I am having a Ross Procedure next week and I’ve been told that I don’t need the PEARS but I don’t really understand why?
I thought the graft was a preventive measure for aortic dilation and there doesn’t seem to be any drawbacks that I can find of having it.
The surgeons said that it’s adding unnecessary complexity to the procedure in my case and that it is still a foreign body and isn’t always a benefit. It is at a hospital where they offer PEARS and I am of course running with their advice but has anyone else had this feedback?
Thank you
Richard
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Richard, what is the main reason for the procedure in your case? Bicuspid aortic valve? And do you have ascending dilatation and if so what is the current ascending diameter?
Hi Cliff, thank you for your response. The reason for the procedure is a bicuspid aortic valve, (or to be precise, Functionally bicuspid valve with fused left and right coronary cusp, sclerotic changes in the fusion.) valve regurgitation is now severe.
I don’t have my measurements from 2022 echo, it just says my aortic root is mildly dilated, I believe around 40mm they said or something but I don’t know.
From 2020 my measurements were Normal diameter of aortic root, SoV 34 mm, and ascending aorta, 34 mm.
Thanks Richard. I'm not an expert but I believe PEARS is most applicable in cases of a functional valve with enlarged root and ascending, where any minor valve malfunction is due to the dilatation, not bicuspid. It does seem to be the case that many people think that on hearing about it, they might be suitable for PEARS but in fact are not. Had it existed before my own dissection, it probably would not have prevented my dissection, which happened in the arch.
I'm sure your doctors' advice is appropriate. (Edit) Your severe regurgitation would not be fixed by a PEARS, but ongoing damage to the ascending due to the bad flow pattern out of the BAV would be prevented.
Hi Richard - and Cliff - the rationale for adding PEARS to the Ross Procedure is to avoid future dilation of the root and ascending aorta, rather than to correct or manage current dilation. The concern is that when the Ross Procedure is done without PEARS, there's a significant risk - they say, 10% - that there will then be aortic root dilation which can lead to the failure of the transplanted pulmonary valve. So the idea of PEARS is to protect the aorta and the valve and avoid the risk of needing additional surgery down the line. This may be something to discuss further with them, but the team at the Royal Brompton really are the world's leading experts on this. There's a page on their website specifically about it (see below), so I can understand the confusion! Personally, I'd be inclined to push for it, but perhaps there are specific reasons why they think the surgery may be trickier than usual? That, again, is something they are expert on because they are a tertiary referral centre and used to seeing unusually complex cases, especially where there has been previous surgery. Whatever you and they decide, all the best! - Julian
Having said that, if you're having the Ross Procedure next week, then if PEARS hasn't already been ordered and planned for, it could delay things another 8 weeks or so and that might be an issue in itself, both for you and for the surgical team.
I'm having Pears surgery done. My aorta is 5.3 mm and they said I was a suitable. I have bicuspid valve. I have been monitored for 13 years since hearing that I had an enlarge aorta., I was 3.8 mm starting off. I believe they tend to do surgery from 5.0 mm ?
Not sure about foreign body ?, I have a few foreign body in put in various operations and am ok, but I know everybody reacts differently.
Hi Richard, are you having the procedure at the Royal Brompton? I had a Ross-Pears procedure there in October 2021 and the pears was in the conversation since the start. It is an improvement to avoid a very unfortunate case of needing Re operation, so not sure why they would not use it.I can understand the foreign object narrative, and that actually caused me to stay in the hospital one week longer than needed and to be on antibiotics for two or three weeks since my inflammatory levels after the surgery would get back to normal very slowly. They said it was the body's reaction to the pears. But eventually they went down and I got discharged. Overall I was in the hospital for 3 weeks.
Certainly including the pears would now mean waiting weeks to produce it, but I would definitely ask for clarification.
I couldn’t help but noticing your name, are you the poster boy for the Ross on the Royal Brompton site? If so, thank you for sharing your story, it was one of the inspirations that helped with my choice.
So I think a factor is time, I’ve delayed the operation due to me not being able to make a decision on the valve choice and I certainly wouldn’t want to wait another 8 weeks for a PEARS so at this point just a Ross makes sense to me. That said, one of the surgeons commented from the beginning that it might not be a good idea for me after looking at my scan so maybe there are other factors involved.
