9 Questions for Those with BioProsthetic (Tissue) Valves

[pellicle]

However, google likely lumped BAVs in with normal tricuspids

google doesn't answer questions, it gets answers from studies that answer questions.
naturally there is many reasons for the need from calcification, bicuspid valve, endocarditis or just a bad strep infection (scarlet fever).

This however doesn't change the demand for valves and the assessment by the valve makers nor does it change the physiology of the humans who get the valve. Even if you have BAV as your driver the other biochemistry mentioned in those articles will likely be the same. Do you see otherwise?

One study:
https://pubmed.ncbi.nlm.nih.gov/8673757/

Conclusions: Bicuspid calcified aortic valves are the predominant cause of isolated aortic valve stenosis followed by tricuspid calcified aortic valves.​

which supports my long standing (like 30 years) view that BAV is the main cause.

 

[BionicBuddy]

One study:
https://pubmed.ncbi.nlm.nih.gov/8673757/

​

Small sample size

which supports my long standing (like 30 years) view that BAV is the main cause.

But yeah, you're probably right. Really old people with tricuspids often die of something else even if their valves are stenotic.

 

[pellicle]

Small sample size

agreed ... as is asking people here; sample size is perhaps smaller and subject to bias


there were others that came up

 

[BionicBuddy]

agreed ... as is asking people here

Yup. Always on the quest for info in all kinds of forms.

 

[Jerry D]

1. At what age did you get your bio-prosthetic valve? 69 (Edwards Lifesciences bovine)

2. How long have you had your bio-prosthetic valve for? 5 plus years

3. If your valve failed, what was the reason? bicuspid stenosis

4. Are there any medications you have had to take after surgery because of the bio-prosthetic valve replacement surgery? Diltiazem, atenolol, atorvastin, xeralto

5. Did you have any complications after your surgery? ended up with a-fib and a-flutter. Had ablation 12/2021 and may have another one this summer.

6. What is your exercise tolerance like now after surgery? I coach and race 6-man outrigger canoes on the open ocean. Did 13 miles last Saturday and will do another 12-13 this coming Saturday. Do kettlebell and bodyweight exercise. No longer lift heavy weights.

7. On a scale of 1-10, with 1 being miserable and 10 being happy, how happy are you with your choice for bio-prosthetic valve? 10

8. Is there anything that you would do differently now, that you have had this experience, and from all the things you have learned thus far? No

9. Any further tips to share on how to experience success and a great quality of life having made this important valvular choice? Just had an echo and my heart and valve are going strong.

 

[Gkeraney]

Good morning

Sun just coming up here in (my part of) Australia, and I like going for an early morning walk in the wintertime to escape the cold of the house; so I'll try to be brief.


nicely phrased question.

So, my short answer is yes; but its probably not what you think.

I don't think its just related to the pressures the valve experiences and increase in frequency of actuation (mechanical wear) that does it. Instead I believe its related to the associated biochemistry of the cocktail of things circulating around in your blood.

First lets say there are correlations and causations. Sometimes correlations are indicators that causality is there and we should look for it, other times its just only that - correlation.

View attachment 889274

That its only correlation is usually cleared up with more data. There is clearly a causal link between Structural Valve Degradation (SVD) and youth. This is well known and not subject to any leaning in the scientific community (I say scientific because surgeons are not the ones who research, design and make valves; they just stitch them in).

If you read up on SVD (I recommend this link as an excellent roundup from 2020) you can see that a lot of what causes SVD is directly related to exersize generated biochemistry. In short the mineralisation of the "piece of leather flap" that is essentially what a bioprosthesis is gets attacked by the biochemistry of the living body.

Much of this slows down with age of course, but it is my view that it slows down less in people who are active.

