2nd valve replacement - do I go mechanical this time?

[CarolynL]

I had my first Aortic Valve Replacement 9 years ago when I was 40. I went with a tissue valve because of my concerns over a life on Coumadin and the 'ticking noise'. That valve was supposed to last 15+ but it unfortunately that is not the case and it needs to be replaced this year along with replacing a part of my aorta that has a 'bulge'.
My cardiologist is very much pushing me to go mechanical this time and deep down I know I probably should. My surgeon, though recommending mechanical, has said he will do whatever I choose.
I would love to hear some additional thoughts on the length of life of tissue valves for others out there.
How loud is the ticking on the On-X? Can others really hear?

Carolyn

 

[Heart Of The Sunrise]

Hi Carolyn: I have had the ON-X valve for 17 months now. I rarely hear it anymore, initially I would only hear it late at night...no more! Coumadin has not been a problem,
I initially was thinking tissue. But, multiple re-ops to replace a failing tissue valve was a bigger fear than Coumadin .I recently started home testing my INR with the Coagucheck XS meter.It is a personal decision. If it were me I would get a mechanical valve..

 

[scott.eitman]

4 years ago i had my second and went with On-X. I do not hear a tick, but I feel a thump, especially later in the day.

I chose mechanical because I did not ever want to have another surgery if at all possible. I believe a mechanical, at our age, is the best solution to that. However, with the advent of trans-catheter VR, I might make a different decision today. The problem with that bet is that at this time, it is only approved for high risk patients. Test have begun in medium risk, but I am guessing that you , like me, do not fit in this category.

 

[mainframe]

My tissue valve which I received at 45 years old lasted 7 years. I opted for mechanical the 2nd time around and have zero problems with ticking noise or "life on coumadin". I do whatever I want. Dr. Craig Miller at Stanford thought a Carbomedics Top Hat valve was a better choice for me than the On-x.

One issue that doesn't get discussed much here is AVR surgery, while mostly problem free, can get problematic. My first was a breeze out of the hospital in 4 days. My second was not. In the hospital for more than 2 months. Others have had tough recoveries too.

While you probably won't have issues with the second, having a third should be given alot of thought. My advice is always "less surgeries" is better than "more surgeries".

Chris

 

[pellicle]

Hi Carolyn

I had my first Aortic Valve Replacement 9 years ago when I was 40. I went with a tissue valve because of my concerns over a life on Coumadin and the 'ticking noise'. That valve was supposed to last 15+ but it unfortunately that is not the case

sadly I read of this far more frequently than I would like to. It is in reality the situation with people younger (such as you were and still are).

and it needs to be replaced this year along with replacing a part of my aorta that has a 'bulge'.

well this may seem weird, but this is actually "the good news" as the development of this (which is an aneurysm) would have ultimatly led you to a another replacement surgery anyway.

My cardiologist is very much pushing me to go mechanical this time and deep down I know I probably should. My surgeon, though recommending mechanical,

I think that your team have your best interests at heart and so too does your deeper down subconscious

I would love to hear some additional thoughts on the length of life of tissue valves for others out there.

I had a homograft put in (which is a human tissue valve) at about 30, I got around 20 years out of mine but I am *way* outside the curve on that, with my own research showing the average was less.

I also had an aneurysm and have now a mechanical valve in place. To be honest its actually not really a significant issue for me and I only rarely hear it.

They say that ignorance is bliss, but let me assure you that there are increasing possibilities of very negative outcomes from each successive surgery. You could quite easily get an infection (and join my club) of having spent a long and difficult battle (which is not yet won I may add) fighting the infection ... which may yet kill me. So what I am saying is this: minimise surgeries. Anyone who knowingly commits to serial redo operations without a significant medical contra-indication for mechanical is unwise in the extreme.

Permit me to make a comparison:
We have all seen heart warming movies where the star of the movie is injured and struggles with his recovery and in the process learns new things. Sees the world differently and is enriched by it. We all think of these movies as telling us something. Yet when we are placed in the staring role we of this drama many recoil from it.

