26, 2nd AVR soon; Mechanical or Tissue?

[Ershin]

So on my last cardiology visit I discovered that my current tissue valve is regurgitating and beginning to fail. It's been there 10 or so years, although it came as quite a shock since I'm still not quite feeling any symptoms, not to mention the doc literally just put the stethoscope to my chest and ordered an echo from that.

My concern right now is making sure to choose the right valve for me when the time comes. When I was 16 I don't remember really being given an option, though I recall asking if I 'ticked' when I came to after the surgery. Being 26, I'd guess I'd need about 3-5 more tissue valves over a "normal" lifetime? That... doesn't sound remotely fun or safe. Mechanical on the other hand has me worried about anticoagulants, as I still forget to take my current meds from time to time. Is there anything really bad about missing a single dose, or would I just have to resume as normal? At the same time, I have only one kidney and asthma. Would they be harsher on my body because of this?

I appreciate any thoughts, thanks for reading.

 

[ottagal]

Welcome to the forum, Ershin! Sorry to hear that you have to go through another operation. If it helps there are a number of members who have been through 2 and even 3 surgeries who can share their experience with you. I don't have any suggestions for you as I have a tissue valve. Others with mechanical valves can chime in about being on coumadin.
Just a thought... how about setting a daily alarm/reminder on your cell phone for medication. Hopefully, you will get some good advice from your cardiac surgeon and cardiologist regarding your current medical situation. Hang in there....we will be here for you. .

 

[pellicle]

Hi

...Being 26, I'd guess I'd need about 3-5 more tissue valves over a "normal" lifetime? That... doesn't sound remotely fun or safe. Mechanical on the other hand has me worried about anticoagulants, as I still forget to take my current meds from time to time. Is there anything really bad about missing a single dose, or would I just have to resume as normal? At the same time, I have only one kidney and asthma. Would they be harsher on my body because of this?

I had a homograft put in at 28, which was my 2nd OHS. It lasted till I was about 48, but I was exceptionally lucky. I have said before that if I was 28 now, with valve technology of today and INR monitoring of today then I believe that I would pick mechanical.

Having been on AC therapy now for 3 years I am now very comfortable with it. I have learned much about it and found that it is not the boogy man often raised.

You will need to get better at managing your time and life, and so a phone alarm is a good start. I have written (and continue to write) on my blog about INR management
http://cjeastwd.blogspot.com/search/label/INR

Basically with modern valves missing a dose here and there is no big deal, heck I've got writeups of the procedures here. In fact if you have no other risk factors its now common practice to go off AC therapy for a few days prior to smaller surgeries if you have one of the new pyrolytic carbon valves (On-X, ATS/Medtronic, St Jude....)

http://www.valvereplacement.org/foru...se-of-warfarin

http://www.valvereplacement.org/foru...k-my-dosetwice

Even if you are 'recalcitrant' in your doses of warfarin (don't be) and you get a massive congestion of stuff on your valve (after failing to take your warfarin for say a year) that too can be cleared non surgically (depending).

So to me for a younger patient the choice of a mechanical is by far less risky than setting up for (as you have identified) multiple surgeries. I was told this time by my surgeon (when I got the last valve) that nobody would be lining up to have the chance to do my 4th surgery.

The older (> 50 years old) membership here having their first OHS will tell you that "no, its fine, have as many surgeries as you want ..." or "no, TAVI will be here soon" (as was said 10 years ago) ... its up to you how well that sounds like the truth or a good gamble. However, every surgery you have you open yourself to more scar tissue, and more chances of infection. Indeed more scar tissue makes it easier for infections to take a hold. Here is my story from my infection from my third: http://www.valvereplacement.org/foru...ges-disturbing

I was "lucky" that my infection was propionibacteria, not MSR ... but even with propi we are now seeing antibiotic resistant strains. This post (in that thread) is less likely now because I have been (yes I still am) on antibiotics. I discussed this with my infection specialist (and brought those papers along) and so to prevent another "outbreak" I've been on supressing antibiotics for 3 years now. Last discussion we had was "well, perhaps it will be permanent, because the risk of infection reaching your prosthetic is too great"

So especially to me, taking a pill to have avoided that is a no brainer. Especially now with modern Point of Care INR management available to the patient. Warfarin is much less problematic as it was back in 1992 when I had my 2nd OHS, a homograft done.

