**4.5 My aortic valve had a piece of heart muscle blocking the implantation of a replacement valve**

The last echo showed a piece of heart tissue protruding into the aorta valve right where the replacement valve would be placed. Proper positioning of the replacement valve is critical for success. You do not want it too far inside the left ventricle, and you do not want it too far into the aorta itself. In fact, during the TAVR replacement procedure, the team has to agree that the valve is properly placed, and they have to agree to implant it. Unfortunately, the piece of tissue was right in the way. The replacement valve can be moved slightly, but only slightly, and there was no way to avoid the extra tissue. It might distort the frame of the valve, or it might push into the heart muscle and cause issues. The team would have to put the replacement valve over the extra tissue and hope for the best should they decide to go ahead with the procedure.

Given all the above: my unusually large aortic valve opening; my football shaped valve; my missing cusp and my fused cusps; my extensively calcified valve; and the piece of tissue blocking implantation of a replacement valve, it was fully understandable that my team was having second thoughts about replacing my valve. Obviously, they did not want a patient to die on the table, nor would they want to be accused of being reckless in going ahead with a risky procedure. However, I did not appear to have too long to live. As mentioned earlier, my EF was dropping, and it had dropped from its long held 55–45%. the opening area of the valve for the blood to flow out of the heart was narrowing to a critical point (due to calcification), and the valve had become stenotic (described to me as a lack of movement due to calcification forming

around the cusp). The risks against a successful procedure were significant, and the risks were discussed with me. I could live out my life as best I could, maybe even have a few years if lucky, or I could have a replacement valve, maybe live many more years, and maybe live a much more satisfying life than otherwise would be the case (i.e., feel better and be more active). The choice was mine. The team was willing to go ahead if I wanted them to do so. I chose a replacement valve, and I was assigned to a scheduling nurse to arrange for the procedure. The scheduling nurse had to reserve the procedure room, schedule all three physicians on my team to be there, of course get me there, and schedule the assistants and assure all necessary supplies are in place, including some replacement valves, and schedule the operating room in case I needed to be moved from the procedure room into surgery. She was able to set it all up for a procedure date in about 4 weeks.

## **5. Do not forget the dental work**

Unfortunately, on the day of the scheduled procedure, I woke up with a significant tooth ache. I tried to call the scheduling nurse and my doctor for guidance, but no one was answering their phone. I went to the hospital and went through the preparatory steps, but the procedure wound up being canceled. I was told it would not be a good idea to proceed if I had an infected tooth and there was any danger of the infection spreading to my new valve. I was told to get my dental work done and then reschedule. Interestingly enough, I began to feel like I had a little more energy. I even commented to my wife, "maybe I don't really need a replacement valve after all." I would later find out why I was having a little more energy, and I will report on that matter in a section below.

There was another issue of concern. My procedure was scheduled during the height of the COVID-19 pandemic. My wife could not accompany me to the procedure. She dropped me off in front of the hospital and wished me luck. It is difficult to imagine how stressful a procedure like a heart valve replacement is for loved ones. All medical members need to be mindful to stay in touch with the listed contact for the patient.

I thought my teeth were in good shape. I regularly visited my dentist, had my teeth cleaned, and had dental work completed as necessary. It turned out that the tooth that was aching on my scheduled procedure day was cracked down to the root and needed to be extracted. That was followed up with an implant and crown. Additionally, I had one other tooth that needed a root canal; another tooth needed a bone graft, and one other tooth needed to be re-filled because the previous filling was leaking. All the dental work took about 3 months, and the scheduling nurse was not able to get me rescheduled for another couple of months. Five months after my original procedure date, I again reported to the hospital for TAVR.

#### **6. The actual procedure**

The actual procedure started out in an interesting fashion as I was lying on the procedure table. One technician set up the echo machine and flashed an image of my aortic valve on a large elevated screen. The first thing that the technician and I both noticed was that a huge section of my aortic valve had torn loose and was being held by just a thread of tissue. On the echo, the large piece of torn valve looked like a flag

flapping in a hurricane. It moved out straight with every heartbeat and appeared as though it could tear loose at any moment. Who knows what my fate would have been had that large piece of valve torn loose. At least I now knew why I had a little more energy. My heart no longer needed to pump blood through a tiny opening in my stenotic valve. The opening was now bigger and apparently my heart was not straining as much. The physicians had not yet entered the room, and the technician's and my eyes met in response to seeing the big piece of valve torn loose and hanging by a thread. She looked at me and said, "Oh, you're in the right place." That was some of my last recollections in the procedure room as the anesthesiologist had entered and was administering my anesthesia.