Anyway, on with the Ross this coming Saturday so here goes!
Hi Richard, yes I am the guy on the Royal Brompton website. They asked me if I wanted to share my story after the surgery. They obviously simplified it lot and although the recovery was quite a good one, I still had to put in the work and lots of determination on a daily basis, since the first day after the surgery when they mobilizer you and try to make you stand up.I wish you the best of luck with your surgery, you are in exceptionally good hands. Staff at the Brompton are absolutely amazing. If you feel like it, keep us posted on your progress!!
Hello Richard, I was dilated 5.6mm and I was getting a lot of pain leading up to my surgery in August 22 I had my unique pears implant prepared and eveyrthing was ready, nobody told me anything about how long it takes to fabricate the support stent or anything else for that matter. Getting information was lile squeezing blood from a stone. I asked for a pears after reading about it and was eventually accepted. When it came to the actual surgery the surgeon decided that it wasn't a good idea so I lost my aorta and had a dacron implant. Is there anybody else here who has had their aorta replaced with a daron implant? I was traumatised because I believe that a dacorn implant has a limited life and eventually it will fail at the seams. Does anyone know how long implants last? I am now discharged and have no way of knowing how long i've got.
Hi there - I totally feel your pain, and your situation could be my own, at some point in the next few years.
The woven dacron implant actually should last every bit as long as PEARS - they're chemically the same thing. The stitching is strengthened by scar tissue, it doesn't come apart.
If you've got through the first few months after replacement surgery without complications, then you've avoided most of the possible downsides of having the more drastic operation.
You don't say what happened to your aortic valve: that is the main issue going forwards. Did the surgeon limit the operation to the ascending aorta and leave the root alone? Or did they replace the aortic valve (a Bentall operation), or do a valve sparing root replacement (David or Yacoub operation)?
There are a couple of mainly American FB groups which are full of people sharing their experiences of replacement operations: the most active one I belong to can be found by searching for Thoracic Aortic Aneurysm Discussion Group ...
Hope this is helpful, and very best of luck going forwards.
Thanks Julian, I thought Pears was a relatively new procedure, originally developed for Marfans sufferrers, so I thought I was a bit of an exception when I was referred to Professor Pepper at the Brompton. Anyway I had a regurgitating valve which the surgeon tightened up a bit when he cut my aorta out and replaced it. I don't know how much of the aorta was lost, I do know it was an ascending thoracic aneurysm and it was very inflamed when the surgeon got into it and that was why he decided to remove it completely. I did go to A&E abotu 10 months before the surgery with classic symptoms of a dissection but it was relatively minor, I still have nightmares about it and I have lost a lot of activity physically. I woudl liek to know what exactly happened in that surgery but I think it's too late to find out.
From what you say, it sounds as if the operation involved some action to protect your valve while replacing the tubular ascending aorta between the S-T junction and the arch.
At some point in the next year you should get an echo (TTE) to check how your valve is performing, and if I were you, I would be asking for an MRI - possibly even a 4D MRI Flow - to check the new structure and (if they agree to the MRI Flow) to look at blood flow patterns and pressures on the aortic wall in and beyond the arch. John Pepper seriously knows a lot about this subject ...
If your doctors are able to show you an MRI scan - I've seen a fantastic one of my own aorta - that could I think help massively to understand exactly what has been done and how it now looks and will be working.
For me, just seeing certain things - in my case, the smoothness of the dilation, the normal arrangement of blood vessels coming off my aorta, the relative normality of my aortic root and descending and abdominal aorta, and the slightly less reassuring weirdness of the tortuous arteries in my neck - has been immensely helpful and reassuring in showing me that my consultant has a clear picture of what's going on, and that it doesn't look like an immediate unmitigated disaster. And that they're not going to give up on me any time soon.
Are you still on any medication? If so, then getting that reviewed would be another point of contact where you could ask questions about the implications of your surgery going forwards, and discuss what further monitoring may be needed.
Hope these are helpful thoughts about how some of the scarier things you have been through might become, and be made, less scary as your recovery continues. All the best.
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