Valve Choice for 33 Year Old: Mechanical VS HomoGraft vs Ross?

[tommyboy14]

Hello,

I was recently diagnosed with severe aortic stenosis and regurgitation (actually a month ago).
The funny thing that I am quite an active guy, am 33 and have never ever felt any symptomps. I used to do ski racing when I was in college and my wife and I regularly Ski/ DO long hikes, etc.
I have never ever felt any symnptomps (apart from over 4000 meter in the mountains, but a lot of people get short breath then).

So I went to the cardio because my doctor wanted me to see him to complete some medical forms and they told me that I will need an aortic valve replacement operation.

Ever since I have been trying to do research on my options.

To be clear I am optimising with respect to only two parameters ==> maximising longevity and avoiding another OHS (first one is already sort of freaking me out).

So, I am 33, and I understand that there are three options:

1) Mechanical heart valve
==> I.e. This seems like the most durable option. ==> But the possibility for stroke/bloodclot and the high perceived risk for that scares me a bit.
I do not mind adjusting my behaviour/diet accordingly, though I am very much a creature of habit: I tend to keep my diet pretty constant over time and happy to give up alcohol and skiing completely if necessary.

But the stroke/ bloodclot risk is non-trivial to me. They say that there is 1% risk per patient year, and at my age (if one plans living into their 90s (my grandparents lived that long so I am planning too)), there is a 50% chance of an event (stroke/major bleed) with mechanical valve.

But I heard that the ON-X valve may somehow generate less bloodclots/ strokes? is that right?

And would anyone mind commenting on here, whehter they experienced Bloodclots, TIAs or strokes and whether they were alright afterwards?
[I.e. are these events really as frequent as the data suggest?].


2) Ross Procedure

I understand that Ross is quite a complex operation because it involves a switch in heart valves.

Some of the surgeons I met with said that it could possibly be a life long solution?
But is that claim correct?

Does anyone know of any statistics on how durable that procedure is?
[Ie. could I expect to live with this for 40+ years?]?



3) Homograft.

Any ideas on how durable Human Tissue valves are would be really appreciated?
[IS there any information on durable Human Tissue valves are?]?
[or any statistics on that?]?


Sorry for so many questions all at once, but I feel like there is a lot of misinformation out there and I would really appreciate if the community/forum members could share their views.

Thanks

Tommyboy

 

[Sammy1973]

Hey Tommy Boy - welcome to the Forum. I just had my OHS AVR just 13 days ago. I feel good - still sore and in some pain but every day is getting better.

As for you, it sounds *TO ME* like mechanical is the way to go for you. However - as you'll learn by reading the great forums in this thread - there is no absolute right or wrong answer. There is the right answer - FOR YOU! I choose tissue valve because I didn't want to deal with coumadin and watching my diet (i'm not a very regimented person) and just felt more comfortable with tissue. I'm hoping that TAVR is far enough along when time comes for another surgery - but if it doesn't I'm willing to live with a 2nd OHS.

Since you are 33 going mechanical route means you'll be able to achieve your parameters. And you'll hear from some very passionate mechanical valvers on this forum that there is minimal to no impact on your after surgery life. There are risks with coumadin - however, research them with facts and data to understand what (and how small) the percentages are of complications.

Good luck in your journey. You'll be fine.

 

[Tirone]

What about a valve repair? You're young and you seem to have aortic valve regurgitation and not stenosis. Depending on the morphology of your valve you might be a good candidate. Aortic valve repairs (David or Yacoub Procedure) show pretty good longterm results at experienced centers, but there aren't many around the globe.

I have to admit that I'm a bit biased towards repairs, as I had one myself. But I guess most people on the forum are a bit biased.

 

[dick0236]

And would anyone mind commenting on here, whehter they experienced Bloodclots, TIAs or strokes and whether they were alright afterwards?
[I.e. are these events really as frequent as the data suggest?].

Tommyboy

Hi Tommy

Welcome. I was 31 when I had my aortic valve replaced in 1967. I had a stroke in 1974 that was due to my ignorance of warfarin. Back then there was a lot of professional and patient ignorance concerning ACT(anti-coagulant therapy). It left me with a vision impairment only and I pretty much adjusted to the impairment over time. It was a "wake-up call" and I have had NO, zero, nada problems since. Warfarin management is pretty simple.....take a pill and test periodically.

