32 and confused re: valve type selection

[Irishgus]

Hi. Im Fergus from Ireland, and looking at an op in the next 2-3 months to replace my aortic valve. Like everyone I know the basic pros and cons or mechanical V homograft (apparently pig and cow arent an option for people my age). This still doesnt make it any easier and I know there is no definitive answer thats gonna make it easier but I guess Im just looking for some positive feedback from those of you who have gone through this . Im still in the processing phase so please forgive me if I sound a bit daunted

I worried the mechanical sound will drive me mad.
If I get the homograft im worried that a second op down the line will cause me problems I could have avoided if Id got a mechanical in the first place.
In many ways I just feel like Ill never be the same again. Please tell me otherwise if you can
I love sports; climbing, mountaineering, running etc.. From your own experiences Can I carry on as before?

I know its a lot but any feedback would be seriously appreciated.

Thank you.

 

[Ola Thoresen]

Go for a mechanical. Most of the time, you won't notice the clicking at all. If it is really quiet around you, you might hear it. But after a few weeks, you will hardly notice unless you think about it, and it is just a reassuring sound of your heartbeat anyway.

I am just as active as before. And it is less than a year since my operation. I even feel I am in better shape than before, so don't worry about that.

The only things that have changed in my life is that I need to take 3-4 little pills every day, and I have a cool scar across my chest.
Oh, and that I now can go skiing or bicycling up the steeper hills and for longer distances.

 

[tom in MO]

It is a good thing that you'll "never be the same again" because if you stay the same as you are now, you will die in a relatively short period of time. Both choices are for life, thus they are both good. Remember if the choice is hard, that's because both paths are equally good

Only a very small number of people are bothered by the sound of a mechanical valve. Most don't hear it at all, unless they try to. With a mechanical valve you will be able to climb, mountanieer and run. If you risk death on a mountain now, use of an anticoagulant means that you will bleed about 2.5 times longer before you clot. If you are like most mountenieers I know, bleeding out didn't stop you before and won't now You will have to take a pill a day and depending upon Irish health care, test your blood at home about every 2 weeks, or at a clinic every 3 weeks to a month. You do not have to "watch your diet" but if you are a binge drinker, you should give up the binging.

If you go tissue, you miss the anticoagulant and the testing. However, your valve will slowly degrade and you will need a re-operation every so often. You will experience pretty much the same stuff as now, your valve will be monitored, performance will deteriorate, it may or may not affect you serverely and then you will need it replaced. Some say every 10-15 years, but a few have only lasted less than 5 years. Nobody knows how your body and tissue valve will interact.

Good luck, it's tough, but we did it and we're light weights

 

[dick0236]

I worried the mechanical sound will drive me mad.
If I get the homograft im worried that a second op down the line will cause me problems I could have avoided if Id got a mechanical in the first place.
In many ways I just feel like Ill never be the same again. Please tell me otherwise if you can
I love sports; climbing, mountaineering, running etc.. From your own experiences Can I carry on as before?

I know its a lot but any feedback would be seriously appreciated.

Thank you.

+I was 31 when I got my mechanical valve in 1967.
+I never noticed the "ticking" after a few months.
+I have gone 46+ years on one mechanical valve and my docs tell me it will probably last my lifetime.
+You are correct....you will not be the same again. You will be much better off. I am still alive and I'm pretty sure I would have died many, many years ago without valve replacement.
+I have had my valve interfere with my life very little. It does require some minor changes....but I have always done pretty much whatever I want to do.

Glad you found us.

 

[pellicle]

Hi Fergus, pardon my 'longer' answer ... I just wanted to try to answer your questions as well as you may wish...

Like everyone I know the basic pros and cons or mechanical V homograft (apparently pig and cow arent an option for people my age).

Ok ... so I won't go there

Im just looking for some positive feedback from those of you who have gone through this . Im still in the processing phase so please forgive me if I sound a bit daunted

as a background to me, I had a 'valve fix' when I was 9, a homograft when I was 28 and that lasted till I was 48. That's a good run as I understood it.

I worried the mechanical sound will drive me mad.

it will if you *focus* on it, but I've lived near train lines and literally stopped noticing that.

A interesting study posted by oldmanemu here suggested that people who were ill and otherwise had lower quality of life tended to focus on it more, people who kept on with their lives only picked up on it for a while. After 2 years barely noticing it. (study link here)

2 years sounds a long time ... what were you hoping to get out of the rest of your life? Say another 30 or so? Suddenly 2 isn't so bad ... in 10 years you may think of it as 'all a long time ago'

If I get the homograft im worried that a second op down the line will cause me problems I could have avoided if Id got a mechanical in the first place.

correct ... see my thread here for just such a possibility. Of course one could say I was unlucky ... well as Clint Eastwood said ... well are you feeling lucky?

