a thousand dollars with test strips costing somewhere between $7-$15 depending on the brand of equipment. If you have good insurance, you're lucky. If you don't -- be prepared to shell out the bucks regularly -- for the rest of your life.

Many things affect the anticoagulation/coagulation of your blood...such as heat, foods and alcohol. And then there's Rains' dog who gets in the flower bed and makes her INR reading crazy.

You could become a stroke victim or suffer a blood clot if it's not in range. It's serious business. It must be monitored.

You're 58 years young. If you choose to be on Coumadin hopefully you'll never require any surgeries down the line. Routine tests such as a colonoscopy can play havoc while trying to lower your INR so as to not cause an internal bleedout. Those are serious. You will have to premedicate for any invasive tests.

You'll have to premedicate everytime you have your teeth cleaned. And if you have to have any invasive dental procedures, you'll have to find a dentist willing to do it while you're still on Coumadin so as to avoid the ramifications of a low INR. I had a wisdom tooth pulled while on Coumadin and I thought the dang thing was never going to quit bleeding... That's hard on the nerves! And then there's the bruising when your INR is too high.

If you like to travel, it's a pain in the patooty to haul around your own testing machine plus the strips. They have to be kept refrigerated. Yep, you'll give up a lot of 'freedom' while taking Coumadin. It's a 'freedom' from worry. And don't even think about going to a third world country...

Hope you are at peace with your decision... That's the most important part of it all. Good luck...

[Bob Bates]

Janie- Thanks for giving me an unvarnished opinion on Coumadin. I am sure I could handle all of the things you mentioned, as many do. And for some , there is no choice. But I am "lucky" to have a choice.

What is still a little scary however, is the pros and cons of coumadin are pretty well known, but what I don't know, is what kind of shape I'll be in to face that second OHS when I am (hopefully) at least in my early seventies. So the decision seems to ,be play it "safe" and take coumadin, or hope for the best down the road and avoid coumadin.

Again, thanks for your insights.

Regards

Bob B.

[ALCapshaw2]

I would like to clarify a few of the points Janie raised.

First, it is necessary to Pre-medicate for ANY and ALL invasive procedures REGARDLESS of valve type and regardless of whether you are on Coumadin or not. This is an absolute requirement for anyone with any type of valve disease.

Second, I notice that QAS is now sending 4 packs of Couvettes WITHOUT refrigeration packs. I *assume* that means they can tolerate not being cooled for a short period of time such as short trips / vacations. It might be wise to ask them about taking Couvettes on vacations etc.

Third, regarding testing, I would recommend visiting your local Coumadin Clinic(s) to determine what type of testing they perform. Look for one that uses fingerstick testing instruments to avoid the necessity of venous blood draws (needles!).

As one surgeon told me, those of us between 50 and 65 are in a 'gray area' when it comes to valve recommendation. It comes down to a matter of personal preference. Frankly, I'm a little surprised more people over 65 don't choose tissue valves since they seem to last longer in older patients (lower BP?).

One more thought. There is an alternative to Coumadin on the horizon (see AL Lodwick's website www.warfarinfo.com) that 'may' become available in the near future (2004 or so?).

And another. If you have BCBS insurance, negotiations are currently underway to provide coverage for Home Test Equipment and supplies nationwide. Hopefully more companies will follow suit.

Finally, when I accidently cut my finger on a sharp saw blade (3 small puncture wounds), I was surprised to note that it took close to 3 hours to stop 'leaking'. It made me rethink using my new chain saw (which remains unopened in it's box). At times like these, I really wish my surgeon had given me the Bovine Pericardial Valve I requested. It's easy to say 'give me 15 good years without Coumadin' and I'll be happy. I'm not sure how I would feel when those 15 years are up.

'AL'

[DANIEL]

Also feel one needs to consider quality of life which means differenent things to each of us, depending on many factors. I have been aware of my bicuspid valve my entire lilfe, had it reguarly montiored, was not on any meds and had no physical restrictions. I lead a fairly active lifestyle, I travel and do not have a consistent diiet or daily routine. I still look forward to many years of rough and tumble actiivities and wide ranging trips. I would like to contine to "spoil" myself with the above "impulse" activities/adventures as the occasion arises. The tissue valve I received (only 12 weeks so far) will allow me to continue my life with an aspirin a day and no other concerns for hopefully the next 12 or maybe 15 years or more. Sure if something goes awry in a few years, I could have to deal with a re-op, but with any valve choice somethnig can go awry at some early stage. For first valve go-around, the tissue at 50 yrs of age, to me, is the easy choice. Second time around, given the identifcal technology as today, I would go for a mechanical. However, I hope when my re-valve time comes, there will be more attractive options that I can consider. If I had to take coumadin , I would deal with it and lead a full life; however, I can avoid the whole issue at this time. Additionally, my big pre-op concern was if the op and recovery was so difficult and dreadful that I would regret getting the tissue and livng with the guaranteed re-op. However, aside from some discomfort and the stay in the hospital, it was not a big deal. Hey, I only go around once in life. The decision I made I can comfortably live with.