I have always been an active person and my mechanical valve and/or warfarin has never interfered with my activity or lifestyle......and if you do a little math, that's over 46 years living a pretty normal life.

It is said that odds of a stroke are about 2% each year in the beginning and remain about 2% per year until late in life....and as you indicate, in the 50th year post op the risk is still about 2%, not 50%.

 

[Mentu]

Hi, Tommy, welcome to VR. We all have felt the anxiety build over the idea of heart surgery. I don't think you can hear too often that this surgery combines very very low risk with an excellent outcome for almost everyone and it won't be as bad as you may fear. I'm a beekeeper and one of the first questions I'm asked is "How often do you get stung?" as though this is a terrible thing. The answer is that it happens but its not a problem because it isn't a surprise and I know how to deal with it. Much of the panic is caused by fear of the unknown. The same is true for heart surgery. The more you know, the less disturbing. As for the type valve, when you have a surgeon that you trust, he will discuss it with you. In order to really take part in a discussion, however, you need to know something of the options and it sounds as though you are doing that now. Consider that this is the Doctor who will be holding your heart in his hand. If you can trust him to do that, you can probably trust his guidance with respect to valve choice. In the mean time, learn as much as you can about your own condition and talk to people who are living now as you would like to live. Unless you have other serious health problems or complex heart problems, you can probably expect to live a long active life after your valve is replaced. Spend more time thinking about that new future.

Larry

Larry

 

[ski girl]

Can I just add that you don't have to give up alcohol or skiing with warfarin. I haven't changed my drinking habits since having a mech valve, and I took up mountain biking post-OHS as well. I've had numerous extreme close-ups with trees and rocks and while I may bruise more now, I have yet to bleed to death.

GerryChuck on this forum just got back from a ski trip doing black diamond runs and the only change he made since OHS was to wear a helmet while skiing. Probably not a bad idea for anyone flying downhill at speed!

Good luck with your decision!!

 

[Freddie]

Welcome Tommyboy,
Changing diet? Give up alcohol? Have I been doing something wrong for the past 7 years with my mechanical valve?..........Actually no I haven't. I/we adjust our dosage to our diet, but that will come in time.....no need to worry about dosages right now or changing your diet.

I've had two black eyes, stitches, some major bruises and cuts while on warfarin with no problems, just had to make sure there was ice handy. I now keep an ice-pack in the freezer just-in-case.

Keeping active is how I roll in life, no medication is going to stop me on doing what I want to do or eat what I want to eat. I do wear a helmet when it comes to sports.

As for Blood clots, TIAs or strokes; it was thought that I did experience a TIA, but test results come back negative and there was no lasting effects.
There is also good possibility that you may be put on 82mg of aspirin if you decide to go with a mechanical valve, it's just a little added protection for mechanical valvers, because it works differently than warfarin.

Any decision you make is the right decision for you.

 

[Leah]

I just turned 40 & I have had my mechanical valve for a year. I am pretty active & I chase my 2 and 3 year old around all day. I have not made any changes to my lifestyle either. I have 1 or 2 glasses of wine at night & have not made any diet changes. Everything in moderation

 

[Julian]

As always this is a personal choice. Every situation is different. I chose mechanical because I wanted to give myself the best statistical odds of avoiding repeat surgeries. I was 28 at the time of my surgery. I took a chance with the On-X valve based on the manufacturers claims. One feature that stood out for the On-X valve to me was the pannus protection. Someone please correct me if I'm wrong but I don't think there has been one reported case of pannus valve obstruction with the On-X valve. Everyone's surgery experience is different. My surgery recovery wasn't fun, it was difficult. I ended up with a pacemaker which happens 5% of the time after aortic valve replacement, this was something I wasn't planning for. If I had to do it all over again I still would of chose mechanical.

 

[pellicle]

Hi Tommyboy

if you don't mind my longer answer to your question I certainly don't mind your long question.

a very quick backgound on me. I'm now 50. I had my first OHS at about 9 and it was (in todays language) repair the valve. I had my second operation at 28 which was a homograft and I had my next (and most recent) operation in 2011 to replace that with a mechanical valve. The primary driver for that operation was because of an Aortic aneurysm but the valve would have needed replacing in another year or two anyway.

So that means that I got about 20 years from my Homograft. In a younger person that's outstanding in comparison to any tissue valve. Since you also ask about homograft I will give you the the related (to you)results of the surgical team who did mine:
The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve replacements.