It's amazing to me to think that a large replacement heart valve could be collapsed down to the thickness of a lead pencil, be inserted into my heart through my groin artery, and then blown up to full size. The frame of the valve, or stent, is a metal mesh made from cobalt and chromium. It is strong yet flexible. The tissue in my replacement valve was bovine (i.e., made from tough pericardium tissue from a cow's heart). The manufacturing of a bovine aortic replacement valve requires hundreds of stitches to form the leaflets of the replacement valve. The tissue is treated with a chemical that sterilizes the tissue, kills any live cells, and preserves the tissue for endurance purposes. It is treated with an anti-calcium building solution to reduce the chance of future stenosis. Finally, it is tested for quality assurance, because the leaflets will be opening and closing around 70 times a minute for many years to come.

The bovine valve is very different from using a pig (porcine) replacement heart valve. When using a pig valve, the entire valve is harvested and implanted as a whole valve. Some people argue about which is best, but the bottom line is that they are both good.

Everything went as planned during the procedure until my team implanted the valve into the heart. At that point, the metal frame of the valve bent around the calcification in my heart and about half of my blood was leaking around the outside of the valve and then leaking back into my heart after every beat. My team was now finding out why they had been reluctant to perform the procedure. They were not sure what to do. I was alive, and if they did nothing more, I probably would live another 6 months to a year. However, I would most likely be wheelchair bound and have no energy for daily activities. If they tried further intervention, I could die on the procedure table, and they certainly did not want that. Also, they ruled out taking me to the operating room. My cardiologist remembered from our prior discussions that I had told him I did not want to live as an invalid. I had always been active, and I wanted to return to my normal active life.

Based on my previously stated wishes, they decided to insert a balloon catheter into the valve and try to force the frame into a normal straight shape. Apparently, the tension was palpable. Too much force and the heart could rupture, and I would be gone on the spot. Using a balloon catheter, they were able to expand the collapsed frame of the valve back into a straight alignment. There was no damage to my heart. The calcification had been pressed out of the way. Some blood leakage existed, but it was minimal. They abandoned any plans they might have had of expanding the valve to minimize any leakage around the outside of the frame. It was working, and they decided to leave well enough alone. Using a smaller valve turned out to be fortuitous. Later, my cardiologist told me I was very lucky. There was a lot happening during the procedure that could have gone wrong but did not. I went home a new person the next day following the procedure.

#### **7. COVID-19**

Despite all my precautions, I contracted COVID-19 just short of 2 years following TAVR. At first, I was not too sick, but after day four I did not feel at all well for another week. I tested positive for 12 days. My general practitioner (GP) felt it was not necessary for me to be treated with antiviral medication. In hindsight, antiviral medication might have both speeded and eased my recovery. I had received all the recommended vaccines and boosters, and that no doubt helped me avoid serious illness of hospitalization. My cardiologist told me the replacement valve was likely important to my being able to fight the virus. My biggest complaint post-Covid-19 has been a loss of energy, but my energy level finally began returning to normal about 5 months since I stopped testing positive for COVID-19.

### **8. Conclusion: life after a TAVR replacement aortic heart valve**

I visit my pacemaker physician every 4 months. I am told that of all his patients, I have been living the longest with a pacemaker – almost 40 years. Unfortunately, his next patient living the longest with a pacemaker is a 42-year-old man who received his first pacer when he was 6 years old. I say unfortunately, because it makes me feel very lucky to not need my first pacer until I was 44 years old.

I am now in my third year following TAVR. I would describe my life as normal, or like it was before I became symptomatic with heart issues. In fact, if anything, I have a little more energy now with less discomfort when I exercise. I walk twice a day (about two miles total). I have been able to vacation on the Central Coast of California for up to a month at a time. This is my favorite vacation. I do not feel that the money spent on my procedure was wasted nor do I feel guilty about the cost of the valve and implantation procedure that was fully covered by my insurance (i.e., in the neighborhood of \$150 K). I fully realize that life is uncertain and that I was lucky. However, I give thanks every day for the skill of my medical team and their staff and for the extra days (now years) I have been given.

I received my TAVR 50 years after Paul Dudley White said I might surprise the cardiologists in the room who wanted to operate, and that he could not recommend me for valve replacement at that time. I thank Dr. White for his clinical expertise and experience. I sincerely hope that hearing my version of my heart valve experience will aid and be of comfort to other patients and physicians in the future.

### **Author details**

Philip Hutchens Independent Scientist (Retired), La Mesa, CA, USA

\*Address all correspondence to: khutchp@aol.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
