5 more days. On-X Mech vs Edwards Magna Ease 3300 TFX Tissue

[VHeart]

My surgery for mini sternotomy AVR is on march 12th. I'm having a hard time deciding on valve. After all my research on here and some medical literature, I'm leaning towards mech but then doubts arise. I don't want more surgeries, but all the little inconveniences and risks associated with warfarin bothers me.

I'm 30 young and healthy male. Live in Canada (are INR monitors and test strips covered?). Not a big risk taker but am mild-moderately active in weight lifting, cycling, exploring nature, some jujitsu, and light parkour, 2-3 times a week. I've needed a hospital maybe 4 times in my life, 2 separate fractured arm, and stitches on my chin from a park BMX accident. Don't care about other sports or physically risky jobs. I think I'm more afraid of injury than the average person.

I have severe bicuspid AV regurgitation which caused enlarged LV, very mild MVR. My my Aortic root has remained at 3.9cm for 10 years. It's expected to stay the same, but may possibly slowly increase in a few decades. My surgeon said my risk for aneurysm is extremely low. The rest of my heart muscle and MVR is expected to return to normal post-op. I developed mild shortness of breath and chest discomfort the past few months which prompted an elective decision for surgery. Surgeon anticipates to use a valve size of 21-23mm. He recommends an On-X mech but will do Edwards Magna Ease 3300 TFX tissue if I want. He didn't try to persuade me choose one over the other.

Valve Decision Pros, Cons, Concerns
MECHANICAL VALVE
- I'm sound sensitive but I'm OK with watch ticking noise at night, but will be annoyed if I hear it during activities and music.
- "<1% risk of requiring another operation for the valve specifically." -surgeon
- Minor inconvenience every couple weeks to monitor INR.
- Rely on medication like I rely on water to live.
- "0.5% cumulative risk per year of anti-coagulation complications." -surgeon
- Higher risk (how much?) of bleeding, but "likely won't be life threatening." -surgeon
- Feel and be more vulnerable to injury or possible accidents.
- Worry about possibility of no access to medication (travel, natural disasters). The coronavirus has already put my non-generic brand of antidepressant on back order until the end of this year.
- I Have OCD and I will probably obsess over INR and drug/food interactions depending on how important it is. That could be both good for my physical health but bad for mental health.
- Possible easy bruising? I currently don't bruise at all. I've ran into metal poles and only had mild bruising. Afraid that will change with warfarin.
- 0% increase risk of stroke after 15 years.
- Spend $$$ on medication and test strips but may have coverage.

TISSUE VALVE
- Less than 5% chance of needing warfarin after 1 year if I get AFib. -surgeon
- Won't be or feel more vulnerable to physical injury.
- Feel hesitant to be as active out of fear of wearing out the valve faster, but data doesn't support this?
- Major inconvenience every ~10 years.
- 1-4 OHS in the future. May only get 5 years out of first valve. "10 years average. 4th surgery is when complications increase the most" -surgeon
- Each surgery has <1% chance of death in surgery, 3% risk of reopening to look at bleeding, 2-3% infection of valve in hospital, 0.2% valve infection within 6months, 5% risk of needing pacemaker.
- Smaller tissue valves wear out faster? Mine will be 21-23mm.
- Months of symptoms (stenosis, regurgitation) during period of valve deterioration?
- Research suggests there is similar risk of stroke as mech valve.
- Spend $ on supplements that I think will reduce calcification of the valve.

 

[pellicle]

Hi
My views
https://cjeastwd.blogspot.com/2014/01/heart-valve-information-for-choices.html
Probably most of what your concerned about with warfarin represents the 0.1%

https://cjeastwd.blogspot.com/2014/01/heart-valve-information-for-choices.html

At 30 ypu might get 12 years from a tissue prosthetic.

Are you BAV?

As to how you'll personally deal with any sound issues I can't say. I'm pretty useless when it comes to giving advice about anxiety or psychology because I'm tpo pragmatic.

I tend to think like this.

Probably after the surgery you'll understand more fully why you'll want to avoid future surgeries, unless like me you get the royal treatment ;-)

 

[pellicle]

PS
I lead a safe and normal life

 

[Superman]

For me, the decision would rest entirely on the possibility of the aneurysm. Your surgeon has exactly zero info on which to base the statement that your risk for aneurysm is extremely low.

If you have BAV, your risk is higher than the general population. Replacing the valve doesn’t change that. I had my valve replace with a mechanical just before I turned 18. My aortic root measures pretty consistently in the high 2’s. Then it rapidly expanded and in about 3 years went from not on anyone’s radar to needing surgery when I was 36. Of course that was 19 years after my initial replacement, which means it likely would have been my third surgery instead of my second ( if that makes sense).