1,022 patients (males 65%; median age 49 years; range: 1-80 years) received either a subcoronary (n = 635), an intraluminal cylinder (n = 35), or a full root replacement (n = 352). There was a unique result of a 99.3% complete follow up at the end of this 29-year experience.
...
For all cryopreserved valves, at 15 years, the freedom [from reoperation] was
- 47% (0-20-year-old patients at operation),
- 85% (21-40 years),
- 81% (41-60 years)
- and 94% (>60 years).

so my age group (and yours) got the best time out if their homografts (except for the elderly for whom many died of other causes before needing valve replacement)

I was recently diagnosed with severe aortic stenosis and regurgitation (actually a month ago).
The funny thing that I am quite an active guy, am 33 and have never ever felt any symptomps.

that's actually a really good factor. For it means that you are most likely to have the best recovery.

I used to do ski racing when I was in college and my wife and I regularly Ski/ DO long hikes, etc.

That's great My wife and I did lots of cross country skiing towing sleds

and I also enjoy stupid things like rock climbing and abseiling.

and I'm a crazy motorcycle rider too. Right now I'm in Finland but will be going back to Australia soon. I'm planning a trip to the UK before returning to Australia to face my "music" (more on that later). I mention this because there is a pervasive but wrong thinking out there which says being on warfarin limits your life. It limits it far less than people grasp, especially with modern self testing equipment such as exists now.

Life is for living and death is the final word.

So it is within that context that I tell you this: I have no concern about warfarin and with a little intelligence its quite manageable. I make no changes to my diet and I drink beer, wine or brandy when I want. Importantly there now exists accuate and reliable INR monitoring tools to enable you to keep your INR within the "theraputic range" which really only have just started becoming main stream (I can write to you at length if you like). These machines make taking warfarin much less hassle than ever and certainly less hassle than being a diabetic.

To be clear I am optimising with respect to only two parameters ==> maximising longevity and avoiding another OHS (first one is already sort of freaking me out).

admirable goals for sure and my reply is totally with that in mind.

1) Mechanical heart valve
==> I.e. This seems like the most durable option. ==> But the possibility for stroke/bloodclot and the high perceived risk for that scares me a bit.

understood ... I would temper your concern with the fact that the data you find on the outcomes of warfarin cover the elderly and the infirm as well also as those with many other complicating "co-morbidities" ... the outcomes for typically healthy adults are quite fine. Skigirl and theGymGuy are two other such examples and of course **** here too is one of our real long termers (who did not benefit from such accurate monitoring as we have in our homes today).

The Mechanical valve is the only option which gives you a possibility of a life without reoperation. To be sure you may need reoperation from an aneurysm (discuss this with your surgeon) but aside from that the newer valves are simply great (and getting better).

But the stroke/ bloodclot risk is non-trivial to me. They say that there is 1% risk per patient year, and at my age (if one plans living into their 90s (my grandparents lived that long so I am planning too)), there is a 50% chance of an event (stroke/major bleed) with mechanical valve.

Firstly that's the absolute worst case scenario, assuming you follow the 'usual care' management promulgated in the USA. If you were to self manage then the worst case results are better by more than 3 times at least.

I think that road accident statistics can also be thought of this way, and you can find people who fall well outside the 'statistics' ... in many cases this is because they are safer drivers.

But I heard that the ON-X valve may somehow generate less bloodclots/ strokes? is that right?

compared to the older valves yes, the On-X valve was also my personal first choice, but my surgeon implated an ATS (now called Medtronics) valve. I have learned since then that the others have similar advantages. The move to Pyrolytic Carbon was perhaps the most important and then the addition of fluid dynamic studies to optimise design to minimise pressure gradients (which occur at opening and closing) was significant as this can prevent clots being initiated.

I have some academic papers on this, so let me know if you are interested and I can email or dropbox them to you.

And would anyone mind commenting on here, whehter they experienced Bloodclots, TIAs or strokes and whether they were alright afterwards?
[I.e. are these events really as frequent as the data suggest?].

I've addressed this above

2) Ross Procedure

I know little about this, but if you search the archives here you'll find that:
* you end up having two valves replaced, destroying a perfectly good one for giving you an autograft for the bad one
* results for your age group suggest between 7 and 11 years on the few reported cases here.

