39 years old..tavr vs mechanical?

[Guest]

Hello, this is my first post. I am 39 years old and was born with congenital bicuspid aortic valve that became quite stenotic and was replaced at 30 years with a bovine valve. I chose that valve so I could have another baby, which I did the year after. Well, the time seems to have come for this valve to be replaced. Doc originally thought we were just in planning stages but not necessarily soon.....plans changed after my heart cath yesterday and I now have less than 2 months and meet with surgeon tomorrow.

So, here's the dilema....Doc thinks no mechanical because I would need a 3rd surgery in 20 to 25 years....he wants to do another bovine with the intention of either doing tavr now or tavr in the future. He said he is thinking of future and not now. My concern is tavr is not long term tested and I worry about the need for sooner if he does that this time. Though I am encouraged at the recovery. Has anyone had tavr to give their experience?

Picking a valve is worse that picking a car. Doc said ultimately all can give me opinions including himself and surgeon but final decision lays in my hands. Eek.

 

[pellicle]

39?


Without significant health issues which would select against it, get a mechanical.

I doubt you'll get 20 years out of a TAVI system ... I could be wrong ... its uncertain.

Doc thinks no mechanical because I would need a 3rd surgery in 20 to 25 years..

fascinating ... which edifice did he pick that from? I'd like to see a single study that shows that to be normal.. You can find people who have had more than 30 years on old (by definition) mechanicals ... you won't find that with ANY OTHER VALVE.

Back on TAVI SciFi is great ... but as Yoda says "Hard to predict the future is"

A mechanical is a certainty that nothing else offers

 

[dick0236]

Picking a valve is worse that picking a car. Doc said ultimately all can give me opinions including himself and surgeon but final decision lays in my hands. Eek.

Your right about that.....It is much harder than "picking a car". I've had 2 or 3 dozen cars over the last 50 years and the buying decision was pretty easy since I knew I wouldn't keep the car for more than a couple years. Fortunately, I've only had one valve over these 50 years and that is a very good thing......and much more consequential than buying a car.

I question how your doc came up with the "20 to 25 year" life of a mechanical valve.......I don't think statistics would bear out his claim. I'd ask a heart surgeon. You've been down this road before so you know that ......yep, in the end, it your call.

 

[cldlhd]

Why does he assume another surgery in 20 years if mechanical? I think tavr is another tissue valve and you only got 9 years out of the last one. So you get 10 years out of the 2nd bovine then at 50 tavr then what when that one goes? Did he give a reason why he thinks you'll only get around 20 out of a mechanical valve?

 

[pellicle]

Your right about that.....It is much harder than "picking a car". I've had 2 or 3 dozen cars over the last 50 years and the buying decision was pretty easy since I knew I wouldn't keep the car for more than a couple years.

and if the car turns out to be a lemon no one had to cut your chest open to change it and you just lost a few grand ... instead of health

So, maybe its easier ... pick a St Judes bileaflet mechanical ... no car has a track record as good

 

[honeybunny]

I made the decision to go with a tissue valve in September 2015. My decision was based on two factors, neither of which was the possibility of having TAVR when it comes time for replacement. You may have other reasons for going with tissue once again, but I don't understand your doctor's rationale for it.

 

[Bodhisattva]

Hello, this is my first post. I am 39 years old and was born with congenital bicuspid aortic valve that became quite stenotic and was replaced at 30 years with a bovine valve. I chose that valve so I could have another baby, which I did the year after. Well, the time seems to have come for this valve to be replaced. Doc originally thought we were just in planning stages but not necessarily soon.....plans changed after my heart cath yesterday and I now have less than 2 months and meet with surgeon tomorrow.

So, here's the dilema....Doc thinks no mechanical because I would need a 3rd surgery in 20 to 25 years....he wants to do another bovine with the intention of either doing tavr now or tavr in the future. He said he is thinking of future and not now. My concern is tavr is not long term tested and I worry about the need for sooner if he does that this time. Though I am encouraged at the recovery. Has anyone had tavr to give their experience?

Picking a valve is worse that picking a car. Doc said ultimately all can give me opinions including himself and surgeon but final decision lays in my hands. Eek.

Hi Guest,

I don't have any personal experience with TAVR but may I share some thoughts?

First of all, do you remember what size your current bovine valve is? Is it 23 mm or 19 mm or ? Your doctor can tell you if you don't know. This size is important for thinking about TAVR. TAVR is putting a valve inside a valve. So you can only do it once before the opening gets too small. And if you have a small opening to begin with, TAVR may not be right anyway unless the person has no other choice.

