Age old question..... tissue or mechanical

[mcarmical]

Well, the good news is that I have selected a surgeon and will be replacing my aortic valve the first or second week of February. More and more, the trend seems to be towards tissue valves. I am having a bicuspid aortic valve replaced. I am 51 years old and my Current valve stats are .7 cm and 60 gradient. My surgeon will support either mechanical or tissue. He indicated that ten years ago he would have definately gone mechanical, however with the advancements of the TAVR procedure he believes that a faulty tissue valve ten years down the road can be replaced using the new procedure. What does everyone think, Do I buy into this "future possibility" and get the tissue valve or go with the mechanical and the coumadin that would be necessary? I definately would like to avoid further OHS in my future if at all possible.

 

[skeptic49]

My surgeon also feels that future valve replacement via TAVR will be available for "valve in valve" procedures. But he didn't guarantee it. For me at age 66 he figures a one shot TAVR replacement down the line to get me through the rest of my life. At your age you might need a couple of replacements, i.e., "valve in valve in valve" if that becomes possible. I know what you mean about reops...they are risky. Good luck whichever way you decide..

 

[cldlhd]

Ya 'valve in valve in valve' seems like a bit of stretch to me,pun intended. I'm a few yrs younger than you ,45, so if mine was being replaced I'd go mechanical but there are pros and cons..Lets say the tissue lasts 12 years so your 63 when you get the TAVR and you get 12 out if that then your 75 . If you're still healthy and they can't do another TAVR.

 

[pellicle]

I am 51 years old ......
e indicated that ten years ago he would have definately gone mechanical, however with the advancements of the TAVR procedure he believes that a faulty tissue valve ten years down the road can be replaced using the new procedure. What does everyone think

I have been involved with technology for some decades ... bleeding edge is just that. Risky.

So far the main supporters of TAVI are the makers of TAVI and some surgeons who like it.

I don't know much, but what I read is this:

http://www.health.qld.gov.au/healthp...avi-report.pdf

Health Policy Advisory Committee on Technology
Transcatheter Aortic Valve Implantation Workshop
Workshop Report
June 2013

Current available international literature suggests that TAVI is potentially a cost-effective treatment for patients with severe aortic stenosis who are inoperable, but may not be cost effective for patients with severe aortic stenosis who are high surgical risk, although it appears to be safe and effective in this cohort. However, doubt remains about the durability of effect.

Caution is advised regarding the interpretation of international literature reporting the cost effectiveness of TAVI until such time as an independent clinical expert committee, such as the Medical Services Advisory Committee in Australia and the National Health Committee in New Zealand, have evaluated cost-effectiveness of TAVI within the context of specific patient cohorts and the Australian and New Zealand health care systems.

[The Committee] does not support the use of TAVI in the Australian or the New Zealand setting outside of properly conducted clinical trials until such devices are included on the ARTG. However, HealthPACT recognises that implementation of TAVI is of significance to the Australian community, in terms of patient care and cost, that consideration should be given to the managed introduction on the basis of an Australian/New Zealand coordinated clinical trial at selected sites. In the interim all outcomes must be carefully monitored using an appropriate data registry.

so, good for the frail inoperable, unclear yet for the otherwise healthy ones ...


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3709202/

Currently, the only proven, long-term effective treatment for patients with severe symptomatic aortic stenosis is surgical valve replacement. However, many patients with severe symptomatic aortic stenosis remain untreated, often because of the operative and perioperative risks associated with surgical repair.
...
Strong evidence supporting the use of TAVI comes from the investigation of the Edwards SAPIEN valve in the landmark Placement of Aortic Transcatheter Valves (PARTNER) trial, in which patients with severe, symptomatic aortic stenosis who were not candidates for surgery

so they're saying its good because people who can't be treated due to risks can take this less (surgically) risky intervention and perhaps get a better outcome than the certain fate of acute stenosis.

So, when you read, read from the perspective of the cohort is frail and on deaths door .. so statements like:

The survival rate at 3 years in patients with symptomatic aortic stenosis who undergo surgery is 87%; in those who do not have surgery, it is 21% (P <0.001).

which reflects the cohort they are studying (because healthy VR patients have much better survial!


lastly some good reading here

https://cartagenasurgery.wordpress.c...-tavi-and-tav/

 

[tom in MO]

I would not buy into any "future" possibility. Make your decision with the assumption that you will need a full reoperation. If the TAVI works for you it will be just "gravy."