Some of the surgeons I met with said that it could possibly be a life long solution?But is that claim correct?

I have never seen any data to support that claim.

3) Homograft.

Any ideas on how durable Human Tissue valves are would be really appreciated?
[IS there any information on durable Human Tissue valves are?]?
[or any statistics on that?]?

addressed above....

Let me end by saying this. I've had a personal 40 year (perhaps longer) history of managing and living with my heart. I've had three surgeries spanning that 40 years. There are few here who have such personal experience. You are very right to be concerned with reoperations, as at your age multiple reoperations are dangerous as you increase the number of reoperations. At your age, improper choices could see you needing 3 surgeries, which has its issues.

Personally I have experience with post surgical infections. In my last surgery I got an infection in the sternal wires, which went beneath the wires. Nearly 2 years later I am no certain of the outcomes from that. I urge you when reading literature to note that they mainly consider themselves with morbidity (death) or reoperation as the outcomes. They do not discuss the management of infections and the rates are higher than you may like to think. This is something to weigh in the balance against the possible outcomes of warfarin therapy. You are in control of your warfarin therapy you are not in control in subsequent surgeries.

I have on my blog many thoughts about my heart valve replacement surgeries. This is a link to the search term "heart valve replacement" on my blog and contains many of my thoughts and experiences in the last few years.

If you wish to chat about things, I encourage you to PM me (so that I know you are asking me something) and if you use skype I'd be happy to have a chat about things with you at your convenience.

Best Wishes

 

[tommyboy14]

Hi ****,

thank you so much for sharing your experience with me.
I really appreciate it.

Your story is so encouraging to someone my age .
If you do not mind sharing how your stroke happened, was it becasue you missed one dose (one day) of warfarin or was it longer than that?

Also did you self-monitor at the time (I suppose not, since self-monitoring is only a recent thing?)?

Thanks
Tommy

Hi Tommy

Welcome. I was 31 when I had my aortic valve replaced in 1967. I had a stroke in 1974 that was due to my ignorance of warfarin. Back then there was a lot of professional and patient ignorance concerning ACT(anti-coagulant therapy). It left me with a vision impairment only and I pretty much adjusted to the impairment over time. It was a "wake-up call" and I have had NO, zero, nada problems since. Warfarin management is pretty simple.....take a pill and test periodically.

I have always been an active person and my mechanical valve and/or warfarin has never interfered with my activity or lifestyle......and if you do a little math, that's over 46 years living a pretty normal life.

It is said that odds of a stroke are about 2% each year in the beginning and remain about 2% per year until late in life....and as you indicate, in the 50th year post op the risk is still about 2%, not 50%.

 

[neil]

hello tommy, welcome fellow brit, do your homework listen to the cardio and surgeon as they are the experts, pick your valve choice for YOU, and you will do just fine,

 

[dick0236]

Your story is so encouraging to someone my age .
If you do not mind sharing how your stroke happened, was it becasue you missed one dose (one day) of warfarin or was it longer than that?

Also did you self-monitor at the time (I suppose not, since self-monitoring is only a recent thing?)?

Tommy

At the time of the stroke I was a mid-level, hi stress, marketing manager with a very large company. My wife, kids and I went on a boating/fishing vacation for 4-5 days and I forgot to take my Counadin(warfarin) with me. I knew that I had forgotten it, but thought I could go several days with no problem.....a very bad idea. My first day back to work after the vacation was very hectic and the stroke occurred that evening. Felt like somebody hit me in the back of my head with a sledge hammer. I was hospitalized three days and, other than the vision thing, suffered no lasting problems. That was 40 years ago and by following the simple rule of "take the pill(warfarin) as prescribed", I have had no problems.

Self-monitoring is a relatively new concept. From my surgery until the late 1980s(?) all testing was done by venus blood draws and lab tested. I've had monthly "finger sticks" by INR labs since then and began self-testing a few years ago. Doctors around my area are reluctant to allow self testing, so I test weekly at home, but have to go to the lab monthly.....although his lab and my self-testing are, almost always, very close.

At the time of surgery my docs told me my valve would last 50 years. In a little over three years I'll reach that threshold. I believe that my longevity is primarily due to having the surgery BEFORE any lasting damage was done to my heart...even tho, at the time, I did not believe I'd be around for 50 years.