Next you should look at the physiology of the native valve, and observe key points like "cellular regeneration". This article is a deep dive but depending on your patience in reading such things is very informative. I'll snapshot a good point

View attachment 889275
Basically the structure of the native valve is such that the tissue is not only regenerative but very flexible, its not "vascularised" (like skin is) because its permanently immersed in a bath of the freshest blood. If its not then you have broader systemic problems ;-)

Anyway I recommend you read that pointer to SVD in the first link and then get further down to Strategies for SVD Prevention. Note these are at the manufacturing stage and note also the words: "Its exact mechanism is unknown".

This leaves us with "more research is needed" as well as the basic observable facts (called statistics), such as the onset of SVD based on age and the interesting observation that all bio-prosthesis manufactures seem to like terminating their research into longevity of valves at 10 years. Perhaps that's because they think that the median age is in the mid 70's for valve replacement. I googled that exact question and got this:

What is the average age for aortic valve replacement?​

The mean age in the study population was 75.1 ± 6.6 years ​

So since that's their market that's what they make. Questions of "will it last longer in young active, sporting and fit 60yo" are not of interest to them.

Thus we are left to conjecture. So, look around this forum and see how many of the fit active sporting weight lifting types have mechanical, and which have tissue.

HTH

Best Wishes

Good morning

Sun just coming up here in (my part of) Australia, and I like going for an early morning walk in the wintertime to escape the cold of the house; so I'll try to be brief.


nicely phrased question.

So, my short answer is yes; but its probably not what you think.

I don't think its just related to the pressures the valve experiences and increase in frequency of actuation (mechanical wear) that does it. Instead I believe its related to the associated biochemistry of the cocktail of things circulating around in your blood.

First lets say there are correlations and causations. Sometimes correlations are indicators that causality is there and we should look for it, other times its just only that - correlation.

View attachment 889274

That its only correlation is usually cleared up with more data. There is clearly a causal link between Structural Valve Degradation (SVD) and youth. This is well known and not subject to any leaning in the scientific community (I say scientific because surgeons are not the ones who research, design and make valves; they just stitch them in).

If you read up on SVD (I recommend this link as an excellent roundup from 2020) you can see that a lot of what causes SVD is directly related to exersize generated biochemistry. In short the mineralisation of the "piece of leather flap" that is essentially what a bioprosthesis is gets attacked by the biochemistry of the living body.

Much of this slows down with age of course, but it is my view that it slows down less in people who are active.

Next you should look at the physiology of the native valve, and observe key points like "cellular regeneration". This article is a deep dive but depending on your patience in reading such things is very informative. I'll snapshot a good point

View attachment 889275
Basically the structure of the native valve is such that the tissue is not only regenerative but very flexible, its not "vascularised" (like skin is) because its permanently immersed in a bath of the freshest blood. If its not then you have broader systemic problems ;-)

Anyway I recommend you read that pointer to SVD in the first link and then get further down to Strategies for SVD Prevention. Note these are at the manufacturing stage and note also the words: "Its exact mechanism is unknown".

This leaves us with "more research is needed" as well as the basic observable facts (called statistics), such as the onset of SVD based on age and the interesting observation that all bio-prosthesis manufactures seem to like terminating their research into longevity of valves at 10 years. Perhaps that's because they think that the median age is in the mid 70's for valve replacement. I googled that exact question and got this:

What is the average age for aortic valve replacement?​

The mean age in the study population was 75.1 ± 6.6 years ​

So since that's their market that's what they make. Questions of "will it last longer in young active, sporting and fit 60yo" are not of interest to them.

Thus we are left to conjecture. So, look around this forum and see how many of the fit active sporting weight lifting types have mechanical, and which have tissue.

HTH

Best Wishes

Thank you for your great response. Over time, I have come to agree completely, partially driven by my own experience so far.

This is my own story, as briefly as I can. As a young man I was very competitive distance runner. At age 19, averaging 6:18 a mile at the Boston Marathon. I soon after stopped improving and got more interested in girls and decreased my activity. At age 40 in spring 2000, I sought care for a feeling of on going chest congestion and aortic stenosis and regurgitation was found. Born with a bicuspid valve as it turns out. Months later receive a St. Jude Toronto SPV, 27 mm. Stentless. The cardiac team was confident it would last 15 to 20 years. They didn't want me to do a mechanical valve as I would then have "warfarin disease."