Not saying you’ll follow the same course. I wish there was an answer though to exactly if or when an aneurysm would occur.

If I knew that in 10 or 15 years I’d need aneurysm surgery, I’d take tissue. Without that knowledge, at your age I’d go mechanical. I’ve been ticking and on Warfarin for nearly 30 years now.

 

[Astro]

I have a Medtronic mechanical aortic valve. Never hear it at the gym. Puffing drowns out any ticking. Music headphones drown out everything. Occasionally can hear it at night. The loudness does depend upon position. I find the valve quieter than the murmur that I could hear preop when in bed. I haven’t noticed any increased bruising but I am yet to “properly” hit something (probably just jinxed myself). Warfarin doesn’t make your skin/tissue weaker. You still have to hit it hard enough to cause bruising. Diet plus warfarin is not difficult. Eat salad every day - be somewhat consistent. Dose the warfarin to your lifestyle and diet. Don’t diet to control INR. Self management of INR is a game changer.

Your summation looks accurate. You have done your homework - top marks. Redo operations traditionally are viewed to have twice the risk than initial (maybe 2% rather than the initial operation’s 1%). However, I have read some doubt about whether this double risk is really true. Tissue means stressing about the echo progression again when the valve fails. Warfarin roughly doubles risk of major bleed compared to tissue. Major bleeds are no fun but dying from a major bleed is fortunately rare. Remember that it is easy to reverse warfarin in an emergency.

Your odds are good either way.

Superman has an interesting point about the aorta. I don’t know what the risk of 3.9 cm progressing is.

 

[dick0236]

I got my valve at 31. I still have that valve at 84.
No issues with that valve except a stroke at 38....probably due to mismanaged INR (they called it PT back then). PT testing was pretty primitive in those early days....and the current self-testing was nowhere in sight.
I've never had any diet, lifestyle or activity restrictions.....but age is taking its toll now LOL.
Fortunately for me, I didn't have to choose between valves.....my mechanical "ping pong valve" was the only commercially available valve at the time.......and I didn't have any choices.........and for that, I'm really glad.

You are doing it right by exploring the pros and cons and your decision will be the correct one for you.

 

[egar]

VHeart, you are well prepared. I suspect you probably already have a choice in your subconscious but a looking for confirmation. I can’t add to any of the information you have collected, but can give you a few points from my experience with a mechanical valve.

- sound/ticking: yes I can hear my valve when I am quiet. I’ve always heard my heart beat when quiet, so the mech valve only makes it a little louder. I do not hear it at all when I’m active, listening to music, or any other time I’m paying attention to something else. On the upside, you can take your pulse just by listening and watching a clock

- bruising: I’ve found I do not bruise any more than before. It takes quite a hit to cause me to bruise. Typically they are not any worse (bigger) than before, but they do take a little longer to go away. Something like 10 days to 2 weeks to fade as opposed to 1 week before warfarin.

- INR management: no big deal. Dosing becomes routine, like brushing you teeth, you just do it everyday. Testing is not hard, I still go to the clinic, but will be home testing in the near future. I just stop in on the way to work. Your OCD may actually be a benefit to you here.

No matter the choice, you sound prepared and will do well!

 

[vitdoc]

I think your OCD is playing a large part in your having a hard time in making a decision. Currently the decision comes down to monitoring your INR with a mechanical valve vs more procedures with a tissue valve.
If you get an aneurysm another procedure with a mechanical valve but if you are old enough you could replace the mechanical with a tissue valve. Also no one knows what new breakthroughs might occur. Perhaps an anticoagulant without need for INR testing that works for valves? Perhaps a mechanical/tissue valve not needing anticoagulants with a long longevity.
Tough decision given these unknowns. So for now it is longevity vs no anticoagulants.
I personally detested my three open hearts so I went for longevity after my first aortic valve.
Tissue age 29, mechanical age 35, aorta + mechanical age 58. Now 71. Also skied, biked and played basketball without problems from bleeding . Still bike.

 

[nobog]

Although it is my opinion, you should go with a mechanical valve.
There is no correlation as to a smaller tissue valve wearing out faster than a larger one - that I know of.

 

[VHeart]

Are you BAV?

Bicuspid aorta valve? Yes.

For me, the decision would rest entirely on the possibility of the aneurysm. Your surgeon has exactly zero info on which to base the statement that your risk for aneurysm is extremely low.

It does complictate my decision. Do you have any theories why your aortic root increased? I wonder if puberty or metabolism had something to do with it.

My ascending aorta has been 3.8-3.9cm and my aortic root fluctuates between 3.5-4cm for the past 10 years. I'll ask my cardiologist about my aorta.