To me (again I stress without medical contra-indications) taking a tissue valve so you can avoid any "unpleasant changes in your life" is like taking the blue pill. Taking a mechanical valve is taking the red pill and accepting that you really can not go back to life as it was before (as your failed tissue valve is showing you), and following through to a new life.

Certainly with a mechanical valve there will be changes, but the most dangerous outcome (another surgery) is substantially reduced. Taking another tissue valve will almost grantee you another surgery, more complex and dangerous surgery (due to the scar tissue) and expose you to greater risks of infections in the hospital.

Finding a surgeon who will do a redo is more complex than finding an initial surgeon. However finding a sugeon who will do your 3rd sugery will be an even smaller circle.

Naturally only you can decide what you want to do, my purpose in posting here is to give you a view that may or may not be what you've already heard. If you have heard it then I'm just another voice in concert with those others.

I believe you will find that you get used to having a mechanical valve, and especially if you are inclined to take charge of your INR monitoring you'll not only get better outcomes but it will increase your awareness of your health (starting to measure things does that).

As we age increasing awareness of our health is only a good thing

Best Wishes

 

[DebbyA]

Carolyn,

I know just how you feel. I struggled with the same problem starting last November when it became evident my 6-year-old tissue valve was failing. It was not because of my young years--I'm in my mid-60s. I tried every which way to convince myself that a tissue valve would be a good decision, but couldn't. My porcine valve basically bought me 4-5 worry-free years and a year or so of worry and decline. I finally decided I couldn't gamble that I'd have to repeat the cycle at such short intervals. The frustrating thing is there is no real way to know in advance how much of a gamble it is.

I only hear my new ATS valve when I'm very still and sitting upright in a cushioned chair. In our climate we use ceiling fans most of the year, and I think I didn't recognize the sound at first because it was like the click of the fan pull-chain. To me it's a much more pleasant sound than I heard from my laboring heart before surgery.

I found getting in range on warfarin frustrating because it took several months. Finally, because of some things I read here, I decided just to take the stupid pills and stop worrying about it.

Best wishes on coming soon to a decision you're comfortable with,

Debby

(This post may look weird because the system threw me out the first time.)

 

[Leah]

I have an ATS too, and I only hear it in a very quiet room. The only time Coumadin has been an issue for me was when I had a stomach bug & unable to eat. My INR shot up, but it came down pretty quickly. It also shot up when I had an upper respiratory infection, I think due to my inactivity and not eating much. So if I have not been feeling well, I just go to the lab so I can catch it before it gets too much out of range. I am getting a home testing unit tomorrow (YAY!!!) so that should make things much easier for me. Good luck to you!!

 

[MrsBray]

42/f/AVR March 2014 I have an On-X and yes I can hear it, but not all the time. Sitting in the bathroom and sitting in my car I can. I can NOT hear it at work, in a movie theater, walking down the street, making dinner, playing video games, riding roller coasters, kayaking, horseback riding, mountain hiking, etc. It took about 5 months to get my INR levels stable. I have increased my activity level, and have not changed my diet.

I chose mechanical because my surgeon told me he didn't want to see me in 5-7 years for a re-do.

I like to freak people out with the ticking noise sometimes - sit behind them in a meeting and wait for them to try to figure out who has a loud watch (this only works in a quiet meeting room though!).

 

[OldManEmu]

My first AVR was only ever going to be temporary because my Aortic aneurysm couldn't be repaired at the time of my first surgery due to my poor physical condition caused by heart failure at age 41. It was almost 7 years before my aneurysm passed the point of requiring repair and a redo of the AVR, my tissue valve was still functioning well and was 3+ years from requiring replacement in the surgeon’s opinion, however was replaced at the same time so as to avoid another surgery in a few years. I chose a tissue valve for the redo and I expect this to last into my early 60's.