I was told to go live my life and not be restricted at all. To come in if I had symptoms, no follow up. I didn't run much for exercise, now more like a jog for sure, but I did start doing about 25 miles a week, much of it hard. This was at 8 years since surgery. The idea was to drop weight and I did and have stayed around the same weight since. I got my mile time back down to 7 minutes. (It felt amazing that I was so much slower but it didn't feel so much different). I felt it when the regurgitation started, and got in again and with some follow ups this led to a 2nd open heart 10 years and 6 months since the first. In retrospect, this valve had done pretty well in a 40 year old.

Now at 51 and a few months I have a Medtronic Mosaic, 27 mm. Stented. It's early 2011. It was a toss up between mechanical or this valve. The cardiac team ends up doing this valve with the idea that tavi/tavr had started and it's a decent enough idea that if this one failed at 10-15 years, I could get one and probably 2 tavi's. The surgeon likes this idea and the cardiologist doesn't...and later has no recollection of any of this.

 

[Gkeraney]

Thank you for your great response. Over time, I have come to agree completely, partially driven by my own experience so far.

This is my own story, as briefly as I can. As a young man I was very competitive distance runner. At age 19, averaging 6:18 a mile at the Boston Marathon. I soon after stopped improving and got more interested in girls and decreased my activity. At age 40 in spring 2000, I sought care for a feeling of on going chest congestion and aortic stenosis and regurgitation was found. Born with a bicuspid valve as it turns out. Months later receive a St. Jude Toronto SPV, 27 mm. Stentless. The cardiac team was confident it would last 15 to 20 years. They didn't want me to do a mechanical valve as I would then have "warfarin disease."

I was told to go live my life and not be restricted at all. To come in if I had symptoms, no follow up. I didn't run much for exercise, now more like a jog for sure, but I did start doing about 25 miles a week, much of it hard. This was at 8 years since surgery. The idea was to drop weight and I did and have stayed around the same weight since. I got my mile time back down to 7 minutes. (It felt amazing that I was so much slower but it didn't feel so much different). I felt it when the regurgitation started, and got in again and with some follow ups this led to a 2nd open heart 10 years and 6 months since the first. In retrospect, this valve had done pretty well in a 40 year old.

Now at 51 and a few months I have a Medtronic Mosaic, 27 mm. Stented. It's early 2011. It was a toss up between mechanical or this valve. The cardiac team ends up doing this valve with the idea that tavi/tavr had started and it's a decent enough idea that if this one failed at 10-15 years, I could get one and probably 2 tavi's. The surgeon likes this idea and the cardiologist doesn't...and later has no recollection of any of this.

I run 35 miles a week the next 8 years. I felt great for about the first 5 years and then start slowing down but keep at it, reassured that the exercise is fine, even this much. I can again tell when the regurgitation starts, and this time they are really slow to get me in. I had complained by now that I was nearly certain I had clots on the valve but they never do a ct scan and don't listen to me. The same surgeon I have had recalls the plan for tavi, and feel its still a good plan. The cardio doesn't and wants me to go mechanical. It's a toss up again but I have a sapien 3 ultra 25 mm placed at 8 year and 10 months since the 2nd open heart. It's Nov 2019 and I'm 60.

I'm feeling certain that I probably cost myself around 4 years with the surgical valves by training too hard, and having blood clots wear out the valve. And I felt not mechanical wear but more likely my body metabolizing the valves. A ct scan in Jan 2021 showed the clots on the tavi, , not just halt but clinically relevant ones effecting velocities. Several and one 7 mm. NOW they keep a close eye on me.

Long story short I go on warfarin 2 plus years ago. After awhile, I have a good handle on the warfarin. Echo results actually the best ever now. I feel fine as I should but it's impossible to know what the next procedure will be, or when.