In many ways I just feel like Ill never be the same again. Please tell me otherwise if you can

well its true ... you won't be the same again. You willl be able to resume your life, resume what you want to do and just have to understand that you got a second shot at it ... you won't be 'perfect' no matter what pathway you pick.

I love sports; climbing, mountaineering, running etc.. From your own experiences Can I carry on as before?

sure. I have, many here have too. We have some athletes, power lifters, competitive rowers, stuff like that.

I know its a lot but any feedback would be seriously appreciated.

not a lot really ...

Don't overblow warfarin ... its not the daemon people make it out to be ... why just the otherday someone here said:

... and warfarin in general, is not the monster I had concocted it to be

look at it this way ... compared to in your parents time you've way more quality choices.

Me now ... what would I do if I was 28 and was in the lineup for another valve? Well given the quality of choices of valve now, given the monitoring equipment available for making warfarin management easier than it is for diabetics to monitor their blood sugar ... knowing what I do about the possibilities for infections ... I'd say to the surgeon "I'll have a mechanical" and shake his hand for it.

best wishes

 

[pellicle]

Tom ...

but a few have only lasted less than 5 years. Nobody knows how your body and tissue valve will interact.

I believe that it was Jarno who only got a year, although I'm not sure which type of tissue valve that was ... very sad that.

 

[Mike59]

Go tissue

Great durability now circa 15 to 20 years is now the norm with latest generation

Really great performance and no noise

Having said that both are great

I just hope those mechanical valvers on this site recognise the significant benefits that tissue valves give

Interestingly for me is if tissue valves are sub- optimal why are more implanted than mechanical?

Why are tissue valves still used if mechanical are "better"

Exactly to my point both are great life saving options

 

[Agian]

Fergus, you said "apparently pig and cow arent an option for people my age". I don't understand why they wouldn't be.

 

[Midpack]

32 and confused re: valve type selection

Mike, it is my understanding that for people over say 70, tissue is the way to go because life expectancy is probably shorter than valve durability (and also the valve wears out at an slower rate). But if you dont count this population segment, i am not sure that tissue is indeed more used than mechanical.

 

[pellicle]

"apparently pig and cow arent an option for people my age". I don't understand why they wouldn't be.

I understood it was because they calcify too fast in younger people.

 

[Agian]

Mike, it is my understanding that for people over say 70, tissue is the way to go because life expectancy is probably shorter than valve durability (and also the valve wears out at an slower rate). But if you dont count this population segment, i am not sure that tissue is indeed more used than mechanical.

The surgeon told me he's putting in more tissue valves. He even said that if he puts a tissue one in me the next one will be 'through the groin'. The latest valves, it is thought, will last longer. It must be exciting to be a cardiac surgeon today.

 

[Ola Thoresen]

For me, there was no real choice. They do not use tissue valves on young people here in Norway. And even if I could, just the thought of two or three new operations later would have put me off.
Why risk that?
If I was 75, sure. At 35, no.
The risks of multiple heart surgeries greatly outweighs the small annoyances of having to use Warfarin and a little, ticking clock inside my chest.

 

[pellicle]

Hi

The surgeon told me he's putting in more tissue valves. He even said that if he puts a

well that's not really a "why" so much as a a preference. Does your surgeon mention the ages of the people who are getting the valves? Putting tissue in elderly is quite different to putting tissue valves in the young.

I would encourage everyone who is interested in this topic to sit down with a cup of their preferred bevarage and listen to this talk

http://mayo.img.entriq.net/htm/MayoPlayer1.html?articleID=4071

It was recorded in 2010 so its not too dated. In that the speaker (a surgeon at the Mayo) goes over Tissue vs Mechanical. I think it is very interesting the points raised on
- patients living longer with mechanicals
- anti-coagulation issues and comparison to other tissue valve patients events
- anti-coagulation and how it is benefited from patient self testing and patient self management.

It is interesting that patients on warfarin who self manage have lower rates of problems related to bleeding events and thromboembolism events than tissue valve recipients who were not on anti-coagulation. Even without self management the difference was not "chalk and cheese".

I won't give his presentation for him but he makes a compelling case for the advantages for mechanical.

Note also that his data was on patients with average age of 59 years. The issues that face tissue valve patients are more significant as they are younger.