You're 39. Your bovine valve has lasted 9 years. Let's say the next one you get also lasts 9 years. So let's guess you will have to replace the second bovine valve when you are 46 or so. Let's say you do TAVR at that time. Then the TAVR valve lasts another 9 years which might be a stretch. So then you are looking needing at another valve at 55 when the TAVR fails. And you won't be able to do the TAVR for this one because the valve opening will be too small to fit in another TAVR. You will probably have to have open heart surgery at that point. They will have to remove the TAVR and the original failed bovine valve that was crushed to the sides when they inserted the TAVR which sounds rather tricky to me and time consuming which means more time on the heart-lung bypass which is not what you want if you can avoid it. And because you're only 55 at this point, if you get another bovine valve (since you won't be able to do another TAVR for this one) that bovine valve will fail eventually and you'll be looking at another TAVR inside this third bovine valve by 65 or so. Then that TAVR will also fail by 75 or so. Then you'll be looking at open heart surgery to remove the TAVR/failed bovine to put in another valve at 75. And so forth.

How many procedures is that possibly? Your first bovine, the second bovine, the TAVR, the third bovine, the TAVR, the fourth bovine. That's four open heart surgeries for the bovine valves and two TAVR procedures which are not without risk either. And in addition to increased risk and longer recovery as you get older, each procedure is very costly. Can you count on having insurance to cover each procedure all the way down the line? In contrast to the one-time cost, both physically and economically, of just getting a mechanical valve this time around. And no worries, there are lots of studies showing that St. Jude mechanical valves, for example, are super durable and can last for 30+ years no problem.

Good luck!!

 

[LondonAndy]

I wonder if your doctor is aware of the improvements in managing 'blood thickness' in recent years? Whilst you will find a number of posts on this site from people like dick0236 who have had a mechanical for many years anyway, one of the main reasons a mechanical valve might fail is because of a thombosis, or blood clot to us non-medial bods. But with the development of reliable home testing of blood "INR" at greater frequency than at clinics (generally weekly instead of monthly at clinics) this risk is significantly reduced because we are able to adjust medication (ie Warfarin) to keep our INR in the optimum range. This 2014 report http://www.nice.org.uk/guidance/DG14 from the UK's National Institute for Health and Care Excellence, which provides evidence based guidance to our NHS, found a 42% reduction in thrombosis for people who self-test their INR. So to me when I was aged 48, the choice of mechanical seemed clearly to be the one that would give me the best chance of avoiding repeat surgery.

 

[Agian]

'Doc' doesn't do another bovine, or any other valve for that matter; unless 'Doc' is also a surgeon.

 

[Agian]

This 2014 report http://www.nice.org.uk/guidance/DG14 from the UK's National Institute for Health and Care Excellence, which provides evidence based guidance to our NHS, found a 42% reduction in thrombosis for people who self-test their INR. So to me when I was aged 48, the choice of mechanical seemed clearly to be the one that would give me the best chance of avoiding repeat surgery.

Ah... the NICE gravy train, where career time wasters with no qualifications can call themselves 'health experts'.

 

[Agian]

Hi Guest,

I don't have any personal experience with TAVR but may I share some thoughts?

First of all, do you remember what size your current bovine valve is? Is it 23 mm or 19 mm or ? Your doctor can tell you if you don't know. This size is important for thinking about TAVR. TAVR is putting a valve inside a valve. So you can only do it once before the opening gets too small. And if you have a small opening to begin with, TAVR may not be right anyway unless the person has no other choice.

You're 39. Your bovine valve has lasted 9 years. Let's say the next one you get also lasts 9 years. So let's guess you will have to replace the second bovine valve when you are 46 or so. Let's say you do TAVR at that time. Then the TAVR valve lasts another 9 years which might be a stretch. So then you are looking needing at another valve at 55 when the TAVR fails. And you won't be able to do the TAVR for this one because the valve opening will be too small to fit in another TAVR. You will probably have to have open heart surgery at that point. They will have to remove the TAVR and the original failed bovine valve that was crushed to the sides when they inserted the TAVR which sounds rather tricky to me and time consuming which means more time on the heart-lung bypass which is not what you want if you can avoid it. And because you're only 55 at this point, if you get another bovine valve (since you won't be able to do another TAVR for this one) that bovine valve will fail eventually and you'll be looking at another TAVR inside this third bovine valve by 65 or so. Then that TAVR will also fail by 75 or so. Then you'll be looking at open heart surgery to remove the TAVR/failed bovine to put in another valve at 75. And so forth.