 

[dick0236]

I definately would like to avoid further OHS in my future if at all possible.

You've been on the forum long enough to know there is no real answer to the mechanical vs tissue choice. At your age a mechanical will most likely last your lifetime and a tissue won't.....and, as I understand, the TAVI can be used a limited number or times, meaning another full operation is likely in your senior years. I am 78+, in good health and physically fit.....but I would not like the prospect of OHS again.

BTW, warfarin really is not a problem.....and, with the advent of home testing, it is really simple.

 

[big_L]

Personally, I find the TAVR "in the future"' option that some surgeons like to talk about to be misleading. I won't start the whole tissue/mechanical subject again, it's been covered many times. I had my vale done at 54 and I chose mechanical. One of the four cardiologists/cardiac surgeons that I spoke with mentioned the TAVR possibility in the future and suggested that I go tissue. When I did more research and found out how experimental it is today, I lost some respect for him.

 

[Eva]

Tissue or mechanical...warfarin or no warfarin is a choice to be made considering other health issues one has besides the heart valves factor!
At 57, I was advised to go with tissue valve being promised that TAVR will be available within 5-7years when I had my surgery in 2008! I lost some confidence in my surgeon who was very sure about that, as well as I realized that surgeons prefer to replace valves with what they had more experience with and feel more comfortable with replacing, even if they tell you they support both!!!!!!!

I take my warfarin every night as I take my Synthroid every morning!

Good luck with your choice!

 

[Paleowoman]

I have other health issues and didn't want to go on warfarin because of them, also didn't want the noise being very sensitive to sound, so I chose tissue. I was 60. No one tried to dissuade me and no one mentioned TAVR. I assume that in my mid 70's I will have to have another valve replacement unless TAVR improves tons. I want to continue to as active as possible right to the end and currently TAVR is usually only done of frail people - when they've done it enough in fit people I would consider it an option for a re-do. I went into my surgery last year wilth the full knowledge I would have to have a re-do at some point - not something I look forward to. This heart suregery is certainly way more of a strain on the body that we are led to believe ! But I'm still happy with my choice of tissue. Apart from the incision scar I don't feel any different from before - what I mean is I'm totally unaware that the valve in my heart is manufactured and sewn in !

 

[knotguilty]

That question of tissue vs mechanical always draws debate. I will tell you my feeling and opinion on it. One there are no guarantees either way. You can have a mechanical go bad right off the bat as well as a tissue valve. I personally didnt like the idea of being on warfarin later in my life. I was 55 when i had my tissue valve. Prospects look very good and the industry has made leaps and bounds on technique. I had a little incision as compared to what they would have done years ago by opening your sternum. My mother who is frail and 81 years old just had a TAVR done late last year. She did very well. I personally did not find a doctor that said he would go mechanical because of the warfarin. In fact my primary says I may never need another one. He only knows one person that had to have a reoperation. He knows a drug adict who had to have three. I knew a couple guys who had a tissue valve done years before me and they are still doing great. You have to go with what you feel comfortable with. A tissue means you will most likely need another operation. A mechanical leaves you vulnerable later in life on warfarin. The operation, while no fun, can be done over and over again. Good luck in what you decide. Just my opinion.

 

[Richie Rich]

Just wondering what the issues are with taking warfarin in later life. My grandfather lived to ninety two and was on it for over twenty years with no issues, perhaps he was lucky.
Thanks, Richie.

 

[dick0236]

Just wondering what the issues are with taking warfarin in later life. My grandfather lived to ninety two and was on it for over twenty years with no issues, perhaps he was lucky.
Thanks, Richie.

I am one of those "later in life" folks and I have no problems with ACT. My only problem happened when I was young and invincible at 38...and due to ignorance on my part. I've talked with a number of my docs over the years about the "danger" of warfarin use and the primary reason for problems is misuse and ignorance on the patients part......and a lot of the problems are due to doctors/nurses not educating the patient when this drug is prescribed......and then blaming the drug for problems.

 

[pellicle]

....and a lot of the problems are due to doctors/nurses not educating the patient when this drug is prescribed......and then blaming the drug for problems.

Hear Hear!