Lastly he makes the point that if any surgeon tells you that the risk of reoperation is not higher than the risk of the initial operation to "run, don't walk" ... all the more interesting given who he is.

 

[pellicle]

Mike

Great durability now circa 15 to 20 years is now the norm with latest generation

from the On-X site on their valves:

The lifetime of a tissue valve is typically 10 to 15 years, often less in younger patients. Over this time the valve will likely be degenerating to the point of requiring replacement. Because valve replacement surgery carries a significant risk of death, patient life expectancy is a major criterion in considering a tissue valve.
...
The primary advantage of tissue valves is their lower requirement for anticoagulation therapy, which reduces the incidence of bleeding. For the majority of tissue valve patients, taking an aspirin a day is sufficient anticoagulation therapy. Many patients with tissue valves, however, do not enjoy this benefit due to anticoagulation requirements for other heart or vascular conditions.

I just hope those mechanical valvers on this site recognise the significant benefits that tissue valves give

I believe I do ... but equally I would hope that those who have chosen tissue valve would recognise their reasons and allow each person to make their own choice. Each person who asks this question has their own issues and faces different factors.

Interestingly for me is if tissue valves are sub- optimal why are more implanted than mechanical?

That is an interesting question, and to answer it I guess that you'd need to look at stats (like the amounts of valves implanted in people at different ages) and what people consider is appropriate. Surgeons are not impartial computers, they are people with biases and preferences. I think that the surgeon who gave the above presentation at the Mayo has just such a question in his mind. I think that the evidence he puts together says as much as why he chose such sets of data.

Anyway I understood that the deciding basis was:
- primarially a preference of those later in life ..
- for women wishing to have a family
- for others who wish to make choices away from warfarin
- in the case where there are other co-morbidities

but fear of warfarin is probably a deciding issue (if arguments back and forth here are any guide on that matter). Surgeons are also business people, more operations are not a bad thing for them. I noted that Ola suggests in Norway that tissue valves are not used in younger patients, I wonder if Norway has (as Finland does) a state run health system where things are not preferred if they will cost more and provide no net benefit?

Why are tissue valves still used if mechanical are "better"

there is no 'better' universally ... that is why there is choice. There is however more suited to a purpose. A nail gun is better than a hammer when building a fence, but if you just have to hang a painting in the house a hammer is probably better.

In that presentation the point was raised of patients saying "I'm so young and healthy, I don't want a mechanical" even a MD used such an argument on himself. Sadly he got only 2.5 years out of his tissue valve.

I had no (rational) choice. If I (at 48) picked a tissue (which I could have) then I would be facing a 4th operation and significantly higher morbidity and also high chances of other non-fatal but equally difficult issues.

All I wish to do is provide people with as many views of the facts as possible. I only challenge people to provide a reason or to support their claims with some facts.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3063655/

Although many caveats exist, the general recommendation is for patients younger than 60 to 65 years to receive mechanical valves due to the valve’s longer durability and for patients older than 60 to 65 years to receive a bioprosthetic valve to avoid complications with anticoagulants

I encourage you to take the time to listen to the presentation I linked above and note what he says about this recommendation. I also find his evidence on this argument to be interesting.

Anyway, the OP was asking about mechanical vs homograft.

Shalom

 

[pellicle]

Fergus

Like everyone I know the basic pros and cons or mechanical V homograft

Even though you said you knew this, I thought I'd go and dig out the followup study done by my surgeons who did my homograft back in 1992. The information may be of use to you. I don't normally see such long term follow up (or one that comprehensively follows such a large cohort)

I was 28 when I had my valve done by them (in 1992) and seems I was about one of their best jobs having freedom from reoperation for 20 years.

The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve replacements.

O'Brien MF, Harrocks S, Stafford EG, Gardner MA, Pohlner PG, Tesar PJ, Stephens F.

The Prince Charles Hospital and the St Andrew's Hospital, Brisbane, Queensland, Australia.

BACKGROUND AND AIM OF THE STUDY:
The study aim was to elucidate the advantages and limitations of the homograft aortic valve
for aortic valve replacement over a 29-year period.

METHODS:
Between December 1969 and December 1998, 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.

Between 1969 and 1975, homografts were antibiotic-sterilized and 4 degrees C stored (124 grafts);
thereafter, all homografts were cryopreserved under a rigid protocol with only minor
variations over the subsequent 23 years.

Concomitant surgery (25%) was primarily coronary artery bypass grafting (CABG; n = 110)
and mitral valve surgery (n = 55).
The most common risk factor was acute (active) endocarditis (n = 92; 9%),
and patients were in NYHA class II (n = 515), III (n = 256), IV (n = 112) or V (n = 7).