Anyway, if you wish to contact me, then PM me and we can arrange time to chat by phone or Skype. I live in Australia at the moment.

Best Wishes with your choice.

 

[dick0236]

.......... Mechanical on the other hand has me worried about anticoagulants, as I still forget to take my current meds from time to time. Is there anything really bad about missing a single dose, or would I just have to resume as normal? At the same time, I have only one kidney and asthma. Would they be harsher on my body because of this?

I appreciate any thoughts, thanks for reading.

Most, if not all, mechanical valvers miss a dose from time to time and the world does not end. It may mess up the INR level a little but generally will not cause other problems....and yes, you can just resume your normal dose while adding 1/2 dose for two days (that's what I do). Going for several days without coumadin(warfarin) is a no-no and can lead to serious problems, i.e. Stroke.
I've been on warfarin a long time and have done a lot of really dumb stuff, that I probably shouldn't have done, without consequences, except one time going several days without warfarin and suffering a stroke. That was 41 years ago and taught me, real quick, to manage my dosing more carefully. I have had absolutely no problems with the drug since.

I have no input as to any problem one kidney might pose but I don't think the asthma would cause a problem.....but that's a question for your cardio.

 

[MethodAir]

Mechanical.

The recovery is long and difficult and the risks increase with every surgery. And then there is the downward phase when a tissue valve starts to decline (with attendant risk of damage to the left ventricle and the cardiologists' view that 'more medication is needed'). Consider an ascending aortic prosthesis like this one. The valve is seated better in the prosthesis, and removes the risk of a future ascending or root aneurysm. Warfarin is not difficult to manage. 5 minute test once a week with Coaguchek.

 

[neil]

at your age I guess mech is the way to go, I would pick the brains of the cardio and surgeon etc just to see what they say to, good luck

 

[epstns]

As usual, pellicle makes great sense with respect to valve choice. He was about your age when he started his valve trek, and is still on the journey. I would agree with pellicle and dick in that at your age, barring other needs/reasons, mechanical would seem to be the way to go. Your profile doesn't have any obvious clues as to your gender, so I'm assuming that you are male. If you are female and have plans of having children, then conventional wisdom would recommend a tissue valve to take you through your childbearing years, as pregnancy and childbirth while taking Coumadin adds many complications. If you are a male, then I would go straight to a mechanical valve and just learn your way through dealing with anticoagulation therapy. Your profile does say that you are a PC gamer, so I will assume that you have average or better ability to learn details of things, thus you should be well able to deal with Coumadin/warfarin management.

Think it through. Read the past discussions on the topic. Then come on back and ask all the questions you can think of. Nothing (well, almost nothing) is out of bounds here, as everyone here is just trying to help other valve patients deal with their new realities. You've found the best place on the web to learn about it, and you're welcome here any time.

 

[ALLBETTERNOW!]

Does seem like mech is the better option in your situation, sorry you have to deal with this. You will figure out the Coumadin I think that's better than facing more ohs

 

[Duffey]

You've received good replies. I'd ask the cardiologist if your kidney or asthma issues have any bearing on your choice, but I doubt that they do. I think you're too young to chose any valve other than mechanical, unless you're a woman and hope to have children. You'll figure a way to remember to take the coumadin; I'm not good about remembering meds, but where there's a will, there's a way! Best wishes going forward. Mary

 

[McCbon]

I would think that both asthma (which I have had since childhood) and one kidney are additional risk factors for OHS. How much of a risk factor they pose is predicated on known and unknown variables. None of this will necessarily be relevant for you but I offer it just for an example: asthma results in less capacity in the lungs especially small airways and also causes inflammation of the mucosa, therefore increasing the risks of lung infections. Losing a kidney can result in slightly (or more) increase in BP plus the body needs good circulation to perfuse the remaining kidney, etc etc. Just sayin' I don't think the pre-existence of those conditions are completely benign even when currently well controlled. Best of luck as you move forward. Others here have given smart feedback. Bonbet

 

[mjd414]

It has been 11 years since my first AVR (porcine valve) and today I visited with the surgeon that did that operation to schedule replacement surgery. I have no symptoms at all but a recent EKG and Echo show that it's time to replace porky and now I am going with a bovine valve. I would be interested in hearing any comments about the benefits, if any, with the bovine valve vs. the pig valve. The surgeon told me that the cow valve is considered the next generation of bio valve. Thanks in advance for any assistance you can provide. Also, at 65, I assume this will be less of a cake walk than the first operation. true?

