High Volume Endurance Training and Tissue/Mechanical Valves...
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I’m 72 yo and almost two years out from getting an Inspiris Resilia tissue valve. I have 3,700 road cycling miles so far this year and often ride in the 65–85% of MHR zone. My last echo was normal. In discussing with my cardiologist the issue of wearing out my valve with hard aerobic efforts, his view was that the relatively small percentage of time I’m in those training zones compared with the time at a low heart rate during daily normal activities isn’t of concern. Of course, I realize two years isn’t a good test of potential longevity of my valves.
I would say that it would've been a concern the other way around if you weren't getting your heart rate to 65-85% MHR, doing exercise
Even if it wears out the tissue valve a tiny bit sooner (which I doubt), it's better to have a strong heart to accommodate future surgical interventions, if any. Or just overall good health and quality of life.
Keep up with your cycling. It's good for your heart, body and longevity.
PS: I think the originator of this thread was mainly interested in the very-high usage (such as ultra marathons, or athletes who put in a very high mileage both in terms of activity level as well as frequency/week etc). Most of us won't go that far. If we do 3-5 days/week type workout in the 80-85% range, it would probably be extremely desirable if not highly recommended for the longevity of valve and good health overall.
I personally choose mechanical valve in hope to remove this guess work.
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retainingwall
New member
I had a Bentall Procedure done 3 years ago with a tissue valve to repair an aneurysm and to replace my bicuspid aortic valve. I was 64 at the time, so that doctor convinced me to get a tissue valve. I was very active with racing MX and other sports. I still work out, but I can’t do anywhere near what I used to do. Like others have said, the tissue valve will wear out faster with rigorous training. It is what it is and I have adjusted. I don’t push it too much because I don’t want to prematurely wear the valve out. Luckily, I can have the TAVAR procedure next time. I’m not on any meds either since my OHS. If you are very active and younger, the mechanical valve might be good for you. Good luckNo surgery yet. Will have AVR and an aneurysm dealt with.... I am the process of figuring out what procedure to get and who to do it
I had OHS for bicuspid AVR and AAA 2 1/2 years ago. I was 39, actively serving in the military. Swam, road biked, weight trained, HIIT, and ran. Was very active and wanted to stay that way. My surgeon told me my lifestyle “could” wear out a tissue valve in 2-5 years, definitely in 7-8. He gave me all the literature and resources to do my own research and make the call that was best for me. I chose an On-X. I was running 5 weeks after surgery. After 12 weeks I eased back into my routines prior to surgery. A stroke at 9 months due to the false marketing low INR for the On-X set me back but I eased back into things again. 2 1/2 years later and I don’t go as hard as I did preop everyday but still push hard and just as intense a few days a week. I don’t feel the same and the valve really clicks in my ears but I won’t complain!There is a ton of great information on the site regarding mechanical and tissue valves and valve selection but I haven't found anything regarding 'higher' volume endurance training and tissue valves (or mechanical valves for that matter, but I'm pretty sure an extra few million beats aren't going to do much to carbon)...
Does anyone know of anyone doing a moderate to high volume of endurance training (more than 10-15 hrs/week with their HR at or above 70-80% HR max)?
Physics usually works
I haven't seen or heard of any people doing that sort of training. I'd love to hear about any cases.
Thanks so much for the time.
Wow what an inspirational story. Glad you're doing great, and still able to follow your intense routine.
May I ask which level you kept your INR that you had the stroke? I've the On-X valve too, and following your foot-steps (in terms of running or aerobic activity although I'm holding back on weight training thus far). I'm now 4.5 months post-op.
I kept my INR at the suggested 1.5-2. Almost always fell on the high end of that. I actually had the stroke while doing a workout on my spin bike. After the stroke my cardiologist bumped me to 3-3.5 for a 6-8 months and now I am 2.5-3.5. I try to stay around 3. The lower INR really makes no sense to me now. I don’t feel a bit different at 3. And I have had many minor nicks, scrapes, and cuts and bleeding is never an issue. Maybe at that level a severe cut or something internal may be a bigger risk. I try not to worry about it and just keep on living!
Thank you Buck83 for this post. After many years on warfarin I also believe that the lower INR guideline, below 2.0, makes no sense. In the mid 1970's (seven years post-surgery) I had a stroke with my mechanical valve because I inadvertently let my INR go to around 1. Since that time I have never let my INR go below 2. My INR range is also 2.5-3.5 and I have never had a bleeding or stroke issue since the 1976 incident. In fact, warfarin has had little impact on my life in any way.
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pellicle
Professional Dingbat, Guru and Merkintologist
Sorry you went through the "university of life on this"
this is exactly why I argue that going below 2.2 is not ideal in the long term and especially if you are active.
Again I place this study here on an opportunity basis for other readers (I'm aware that you Buck know it well already).
so the lowest risk of bleeds and clots is from 3 to 4 ... the On-X protocol is aimed at enticing the hysterical warfarin fears to its fold (profit balance sheet).
this is exactly why I argue that going below 2.2 is not ideal in the long term and especially if you are active.
Again I place this study here on an opportunity basis for other readers (I'm aware that you Buck know it well already).
so the lowest risk of bleeds and clots is from 3 to 4 ... the On-X protocol is aimed at enticing the hysterical warfarin fears to its fold (profit balance sheet).
Windfinder
Active member
Thanks so much for sharing!!!! Were you also taking aspirin when the stroke happened after your On-X implant? Had you ever had a stroke before or had any risk factors? The other case I heard on this forum about a stroke with On-X while on lower INR range the patient was not taking aspirin and that’s not the protocol so you can’t blame the false marketing for that. But if you personally never had stroke and you were on low aspiring when you had the stroke it changes things for me and I think I would shoot for INR of 2+ in my case. even if an individual case doesn’t prove anything statistically it scares me enough having one case in such a small sample (n= this group) and I’d be inclined wait until 2027 when the large study of the low INR for On-X is over.