Do your homework, make YOUR decision...."git 'er dun"

 

[tommyboy14]

Hi Pellicle,

thank you so much for your help and sharing your experience. You are a real light at the end of my tunnel. I..e I am really impressed that one can still do all of these great things when on coumadin/warfarin and putting all of the pictures up really gave me hope that my life will go on as before. Thank you so much.

Can I just ask about a couple of things that you mentioned:

1) Only one of the surgeons mentioned Homografts to me. But they seem like a really good idea, i.e it seems to last longer in young adults than tissue valves, but they seems to have gone out of fashion. Does anyone have any idea why that happened maybe other than scarcity?

2)Are the machines that you mentioned for INR managment really so reliable?
[I.e. I reckon that even if you are off by .3 and the machine says 2, when it is 1.7 could be risky?]

3)I am really interested in academic material on these issues. I.e. are there any studies that show that self-management leads to risks that are three times lower as you say?

Thanks a lot for all your help.

Reading this forum and interacting with you is incredibly helpful.

Thanks

tommyboy

Hi Tommyboy

if you don't mind my longer answer to your question I certainly don't mind your long question.

a very quick backgound on me. I'm now 50. I had my first OHS at about 9 and it was (in todays language) repair the valve. I had my second operation at 28 which was a homograft and I had my next (and most recent) operation in 2011 to replace that with a mechanical valve. The primary driver for that operation was because of an Aortic aneurysm but the valve would have needed replacing in another year or two anyway.

So that means that I got about 20 years from my Homograft. In a younger person that's outstanding in comparison to any tissue valve. Since you also ask about homograft I will give you the the related (to you)results of the surgical team who did mine:
The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve replacements.


so my age group (and yours) got the best time out if their homografts (except for the elderly for whom many died of other causes before needing valve replacement)



that's actually a really good factor. For it means that you are most likely to have the best recovery.



That's great My wife and I did lots of cross country skiing towing sleds

and I also enjoy stupid things like rock climbing and abseiling.

and I'm a crazy motorcycle rider too. Right now I'm in Finland but will be going back to Australia soon. I'm planning a trip to the UK before returning to Australia to face my "music" (more on that later). I mention this because there is a pervasive but wrong thinking out there which says being on warfarin limits your life. It limits it far less than people grasp, especially with modern self testing equipment such as exists now.

Life is for living and death is the final word.

So it is within that context that I tell you this: I have no concern about warfarin and with a little intelligence its quite manageable. I make no changes to my diet and I drink beer, wine or brandy when I want. Importantly there now exists accuate and reliable INR monitoring tools to enable you to keep your INR within the "theraputic range" which really only have just started becoming main stream (I can write to you at length if you like). These machines make taking warfarin much less hassle than ever and certainly less hassle than being a diabetic.



admirable goals for sure and my reply is totally with that in mind.




understood ... I would temper your concern with the fact that the data you find on the outcomes of warfarin cover the elderly and the infirm as well also as those with many other complicating "co-morbidities" ... the outcomes for typically healthy adults are quite fine. Skigirl and theGymGuy are two other such examples and of course **** here too is one of our real long termers (who did not benefit from such accurate monitoring as we have in our homes today).

The Mechanical valve is the only option which gives you a possibility of a life without reoperation. To be sure you may need reoperation from an aneurysm (discuss this with your surgeon) but aside from that the newer valves are simply great (and getting better).





Firstly that's the absolute worst case scenario, assuming you follow the 'usual care' management promulgated in the USA. If you were to self manage then the worst case results are better by more than 3 times at least.

I think that road accident statistics can also be thought of this way, and you can find people who fall well outside the 'statistics' ... in many cases this is because they are safer drivers.




compared to the older valves yes, the On-X valve was also my personal first choice, but my surgeon implated an ATS (now called Medtronics) valve. I have learned since then that the others have similar advantages. The move to Pyrolytic Carbon was perhaps the most important and then the addition of fluid dynamic studies to optimise design to minimise pressure gradients (which occur at opening and closing) was significant as this can prevent clots being initiated.

I have some academic papers on this, so let me know if you are interested and I can email or dropbox them to you.



I've addressed this above



I know little about this, but if you search the archives here you'll find that:
* you end up having two valves replaced, destroying a perfectly good one for giving you an autograft for the bad one
* results for your age group suggest between 7 and 11 years on the few reported cases here.