I walk around 25 miles a week and still work as a health care provider about 30 hours a week. I am hoping for a bit of a miracle that the tavi lasts until I am 72 or so and that I have the decision to take the easy way out and get another one or I have to do open heart. I expect to head over to the Cleveland Clinic to see what they think in around 2 years.

I do wonder if other people also thought they did too much, but even if no one does, I wont be running much ever again. Thanks again for you great post and listening to my meandering.

 

[pellicle]

Hi
I'll assume this one:

Thanks again for you great post and listening to my meandering.

was actually meant as a reply to me not you ;-)

This is my own story, as briefly as I can. As a young man I was very competitive distance runner. At age 19, averaging 6:18 a mile at the Boston Marathon.... At age 40 in spring 2000, I sought care for a feeling of on going chest congestion and aortic stenosis and regurgitation was found. Born with a bicuspid valve as it turns out. Months later receive a St. Jude Toronto SPV, 27 mm. Stentless. The cardiac team was confident it would last 15 to 20 years. They didn't want me to do a mechanical valve as I would then have "warfarin disease."

Its a reasonable choice and since you mention 'warfarin disease' I think its important to observe that there is no cure to valvular heart disease; instead we exchange valvular heart disease for prosthetic valve disease.

There are two main types of this disease, one is treated with ongoing surgical interventions the other is treated by Anti Coagulation Therapy (ACT aka warfarin or ratsack)

Me myself I prefer ACT to the certainty of another surgery (in my career of already having 3), but I accept that many people are just idiots and are unable to properly approach the discipline of taking warfarin and testing. Now before anyone gets their knickers in a knot let me say that the stats totally bear this view out.

Best example of an idiot is found here:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8202806/

Our patient is a 24-year-old African American female with a past medical history of bicuspid aortic valve and aortic insufficiency with aortic valve replacement eight months prior with a 25 mm On-X mechanical prosthesis aortic valve on warfarin. Recent history was significant for two transient ischemic attacks (TIAs) due to medication non-compliance and previously documented subtherapeutic international normalized ratios (INRs). She presented to the emergency room with complaints of pain in both her lower extremities for nine months. The pain was gradually progressive, bilateral, ascending from the feet to the knees, burning in character, aggravated by touch and ambulation, and relieved by rest. She admitted to recent medication non-compliance, followed by taking higher doses of warfarin at onset of symptoms.​

bold mine

It is no doubt for the above reason that so many surgeons want to move people towards the "surgical management" stream (among others).

The facts are very clear on this, but so too is the psychology.

I felt it when the regurgitation started, and got in again and with some follow ups this led to a 2nd open heart 10 years and 6 months since the first. In retrospect, this valve had done pretty well in a 40 year old.

I agree ... that's about normal, and indeed some get far less (usually the younger ones) and its emerging that Lp(a) levels are an indicator of early bioprosthetic failure.

Something you mentioned (BAV) makes me want to ask are you aware of the strong association with BAV and later age aneurysm? That indeed is what drove my OHS #3 ... where I chose mechanical to do my best to avoid OHS #4.

If you are not being monitored for aortic artery aneurysm I strongly recommend you discuss this point with your cardiologist. I'm quite sure I'd be dead back in 2011 if I hadn't had a scan to find it.

I hope your plans for a TAVR work out.

Best Wishes

 

[Gkeraney]

Hi
I'll assume this one:


was actually meant as a reply to me not you ;-)




Its a reasonable choice and since you mention 'warfarin disease' I think its important to observe that there is no cure to valvular heart disease; instead we exchange valvular heart disease for prosthetic valve disease.

There are two main types of this disease, one is treated with ongoing surgical interventions the other is treated by Anti Coagulation Therapy (ACT aka warfarin or ratsack)

Me myself I prefer ACT to the certainty of another surgery (in my career of already having 3), but I accept that many people are just idiots and are unable to properly approach the discipline of taking warfarin and testing. Now before anyone gets their knickers in a knot let me say that the stats totally bear this view out.