[Bob Bates]

Daniel- your thoughts are mirroring mine as I face AVR on 11/3/03.
I was also encouraged by your comments about the first surgery. Since that is still vast unchartered territory for me, its one thing to say at this time I'll do a second surgery, it may be another to actually have to do it. Having someone say it was doable who has been there is a big help.

Thanks again

regards

Bob B.

[rcatalano]

Maybe I'm missing something, but I didn't see Daniel mention anything that is a problem for Coumadin. Can you possibly specify what it is you won't be able to do? There are definitely some no-no's, but I haven't seen any real coumadin issues mentioned yet.

As Al said, the pre-medication has nothing to do with Coumadin. Heck, I was pre-medicating just for having mild AI, 9 years prior to my first AVR, and I pre-medicated with a homograft for 14 years.

When I go to my lab for testing, I get the results right there. They do a finger prick, and 2 minutes later I have the number. As for diet, I have been avoiding green leafy things, but thats about it.

I'm looking into getting the Lifescan Harmony INR monitor. I don't know if the test strips need refrigeration. But I'll still have to go to the lab monthly or every other month. From what I've learned, home testing is to get tested more often, but trips to a lab would still be required (possibly less frequently).

[DANIEL]

Rcatalano,

As I stated in my email:

"Also feel one needs to consider quality of life which means different things to each of us, depending on many factors."

I hope I made it clear that this is a personal decision and I am not here to convince anyone to do anything one way or another. Maybe you are missing something (that is important to me) and maybe you are not missing anything (that is important to you). Most important is that each person makes the correct decision for themselves. I feel that any valve choice is a good choice. Most important is that each of us takes the best care of our health and does not delay any procedure available to us

LIVE LONG AND HEALTHY AND HAPPY LIVES TO OUR FULLEST.

FYI: I have been pre-medication my entire life too.

Daniel

[fyrfytr]

Hey Bob,
One other thing you need to remember is even though you decide on a particular valve your surgeon will have the last say as to which valve will best work for you, it will depend on what he finds when he gets in there. My surgeon told me after the surgery that it was a good thing I decided to go with a mechanical valve as a tissue valve would not have worked for me.
Hope everything is going OK.

Dave
___________________________
Surgery: 4/21/03
Aortic Aneurysm Repair
AVR, with a St. Jude Mechanical
Heart Center of the Rockies

[rcatalano]

Sorry Daniel, I was not trying to imply you or anyone is right or wrong. I guess I was going by the rest of your message, where I assumed you meant those activities couldn't be done while on coumadin.

As I am overly analytical, I guess I gloss over generalities and focus on specifics. But I get your point - a perfectly valid one.

[Bob Bates]

To Rob and Daniel- Thanks again for your input. Thats why I am on this site, to gather as many opinions as possible while I am still considering my choices for my 11/3/03 AVR.

I guess I am leaning toward the tissue (CE Perimount Bovine) valve for reasons I have mentioned before. Its not any one thing associated with taking coumadin, its sort of all the things added together. These are: some additional (but small?) risk of clotting/ stroke: testing, and retesting if adjustments needed: inconveniences associated with travel: risk of bleeding if injured in a remote place (Iused to backpack in wilderness areas, and hope to start again), or even on the street (I ride a motorcycle): and monitoring, to some extent, food and beverage (alcohol )intake.

If coumadin was just about taking a pill a day, as I understand a new drug on the horizon ,Exanta, may allow, then yes, I'd opt for the mechanical valve. By the time I have the second OHS, that will probably be the case. Because of course ,there is the re-op risks. But all of the current coumadin items are with you forever, whereas the discomfort and risks for the re-op are more or less a one time roll of the dice.

Anyway, again thank you taking the time to respond.

regards

Bob B.

[ShezaGirlie]

Bob -- wouldn't it be easy to make a decision if on the outside of the little valve boxes it said, "guaranteed for life."

Another point for you might be the fact that a mechanical [however rare it is] has an immediate and drastic failure and a tissue valve has a gradual failure.