"For the thoracic aorta, a diameter greater than 3.5 cm is generally considered dilated, whereas greater than 4.5 cm would be considered aneurysmal. " Thoracic Aneurysm: Background, Pathophysiology, Etiology

 

[pellicle]

...There is no correlation as to a smaller tissue valve wearing out faster than a larger one - that I know of.

me neither .... but there is one which is significant which should be mentioned, and that its the first point in their list makes it significant:

Early SVD is associated with several risk factors; the most common of these risks include young patient age, renal failure, abnormal calcium metabolism, and prosthesis-patient mismatch of the implanted valve
https://www.ahajournals.org/doi/full/10.1161/circulationaha.117.030729

I missed this point:

I have severe bicuspid AV regurgitation

and so @VHeart you need to ask your surgeon quite seriously why they are sure you won't get aneurysm? As Superman rightly points out (and I concur with his points).

My 3rd OHS (2nd was at 28 yo) was driven by the discovery of an aneurysm which was already 5.3cm (IIRC) and while the homograft was packing in would have done a few more thousand km before needing the heads off (so to speak). I am sort of glad it panned out the way it did.

 

[Protimenow]

A few thoughts:

Regarding Warfarin, you should be testing weekly. Testing every few weeks exposes you to potential risks between tests.

Many of us on this site self-test, and some (myself included) self manage. The meters can be somewhat expensive, but insurance may cover the cost, and you can probably buy one on eBay for less money.

As far as Warfarin availability is concerned, some of it is manufactured in Israel. It'll probably be fairly safe to assume that it will be available.

In terms of a tissue valve, a lot of doctors are talking about doing a TAVI on a failing tissue valve. If you can get one, this may extend the time before you need another valve.

 

[tom in MO]

One piece of advise given to me by both my surgeon and cardio is to not base my valve decision on future possibilities. Base it on the reality of now, then you won't be disappointed.

Another piece of advice by a philosopher whose name escapes me: If the two paths for a decision are difficult, rest easy with the knowledge that they are difficult because both paths have equal merit.

Your risks are on target, but in my opinion can use some tweaking:

MECHANICAL VALVE
- I'm sound sensitive but I'm OK with watch ticking noise at night, but will be annoyed if I hear it during activities and music. Most people don't have a problem.
- Higher risk (how much?) of bleeding, but "likely won't be life threatening." -surgeon The risk if fully quantifiable from a different angle. If your INR is 2, it takes 2 times longer for your blood to clot.
- Worry about possibility of no access to medication (travel, natural disasters). The coronavirus has already put my non-generic brand of antidepressant on back order until the end of this year. Warfarin is very common, very cheap, I keep a two month supply on hand.
- I Have OCD and I will probably obsess over INR and drug/food interactions depending on how important it is. That could be both good for my physical health but bad for mental health. If you are truly OCD, then you can get help for your OCD and it will make your whole life better. However, I'll bet you're just normal and overthink some things.
- Possible easy bruising? I currently don't bruise at all. I've ran into metal poles and only had mild bruising. Afraid that will change with warfarin. An INR of 2 means it will take 2 times longer for your blood to clot.
- Spend $$$ on medication and test strips but may have coverage. Warfarin is cheap. Testing at the doctor's office is generally free.

TISSUE VALVE
- Feel hesitant to be as active out of fear of wearing out the valve faster, but data doesn't support this? Not true. They don't know why some peoples bodies eat up valves quicker. All they know for sure is once you are over 60-65, you generally are good to go.
- Major inconvenience every ~10 years. Slow deterioration with major surgery (not just an inconvenience) and 6-8 weeks loss of work every 2-15 years, but if your tissue fails in 2 years, you will probably go mechanical.
- 1-4 OHS in the future. May only get 5 years out of first valve. "10 years average. 4th surgery is when complications increase the most" -surgeon The low end for a few is more like 2 years not 5 but some go for 15-20 years.
- Each surgery has <1% chance of death in surgery, 3% risk of reopening to look at bleeding, 2-3% infection of valve in hospital, 0.2% valve infection within 6months, 5% risk of needing pacemaker. Need to add in the risk of infection due to hospital stay. At 62 I know of two people who died from infections caught in the hospital, not the original condition that brought them in.
- Research suggests there is similar risk of stroke as mech valve. Not true since with the mechanical valve you are on warfarin. This reduces your risk of stroke from all kinds of causes.
- Spend $ on supplements that I think will reduce calcification of the valve. They don't work. No need to do that. They don't know why some people run through valves quicker than others.