Best example of an idiot is found here:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8202806/

Our patient is a 24-year-old African American female with a past medical history of bicuspid aortic valve and aortic insufficiency with aortic valve replacement eight months prior with a 25 mm On-X mechanical prosthesis aortic valve on warfarin. Recent history was significant for two transient ischemic attacks (TIAs) due to medication non-compliance and previously documented subtherapeutic international normalized ratios (INRs). She presented to the emergency room with complaints of pain in both her lower extremities for nine months. The pain was gradually progressive, bilateral, ascending from the feet to the knees, burning in character, aggravated by touch and ambulation, and relieved by rest. She admitted to recent medication non-compliance, followed by taking higher doses of warfarin at onset of symptoms.​

bold mine

It is no doubt for the above reason that so many surgeons want to move people towards the "surgical management" stream (among others).

The facts are very clear on this, but so too is the psychology.



I agree ... that's about normal, and indeed some get far less (usually the younger ones) and its emerging that Lp(a) levels are an indicator of early bioprosthetic failure.

Something you mentioned (BAV) makes me want to ask are you aware of the strong association with BAV and later age aneurysm? That indeed is what drove my OHS #3 ... where I chose mechanical to do my best to avoid OHS #4.

If you are not being monitored for aortic artery aneurysm I strongly recommend you discuss this point with your cardiologist. I'm quite sure I'd be dead back in 2011 if I hadn't had a scan to find it.

I hope your plans for a TAVR work out.

Best Wishes

I went over the total letter count and so I was forced to split the post I made. Poor form for a first try, really. I have had two ct scans, full abdominal and chest, to keep an eye out for anything that is going wrong. This in 2019 and then 2021. I was aware of the association and so far so good, but another reason for me to go to Cleveland. I have had everything done by the same surgeon and cardiologist in Seattle so far and do want other opinions. I again want to thank you for your contributions that caught my eye immediately when I recently joined. I wish I had found this place much sooner.

I use coaguchek and test once a week. Once I started doing that and become more comfortable taking something I avoided for 21 years, it became easy. I would go back and get a mechanical valve either in 2000 or 2011 if I could but here we are. Particularly in 2011 it almost happened. The plan hatched at that time is working out oddly since I am on warfarin, but perhaps that will extend the tavi valves life.

Best Wishes to you also

 

[pellicle]

Hi

wait ... I missed this bit

Long story short I go on warfarin 2 plus years ago.

so I was surprised when I saw

I use coaguchek and test once a week.

glad you've got it nailed. Its actually not rocket science. That one finds a need for being on ACT for something else (say ... AFib) is a topic which I raise when people are "stamp their foot down" not going on ratsack no matter what ... and that something occurs to them.

But while coming here to ask actual patients about what actually happens I still see many people over the decade I've been here seem to say "well what would you know". IDK

I went over the total letter count and so I was forced to split the post I made

yeah ... I've been caught on that one plenty of times. I now copy paste into notepad, cut it in half and continue ...

HTH

 

[BionicBuddy]

1. At what age did you get your bio-prosthetic valve? 69 (Edwards Lifesciences bovine)

Is this the Insipiris resilia? If you should need something in the future, say when you're 90, did your surgeon say they could do a TAVR at that time? Thanks!

 

[BionicBuddy]

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8202806/

Our patient is a 24-year-old African American female with a past medical history of bicuspid aortic valve and aortic insufficiency with aortic valve replacement eight months prior with a 25 mm On-X mechanical prosthesis aortic valve on warfarin. Recent history was significant for two transient ischemic attacks (TIAs) due to medication non-compliance and previously documented subtherapeutic international normalized ratios (INRs). She presented to the emergency room with complaints of pain in both her lower extremities for nine months. The pain was gradually progressive, bilateral, ascending from the feet to the knees, burning in character, aggravated by touch and ambulation, and relieved by rest. She admitted to recent medication non-compliance, followed by taking higher doses of warfarin at onset of symptoms.​

Jeezuz.

Another huge reason this forum is so important in successfully supporting those on Warfarin.