You're so fortunate to have this venue to gather opinions -- hey, another thanks goes to Hank our 'founding father.'

Why don't you motor on to Chicago and the reunion where there will be around 30-40 of us there. Talk about opinions!

[Rain]

Bob,

Let me just tell you why after being on coumadin for nearly four years I prefer my son have a tissue valve.

I know he’s apt to be rock climbing one weekend.. eating trail mix, sitting in an office, drinking coffee and getting all stressed out during the week, the next weekend he’ll most likely be at the lake water skiing.. probably camping out and not getting enough sleep, then of course there are all those girls he has to wine and dine, hopefully he’ll find time to ride that motorcycle home to visit and enjoy his Mama’s veggie cooking. While he’s here there’s no doubt we’ll have to fight the dog for rights to the flower bed!! These are just a few of the things about his life that would not be coumadin compatible...

On the other hand.... if I thought he was going to be getting up at the same time every day, getting the same amount of sleep every night, eat the same dang stuff every day, get the same amount of sun EVERYDAY, same amount of stress everyday, same amount of exercise every day, etc. of course I would recommend he go with the mechanical. And who knows what advances will be made between now and when he needs the next operation?

I know being 58 is just a tiny bit different than being 20 :eek: ... but still... a lot of the issues are the same. Obviously there are a lot of opinions on the subject. I think Daniel said it very well in his first post.

Good luck. :)

[Susan Allen]

Hi Bob,
I found out 2 years ago at age 40 I had a congential bicuspid valve which resulted in aortic stenosis. The stenosis progressed rather quickly once I started symptoms. I am having the Ross Procedure on Oct. 16th. I, like you, took careful consideration of all my options. I chose the Ross Pocedure after many many nights of research. Although a highly technical procedure, and you must find a surgeon who has much much experience, I feel this is my best choice. What I feared with mechanical is (although this is my back up plan if the surgeon gets in there and can't do Ross) mostly blood clots, sound, sudden failure and infection. The coumadin is certainly an issue but not the biggest one on my list. I realize I may face a second surgery, however, new studies show great results from the Ross 18 and 20 years out. I also feel the way medicine is progressing by the time I would need another there will be better options.
I am really grateful I had some time to make a choice and find a top notch sugeon to perform my surgery.
Good Luck in your choice.
Pick what is right for you - you'll know deep down once you make you choice it was the way to go.
Susan Allen

[DANIEL]

Bob,

I enjoy this forum and everyone who participates. Many perspectives, all good stuff. For those of us who have studied-up on our condtions, the technological issues involved are pretty well understood. It's those seemingly black and white areas that appear kind of grey to some of us that makes this such a great place to see other people's viewpoints.

All the best
Daniel

[Bob Bates]

To Janie, Rain,Susan, and Daniel: Thank you for taking the time to comment on my situation. Just when I think I have this issue settled, someone come along and brings up something I hadn't thought of.

In this case, its the idea tyhat I may be OK with that second OHS if I go with a tissue valve, but what about my poor wife? Am I being selfish to assume she will be OK with this. Actually, she is very much for the tissue valve (she is an RN) in order to avoid coumadin. But she may not realize what she is in for otherwise. This is something I'll want to discuss with her tonight, her role as caregiver.

Thanks again for comments.

Regards,

Bob B.

[Nancy]

Hi Bob-

If your wife has any questions, I would be happy to answer them as the spouse of a man who had 5 thoracic surgeries, 3 valves and 2 lungs, plus a pacemaker.

[Bob Bates]

Nancy, thank you for your very kind offer. I'll let her know. She has been impressed by this site, and evryone's responce to my questions.

Thanks again.

Regards

Bob B.

[Lasker]

Dear Bob Bates,

Like you, I am considering the CE Perimount bovine pericardium valve. I am several weeks behind you, in that I am planning surgery for the beginning of December. Selecting a valve is the reason for delay, since I have been recommended to have surgery ASAP for severe aortic stenosis.

Have you been able to learn anything additional about this valve since beginning your inquiries?

Have you looked into minimal incision surgery? I am wondering if anyone knows the criteria for patient suitability for this procedure.

Best of luck on November 3.

Lorraine Lasker

[Bob Bates]

Dear Lorraine;

I can't quote you the statistics or details, but I have read the summaries of two studies for this valve (CE Perimount Bovine), which show that the valve is still functioning well after 17 years (an earlier study) and 20 years ( a later study). The higher the age of the patient, the longer the valve seems to last. These studies have been referenced on this site, but I am sorry, I can't tell you exactly where to find them. Apparently a Dr. Cosgrove in Cleveland ( very well respected heart center) is a strong advocate of this valve as well. I have read nothing negative about the valve, except of course, as a tissue valve, it will not last as long as a mechanical. Also, if a second surgery is required, this valve is one which does not cause undo complications to replace it.

