Age 43 - Active person - No health issues - Any reason NOT to go mechanical?

[Mentu]

Clement, the Mountain Biker touched on the essence of this problem and that is there are just too many variables to choose with certainty. It is hard to play "Devil's Advocate" without a lot more information. With my own choice of a tissue valve, I was largely following my surgeon's recommendation based on my own family history. The facts are that people lead very active lives with both types of valves. If you have normal heart function after surgery, you can probably, physically, do most or even all of the things you did before surgery; whether that is wise is another issue. Whatever your choice of valves, after surgery you will need to live more deliberately than before.

Larry

 

[clement]

At this point, mechanical it will be.

I am too much of a wuss to visualize another certain surgery in 10 years.
My hat off to the young or middle-age folks who have gone tissue.

Clement

 

[tobagotwo]

At the tender age of 43, I would say you would require at least two more surgeries with current technology (more likely three). A Ross Procedure or a mechanical valve would seem the best move, if possible. (Note: If you have a bicuspid valve, a Ross Procedure becomes an iffy proposition.)

The only other considerations I can think of offhand are...

- any blood clotting diseases that you may have (by far, most people don't)
- a known tendency toward GI bleeds, recurring ulcers, Crohn's disease, or similar
- detected aneurysms, especially intracranial
- unwillingness to give up "physically violent" sports (you are willing - and then again, some play rough afterwards anyway)
- knowledge of upcoming surgeries for other physical problems
- desire to become pregnant (for you, that would likely involve a very different forum - and a psychiatrist)
- known adverse interactions of warfarin with any other prescribed drugs that you know you will need to take
- having a rebellious or depressive nature that you believe would prevent you from taking your warfarin appropriately

Certainly, none of these is a slam-dunk, but each could be a part of the consideration process, if it applies.

Best wishes,

 

[drivetopless]

Touchy subject, huh? It's interesting how most folks feel very strongly about the type of valve they received and get a little touchy of someone else criticizes. Understandably so. It's a topic that is near and dear to everyone's heart.

I truly believe that you have to get as much info as you can and trust your gut. If you are leaning toward one particular valve type--find the best surgeion who has lots of experience installing that type. Also, learn about the differences amoung the options that are available.

I'd also like to point out that a mechanical valve is not necessarily a guarantee of no reop. If you have an aneurysm that develops later or issues with another valve, as often happens, you may be cracked open again. Pannus overgrowth (scar tissue) can also imped the function of the valve.

There are many here who have been on coumadin for years with no major issues, which is very comforting. I suspect there could be issues in the 80's and 90's if dementia sets in causing dosing mistakes or if someone who doesn't understand the monitoring of INRs is managing the meds. But if I have dementia, I figure death by stroke would be merciful.

I'm going with a mechanical. I've chosen the latest mech valve on the scene, the On-X, because it's shown no issues with pannus overgrowth in the time it's been around (about 15 years I think). There are also ongoing studies of reduced anti-coagulation therapies for the On-X. So, it's a good choice if you go mechanical. The St. Jude Regent is also very good.

Good luck and keep us posted!

 

[normofthenorth]

A half-hearted defense of a tissue valve for a 43-year-old athlete

A half-hearted defense of a tissue valve for a 43-year-old athlete

Clement, I wish you well. I'm heading for a porky valve, but I'm 22 years older than you, which seems to be on the other side of where the lines cross. Unless you've got a good reason to avoid ACT (like one of Bob H's reasons), I'd probably go with the mechanical.

OTOH, in an area where there are no guarantees no matter what we choose, I'm not sure that 10 years is still a reasonable "best guess" for the life of the top tissue valves, even at your young age. I've just gotten a copy of the newest (2010) review of the long-term results from 1100-odd instances of "my" upcoming pig valve (Medtronics Hancock II) implanted at "my" hospital (Toronto General) -- entitled "Hancock II Bioprosthesis for Aortic Valve Replacement: The Gold Standard of Bioprosthetic Valves Durability?" by Tirone E. David, MD, Susan Armstrong, MS, Manjula Maganti, MS, in Ann Thorac Surg 2010;90:775-781, abstract at ats.ctsnetjournals.org/cgi/content/abstract/90/3/775? -- and I THINK that your mean statistical expectation for avoiding valve failure looks closer to 15-17 years than 10. That certainly doesn't eliminate the prospect of a surgical re-do (unless you ski the trees a lot without a helmet -- sorry! :tongue2: ), but it does push it out into the future, and drops your chances of needing two of them.

Getting the best number for you is not an easy calculation for me from the article, unfortunately, since (a) age is clearly the most important determinant of valve life, but (b) most of the patients were more my age than yours (mean age 67 +/- 11, range 19-94), and (c) they only group the 1134 patients into 3 pretty broad age groups, which puts you in the "<60" group. That includes everybody from 19 to 59, and I'm guessing it's heavily skewed toward the 50-somethings.