 

[Paul Schur]

I'm 8 weeks out from having my bicuspid aortic valve replaced and I went mechanical. It was my 1st surgery and i didn't want to see my surgeon 3-4 more times in my lifetime, which would have happened had I gone with a tissue valve. So far, so good. I definitely hear it, usually when I'm alone sitting quietly. Others sitting close to me, as in inches from my chest so not random people, when it is completely quiet and their heads are turned just so slightly the right way, can hear it. The noise is faint, I hear it now as I am writing this. I went back to work last week and I'm not aware of the sound at work. The Coumadin concerned me because being a few hours late with a daily dose could easily happen in my world, especially when I'm working. It's happened a few times already, and I need to get better with it. But I've had no problems/complications because of a late dose. I'm waiting for my home testing machine and until then I go in to get my blood drawn. It's the least bothersome 30 minutes of my week.

 

[pellicle]

Hi Paul

The Coumadin concerned me because being a few hours late with a daily dose could easily happen in my world, especially when I'm working.

please allow me to remove one more concern from your list. Being a tad OCD (and working in IT) that same anxiety befell me when I first started on Warfarin. Especially if it was a day before a "lab draw" which I just knew would result in them calling me back in early (rather than see you in 2 weeks). I can say that it makes not much difference at all and will correct quite quickly. One of the first things I did when I got my Coaguchek was to record daily INR measurements when I missed a dose (I am my own lab rat). I found that it went like this:

In the above figure I've plotted two scenarios : do nothing about it and take half yesterdays with todays.

The two 'trend lines' are from my work on developing a model for understanding my INR and allowing me to better tune my dose by better understanding what happens (rather than rely on myths propagated by professionals to simplify things to make people feel happier).

Short answer is "its ok if you miss a dose" which is then made easier by "keep to the middle of your range". Even if you were to drop below range for a day or two it is less risky than crossing the road while talking on your phone.

PS: on the subject of late dose, understanding the kinetics of warfarin I would also say that do not worry about being even 6 hours late on a dose (which is only 6/24th of a time shift on a thing which has a 2 day half life). When I've flown long flights (30 hours door to door) I've just kept my dose taking on local time and have found zero difference.

 

[Protimenow]

At age 41 (23 years and two days ago) I had a St. Jude Mechanical AVR. At that time, there weren't too many choices for mechanical aortic valves and I put complete trust in my surgeon to select the appropriate valve. It's been ticking for me for all these years, and I'm certain that I'm a lot stronger than I was before surgery.

I don't know if the valve has gotten quieter or if something else is going on, but the ticking is rarely an issue. One factor that may be worth considering when choosing between mechanical and tissue -- do you know that you'll actually be able to AFFORD a replacement surgery 7-15 years down the road? When I had my mechanical valve implanted, I had a good job and good insurance. This, unfortunately, has been an exception much of the time since then -- if I had gotten a tissue valve, and needed a re-do, affording this once, or maybe twice, would have been prohibitively expensive. With my mechanical, I've been able to go for 23 years, and will probably continue clicking until something else kills me.

The thing with coumadin is pretty much a non-issue, now that I self-test and self-manage (with the 'assistance' of an anticoagulation clinic that likes to feel as if it's helping me, even though I know that my INR is in range when I get my blood draws). With my own meter(s), I am able to monitor for any changes that may result from illness, antibiotic use, or other issues.

Paul -- coumadin/warfarin isn't as time-sensitive as you seem to think that it would be. Personally, I take my dose at bedtime (which is often within a 3-5 hour range). Warfarin is slow acting -- late or early doses shouldn't make too big a difference. (Yesterday, my INR on one of my meters said 1.8 -- which means that it was probably closer to 2.0 -- at that time, early in the afternoon, I took a 2 mg dose of warfarin expecting it to slightly raise my INR a bit earlier than just a boost at bedtime. Unlike Vitamin K, with effects that can be seen in hours, warfarin takes considerably longer to make changes in INR).

Carolyn -- if I was in your situation, I would opt for a mechanical valve. The anticoagulation management isn't a big deal -- especially if you self-test and have someone who you trust to manage your dosing. (I trust myself to do this). As Pellicle noted, repeat surgeries are increasingly problemmatic, especially when issues of scarring and the reduced amount of tissue to graft the valve onto are taken into consideration. OTOH, by the time you need another tissue valve, it's possible that it can be repaired without cracking your chest. However, there are no guarantees that it'll happen so soon.