This valve was also the first one my surgeon ( Dr. Donald Glower- Duke Medical Center, Durham NC) mentioned when I asked him for a recommendation for a tissue valve. He did say that one's aortic root cannot be "small" with this valve, because it is a stented valve, which makes the valve opening a little smaller than a non-stented valve. I will know more about this in my case after tomorrow (10/21/03) when I undergo my Heart Cath.

My surgeon does do "port access" / minimal invasive surgery. Again, I don't know the specific criteria for patient suitabilty, as this is a topic my surgeon and I will discuss in more detail after my heart cath. He did say however, that it takes about 1 hour longer than the "normal surgery", and is a little more complicated of a procedure.

I still must discuss this with him of course, but my own feeling as of now ,is I would rather have the regular procedure. The reasons are, I want to spend as little time as possible on the heart-lung machine, and I don't want to make the surgery any more complicated for my surgeon than it has to be. This sentiment was also voiced by another doctor I asked. If there is any sort of problem, he said he would want the surgeon to have full and immediate access to my chest.

Good luck

Bob Bates

[DANIEL]

Excellent point that I have heard from 2 top heart surgeons. Supposedly the homograft valve requires the most cutting and pasting.



"Also, if a second surgery is required, this valve is one which does not cause undo complications to replace it."

[Lasker]

Dear Bob,

Good luck on your cath tomorrow. I am on a laptop that's not mine and so have lost two responses to you. I'll write more fully when I return to my own computer at home in Westchester later in the week.

The cath is not bad at all. I had mine in July when I didn’t know much about valves so I didn’t find out if I am a candidate for the C-E Perimount.. I’ll check the cath report about aortic root size.

I feel as you do about the extra time on the HL machine and so do not want the port. We still are trying to learn more about the sternum MI but as yet do not access to the full papers , just abstracts, of the group at NYU which publishes their outcomes with this procedure.

The 17 year C-E study is by Banbury at the Cleveland Clinic who followd 268 patients, I believe, at four institutions. The VA did a 15 year outcome study. I don’t know about 20 years.

I was able to watch the monitor and converse wiith the cardiologist during the cath. The most alarming thing was the nurse approaching with the razor to prep the site. The clamp following the procedure (opt for a stitch if possible) and lying flat for four hours afterwards were the uncomfortable part. All in all, better than I would have expected.

Best,

Lorraine

[chilihead]

Bob have you considered a stenless pig valve?

[conk]

I know you've had many opinions on both sides of the tissue/mechanical decision, but I'm viewing things for real on both sides. I was in your same situation just 1 year ago. For the same kind of reasons as you've expressed, I ended up choosing a Homograft valve for my AVR that was performed 12/20/02. I also had a bicuspid Aortic Valve.

The surgery went well and I recovered very fast, however there was bad news. My echo 2 weeks after surgery showed the valve was leaking. Turned out that one of the cusps was prolapsing and allowing the blood to leak back into the left ventricle.

I was able to get only 8 months out of this valve. Not wanting to take the chance on this happening again, I chose a St. Jude’s valve for my second AVR performed 8/26/03.

Since I could not have known what would happen prior to my first decision, it's wrong to second guess the decision, but can't help wondering how I would be doing now if I had chosen a mechanical valve the first time around.

I am into cycling and understand there are some risks associated with a bad fall, but I'm willing to deal those risks and coumadin thus far in my two months has not been a big deal, although I'm starting the process for a home test system.

Good luck with your decision. I know most tissue valve choices don't end up like mine, but you do need to consider this possibility. I had not even thought about it prior to my surgery. Probably would have made the same decision, but maybe not.

[Bob Bates]

Conk;

Thanks for your insights based upon your own experience. I do understand there are pitfalls no matter which way you go on valve choice. As I have mentioned before on other posts, it seems for every "success" story about a particular valve, someone has a story which counters it.

Most people seem to have no real problems with coumadin use, and if I was in your shoes, I too would have chosen the mechanical the second time. All I can do right now is evaluate the statistics in light of my own situation and preferences, and take a calculated risk that my choice will be right for me.