It's possible that a better statistician than I could take the "67 +/- 11" (which shows 1 Standard Deviation in the age distribution) and figure out just how (a)typical you are for that "<60" group, but that's more math than I remember from MIT in the 1960s. But that whole GROUP had 89.5% freedom from Structural Valve Deterioration at 10 years, 54.5% at 15 years, and 29.2% at 20 years post-op.

They also had pretty low rates of most other complications in that whole patient group -- e.g., they mention ONE case of pannus (which required reoperation) out of the whole 1100-odd patients, which MAY be much lower than with the mechanicals. (I'm just going from my impression from recently browsing the non-random reports here at VR.org, but I think I've seen more than one of those reported here alone.)

With any decision this important, and this "guarantee-less", I think the most important thing is that you are as comfortable as possible with your decision. Unfortunately, I think one test of that comfort is that you be "OK", at some level, even if (God Forbid) things don't go as well as planned. In a much more trivial arena, I decided to return to competitive "110%" volleyball in late 2002, 10 months after I tore my right Achilles tendon. I ALWAYS knew I was at elevated risk of tearing the left one, and I was always nervous about that, in the back of my mind. I NEVER let it interfere with the joy I got from beating up my body in volleyball -- court and beach, mostly playing with guys younger than you! Last December, I actually did rupture my left AT, and I'm OK with that, no regrets at all. So check that you wake up content with your choice the morning after you make the choice, but maybe then give yourself a similar test or two. In math and science and economics, they call that "sensitivity analysis", but I think it may be of some value here, too.

(BTW, I've already made it back to Whistler for a week of downhill skiing, 17 weeks after skipping the AT-repair surgery! I hope to make it back there this coming season after my sternum and heart recover from my upcoming OHS.)

 

[ottagal]

At this point, mechanical it will be.

I am too much of a wuss to visualize another certain surgery in 10 years.
My hat off to the young or middle-age folks who have gone tissue.

Clement

Thanks for the 'hats off', Clement. Glad to read that you are getting closer to a decision. That is half the battle. In my case, I really agonized over my decision, but when I finally made it (with the help of my surgeon, research, family and friends) , I did feel some peace with it and didn't look back. I hope you do as well.

Good luck!

 

[Lily]

Best wishes to you Clement

What Ottawagal said is very helpful I think -- if we all make our peace with our own choice and don't look back.

I'm no athlete but I was 42 when I chose tissue. One of my distant relatives asked me why. Among the things I explained to them was related to some realistic valve-life-expectations I'd read about; and so if a tissue valve lasted fifteen years my reop would be at age 57, and if a mechanical valve lasted thirty years my reop would be at age 72; and to me, 57 sounded better than 72 for a reop [assuming also that the second tissue valve would last longer than the first].

 

[RunMartin]

I am very active (run swim and cycle) and was in a similar position to you. I had known for years that I would possibly need valve surgery but in 2003 (age 41) I was told it would be soon. I became a member of this forum and eventually decided on mechanical. It was not until February this year (age 48) that I had my AVR and root replacement. When I went to see the surgeon, I told him what my choice was. He said it was probably the right choice for me due to the work required on the ascending aorta and not wanting to redo that again if possible. The week before surgery doubts started to creep in about my choice (even though I decided along time before). I think that is why agree with the comment about making your choice and sticking with it. I do think that if the surgeon had suggested tissue I would have gone for that.

I am now back running, swimming and cycling but at a lower level at present. I am just about to set off to a do a 5 mile race which will be interesting to see how I do compared to others I used to race against. I believe the lower level would have been the same whether it was a tissue or mechanical valve. I have some irregular heart beats which would probably mean I would be on warfarin.

So far warfarin has not been a big problem except for one nose bleed that took a while to stop.

I can see both arguments for tissue and mechanical and it eventually came down to what was best for myself and NOT what was best for someone else.

Good luck and go with your instinct.

Martin

 

[dtread]

I was 58 when I had my operation, and went mechanical to avoid the reops. After the fact I think I made the right choice as the surgery came close to killing me. Was able to recover about 70% - 75% athletic capability within 3 - 4 months. The remaining 25% - 30% took about a year; i.e., to get back near 100% of what I was before the surgery. The mechanical has proven to be very efficient and capable when exercising. I have never had any problems when exercising, even with heart rates in the 160's and 170's when doing strenuous exercising. Valve noise is practically nonexistent and is not a problem. About the only other factor with mechanical valves is the anticoagulation. I have not found that to be a problem. Also, the side effects have been nil for me and the monitoring became a breeze once I got a home tester. Good luck!