On a related note, something that is a common theme is "I want to go back to how it was before surgery" ... to me this is a reasonably natural response to a change you don't like. However although no one seems to like it we all should accept that life is about change. Some people wish they were in their adolescent years again (some continue to act that way), few however seem to say "I want to go back to nappies"

My point is that change happens in life and we should do our best to adapt to that.

Psych-babble is "accepting change"

 

[pellicle]

Hi

My mother who is frail and 81 years old just had a TAVR done late last year. She did very well.

if you don't mind I think that it would fantastic if you could share some of this. I mean since its a question so much discussed and to my knowledge there are no other participants on this forum in such a position. It would be fantastic to hear actual experiences.

To start with stuff like:
why it was chosen (was it just a preference, did the Drs think that she was too frail to recover from regular aortic surgery)

I personally did not find a doctor that said he would go mechanical because of the warfarin.

for you or for her? My friend who is a pharmacist says that (his words) the "great majority" can't be relied to take their medications reliably. So it would seem logical if the person was unable to be relied upon to take their medications (and or not get confusded by which dose to take which day in the case of alternating doses). In that situation I think avoiding warfarin (in combination with elderly years) is logical and wise.

The operation, while no fun, can be done over and over again.

I would be careful with this "over and over again" stuff as this is just NOT the truth. First redo is usually straight forward, second redo is always more tricky (anyone who says otherwise is a hopeful victim or a meat cutter you want to avoid) third redo is very risky, its very common to come out with significant negative side effects ... fourth redo is much more risky and as my surgeon said to me "you won't find surgeons lining up to do it". Why? No one likes a death on their table.

So be careful with factoring in your addition of age at operation and likelyhood of redo ... if you are under 40 don't expect to get off lightly. There are many here who have reported taking tissue at under 50 and not getting more than 10 years out of it.

Opinions are one thing, but be careful about spreading mistruths.

 

[Roberta]

Hi



if you don't mind I think that it would fantastic if you could share some of this. I mean since its a question so much discussed and to my knowledge there are no other participants on this forum in such a position. It would be fantastic to hear actual experiences.

To start with stuff like:
why it was chosen (was it just a preference, did the Drs think that she was too frail to recover from regular aortic surgery)


So be careful with factoring in your addition of age at operation and likelyhood of redo ... if you are under 40 don't expect to get off lightly. There are many here who have reported taking tissue at under 50 and not getting more than 10 years out of it.

Opinions are one thing, but be careful about spreading mistruths.

Pellicle:

RE: TAVR
My aunt, at age 84 had TAVR (two years ago in February) along with 3 stents! Because of her age and other health issues i.e. on medication for a rare blood condition and because she was frail, they decided against standard OHS. I have a posted if anyone is interested in reading about it: http://www.valvereplacement.org/foru...ecovery-period

RE: Longevity of Tissue Valves:

Here is a good research article abstract from 2010 that provides the mean age of re-operation for bioprosthetic aortic valves in individuals under 60.

They have a good sample size. I am not sure what type of biosprosthetic valves the patients had implanted, but read patient age, valve type and other co-morbidities play a role in re-operation rates.


If you are interested in reading the full article, here is the link.:

http://circ.ahajournals.org/content/...ppl_1/S75.full

"We examined the need for reoperation in 3975 patients who underwent first-time bioprosthetic aortic valve replacement (AVR) (n=3152) or mitral valve replacement (MVR) (n=823).

There were 895 patients below the age of 60 years at bioprosthesis implant (AVR, n=636; MVR, n=259).
The median interval to reoperation following bioprosthetic AVR was 10.27 years (95% CI 8.48 to 12.08 years) in patients less than 40 years of age, and 11.48 years (95% CI 10.47 to 13.07 years) in patients between 40 and 60 years of age.

Notably, the median interval to reoperation was not reached in patients more than 60 years of age.

When restricting the analyses to patients who had contemporary stented bioprostheses, the median interval to reoperation in patients between 40 and 60 years of age was 12.93 years (95% CI 11.10 to 15.76 years), and it was 7.74 years (95% CI 7.28 to 9.97 years) in patients less than 40 years of age (Figure 1B).
Univariable risk factors associated with reoperation following AVR with a contemporary, stented bioprosthesis included age and concomitant CABG "

 

[pellicle]

Roberta

wow ... thanks that's great information ... that is going straight into my evernote (not the pool room) Thank you for posting that

thanks also for the link to the post here too!

