Decisions on Incisions

A week after my angiogram, I visited my cardiologist to discuss the results and formulate an action plan. The main action was to start me on low-dose aspirin, in addition to the pravastatin she’d prescribed immediately after the angiogram; I’d already planned to interview two thoracic surgeons:

  • Dr. M., who would operate at Good Samaritan Hospital, a mile from home — he’d seen me right after my angiogram (though I don’t remember!)
  • Dr. G., who would operate at Sequoia Hospital in Redwood City, about 30 miles away — I’d found him through web research and talking with physician friends.

Our first appointment was with Dr. M. We sat in the office for about an hour after our appointed time, but once we started talking, I realized that was because he was willing to spend as much time as necessary with a patient rather than sticking to the scheduled slot (and I suspect we put the next person even farther behind). He proposed doing both the valve and bypassing my circumflex artery in one operation, which would require a full-length sternotomy. I asked if it would be reasonable to stent my artery instead, but he said that a bypass, especially since my mammary artery was available, was the gold standard for treatment. He leaned towards a mechanical valve, since it would probably last my lifetime, though it would require me to take a blood thinner forever.

A few days later, we drove to Redwood City to see Dr. G. He ran about 30 minutes late, but his staff kept us informed about what was going on, and we saw him pop out from the office between patients. Interestingly enough, he was dressed in scrubs (Dr. M. wore a jacket and tie), and he pushed one patient’s wheelchair himself. He introduced himself by first name, too, and then dove right into what was going on with me. He started by explaining why aortic stenosis is considered “critical” once the vessel narrows beyond 1cm — it’s because of Poiseuille’s Law, which states that the resistance to flow is inversely proportional to the fourth power of the radius of the vessel. This is not a trend which leads to a happy ending.

Dr. G. said that he didn’t think my circumflex artery was a serious problem, so he suggested only replacing my aortic valve, leaving the circumflex to be stented later if it caused me any problems; he said I should have my cardiologist give me a full-on treadmill test after I’d recovered from the surgery and use those results to decide whether or not to stent the vessel; he also quoted the COURAGE study, which would suggest that medical therapy might well suffice. Since he only wanted to deal with the valve, he would do a mini-sternotomy — he said that was faster than going through the ribs and required less time on the heart-lung machine, both of which sounded good to me.

Dr. G. leaned towards using a biologic valve, even though it would probably require replacement in 15 years or so. He said his results operating on patients at the age I’d be then are good, and no worse for a second operation than for a first one. And, of course, techniques are improving. He also pointed out that using warfarin has its own risks, and over the fifteen-year period, they’re about as severe as the risks of a second operation. He explained how warfarin works (it’s a vitamin K analogue) and why it’s critical to keep the level of warfarin steady (they now are starting to let patients monitor their own warfarin level, which generally results in smaller deviations than if the only monitoring happens during doctor visits).

When I was reviewing my notes, I realized I needed some clarifications to be sure I understood everything Dr. G. had said, so I called his office. They told me to email my questions to him, and he called me back the same evening and we talked for 10 minutes. After that call, I was sure I wanted to have him operate, but I thought I should run it past my cardiologist, since she’d be taking care of me after the operation.

She and I talked yesterday, and while it was obvious that she’d prefer I went with Dr. M. (if I were to be operated on at Good Sam, she could stay in the loop while I was in the hospital), she said that Dr. G.’s plan was “not unreasonable”, especially if I chose a biologic valve. (Stenting, if it’s necessary, would mean taking Plavix, which is not a good combination with the warfarin required for a mechanical valve.) She also said there wasn’t a clear choice from her perspective.

After talking about it with Diane, I called Dr. G.’s office and scheduled the surgery for mid-January, and I plan on a biologic valve.

By the way, I spoke with patients who’d been operated on by each surgeon — both patients praised their doctors, but, as Dr. G. had said, “our unhappy patients can’t tell their stories”.

Dr. M. gave me one very good piece of advice about the decision: “make your decision, then be at peace with yourself. Don’t second-guess.” He was mostly talking about the choice of valve, but I think it applies to the whole process.

The next step is in the hands of the Postal Service — I have papers to sign. And then I wait for mid-January. In the meantime, it’s lots of walking and careful eating for me, though I do plan to have half a slice of chocolate peppermint pecan pie on Thanksgiving!

2 thoughts on “Decisions on Incisions

  1. Thank you for documenting this useful info, David. It sounds like you have done your
    homework and have a very good plan. Will keep you in my prayers for a
    very successful surgery in January.


  2. David, this is all so momentous. The good thing, I guess, is that these operations are now so widespread that one can have a true choice among excellent surgeons. Your post also made me think of this clip in which Bill Clinton talks about changes in his own post-surgery lifestyle. I’ve found it very thought-provoking and you might too.

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