Regards,

Bob Bates

[Bob Bates]

Chilihead;

Regarding your question about Stentless pig valves: I have not done as much research on them as I have done for the CE perimount bovine pericardial, because the bovine seems to have some good durabilty stats. Whereas I haven't come across any stats on the durabily of say, the Toronto SPV, since its a newer valve.

If you have any reasons why you think they may be a good choice in a tissue valve, especially versus the CE bovine pericardial, please pass them on.

Thanks very much.

Bob Bates

[bvdr]

Hi Bob,

Dr. Glower did a mitral valve replacement by way of a heart port procedure on me in August of this year. On my Operative Note it states I was on the bypass for 198 minutes and I was cross clamped 149 minutes. I only had to be defribrillated 1 time. Total surgery time was a little under 8 hours and time I was under anesthesia was 507 minutes.

I don't know if this amount of time is about average or not.

The heart port procedure causes alot of stress to the right lung according to my cardiologist so you may want to factor that in as well.

[Christina]

Hi Bob,

I see that many people already expressed their thoughts on this very important issue, but I want to give you mine because I have my own personal story. (read in the personals)
I had two AVR's in August 2000 and my doctor made the choice for me because I was over 50 and he told me "you don't want to do this too many times, especially not at an older age". I agreed as "I NEVER WANTED TO DO THIS A SECOND TIME".
I received a Sultzer Carbomedic mechanical valve the first time and was told that this valve would last "a lifetime". Little did I know that something would go wrong and I'd be on the table again to receive a second mechanical valve within 11 days after the first surgery.
Coumadin needs to be regulated & monitered regularly by a professional, (later you learn and can do it yourself) and if you go with the mechanical I would recommend you get your own machine so you can test anytime, and not have to deal with the labs. Those are a pain in the you know what, plus scar tissue becomes an issue within the first year. That was my main concern, plus my doctor's conduct towards me was less than desirable and totally stressed me out every week. I had to fire him later.
I am fine now three years out, but two OHS do a number to your system. It took me more than a year to fully recover.
Coumadin can fluctionate quite a bit, and interferes with many things. I have my own Protime machine. Insurance didn't cover, so I paid out of pocket. I have been doing my own testing since January 2001 and I like it this way. I eat what I want and do what I want. I adjust the dosage according to my lifestyle, and not the other way around. I test once a week and call the results in to my doctor once a month. He agrees me doing it this way, so I feel free.
I've had no problems so far, but that doesn't mean I take this drug lightly. I am much more concerned with a low INR than with a high INR, so I keep my numbers higher. I can deal with a bleed (never have had one) but a clot or stroke can be fatal, so I try to stay safe.

Wishing you all the best in this difficult choice.

[Bob Bates]

Christina;

Thank you very much for your insights. You highlighted very well the dilemma I am facing: the issues involved in taking coumadin, versus the very likely second operation. I have given this a lot of thought. There are very real risks in the second OHS, not to mention the discomfort and recoverey time.

But I want to live a very active lifestyle, as close to "normal" as possible, and I believe that a tissue valve is more compatible with that than the mechanical.

Thank you very much

Bob

[Bob Bates]

Betty

Thank you for your comments on "port access" surgery. Since we have the same surgeon ( Dr. Glower -Duke Medical Center). its especially noteworthy.

I have not discussed this with Dr. Glower in depth yet ( I just had my Heart cath. on 10/21/03), but he told me in our initial meeting that the PA requires about an extra hr. on the heart-lung machine, and makes the surgery a little more complicated that the regular incision.

I am not concerned too much with the cosmetics of the cut.
My thought right now is I want to minimize my time on the HL machine, and make the surgery as easy as possible for Glower. So if I had to make the choice now, I would opt for the regular procedure.

I welcome any additional comments from you, or anyone else for that matter, regarding my thinking on this issue.

Thanks

Bob

[rcatalano]

Bob,

I agree with you on this - I'd rather make the surgery as easy as possible on the surgeon. Sure, he could probably do the port access, but why make it more challenging for him? It's like giving Michael Jordan a layup instead of a foul shot!

I also didn't care about the cosmetics. For my second AVR, the surgeon told me the incision wouldn't be as long as my first one 14 years earlier. The 2 inch shorter scar - well - I could care less at this point.

As for the tissue vs mechanical, well, I already tried to address that tactfully but some still get their feathers ruffled. You know the issues and will make an informed decision. You seem to have done a good job separating the facts from the opinions. Having had both tissue and now mechanical, I can understand both sides of the issue.

The big day is approaching fast. Good luck!