RESULTS:
The 30-day/hospital mortality was 3% overall, falling to 1.13 +/- 1.0%
for the 352 homograft root replacements.
Actuarial late survival at 25 years of the total cohort was 19 +/- 7%.

Early endocarditis occurred in two of the 1,022 patient cohort,
and freedom from late infection (34 patients) actuarially at 20 years was 89%.
One-third of these patients were medically cured of their endocarditis.

Preservation methods (4 degrees C or cryopreservation) and implantation techniques
displayed no difference in the overall actuarial 20-year incidence
of late survival endocarditis, thromboembolism or structural degeneration requiring operation.

Thromboembolism occurred in 55 patients (35 permanent, 20 transient)
with an actuarial 15-year freedom in the 861 patients having aortic valve replacement
+/- CABG surgery of 92% and in the 105 patients having additional
mitral valve surgery of 75% (p = 0.000).

Freedom from reoperation from all causes was 50% at 20 years
and was independent of valve preservation.

Freedom from reoperation for structural deterioration was very patient age-dependent.

For all cryopreserved valves, at 15 years, the freedom was
47% (0-20-year-old patients at operation),
85% (21-40 years),
81% (41-60 years) and
94% (>60 years).

Root replacement versus subcoronary implantation reduced the technical causes for
reoperation and re-replacement (p = 0.0098).

CONCLUSION: This largest, longest and most complete follow up demonstrates
the excellent advantages of the homograft aortic valve for the treatment of acute
endocarditis and for use in the 20+ year-old patient.
However, young patients (< or = 20 years) experienced only a 47% freedom from reoperation
from structural degeneration at 10 years such that alternative valve devices are indicated
in this age group. The overall position of the homograft in relationship to other
devices is presented.

____________________


now ... with a mechanical valve freedom from reoperation is potentially much longer. Dick (a member here) has so far had something like 46 years freedom from reoperation. So while there is no guarantee that your mechanical will last that long, there is no tissue valve that ever gets that.

 

[OldManEmu]

I have attached an published article on AVR redo risks.
http://www.pccvs.com/files/documents/articles/redoavrarticle.pdf

 

[big_L]

While I'm older than you, I still hope to live 30+ years, so I had to make the same decision. I went mechanical, as I couldn't bear the thought of re-operation. Plus the Mayo video (link in post above) really swayed me.

Tissues are likely used more. I would attribute this to average age of the valvers (maybe 68-72?), poor understanding of warfarin by the surgeons, and some unreasonable (my opinion) optimism by surgeons as to the future of the TAVI replacement.

That said. It's a personal decision. Gather your information, sleep on it, do a gut check and decide. You're the one that has to live with the decision.

You'll be fine and back to your active lifestyle ASAP. Yes - it's a hell of a hurdle to get over but the rest of us have (somehow) managed to do it.

 

[pellicle]

Hi OldManEmu

I have attached an published article on AVR redo risks.

thanks for posting that ... it was interesting to read.

also an interesting read
http://tgkdc.dergisi.org/pdf/pdf_TGKDC_1232.pdf

 

[Mister_James]

Go tissue

Great durability now circa 15 to 20 years is now the norm with latest generation

Really great performance and no noise

Having said that both are great

I just hope those mechanical valvers on this site recognise the significant benefits that tissue valves give

Interestingly for me is if tissue valves are sub- optimal why are more implanted than mechanical?

Why are tissue valves still used if mechanical are "better"

Exactly to my point both are great life saving options

Great durability 15/20 years compared to lifetime durability? No one says tissues are sub optimal in of themselves. They are sub optimal depending on the patient. There is a higher failure risk of tissue in younger patients. More tissues are transplanted because heart disease, for the most part, is the domain of "older" patients and the 15 to 20 years may be a lifetime.

 

[tom in MO]

Per "Interestingly for me is if tissue valves are sub- optimal why are more implanted than mechanical?"

Tissue valves are not "sub-optimal." They are actually better than mechanical valves when it comes to their effect on your blood. That is why there is no need for anticoagulation therapy if you have a tissue valve.

There are three interactive reasons why tissue valves more common than mechanical. First, better action on your blood (i.e. no need for warfarin). Second, the older the patient, the longer the tissue valve lasts. Third, because most valve replacments are in people >65, this means little risk of a reoperation. The only other person with a replacement valve in my family got a tissue at 82. Mechanical valve wasn't even discussed, even though she was already on warfarin.