How many procedures is that possibly? Your first bovine, the second bovine, the TAVR, the third bovine, the TAVR, the fourth bovine. That's four open heart surgeries for the bovine valves and two TAVR procedures which are not without risk either. And in addition to increased risk and longer recovery as you get older, each procedure is very costly. Can you count on having insurance to cover each procedure all the way down the line? In contrast to the one-time cost, both physically and economically, of just getting a mechanical valve this time around. And no worries, there are lots of studies showing that St. Jude mechanical valves, for example, are super durable and can last for 30+ years no problem.

Good luck!!

Fair comments, but technology would have advanced by then. Anyways, if I was in her shoes I would go mechanical (with an ohs already). I would quiz the cardiologist a bit more, just for the sake of completeness, before rejecting his opinion outright. Although, I suspect he's talking out of his... Hat.

 

[epstns]

Agian - Doc must have a really strange . . . Hat.

Anyway, to the Guest, I think you have been given some really good advice here. The true nuggets I see are the caution to be sure to discuss your valve options and their pro's and con's with a surgeon, and preferably the surgeon who will operate on you. I am really concerned about a doc who says that with a mechanical valve you will definitely need another in XX years. That just isn't shown in reality. Look around this site. The newer generation mechanical valves just keep lasting longer and longer. Very rarely do they fail, and when they do it usually is from scar tissue encroaching the valve leaflets, not from pure mechanical failure of the valve.

Tissue valves are great, too. I have one myself. The only thing is that they don't last as long as mechanicals - at least not that has been demonstrated yet. The newer generation tissue valves are projected to last longer, but older patients reap the greatest benefit from this. Younger patients tend to calcify tissue valves faster than older folks, so they often are not recommended to younger patients. (That is, unless you are still considering adding to your family.)

And TAVI/TAVR? None of us are depending upon it. We anxiously follow progress of this phenomenal technology, but until it is proven to be good enough for lower risk patients, we see it as the best option for patients who can't or shouldn't have traditional open-heart surgery. Yes, they are working with it and it may actually become as good as tissue valves implanted via open methods. That would be the best possible outcome for TAVI. But it is still a tissue valve, with the inherent limitations of tissue among younger patients. TAVI is a great dream, if a tissue valve is best for you now. At your age though, I'm not so sure I would go the tissue route.

 

[Mldelag1]

Thanks for all the replies. I could not reply until today. I meet with the surgeon at 10 AM so I will know his opinion soon. I know my current valve degenerated rapidly in the last year. I knew it would because I had another baby. I was surprised about the opinions he had about length of the mechanical from my research. My current valve is 23mm. I am skeptical of the tavr especially at my age. He keeps telling me if I was 80 years old this would be a no Brainer decision. Thank you again and I will update when I get home

 

[honeybunny]

But you're not 80 years old, are you?

 

[dick0236]

........... He keeps telling me if I was 80 years old this would be a no Brainer decision. Thank you again and I will update when I get home

Why would a Doc tell a young patient of 39 that if she where twice as old (80), it would be a "no brainer"?.......I agree with Honeybunny.

BTW, I am now 80, and soon to be 81, and I would think long and hard about getting TAVR, even at my age. I understand it is only a bandaid......that lasts only a few years.....but long enough for most elderly patients.......but not for younger active patients.

 

[pellicle]

Why would a Doc tell a young patient of 39 that if she where twice as old (80), it would be a "no brainer"?.......I

Self projection? (IE the Dr has no brain with which to make decisions of this nature?)

BTW, I am now 80, and soon to be 81, and I would think long and hard about getting TAVR, even at my age. I understand it is only a bandaid......that lasts only a few years.....but long enough for most elderly patients.......but not for younger active patients.

Sorry Dick, you have the mechanical now so you are stuck with getting old instead ...

 

[Mldelag1]

I met with the surgeon and he was amazing. I am scheduled for surgery on the 21st. SO SOON.......we talked all options and I am almost 100 percent sure I will do mechanical.

 

[pellicle]

I met with the surgeon and he was amazing. ...

glad to hear you finally got through to someone who met your needs

best wishes with the surgery and outcomes. If you do end up going mechanical (you said almost) then feel free to drop back here and get INR management advice so you can get the best possible outcomes long term too!

 

[neil]

good luck, onwards and upwards

 

[cldlhd]

That is soon but it must be nice to get answers and some certainty as to what you are going to do. Best of luck.