"We examined the need for reoperation in 3975 patients who underwent first-time bioprosthetic aortic valve replacement (AVR) (n=3152) or mitral valve replacement (MVR) (n=823).

There were 895 patients below the age of 60 years at bioprosthesis implant (AVR, n=636; MVR, n=259).


The median interval to reoperation of contemporary, stented aortic bioprostheses was 7.74 years (95% CI 7.28 to 9.97 years) in patients less than 40 years, and 12.93 years (95% CI 11.10 to 15.76 years) in patients between 40 and 60 years of age."

 

[neil]

Lots of data and graphs being thrown around. Bottom line is do you fancy a re op down the line or being on warfarin and the problems that may occur with that.

 

[Roberta]

Good point Neil. As others have said, we have to figure out what we can live with to help make the decision. I am a data type of person, so like the statistics side. Of course, none of us know where we will fall in the statistics! I have a tissue valve so am interested in this information.

Pellicle:
As a follow up, I decided to delve further into the research article. Here is the list of the aortic valves that were implanted and included in the study. Some of them must have been implanted in the 80's for the authors to do a long term follow up. It will be interesting to see what the next 20 years shows.

Please note that results for the median age for re-op for contemporary stented valves included both the Edwards Perimount as well as the Medtronic Hancock 2.
I found it interesting that when the authors included all types of bioprosthetic aortic valves in the study, the median interval for reoperation was a little better.

Aortic valve replacement	3152
Edwards Lifesciences Perimount[SUP]*[/SUP][SUP]†[/SUP]	1006	32
Edwards Lifesciences Standard Porcine[SUP]*[/SUP]	9	0.3
Autograft/homograft	176	6
Ionescu-Shiley[SUP]‡[/SUP]	491	16
Medtronic Hancock Modified Orifice[SUP]§[/SUP]	137	4
Medtronic Hancock II[SUP]§[/SUP][SUP]†[/SUP]	1152	37
Medtronic Intact[SUP]§[/SUP]	103	3
Stentless prosthesis[SUP]¶[/SUP]	78	2

The authors also stated "that patients between 18 and 60 years of age who select a bioprosthesis at the time of initial heart valve surgery have an increased reoperation risk but experience NO long-term survival detriment compared with patients who select a mechanical valve."

MCARMICAL, best wishes as you move forward. As others have said, whatever valve you choose will be much better than the one you currently have.

 

[epstns]

I think we also need to remember that virtually ALL of the published statistical data relates to tissue valves of the generation prior to the current. In other words, in order for the researchers to have long-term data, the valves have to be in service for a long time. The valves in these studies are called "second-generation" tissue valves, and IIRC, the current ones are considered "third-generation." There are differences in how the valves are treated to slow calcification, as well as possibly some mechanical differences which may change the expected number of cycles a leaflet may last before material fatigue occurs.

So, for all of us tissue valvers, the only information we have on which to base our decisions is the track record of the prior generation of valves, along with the beliefs and expectations of the manufacturers regarding their newest products.

Also, not trying to disparage any statistics, but don't forget that the data above are the mean lifespans of the valves. This is an average, meaning (pun?) that there are values above and values below the mean. So, as Roberta noted, none of us can know where we will fall within that statistical distribution.

 

[knotguilty]

pellicle, Just wanted to comment on your response to my post, When I say that heart surgery can be performed over and over again, I am going on people like you who have been opened up a few times and are doing great. My primary told me of a girl who unfortuetely is on drugs and has had to have three valve replacements. But I do see here many people who have gone under the knife more than twice. I did not say it gets any easier, but you can survive. All operations, especially open heart have their risks.

As far as being on ATC, I know of people that have passed from a bump on the head, internal hemorage. On ATC, any bumps, falls, or forgetfullness can be life treatening. My grandfather died from masive hemorage so I know that being on ATV as an elderly person can be dangerous. But probably not too many elderly people aren't on some kind of blood thinners.

They decided to do TAVR on my mother because of a number of reasons. She is on maintenance doses of chemo for lung cancer that is in remision. She had a masectomy(sp?) years ago and an implant, they cannot access her body or do anything through that arm,. Her veins are very small and she bruises very easily. Having gone through a lobectomy, she has had terrible experiences from surgery and has a long recovery from anything. The only problem she has coming out of this TAVR surgery, is she has some memory problems. Very significant since her surgery and I wonder if it was from a lack of oxygen, but I don't know. She is alive and moving well.