Good luck with whatever you (and your doctor and family) choose to do.

 

[dick0236]

The Coumadin concerned me because being a few hours late with a daily dose could easily happen in my world, especially when I'm working. .

I have never found warfarin to be time critical. Develop a daily routine that is convenient, morning, noon or nite. I use a seven day pill box and take ALL my maintenance drugs(warfarin, BP, vitamins, etc) at the same time each day as part of my morning routine. Warfarin will only become a problem if you forget, or double up, doses. A multi-day pill box will solve those kinds of problems.

 

[big_L]

I have the St. Jude valve and I rarely notice the click. Yes, it is there, but I only hear it if sitting and more if my left arm is crossing my chest (I guess it's reflecting the sound upwards). Yes, we all have to choose between two alternatives, both of which have drawbacks. The warfarin hasn't been an issue for me and the noise isn't an issue at all. I'm very pleased that I chose mechanical.

 

[cewilk]

I had the Ross Procedure in July 2012 at 24 years old and I chose it because I wanted to avoid being on anti-coagulants which would have medically separated me from the military. Only 2 1/2 years later and my operation has pretty much failed due to my valve being even more leaky than before the first surgery. I am most certainly going with a mechanical this time due to my fear of having any more than 2 surgeries.

 

[Duffey]

I had a tissue valve implanted nine years ago at the age of 53. My surgeon gave me a figure of 12 years before it would need replacing. So far, so good. In addition, at the age of 62 I'm looking at needing my tonsils removed in the very near future. Unfortunately it's not an elective surgery, and it is one that involves significant blood loss and post-op bleeding issues. My surgeon for that surgery told me yesterday that the tissue valve would have virtually no impact on the surgical process and subsequent recuperation. He said if I had a mechanical valve, it would be a big deal. Today I am very happy that I chose non-mechanical nine years ago.

 

[tom in MO]

Having surgeries while on warfarin has proven to be a "big deal" for some doctors but not for others. I specifically asked about this before I had a mechanical valve, and was told that it was different due to the need to get off warfarin and "bridge" with a different anti-coagulant, but not really a "problem" that cannot be readily handled. On this board, many have had successful surgeries while on warfarin. Often the problem is not in the medical procedure or anticoagulation, but in finding a doctor that is just a little bit more knowledgeable about anticoagulation therapy.

 

[Duffey]

Tom, have you had to undergo any surgeries since you went on warfarin?

 

[joanpieroni]

Duffey- I'm not sure what brand of Tissue valve you have but I have the Edwards valve and my doctor has seen them last between 20 - 25 years. I was 49 when I got it and didn't want the risks of blood thinners. Good luck with the tonsils.

 

[tom in MO]

Duffey,

No.

My dermatologist has offered to do some cosmetic and exploratory surgery to see what some big lump was. No need to go off warfarin. I pierced it myself with a very pointed and sharp knife and found out it was a bloodless fat deposit that i emptied with pressure. I have hemrhoids and my colerectal surgeon says we can band them and scope my whole colon on warfarin, but not for a biopsy. I think he said we'd bridge for that. Have not yet had the pleasure of those experiences, but if past performance is a good prediction... My hemrhoids were my big worry, but to tell the truth, it's no worse than before warfarin...all that worry for nothing : )

But my mil and mother have had more than one surgery on warfarin. My mil had two knees and a heart valve and my mother had a couple of stents, pacemaker and orthopedic surgery and an implant for a broken hip. The only problem was a slight stroke from the valve replacement for my mil but her stroke risk was totally unrelated to a mechanical valve. She recovered fully from the stroke.

My expeience with anticoagulation therapy is due to my research, my two short years and about 15 years of variou family members telling me their situations. I had 4 surgeries between 38 and 51 when i got my valve, so i am quite sure i will some day have surgery on warfarin.