4 Days to decide between bio and mechanical aortic valve

[dougsweetser]

My surgeon Dr. Prem Shekar said I could decide in the morning whether to go for the biological or mechanical heart valve. At my age of 55, if I was older, he would strongly suggest the biological. If younger, then he would suggest the mechanical. In between is in between. My coronary arteries are in great shape according the the catheterization study just completed. The aorta looks great as far as the x-rays can see. I am asymptomatic and do workout 4 times a week (BMI 25). But there is a growing pressure differential over the bicuspid valve that I have had every day of my life, so it is time to replace it.

There are many trade-offs to balance. The heart is an amazing organ. One primary quality of the heart is how everything moves elastically. Both approaches have the ring that gets sewn into the heart. I am leaning toward the biological one because at least that has material that is elastic. The mechanical valve looks like it could be part of a car engine (a very refined engine at that). One article I found that argued for the biological valve is here: http://www.acc.org/latest-in-cardio...c-valves-are-better-even-in-the-young-patient

The consensus opinion appears to slightly favor a mechanical valve. I can change my mind up to 5:30 am on Monday, July 17. What is your opinion about my choice?

 

[FredW]

Doug,

You have an interesting decision. Thanks or sharing the link. Based on your profile, I assume you are already use to being on regular medication and are fairly analytical. If true, you should have no problem managing your Warfarin and INR. That means a mechanic valve will work fine for you and should remove most risk for a second AVR. Be ready to accept the clicking as well as taking Warfarin. However, a tissue valve will also provide good results, but you may have to face either a redo AVR or TVAR procedure at age 70 - 80. Redo surgery is a reasonable risk at 70, but I wouldn't want to do it in my 80's I'm sure you have thought of this. As for TVAR, I might risk betting money on TVAR in my 80's, but I'm wouldn't bet my life on it.

At age 72, I went with a tissue valve. It was a St. Jude Trifecta with Guide technology and says it lasts 8 to 20 years. I'm hoping it will outlast whatever else will kill me. If I were 55, I may had opted for a mechanical valve.

Here is the good news: no matter what you decide, it has a very high probability it will save your life and work out fine. Iwish you the best. You are in a good area for getting great health care.

See you on the other side.

 

[LondonAndy]

Having read your impressive Resume in the link you provide on your profile, I do hope that whatever you decide you will come back and tell us!

You are right: at age 55 there is no obvious way to go other than proceeding to have a diseased or failing valve replaced with something else. The balance depends on our own sensibilities, lifestyle and experiences.

If you stumbled across some of my postings on the subject, you will know that I am a keen advocate of the mechanical route, my decision being based on avoiding re-surgery for many years (indeed if ever needed) rather than 95% certain of going back under the knife when I am about 10 - 12 years older and wider (yes, that's how life seems to go in our family). Personal factors include an embracing of technology (and so no concerns about a mechanical device versus tissue), and a desire for independence (self-testing and managing my Warfarin doses with a home INR meter in my weekly routine).

But the article by Dr Ani Anyanwu you mention has caused me to question my certainty somewhat, though currently I still favour mechanical. The prognosis of more mid-term issues for mechanical valves is interesting, but although the article refers to studies of self-managing INR showing little difference in morbidities, I would challenge this for the reasons best set out by Pelicle elsewhere on this forum and his own blog. Self-managing only became recommended as best practice here in the UK in September 2014 - ie just months before Dr Anyanwu's article, and although earlier in the US and doubtless other countries I feel there is not sufficient data available to draw such a conclusion yet. If the reason for bleeds and strokes mentioned in the article is down to poorly controlled INRs, then a well managed mechanical valver can significantly improve their odds with the frequent convenient testing home meters offer.

How much of this is me re-affirming a decision I have already taken I don't know. I hope I am open minded, and look forward to reading the views of those who have a different opinion.

 

[dougsweetser]

This is a clearly a topic in valve replacement that will continually evolve. I already use one meter to keep track of glucose 5 times a day, so it would be a non-issue to add a second meter that I only have to use once a week. Since I am quite the creature of habit, I think I could manage the Warfarin and INR.

I saw enough YouTube videos to frighten me of a second open heart surgery. It is my hope that by the time I need to replace the biological valve, the TVAR procedures will have advanced considerably in 12-15 years. This is a form of wishful thinking but one based on demand from the patients. People fear the saw.

That just raised a question for me: which saw? The power of this internet thingie is amazing.... It might be a Skyler Precision Saw that cost about $5k. They go into some detail in a popular mechanics article, http://www.popularmechanics.com/science/health/g542/step-by-step-heart-surgery The sawing part only takes about 30 seconds. I find that comforting in a way.

Significant progress has also been made in putting folks back together. With no reading on the subject, I feared I might just split open from lifting too much. Wires are used to keep thing together. Or at least, they were used. I bet I will get a custom plate and screws to keep the chest together while it heals over three months.

What was most impressive about both my cardiologist and cardiac surgeon was that they thought it was a close medical decision and would respect whichever decision I made.

I remarked to a friend that if there was a mechanical device that had some flap to it, some elasticity, that might tip the balance for me. The heart is the crazy dance of motion with purpose. The 6th generation mechanical valve don't have a biological vibe to them yet. The bottom line of mortality does not look different between the two in this shifting field. So as of Thursday night, I still am in the biological camp.

 

[dreamy885]

That's such a tough decision, I thought I'd never decide! I'm a bit younger so my doctor and surgeon highly recommended mechanical which is what I ultimately went with. The sad part is that I don't get the one big pro of having a mechanical valve; I'll need surgery again someday because my mitral repair didn't completely stop the leak. I think if I had been your age I would have chose biological, in fact that's what I wanted for myself but I had already had one OHS, and now just had this one and if I live a long life I would've needed a couple more, each one carrying more risk. I wish you luck in deciding and being able to relax once the decision is made, for me that was the worst part (trying to choose which valve.)