 

[LondonAndy]

Ershin - have to say I agree with the majority of posters: go for mechanical valve, self-test your INR to manage the anti-coagulant doses best, and use a pill box with alarms to remind you when to take the tablets! I have a Tabtime 5, which has 5 compartments for pills at different times of day, and 2 of them are quite large. An alarm goes off each time I need to take something. The ticking from the valve is not something I wanted, but avoiding future surgery etc was important and I hardly notice any noise.

Best of luck.

 

[mainframe]

Hi Ershin,

I choose tissue my first surgery then decided on mechanical for my second. I'm hoping to avoid a 3rd as the 2nd was pretty rough and was touch an go. I was in the hospital for more than 2 months. Others find the 2nd surgery easier than the first. YMMV.

I also was born with only 1 kidney. I didn't find out until after my first surgery. During my second surgery, my kidney function was watched closely. They suggested my kidney would take a hit and I could end up requiring dialysis, at least short term. Fortunately that wasn't necessary. They tried to take it easy on the kidney before/after the surgery. Not using dye for scans was one way. Making sure I was well hydrated with IV fluids was another.

Like pellicle, I also developed a chest infection as a result of my second surgery.. I was about a 3 year ordeal trying to get rid of it. I had 3 more surgeries to my sternum/chest. I do believe that it's gone. No problems the last couple of years.

Bottom line for me is the less surgeries the better, IMHO.

Chris

 

[Ershin]

Hi again everybody, thanks for all your thoughts and opinions; and sorry for not responding sooner. I just got back from my 3 month followup MRI yesterday and will undergo surgery within the next couple of months. My cardiologist recommended the mechanical (specifically the on-x), but it will be interesting to see what the surgeon says. I'm definitely on board with it unless the surgeon suggests something else may be a better fit, as declining in health again is ridiculously off-putting. The only thing that he brought up that I have new questions about is he said if I go with mechanical I will need to monitor and maintain a much more "consistent" diet. This doesn't sound so bad, but is anybody able to clear this up for me?

Basically with modern valves missing a dose here and there is no big deal

Thank you, this helps a lot. I only ever miss maybe a couple times a year so it sounds like no big deal then? It's usually from something stupid like "I fell asleep early" or not realizing I'm out of refills.

 

[pellicle]

Hi

Hi ... about is he said if I go with mechanical I will need to monitor and maintain a much more "consistent" diet. This doesn't sound so bad, but is anybody able to clear this up for me?

Short answer is it makes rats arse difference in reality, your general health will be the major beneficiary from good eating habits.

Thank you, this helps greatly. I only ever miss maybe a couple times a year so it sounds like no big deal then? It's usually from something stupid like "I fell asleep early" or not realizing I'm out of refills.

Your welcome

Short answer is "yep, no big deal" but dont miss a weeks worth. There will be an INR drop but its effect will most likely be nil. I have put up posts here about whoops missed a dose and a plot of what happened. NB nothing mlre than a brief turmoil in my INR.

Two related posts on dose whoopsies

http://www.valvereplacement.org/for...need-dosing-advice-please?p=786482#post786482

http://www.valvereplacement.org/forums/forum/anti-coagulation/851030-whoopsi-took-my-dosetwice



The Long answer to both these questions is amid the posts on my blog, but this one is the best one to start with.

http://cjeastwd.blogspot.com/2014/09...ng-my-inr.html

Food

Have you noticed that I haven't talked about food? Well the reason is that I've found that it makes stuff all difference (unless you eat a whole case of spinach in a sitting) and if you did start get any change to your INR you'd see that in the next weeks measurement If you do see anything, work out if this is important and if its actually a consistent diet change.

BTW I don't do fad diets. Instead I more or less watch what I eat ... almost all the way to my mouth so as not to get it on my shirt.

So, in short, don't stress, be happy, keep a weather eye on the horizon and a steady hand on the tiller. Make course corrections only when you are sure they're needed ...

Hopefully all this has helped you become a better navigator of your INR

Live Long and Prosper

Just steer clear of large volumes of grapefruit juice