 

[d333gs]

What type of tissue valve was it, and is it TAVR ready, or did your surgeon say a valve-in-valve was an option for you in the future if necessary? Thanks!

Hi BB, he said TAVR

 

[d333gs]

I've had very high pressure gradients ever since my AVR, around 56 peak, 35 mean. Three years after surgery I was referred to a cardiac surgeon for review about this (I didn't see the surgeon who did my AVR because I wasn't too happy with her). I liked the new cardiac surgeon very much. This is when he confirmed that I had moderate patient prosthesis mismatch which can be worked out from the size of the replacement valve, the patient's weight and height and calculations in echocardiogram. The surgeon explained that when the bicuspid aortic valve is removed the 'annulus' is measured and that tells the surgeon what size valve to put in - he explained that the annulus is made of very fibrous material and it doesn't stretch to put in a bigger valve than it's size.

A surgeon should be able to calculate at that point in surgery if the replacement valve will be appropriate - if there is some patient prosthesis mismatch I suspect they have to decide if that will be acceptable or if they have to do something else like putting a bigger valve in supra-annular position. I've no idea what my surgeon thought because in the Operation Note she simply wrote she measured the annulus and put in the 19mm valve.

Nine years later the valve is still okay despite the high pressure gradients.

Interesting , thank you!

 

[BionicBuddy]

Now at 51 and a few months I have a Medtronic Mosaic, 27 mm. Stented. It's early 2011. It was a toss up between mechanical or this valve. The cardiac team ends up doing this valve with the idea that tavi/tavr had started and it's a decent enough idea that if this one failed at 10-15 years, I could get one and probably 2 tavi's. The surgeon likes this idea and the cardiologist doesn't...and later has no recollection of any of this.

Thanks for sharing your story.

Do I understand correctly, that you had a TAVR inserted almost 9 years after your second SAVR with a Medtronic Mosaic? My understanding from others on this site, is that bioprosthetic valves developed prior to the Insipris Resilia are not TAVR ready. Obviously you have shown that TAVR can be done on older generation valves because you had it done, and may be able to get another TAVR in the future.

Of course everyone is different and each surgeon's approach is different. Making it to 72 may not be so much of a miracle as a very real possibility. The father of my daughter's friend, for his first valve replacement in his late 60s, had a TAVI done in the hospital by the interventional cardiologist that was one of the pioneers of TAVI and an investigator in the PARTNER trial. (I know know some on here don't like that trial). Anyway, he was the doc that did the TAVI on this man and he told him confidently, that he will get 10 - 15 years out of the valve. So it is very conceivable that you may too.

I understand your query and concerns regarding exercise with a bioprosthetic valve. I wonder about that too.

 

[Gkeraney]

Yes, the surgeon chose a medtronic mosaic valve and said he placed the biggest one he could get in to provide room for a tavr next. This led to a dispute later as I spent nearly a decade expecting the next valve to be a tavr and then when the mosaic valve failed the only one who wanted to do the tavr was my almost retired surgeon. The cardiologist and the interventional cardiologist who ended up doing the tavr, weren't in on the plan, so to speak. The less I say the better but I have had surgeons as friends in my life and lets just say I grew to think they were much more on top of there game than anyone else in the traditional medical field...on average anyway. It's counter intuitive but they seem to recall better and have better notes when they dont.

The mosaic valve is a stented valve vs the prior stentless St. Jude. He even told me he was guessing from what he knew that a stented valve should work better to put a tavr in. This was in late 2010. I asked the interventionalist in 2019 and he agreed though I know they were tight personally and he doesnt love the cardiologist who is conservative. She is a well known doc internationally who helps set standards for these decisions. She is still my cardio and I do listen to her opinion though she isnt super kind. She has no recollection that I didnt do a mechanical valve at age 40 because of her AND the surgeon who thought i would deal with "warfarin disease" to long. So she thinks I have made poor decisions that she participated in me making. It's great fun.