Rob

[Bob Bates]

Rob;

Thanks for your comments, and the compliment about separating fact and fiction. The problem is however, as you are well aware, there are facts, and then there are emotional / subjective issues to consider which are quite different for each person. Even the so called "facts' can be interpreted different ways depending on your point of view.

I have enjoyed reading your posts due to your somewhat unique perspective on both the mechanical and tissue valves. Also ,as someone who will probably face two OHS, I have to admire your apparent "coolness under fire" so to speak, in facing the two you have undergone.

But frankly, I am almost tired of thinking about it now. I have made my decision to go with the tissue valve, and now as I face my AVR on Nov. 3rd ,I just want to get it over with.

My only concern now (other than the fear factor !), is that the surgeon will get in there and find some reason why my valve choice can't be implanted. My heart cath. on 10/21/03 was good however, no blockages other that the valve. Of course, I will be discussing a backup plan with my surgeon before the big day.

Regards,

Bob

[rcatalano]

I had a great sense of relief when the decision was made, though I still had a few months prior to surgery. I even refused to re-evaluate it, as some tried to get me to do. Like you, I was tired of thinking about it.

I think you made a sound, reasonable decision.

I never even thought about a back up plan. Good idea, at least the surgeon will know what your input is. Of course, at that point, its all up to his judgement.

You've covered all the bases, sleep well knowing your cath was 'clean' and your surgical team is one of the best in the country. OK - try to sleep well...

Rob

[Bob Bates]

Rob;

Thanks again. At the risk of getting too emotional here, I want to say to you and to all on this site how much the words of encouragement have meant to me.

Most of us are strangers to one another, but there is a bond here due to the obvious shared experiences. Its one thing for someone who has never been through this to say "it will be alright / heart surgery is almost a routine thing", etc., and quite another to hear good things from someone who has been there.

Bob

[HFK]

Dear Bob , Congratulations on your decision. I felt a big weight was lifted when I made my choice. I think all along in your heart you knew you wanted, a tissue valve, you just had to look , listen , and you now know it feels right for you. I am happy for you and hope you surgery goes well. HFK

[LKC]

Bob,

I well remember that "I just wish this was over with" feeling. I had a leaky bicuspid aortic valve replaced with a CE perimount bovine valve in January 2002 at Cleveland Clinic. I believe that is the preferred tissue valve at Cleveland. I was 52 at the time. I did not do much research on valves except to decide I wanted a tissue one rather than a mechanical. My reasons were similar to yours.

They did a traditonal operation on me, cracking my chest and all, and I must say it was MUCH LESS traumatic than I had anticipated. I flew home to South Florida five days after surgery. The operation has had no effect on the routines of my daily life; I quickly returned to the lifestyle I enjoyed before the surgery. I hardly ever think about it now.

I don't have a pre-op fitness baseline to compare to, because although I had been an exerciser in my younger years, I had not been very active in the years leading up to the surgery (lazy-related, not cardiac). Nevetheless, I have exercised some since the operation, and when I'm puffing hard I get a sense that the artificial valve does not function as well as the original, but the difference (if there really is one) is insignificant for a person of my age and athletic prowess.

Sometimes I think about the fact that someday I will need another operation, and it is not a pleasing thought, even though my experience was about as benign as it could be. On the other hand, it is not an unsettling thought either, or something I worry about. It seems like a distant challenge, and I feel sort of how I felt 12 years ago when I was first told that someday I probably would need the first AVR.

Good luck. I'm sure things will go very well for you. We will be thinking of you.

Landon

AVR - January 2002

[Bob Bates]

Landon;

Those are the words I want to hear: that the OHS was MUCH LESS traumatic than you thought it would be! Obviously, that is a major concern as my surgery date is a few days away (11/3/03).

I admit I am still second quessing a little bit about my valve choice ,since I don't know just how bad the first OHS is going to be. So your words of encouragement are very , very welcome.

A question for you since you in fact had the CE bovione valve, which is my first choice in a valve. Were you told before the surgery that you would be able to engage in very active pursuits with the CE bovine valve? Have you felt restricted in any way with this valve, other than what you mentioned in your post to me?

Again, thanks for taking the time to pass on your thoughts.

Regards,

Bob

[LKC]

Bob,

I don't recall any restrictions after the 6 weeks recuperation period. I think there may be an issue about lifting heavy weights, but since I don't do that and have no plans to take it up, I didn't ask. My understanding was, and is, that there are no restrictions, but you probably should go over that with your doctors. In addition, unless you are a high-level competitive athlete, I don't believe that the valve will significantly affect athletic performance. To the degree that the valve does affect performance, I can't believe there would be much difference between valves.

