I have 4 days to decide - help!

[deanmenta]

Hello Everyone -

I currently have a St. Jude aortic mechanical heart valve that was implanted in 1999 and has been functioning without issue since.

A month ago I had a CT scan of my aorta and an aneurysm was detected that is worrisome enough to my surgeon that he is recommending surgery to fix this problem.

I am scheduled for OHS this coming Tuesday July 29th.

My dilemma is that my surgeon has said he could switch out my current mechanical valve with a tissue valve and therefore alleviating the need to take Coumadin any more.

He is leaving this decision up to me: leave the functioning mechanical or replace with a tissue.

He claims that either operation with be of equal challenge for him, with very high confidence of success with either choice.


WHAT SHOULD I DO ?!


I love the idea of not having to be on Coumadin anymore, but should I try to fix what isn't broke? (unless you consider taking Coumadin a 'broken' situation.


If anyone has thoughts, ideas or experiences I'd love to hear from you .

Many thanks!

Dean

 

[dick0236]

How old are you? From your profile you have had two heart surgeries so far, so this will be the third. If you are 60, or so, a tissue valve might go all the way....but if it didn't you would need a fourth surgery in your senior years. I know, at 78, that I wouldn't want to go thru it. I assume that you understand ACT and unless you have a real problem with INR management, why set yourself up for another possible surgery.....and you might be put on warfarin anyway.

 

[T in YVR]

Hi Dean,
You don't mention your age....if you're getting on in years, maybe so. If you're younger maybe not....pretty personal decision that no one here can really answer but you. I'm sure you must know the pros and cons and what life on warfarin is like after 15 yrs. Personally I subscribe to the age old philosophy that "if it ain't broke don't fix it"...but I would want him to have a good look at it and check it over, which I am sure they would do! I assume that the correction of the aneurysm has 0 impact on your current valve's performance...
T

 

[deanmenta]

Hey guys - sorry for not including my age and other specifics.


I am 48.
I had a Ross Procedure in 1999 that failed 6 months later then had the St. Jude Mechanical valve put in with no problems since.

The aneurysm seems to be a result of something going wrong near the top suture line of where my current aortic root is.
When I first met with my surgeon (Starnes @ USC) he said he would recommend cutting out the section where the aneurysm is and putting a graft aorta section there to fix, and leave the mechanical as is since it seems to be doing well.

A day or so after this meeting with Starnes I asked Starnes if it would be OK to replace the current mechanical with a tissue valve, mostly for the reason of getting off Coumadin.

He responded by saying 'yes' he could do that and it would not add complication to the surgery process.
Also, he said that the tissue valve would last approximately 15 years and at the point if it every needed to be replaced via Transcatheter Heart Valve procedure.

 

[pellicle]

Hi Dean

the only thing I can suggest is to consider that as you are already on Warfarin you at least know the drill. I have seen your earlier posts expressing the desire to get off it. Of course it is very personal. I can assure you that there are worse outcomes than just being on warfarin.

I for instance am now on antibiotics for an infection I got in the hospital during my last surgery. It looks to be set for another 5 years on antiobiotics.

Surgeries are gambles, my advice is to aim to minimise the times you roll the dice and minimise on the scar tissues.

Only you can decide, and it seems to me you are experienced enough to know the drill. Its a tough call to make and to me it boils down to your anxiety about warfarin vs the other outcomes. I leant towards mechanical for my third surgery, but I am 50 and wanted to reduce the surgeries in future.

Food for thought

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60520-5/fulltext?rss=yes

those error rates are sobering. Life may not be perfect, but it can be easier to adjust to what is than need also to cope with it getting worse...


Best Wishes

 

[river-wear]

This is going to be your third surgery? If I were you, I would hope there could never be another one. There's never a guarantee, but I'd keep the valve I have to have the lowest chance of doing it again.

I'm not on coumadin, so maybe I can't quite relate, but unless you're having a problem with it (again, my personal opinion) I would rather take medication every day than have to go through another surgery.

Whatever you decide, good luck with your surgery!

 

[joel1947]

It is likely that AVR could be done much less invasively in 10 years, either robotically or transcatheter or percutaneously. So switching does not mean another OHS. But I also am an, "if it ain't broke, don't fix it" kind of guy.

 

[epstns]

Maybe I'm the cautious one, but at 48, with a new tissue valve, you are most likely going to have to go through at least one more replacement. The possibility of TAVI or other far less invasive method of valve replacement is real, but by no means guaranteed. Therein lies the rub. The surgeon's assertion that you would be able to have a future replacement via catheter is, at this point, only his opinion.

Do you feel lucky today?

Given, as pellicle said, that you know the drill about warfarin, is it worth the gamble? I doubt that I would take it, myself.

 

[deanmenta]

I guess ultimately luck is a big factor with either decision.

If I stay with the mechanical valve and if that valve ever needs to be replaced then I am guaranteed to have to have OHS.

Going with tissue at least gives me the possibility of having TEVAR if it fails.

This is really a tough one.

Thanks for your thoughts so far !

 

[deanmenta]

I just spoke with Dr. Starnes' assistant and he imparted some more information to help my decision making.

He said that he believes Starnes would support the decision to go for a tissue valve. Their thinking is that the prevailing trend of doing TEVAR procedures to replace aortic valves will become more common-place and even the first choice to address aortic valve issues and that putting in a tissue valve now would get me to a point (10 - 15+ years) where the next surgery would likely be TEVAR.

He also said that if I had come to Dr. Starnes today as a 32 year old needing AVR he would recommend going for a tissue valve rather than Ross (my first OHS) or mechanical (my second OSH) for the reason stated above.