 

[AZ Don]

If it were me making this decision, and it could be any year now (I just turned 56 and have moderate aortic regurgitation), I would opt for mechanical primarily because I would rather be in control of my fate. With a biological valve you are hoping that TAVR improves or other options become available and that the battle against bacterial infections, which we appear to be losing, doesn't get worse making even minor surgery more risky. With a mechanical valve you just have to take your medicine regularly, test regularly, and adjust as needed. In any case, either choice is going to give you a much longer life than you native valve will. Best wishes on a speedy recovery from whatever you choose.

 

[dick0236]

.......I would rather be in control of my fate. With a biological valve you are hoping that TAVR improves or other options become available and that the battle against bacterial infections, which we appear to be losing, doesn't get worse making even minor surgery more risky. With a mechanical valve you just have to take your medicine regularly, test regularly, and adjust as needed......... .

AZ Don's post makes a lot of sense to me.

 

[neil]

I went tissue as didn't want to be on warfarin and the problems that may occur, I was 51 and my porky is still honking away, whichever you have choosen will save your life so theres no wrong choice, good luck

 

[pellicle]

AZ Don's post makes a lot of sense to me.

I agree Dick, it's actually pretty much the exact logic I followed when I picked mine. I often wish I could phrase it as well as he does.

 

[Lisa2]

I find it interesting that so many of you have surgeons that make a recommendation one way or the other. My surgeon simply states the facts, at present, and says it is completely up to me. He says that I must decide this myself. My cardiologist is in favor of a mechanical valve for me at 44. He is also my Mom's doc and just told her that it is time for her to have surgery. He favors a tissue valve for her.

 

[neil]

lisa in my mind that means there is no golden rule for one or the other, my cardio and surgeon couldn't agree on my valve so what hell chance did I have lol, your right its down to the individual choice which path you go down in most cases, neither is perfect but hey it saves our lives,

 

[mikeccolella]

The article you cite pushed me to go with the tissue valve but it is certainly not an easy decision. One important point that swayed me was that a mechanical valve does not lower the rate of reoperation due to the probability of side effects of warfarin. This is often an argument for the mechanical valve but the article challenges it.

 

[Superman]

I say flip a coin!

http://www.pbs.org/newshour/making-sense/cant-decide-just-flip-coin/

 

[pellicle]

Hi

The article you cite pushed me to go with the tissue valve but it is certainly not an easy decision.

agreed its no easy or simple decision. Out of interest which parts of the article suggested:

One important point that swayed me was that a mechanical valve does not lower the rate of reoperation due to the probability of side effects of warfarin. This is often an argument for the mechanical valve but the article challenges it.

what I read was that mortality after 12~15 years was similar (not sufficient), there were complications with warfarin (which I believe there is strong evidence these are mitigated with better warfarin care [and exactly what level of care, who and what was not made obvious]).

Obviously (as some of us here know only too well) a mechanical is not a ticket to "never need an operation again" due to things like aneurysms, but reoperation due to thrombosis is now less likely with the more recent treatment with tPA (https://en.wikipedia.org/wiki/Tissue_plasminogen_activator)

Given that article is slanted towards younger people I can say that myself an aneurysm would have driven a reoperation had I had a mechanical done in 1992 (at 28 years old). So no argument from me there so I'd have been one of the cohort who would have been reoperated.

 

[Agian]

That Anwanyu guy is a whiz at re-do's. So from his perspective a re-op may not be that big a deal.

He makes some generalisations, but it's a reasonable opinion piece. He is entitled to an opinion like all of us, but hard-hitting science it ain't.

I have read of people, and met one, who really struggled with the clicking. The Warfarin is meh, but you don't want to make a mess of it, because it might make a mess of you. A well-anticoagulated mechanical is as much at risk of a clot as a bioprosthesis. The increased risk comes from bleeds. Mechanical valves are higher maintenance, but only just. Young people resent having to take tablets, but as you get older you accumulate them and it's just one more. A guy in his 20s having a tissue is likely to need another ohs in his 30s. Then what?

 

[jcgtok17]

Doug, Tough call. I recently went with a tissue valve (St. Jude Medical 28mm GT model). The AVR (BAV) operation was 5/1/17 and mechanical was not given much consideration in Japan, where I had the procedure, despite my age (50). Crown is a popular valve in Japan (average 22mm). I read that in Germany 70% of value replacements are now tissue values. I'm comfortable with my choice (no Warfarin) and recovery is going very well. I take Crestor and recent studies show use (statins) extends the life of tissue valves. Best of luck with both your decision and the operation/recovery. JCG

 

[LondonAndy]

. I'm comfortable with my choice (no Warfarin) and recovery is going very well. I take Crestor

Ummm, Crestor is Warfarin.

 

[pellicle]

Ummm, Crestor is Warfarin.

Whoops

Rosuvastatin (INN),[SUP][3][/SUP] marketed under the tradename Crestor, is a member of the drugclass of statins, used in combination with exercise, diet, and weight-loss to treat high cholesterol and related conditions, and to prevent cardiovascular disease.

https://en.m.wikipedia.org/wiki/Rosuvastatin

 

[dick0236]

Ummm, Crestor is Warfarin.

LondonAndy.....are you confusing Crestor with Coumadin? In the US Crestor is a statin.

 

[pellicle]

Anyway, I think the bottom line is that once one is informed and understand the true nature of the (outcomes of the) choices , being comfortable with that choice is the only real issue.

As long as we are each comfortable with our choices it's all that matters (I ride a motorbike and have an old 4wd with wind up windows because that's my choice and others wouldn't pick that).