I certainly have not encountered any restrictions or differences. After the surgery, I took up handball again after 20 years, to stretch and strengthen the upper body, and felt just fine. I believe that if I wanted to train for it, I could easily start doing 5 and 10K footraces like I used to do 10-15 years ago.

The second guessing is natural; we all do it. The best advice for post-op I received: when you feel a sneeze coming on, push firmly immedately below and between your nostrils and the sneeze usually goes away. Good luck next week.

Landon

AVR - January 2002

[Bob Bates]

Landon;

Thanks for you reply about the CE bovine valve performance. I am no athlete by any means, but up until a few years ago , I jogged a couple of miles a day, and went backpacking on a regular basis. I want to resume those activities, perhaps even start a weight trainning program.

The CE valve is a stented valve, which all else being equal provides a smaller orifice than an unstented valve. But I was told by my surgeon that unless I had an very small arotic root, this valve would allow me to do the above activities. Your experience seems to confirm that possibility.

Thanks again for the information and your words of encouragement.

Regards,

Bob Bates

[Birky]

I was hoping for a repair but have a St. Jude mechanical. I ordered my operative report from the hosptial and found that when they opened me up, they thought that the valve had another infection on by the way it looked so they opted for the mechanical. Turned out to be vegetation. They took pictures of the valve to give to me. Pretty gross. If it wasn't for that , I guess they could have done the repair. My cardiologist had no way of seeing this prior to surgery or did the surgeon. Coumadin isn't really an issue. I took it for 7 years prior to the surgery as a precaution. I now have the readings sent to a Coumadin clinic versus the family Doc. Having the family Doc regulate was a nightmare. At this point I am so glad to be fixed. I am going to look into the home testing but not for a while. We have bcbs so maybe they will pay for this since they pay for my husbands needles, strips etc. for diabetes. I was 55 when they replaced my valve on 02/27/03. Good luck in your choice.

[bvdr]

Hi Bob,

I just found this note and thought you might be interested.

ABSTRACT 102

PORT-ACCESS AORTIC VALVE REPLACEMENT

Donald Glower
Duke Univ, Durham, NC

Purpose: To apply port-access techniques to aortic valve operation (AVR} via right thoracotomy.

Methods: A 60yo lady presented with severe aortic stenosis after pervious median sternotomy. An 8 cm incision was made in the right 3rd interspace. The right 3rd and 4th costal cartilages were detached from the sternum. A standard pursestring was placed in the ascending aorta, and the aortic was cannulated through the incision. A percutaneous 25Fr venous catheter was passed from the femoral artery into the right atrium. Once on pump, AVR was conducted in the standard fashion using a flexible external aortic clamp. Laparoscopic instruments can be used but are not necessary. The groin stab was repaired with 2 absorbable subcutaneous sutures. The rib cartilages were reattached to the sternum using two #4 figure-of-eight sternal wires.

Results: The postoperative course was unremarkable and the patient was discharged on the 5th postoperative day.

Conclusions: In patients desiring minimally invasive AVR, a small right thoracotomy with modified port-access techniques is an excellent option. Advantages relative to other sternal splitting incisions include avoidance of sternotomy, excellent cosmesis, and few wound complications.

[maxximom]

Hi Bob.. Sorry I didn't see your post before this.. I have been off the computer for the last few weeks..the heart's fine..the darn back has been causing me problems..but that's another long story:o I had a triple bypass and a AVR 2 years ago at Duke with Dr. Glower as my surgeon. I have a St Judes Toronto Stentless Porcine Valve. Dr Glower is very open to whatever valve that you may want..but in the end HE must make the decision of what will be the best for you when he actually gets in there and takes a good look.I was older 70 at the time of my surgery and told Dr. Glower that I wanted a tissue valve and not a mechanical valve if possible..we discussed my choice for quite awile and he understood my point of view. If I can help you in any way please feel free to email me and I will give you my phone number. I live in Wake Forest not to far from Duke..so if I can help you or your family in any way..I would be very happy to do so.Much good luck with your surgery..you are in good hands with Dr Glower
Joan
AVR, triple bypass,Sept25.2000, St Judes Toronto stentless Porcine Valve, Duke Medical Center, Dr Donald Glower

[mike anthony]

Bob, everyone is different and I think you made the right choice. I had 2 open heart surgeries within 9 months and went with a tissue valve(Bovine). My first surgery was due to an AA. It has been 9 months since my last surgery and I'm back playing basketball, golf, ect;. My second surgery was much easier than my first and I know at sometime in the next 15-20 years I will need another one. What helped me more than anything was I asked my surgeon, what would you do? He indicated to me without a doubt he would go with a tissue valve. I hope everything goes well for you and you will be in my prayers.