 

[Protimenow]

A few things:

If you have OCD, this may actually help you with your medications. If you obsess about taking warfarin daily, and maintaining your INR, you probably WON'T miss your doses - it can become a weak obsession.

An INR of 2.0 doesn't mean it takes two times more to clot - it takes two times AS LONG to clot as a person (non- anticoagulated) with an INR of around 1.0. An INR of 3.0 means it takes three times AS LONG to clot as a person with INR of 1.0.

Yes, Warfarin IS inexpensive and readily available. It's not made in China (as far as I know). I keep more than two or three months supply - and even more - because my dose changes occasionally. I keep supplies of 4 mg, 7.5 mg, 2 mg, and some 5 mg pills. This way, not only can I make up practically ANY dose that I need, with a 60 or 90 day supply of each, even if it somehow becomes unavailable for a while, I still have enough to last through many months if it ever becomes unavailable.

 

[user 15848]

When i dropped 5 times in one day on the floor i went to see my cardiologist, he said i "must" take a tissue valve because he knows best, i come from a long family of "doctors" in Cuba and i know good doctors and bad doctors and for sure know "Castros wanna be" they guy that is always right and is always wrong; So, i dropped the cardiolgist went with another; and everybody told me , tissue valve is best for you because you are 62; then i read all about if at mayo clinic and cleveland clinic youtube presentations etc, and it hit me that it was not so clear to go with tissue valve at 62, even 65, They all told me "it will last x amount of years".... then... talked to all the dozens of doctors in my family all said "go mechanical", avoid 2nd operation, every time you go to hospital you dont know what is going to hit you, wether is a virus from china or habana, so i talked to my surgeon, very warm human like doctor whihc is hard to come by in Canada; and he offered the choice of tissue or mech, only condition was that IF i choose mechanical he "only" uses OnX valves because its design improvements; Then he said, tissue valve no pills and it should last you till your mid 70s; so.... mid 70s will i be alive or dead i asked myself, the reply was, maybe alive, do i want to be back in hospital at 77 ?... nah,..... and so it was Mechanical and Warfarin; i dont eat much veggies, never did, so my dosis is 3 mg a day and that keeps inr around 2.2 with a 81 mg ASA every day ; no complains, and yes, would love not to have to take pills, but , no, dont want to go into a hospital for heart surgery again, even though is free here; just a thought

 

[nobog]

Don't be fooled by the "design improvements" of the OnX valve. Advertising does wonders.

 

[Protimenow]

Physicians and surgeons used to recommend tissue valves for 'old people' because they expected your lifespan to be around 70 years. They didn't seem to realize that a good proportion of people, who've already hit 60 or more, are living into their 80s and 90s. The reasoning to go with tissue is much more shaky than it was, maybe, 30 years ago, when these surgeons covered the subject for a few weeks in Medical School.

Sure, some tissue valves can lost much longer than the 15 or so that they say they'll now last, and it's possible that there will be non-invasive procedures that are proven effective, by the time you need a replacement or repair, but WILL THERE?

As far as 3 mg dose goes -- each of us responds to warfarin slightly differently. Your dose is the dose that works for you. You can't predict what your dose should be. It also takes a while post-op for your body to adjust to the warfarin.

I strongly suggest - if you're able to self-test (some people have problems with dexterity, others have visual problems, etc. that make it difficult to do the test) - get yourself a meter, self-test weekly, and either self-manage (there are many resources to help you do this) or get some (often bad) advice from your physician.

 

[rwsp768]

Protimenow I quit this site years ago for being flamed by a member so it is adios time again

 

[Protimenow]

rwsp768 - I went through my posts and didn't see that you were 'flamed' anywhere. I indicated that your anticoagulation clinic didn't know what it was doing - not that you didn't know what YOU were doing. My comment echoed the comment of others You shouldn't take a comment about your clinic to reflect in any way onto you.

At this forum, we value every person's input. (At least, as far as I'm concerned). If an error is apparently being made (in dosing, or with incorrect assumptions, etc.) someof us will comment on it. These usually aren't personal attacks.

Don't 'adios' now - because I don't think you've been flamed at all -- if I wrote something that you didn't appreciate, I'm sorry - but no insult was intended.

FWIW - years ago, I was subject of some really vicious attacks and, in fairness, I may have reacted in kind. I stayed away for a few years. But these were ACTUAL ATTACKS - not clarifications or advice.

Hang around - it'll get better.

 

[Superman]

It does complictate my decision. Do you have any theories why your aortic root increased? I wonder if puberty or metabolism had something to do it.

Just saw this, @VHeart. No clue. In my mid 30’s it just started to go. I think of it like a new balloon. Really hard to inflate at first. Then a certain threshold is reached and it suddenly inflates easily the rest of the way.