I'm down her in Seattle and many of those docs in Vancouver and Seattle know each other well. My main concern in getting 12 years out of what is in me is that I have never gone past 10.5...AND we know I developed clots we saw on ct on this current tavi. Mind you I am 100% sure I had clots already from 2011 to 2019 but couldn't get them to image me...and I am doing warfarin now. My only shot is the warfarin, and it may well be it gets me to 2032 and beyond. My echo results have never been better. All the best to you and yours and thank you so much for the positive thoughts!

 

[BionicBuddy]

Mind you I am 100% sure I had clots already from 2011 to 2019 but couldn't get them to image me...and I am doing warfarin now. My only shot is the warfarin, and it may well be it gets me to 2032 and beyond. My echo results have never been better.

Yet another positive story about Warfarin! Great!

I apologize for the navel gazing, but I do have a question for you, given all of your experience with AVRs and the fact that you are very athletic.

While you don't say so explicitly, in your stories you imply that with what you know now, you would have perhaps made a different choice regarding mechanical valve at 40 or 51. I understand this.

Hypothetically, if you never had an AVR before, were very athletic as you have been, and needed an AVR at 65, with the benefit of hindsight and experience, would you choose a mechanical valve or bioprosthetic?

(I have asked this question of others who are athletic with lots of AVR experience as well. And in the end, I know it is hubby's decision to make in conjunction with his surgeons, cardio and entire cardiac team, but I am interested in how others navigate their choices and their reasoning in the event something could twig and be helpful for us).

Thanks!

 

[Gkeraney]

Yet another positive story about Warfarin! Great!

I apologize for the navel gazing, but I do have a question for you, given all of your experience with AVRs and the fact that you are very athletic.

While you don't say so explicitly, in your stories you imply that with what you know now, you would have perhaps made a different choice regarding mechanical valve at 40 or 51. I understand this.

Hypothetically, if you never had an AVR before, were very athletic as you have been, and needed an AVR at 65, with the benefit of hindsight and experience, would you choose a mechanical valve or bioprosthetic?

(I have asked this question of others who are athletic with lots of AVR experience as well. And in the end, I know it is hubby's decision to make in conjunction with his surgeons, cardio and entire cardiac team, but I am interested in how others navigate their choices and their reasoning in the event something could twig and be helpful for us).

Thanks!

The thing is that I know my valves have struggled and been below average on durability. And I also know that with valve in valve I now have, I have ended up on warfarin. If I somehow knew that was going to happen, and I was starting from scratch at age 65, yes I would pick a mechanical valve...and probably on x, with the idea that I might need less warfarin by a little. Now more realistically not knowing what the future would hold, I would have picked a bio valve and expected to get a tavr inside that around 13 years later. I'm actually a licensed physician in the state of Washington. If someone asked me what to do I would say they have two nearly equal ways to go, starting from scratch at age 65. The tavr at age 75-80 ish is likely to be easy to do and probably would require minimal warfarin...though apparently not for me.

As importantly I would moderate the exercise, either way. I wouldn't want to have my body trying to metabolize any valve. The mechanical valve could be affected too by scarring all around it. Then you have another open heart after age 80. That's real trouble, right?.

 

[sharky7]

Good morning

Sun just coming up here in (my part of) Australia, and I like going for an early morning walk in the wintertime to escape the cold of the house; so I'll try to be brief.


nicely phrased question.

So, my short answer is yes; but its probably not what you think.

I don't think its just related to the pressures the valve experiences and increase in frequency of actuation (mechanical wear) that does it. Instead I believe its related to the associated biochemistry of the cocktail of things circulating around in your blood.

First lets say there are correlations and causations. Sometimes correlations are indicators that causality is there and we should look for it, other times its just only that - correlation.

View attachment 889274

That its only correlation is usually cleared up with more data. There is clearly a causal link between Structural Valve Degradation (SVD) and youth. This is well known and not subject to any leaning in the scientific community (I say scientific because surgeons are not the ones who research, design and make valves; they just stitch them in).