I have never seen any data to support that claim.






addressed above....

Let me end by saying this. I've had a personal 40 year (perhaps longer) history of managing and living with my heart. I've had three surgeries spanning that 40 years. There are few here who have such personal experience. You are very right to be concerned with reoperations, as at your age multiple reoperations are dangerous as you increase the number of reoperations. At your age, improper choices could see you needing 3 surgeries, which has its issues.

Personally I have experience with post surgical infections. In my last surgery I got an infection in the sternal wires, which went beneath the wires. Nearly 2 years later I am no certain of the outcomes from that. I urge you when reading literature to note that they mainly consider themselves with morbidity (death) or reoperation as the outcomes. They do not discuss the management of infections and the rates are higher than you may like to think. This is something to weigh in the balance against the possible outcomes of warfarin therapy. You are in control of your warfarin therapy you are not in control in subsequent surgeries.

I have on my blog many thoughts about my heart valve replacement surgeries. This is a link to the search term "heart valve replacement" on my blog and contains many of my thoughts and experiences in the last few years.

If you wish to chat about things, I encourage you to PM me (so that I know you are asking me something) and if you use skype I'd be happy to have a chat about things with you at your convenience.

Best Wishes

 

[tommyboy14]

Hi ****,

I am very grateful for you sharing your experience. While I am sorry for you that you experienced a stroke your longevity is a testament to the fact that life goes on after heart replacement surgery.
Thanks a lot for sharing your story with me.

Tommyboy

 

[pwoglom]

Hi Tommy,

I had my surgery a year ago and opted for the Ross Procedure. I seemed to do an endless amount of diligence and it was the best option for me. If you're interested in going that route, I would strongly recommend that you find a surgeon with significant Ross experience. As you noted, it is a complex surgery and what I learned is that not all great surgeons are necessarily great Ross surgeons. I was RP #532 for my surgeon in the US and he has done more than anyone in the US but I believe he mentioned there were two surgeons in Germany who had done more than him so it's still a relatively miniscule amount of procedures compared to valve procedures as a whole.

I ended up doing a little marketing piece with my surgeon not too long after my surgery which cites some of the advantages for younger patients if you're interested - http://www.youtube.com/watch?v=YUXt7h0a5z4

 

[ski girl]

Interesting video Peter! However I find it a bit sad that a cardiac surgeon talks about having a mechanical valve as 'having your life revolve around blood tests and blood medicines'. That's certainly not the case with me, and I don't think there are many (if any) mech valvers on this site who will say their life revolves around blood tests and blood medicines.

I chose a tissue valve my first time around (at 39 years old) due to stories of 'blood thinners' drastically reducing my ability to do anything that might result in a bruise or a cut. Eleven months later I had to have a redo and had no choice but a mech valve - and knowing what I know now about the impact of warfarin on my life (basically, no impact) I wish I had gone with mech the first time around.

For anyone considering tissue/mech/homograft/Ross, read around on this site about the actual impacts of warfarin before discounting mech (and if you go tissue and you're young, accepting repeated OHS) based on what anti-coagulation medicines will mean to you!

 

[pwoglom]

Hi Ski Girl. Point taken and by posting that, I hope it didn't come across as "anti-mech" because I was just trying to highlight some of the pro-Ross attributes which I don't think are related to any perceptions regarding warfarin. As I learned when I was in Tommy's position more than a year ago, unfortunately, there is no absolutely perfect solution to the problem. There are valid arguments to each approach but we all assign different values to the various advantages and disadvantages, hence the different choices.

 

[ski girl]

Agreed Peter - the reason it's so difficult to make a choice on valve types is that there are so many really good solutions!! And they're all better than our native valves

But to have a cardiac surgeon say that mech valves set you up for a lifetime of restrictions due to testing and taking meds is sad to see, there's enough misinformation out there already!!

(getting down from my sopabox now, very carefully, in case I fall and bleed to death HA HA)

 

[TheGymGuy]

Just read this forum, there is so much great data here. I am also a mech. valve receiver, and still, currently, a powerlifter, snowboarder, and a meathead. I eat clean, so there are greens in my diet, I occasionally have 1-3 drinks (new for me, but you got to live,right?) and I self test my INR and posted multiple times here about INR stabilization protocols, and Vit. K intake.

Mech Valve is noting to be scared of. My biggest reason for it was to reduce probability of redo's.