[Bob Bates]

To Betty, Joan, and Mike Anthony;

Thanks to you all for your information, advice, words of encouragement, and offers of support.

Betty- your comments were especially timely, as I must make the decision of port- access vs. sternal splitting soon. I am thinking sternal splitting for reasons I may have mentioed before: less time on the pump, and less risk if there is a problem, so Dr. Glower will have full and immediate access to my heart.

Mike: I have read many of your posts, since you had the bovine valve I was very interested in what you had to say. Although there are no "right or wrong" answers on valve choice, it is nice to hear someone say I made the right decision.

Regards,

Bob

[peter zug]

I had an aortic valve replaced 4 years ago when I was 49years old . I was sure I wanted a tissue valve (until my surgeons reccomended a mechanical valve) due to the coumadin life therapy.
The reality of a second open heart operation forced me to rethink the options. The valve I got was a Carbomedics valve supposedly "Bench tested for the equivalent of 200 years"
Hopefully your surgeon is up on the latest model of whatever valve they reccomend.
I returned to my job as a Ski Patroller after a few days past 2 months.
The following summer I returned to work roadbuilding as a construction laborer.
You can do everything you want to do for the rest of your life.
Coumadin hasn't proven to be that much of a big deal either. Blood is a little thinner but after you get used to it, and are able to keep blood in acceptaable ranges reccomended by the cardiolgists,it is no real problem.
I also self test INRS so with the advise of the doctor's office, I make all the dosage decisions for coumadin.
I was worried about getting out somewhere without the drug, but like most other things , it becomes part of your life.

Good luck, ask alot of questions, do alot of research.Hang in there and work hard to get through the first week or two and things get better fast.

[Bob Bates]

Peter;

Thanks for your comments. I have to admit a second AVR is a big scary unknown, due to advanced age and potential poor medical condition at the time it takes place. Plus, like you, many folks have indicated that coumadin is no big deal. However, it can be a big deal, and there are definite risks associated with its use as well. I am sure I could deal with it if I had to.

But, I've expressed the thought before, for me , the trade off is no real restrictions/ risks associated with coumadin for hopefully 15 years or so, in exchange for the second reop and its risks.

To me, assuming you do in fact have a choice, the coumadin route is the "safe" path, taken to avoid that 2nd OHS. But you pay a price for that the rest of your life in having to deal with coumadin.

All of this is very subjective. You belive the "price" you are paying to take coumadin is not that high. Others have expressed a different opinion. There really is no right or wrong.

I appreciate you relating your experiences to me. This has been one big learning curve for me, made possible by hearing from many good people.

regards,

Bob

[bvdr]

Bob,

You are right. The choices are varied but there is no real right or wrong choice. I wish you the very best with your surgery and you will be in my prayers.

About my heartport....I hadn't ever really discussed it with Dr. Glower until the night before surgery. He suggested it as he thought I might have a faster recovery time. (Maybe he had a resident or another Doc. that needed to do a heartport to complete their training);)

[Bob Bates]

Betty;

Thank you for your kind words. I hope I don't need God's intervention, or good luck, but I'll take as much of it as I can, just in case.

Dr. Glower just emailed me and said we would be discussing the port access decision at my pre-op screening this Sunday, 11/2/03.
I know he is known for this procedure, and probably does need to instruct his residents. And I would like a shorter recovery time. But like I said before; I want this to be as quick as possible, with the least amount of risk to me as possible. The trade off may be a big scar, and a longer recovery time.

Regards,

Bob

[mike anthony]

Bob, like my doctor told me," they can cut my head off as long has they put it back together right. If something goes wrong I would rather they can get to it right away". You are going to be fine and I really think you will be amazed on how fast you recover.
I was out playing golf today and as I was walking, I thought jeez just 9 months ago I was under the knife for the second time. Today I hardly know that I've had surgery, accept for some pain do to the nerves. Again. good luck and you will be on your way to recovery before you know it.

[mike anthony]

Bob, like my doctor told me," they can cut my head off as long has they put it back together right. If something goes wrong I would rather they can get to it right away". You are going to be fine and I really think you will be amazed on how fast you recover.
I was out playing golf today and as I was walking, I thought jeez just 9 months ago I was under the knife for the second time. Today I hardly know that I've had surgery, accept for some pain do to the nerves. Again. good luck and you will be on your way to recovery before you know it.