If you read up on SVD (I recommend this link as an excellent roundup from 2020) you can see that a lot of what causes SVD is directly related to exersize generated biochemistry. In short the mineralisation of the "piece of leather flap" that is essentially what a bioprosthesis is gets attacked by the biochemistry of the living body.

Much of this slows down with age of course, but it is my view that it slows down less in people who are active.

Next you should look at the physiology of the native valve, and observe key points like "cellular regeneration". This article is a deep dive but depending on your patience in reading such things is very informative. I'll snapshot a good point

View attachment 889275
Basically the structure of the native valve is such that the tissue is not only regenerative but very flexible, its not "vascularised" (like skin is) because its permanently immersed in a bath of the freshest blood. If its not then you have broader systemic problems ;-)

Anyway I recommend you read that pointer to SVD in the first link and then get further down to Strategies for SVD Prevention. Note these are at the manufacturing stage and note also the words: "Its exact mechanism is unknown".

This leaves us with "more research is needed" as well as the basic observable facts (called statistics), such as the onset of SVD based on age and the interesting observation that all bio-prosthesis manufactures seem to like terminating their research into longevity of valves at 10 years. Perhaps that's because they think that the median age is in the mid 70's for valve replacement. I googled that exact question and got this:

What is the average age for aortic valve replacement?​

The mean age in the study population was 75.1 ± 6.6 years ​

So since that's their market that's what they make. Questions of "will it last longer in young active, sporting and fit 60yo" are not of interest to them.

Thus we are left to conjecture. So, look around this forum and see how many of the fit active sporting weight lifting types have mechanical, and which have tissue.

HTH

Best Wishes

Your awesome, and it is wild how they choose research to and to not do! Then publish something most us cannot read cause of lack of education, etc. It was my understanding that doing cardio was a big plus, now I have to worrying about perhaps doing, too much cardio. And how much is, too much. My cardio doc told me that I should not do any weight training, although aren't there some here that do it? So makes me think, duh, what am I missing? And to all FATHERS, HAPPY DAY!!! and all mothers, even those male ones, which I am one.......LOL

 

[pellicle]

Mornin

it is wild how they choose research to and to not do!

well happily there is nobody telling anybody what they should research. I did my masters resarch into "Identifying Sustainable Urban Water Supply" and chose a city (mine) to do the research around. I did this because:

1. Local Government Authority couldn't find their arse with both hands
2. the LGA published a plan on "the solution" to our water crisis that must have been decided by a committee of 20 morons who were throwing darts at a scattering of ideas on an "idea" board written up by 20 other morons.

My thesis was judged by a pair of reviewers (one from the Uni, the other from as it happened the Water Board of the LGA). It was accepted and rated highly.
It was all pointless however because soon after that the State Government decided to absorb (steal) all water assets from the LGA (because they make a lot of money) and centralise theme (that always works) for "better administration" (AKA giving them the money stream).

So frankly picking research topics is often done for an agenda as much as pure enquiry.

Often research is done because someone feels the "present understanding" is wrong and then in a systematic and clear way goes about developing an argument based on evidence to support why they think its wrong (and in what circumstances).

Then publish something most us cannot read cause of lack of education

This is an excellent point and comes back to what it called the democratisation of science:

Democratizing science is the process through which lay understandings are taken into account when scientific knowledge production is used to make political decisions.​

link

However one can not sidestep the fact that to write about or even read about a complex topic you need to know something to being with. One can't write about something if the reader has no knowledge. Knowledge of things like units, organisation, structure and terms.

For instance when I speak to people about EV's I find that nobody knows:

• what a kWh is
• how much power they even use in their house
• how many litres or gallons their car uses per kilometer or mile
• why you wouldn't use gallons (which gallon btw US or UK?) per 100 kilometers
• what difference tyres make
• anything at all about battery technology, charging or grid loads

Which sort of means that they should just accept what's written by people who know and are presently arguing the matter.

If these people get in on the act it becomes the politicisation of science ... politics is never about the truth.

This is all none the less true in the domain of heart valves (witness the storms here over bio vs mech).

HTH