St Jude is doing the same study for lower INR in China but a bit more conservative with target INR 1.5-2.5 for aortic position but not sure when results/study ends….
Yes. I was on low dose aspirin to supplement the warfarin.
Negative. I had no history of any cardiovascular or neurological issues. No history with any clotting disorders or blood issues in general.
On-X manufacturers also marketed the ability to use eliquis (apixaban) with their valve. Something else that was very attractive to me. I was asked to participate in the trial after my surgery but decline, thankfully, as the trial failed miserably and was shut down.
Windfinder
Active member
Thanks a lot, very interesting to hear from a real case in such a relatively small group/sample.
pellicle
Professional Dingbat, Guru and Merkintologist
ah yes, yet another marketing claim not met in reality ...
personally I'd rather be on warfarin; not a "one size fits all" product (that never fits anyone properly) and I mean the anticoagulation amount.
https://www.acc.org/Latest-in-Cardi.../05/10/16/59/apixaban-or-warfarin-in-patients
Results:
The trial was stopped after 863 patients had been randomized owing to an excess of thromboembolic events in the apixaban group. Aspirin was used by most patients (94%) in addition to anticoagulation. The primary endpoint occurred in 4.2%/patient-years (95% confidence interval [CI], 2.3-6.0) in the apixaban-treated cohort and in 1.3%/patient-years (95% CI, 0.3-2.3) in the warfarin cohort (hazard ratio, 2.6; 95% CI, 1.0-6.7). Major bleeding rates were 3.6%/patient-years in the apixaban cohort and 4.5%/patient-years in the warfarin cohort (HR, 0.6; 95% CI, 0.3-1.3).
Conclusions:
The authors concluded that apixaban is less effective than warfarin for the prevention of valve thrombosis or thromboembolism in patients with On-X mechanical aortic valve replacement.Windfinder
Active member
Windfinder
Active member
Windfinder
Active member
Pellicle, I have done some search to look for similar graphs to the one you usually post and have realized most of the ones I find are very similar but show a little move to the left showing optimal anticoagulation (balance between major bleed and thrombosis) around INR 2.2 for the general population. There are some that are split by age ( >70 y.o and < 70y.o) with small variations, some are specific to Asian people (it was thought they bleed easier on warfarin) etc… but I haven’t found a good chart that is more recent ( let’s say 2018+) and more importantly one that shows the trade off of bleeding vs thrombo just for aortic mech valves. The vast majority of charts/graphs/studies seem to be for people with AF and I was told it’s not the same thrombo formation when caused by valve vs caused by AF. do you have any insights on that or can you give it a try to find? You are for sure much better than me in researching these things!
pellicle
Professional Dingbat, Guru and Merkintologist
That's interesting, would you be so kind as to share one or two?
I'm quite sure that the curve will change for younger vs older patients.
My surgeon initially directed me to keep my lower bounds to 2.2, which is interesting.
With respect to AF vs Mech that is covered in the articles for that graph.
I guess that it becomes more complicated if you have both. However I'll have a poke around in the morning.
Best Wishes
Windfinder
Active member
Windfinder
Active member
Pellicle, just took a few screenshots, sorry it’s messy but doing this while on a train with my phone but you get an idea…I just clicked on “images” after my search words as sometimes when clicking on the links the image disappears…may be my phone or my ignorance!
pellicle
Professional Dingbat, Guru and Merkintologist
Thanks ... actually I'm not interested in the pictures themselves, because I'll go and read the studies (that's important to me to read the study). I got the search terms you used in one but normally I want the actual URL, which I see that Safari hides that from you.
The URL allows one to simply click and go to that study
Eg
https://www.valvereplacement.org/th...e-mechanical-valves.889793/page-2#post-938080
This was one of your search terms
so knowing that means I can google that exact set of key words in that exact order and (more than likely get the same results, however you seem to have clicked "display images" because I get this sort of thing:
first I get the AI summary
AI Overview
Learn more
The relationship between international normalized ratio (INR) and major bleeding is that an elevated INR is associated with an increased risk of bleeding
This now shows me the references it used to make that assessment
I'll usually read all of those ... but when I asked for links I meant such as to what articles you've read. That list cited (down to the section of text):
https://www.ncbi.nlm.nih.gov/books/...below the target,bleeding from any other site.
https://pmc.ncbi.nlm.nih.gov/articl... levels,observed in warfarin-treated patients.
this last one in that list didn't give a meaningful "cited text"
https://www.thrombosisresearch.com/...t=Open AccessPublished:November 10,Objectives
if you don't know what the actual article says you can't get any feel for if the article is somehow slanting their take on the data. Reading the article yourself is important because if you don't you're just being spoon fed what the writer wants to put into your mouth.
An example here of how I read and critically explore what I'm reading. Seems like it takes a lot of thought but then since I've been doing this for at least the last 25 years it happens almost instantly per sentence in my head.
However I suspect that your key words were not helping you because you didn't seem to get thormogenesis risks discussed well.
Research showed that more than three-fold risk of recurrent venous thromboembolism is associated with the subtherapeutic INR level. On the other hand, INR above the therapeutic range is associated with increased risk of bleeding among which the most concerning condition is an intracranial hemorrhage.
International Normalized Ratio (INR) - StatPearls - NCBI
I'll address another point of yours above in a sec (gotta get things done here).