He also mentioned a statistic that shows every year you are on Coumadin your risk of having a major event increases 2%. So being in Coumadin for 20 years equals 20% risk and so on.

I have the weekend to mull it over but I am leaning towards tissue.

Any more thoughts guys?

Thanks!

 

[pellicle]

Hi

II have the weekend to mull it over but I am leaning towards tissue.

Any more thoughts guys?

well being an engineering guy I'm of course curious about the details of replacing the existing (but structurally failing) tissue prosthetic valve with a "valve in valve" TAVI. Naturally I know little about it, but I thought I'd do some reading. I found this article:

In conclusion, the 23 mm Sapien™ XT seems to be the most useful TAVI valve because it fits within the majority of currently used bioprostheses (23 mm and the 25 mm diameter). We suggest implanting large bioprosthesis during first-time standard AVR in order to prevent size mismatch in case of future VinV procedures.

There are points which concern me in the article but it is generally encouraging.

The point that your clinic raised of :

He also mentioned a static that shows every year you are in Coumadin your risk of having a major event increases 2%. So being in Coumadin for 20 years equals 20% risk and so on

I think misrepresents things but does not the risk of having events (even without warfarin) increase with age anyway?

My view is that you seem quite enthusiastic about the approach which you have listed as your preference: so why not just do it?

While some of us here may feel differently ultimately its not like you are discussing having "Psychic Surgery" in the Philippines or anything. What you are talking about is recognised and increasingly mainstream surgery.

If you don't do it the way you want to, I suspect that any bump on the road will be viewed as "Ouhh ... if I only I had done it my way this would not be happening" while if you do it your way any bump on the road will be "well, bumps on the road happen..."

My vote is do it your way.

Best Wishes

PS: and I agree with your reasoning in this post. It is about odds and so it is always a gamble. So from that view, its your money and I think you should place the bets how you feel about it.

 

[deanmenta]

Thanks for your response pellicle.

That info about sizing is great and I will take that up with my surgeon for sure.

I guess in my gut I feel that going with the tissue valve seems like a good decision.

Maybe in another 30 years Psychic Surgery will solve all these issues.

I'm going to keep researching and pondering it more over the weekend and hopefully come to a resolute decision by Monday.

Have a great weekend all !

 

[pellicle]

Thanks for your response pellicle.

Glad to act as a sounding board. You are after all an "old salt" at this, so you no doubt know your situation better than any of us.

The thing now (in my view) is not the decision, but to sure up your confidence that it is the right one.

My gut feeling is that this is the right one for you.

That info about sizing is great and I will take that up with my surgeon for sure.

Best Wishes

 

[river-wear]

The sizing issue is a very good point. My surgeon said that if he put a tissue valve in me, he would use the largest one he could in order to leave room for future valves via TAVR.

I'm hoping that if my repair ever fails, TAVR could still be an option for me. (However, my back-up plan was for a mechanical valve.)

As for the warfarin risk, it isn't cumulative. It's 2%/year and with home testing it's lower. I had a long conversation with the first surgeon I consulted about that.

Still, it sounds like you've done your homework and decided on a new tissue valve. You need to do what gives you peace of mind and that sounds like the best course of action for you. Good luck with everything, and I hope you have a smooth recovery.

 

[deanmenta]

thanks pellicle!

 

[Cooker]

Of course it's your choice but at age 48 I'd stick with my current St Jude. I got mine 2 months before I turned 50 and I'm still happy with my choice.

 

[Luana]

I just spoke with Dr. Starnes' assistant and he imparted some more information to help my decision making.

He said that he believes Starnes would support the decision to go for a tissue valve. Their thinking is that the prevailing trend of doing TEVAR procedures to replace aortic valves will become more common-place and even the first choice to address aortic valve issues and that putting in a tissue valve now would get me to a point (10 - 15+ years) where the next surgery would likely be TEVAR.

The tissue valve may not get you 10-15 years. You may need a replacement earlier. I've seen too many posts from those who opted for tissue having been told they'd get 10-15 years, and they needed VR much sooner.

I've been hearing about the TEVAR for almost 5 years ago when I pondered tissue vs. mechanical. If you don't mind having a few more surgeries, opt for tissue. I based my decision on not wanting an additional surgery.

No regrets. I wouldn't make a decision based on what might be possible in 10-15 years. If you don't make it that long, you're SOL.

 

[Duffey]

Thanks for your response pellicle.

That info about sizing is great and I will take that up with my surgeon for sure.

I guess in my gut I feel that going with the tissue valve seems like a good decision.

Maybe in another 30 years Psychic Surgery will solve all these issues.

I'm going to keep researching and pondering it more over the weekend and hopefully come to a resolute decision by Monday.

Have a great weekend all !

Best wishes going forward.:smile2:

 

[deanmenta]

Thank you Duffey!

 

[deanmenta]

I just re-listened to the recent Webinar conducted by Adam Pick and Dr. Allan Stewart conducted here last week.

During the Q&A section at the end there was a very interesting question posed and Dr. Stewart's answer really spoke to my situation in a very non-ambigiuos manner.

You can here the question and response here > https://www.youtube.com/watch?feature=player_detailpage&v=3RU9bIzBIM0#t=2929

That link should go to the time where the question occurs , but if it doesn't then skip to the time mark around 48:48.

Dr. Stewart states that he would choose a tissue valve for himself if he need AVR (he is 45 years old) and then rely on TAVR for future therapy when needed.

very interesting