Anyone wish they had chose the other option?

[Superman]

His next questions caught me off guard a bit, he asked "do you eat spinach for every meal?" Of course my answer was no and he said "then you probably won't notice a difference."

Even if you did eat spinach with every meal, you wouldn't notice a difference. Typically, a consistent diet would lead to a consistent dose. Your dose might be higher than if you didn't eat spinach - but you wouldn't notice any symptoms simply from a higher dose.

Everyone is different and maintenance doses are all over the board. If you ask 20 board members, there would be 20 different dosing levels to maintain their acceptable INR.

As far as valve choice. Don't even know if I had a choice in 1990. Even so - I didn't avoid a re-op as I developed an aneurysm 19 years later. But, had I gone tissue the first time, that likely would've been my 2nd re-op. I'd be three years now into my 3rd tissue valve and still just 40. If lucky, I'd be looking at two more OHS's - maybe more if not so lucky. Five seems like a lot of times to be opened up. I'm happy with mechanical - both times.

All that said - still doesn't mean mechanical is right for the OP. Doesn't mean it's wrong either. At 57, it's possible you'd be facing one if not two more OHS's. Depends how your body treats the valve and how long you live otherwise.

The only thing I disagree with my surgeon on is basing a valve decision on the likelyhood of a potential replacement with a catheter years down the road. The only way I'd do tissue is if I can get comfortable with the idea of a re-op and absolutely don't want to deal with coumadin. We don't know the durability of these valves long term. We don't know how they'd hold up to the pressures in the aorta in an active person. We don't know how many of these they can stack on top of eachother (assuming they don't last forever and they can't pull the hard ring that a tissue valve is built on out through a vein).

 

[MarkU]

I've never regretted or second-guessed my decision.

Pre-op, both my surgeon & cardio strongly suggested a mechanical, primarily to reduce the probability of future re-ops. Although my surgery was textbook, it's something that I'd prefer not to go through again, especially since at age 47 I would have been looking at a couple of re-ops down the road.

Coumadin has not been a big deal. I've been on it for almost 12 years now and my INR has been rock-steady most of that time (I check it every six weeks if I'm in range). I've done Lovenox bridges several times for colonoscopies; a bit inconvenient, but not bad once you get used to giving yourself the injections.

Prior to my AVR I was an avid weightlifter/bodybuilder. Post-op, my cardiologist suggested I cut back on the weights and do more aerobic exercise. That eventually led me to doing my first triathlon almost nine years ago (with my doc's blessing). I've also done several half-marathons in the past few years. I always wear a helmet and am cautious when riding my bike out on the road, but no more so than if I wasn't on Coumadin. Riskier than lying in the couch maybe, but acceptable to me.

I've been very blessed and lucky that my experience has gone so well; I know that others have not been so fortunate. The best advice I can give is to do your research, make an informed decision, and not look back once you do. Any decision that extends your life is a good one.

Mark

 

[neil]

its great we have a choice, and also great that most on here do well on anti coags, but i think its more than just popping a pill no problems, anti coags is a risk no matter what people say, a piece in a british paper stated a million britons are at risk from fatal bleeding,experts say numbers suffering castastrophic haemorrhages are grossly underestimated, these facts shouldnt be overlooked, now before anybody jumps down my throat am not saying mech are not an option far from it,just the full picture is sometimes not shown, bit like me saying a re op is a walk in the park no problem, BOTH choices are good and who knows when i have my re op i might get mech myself, there are good and bad in both,

 

[MarkU]

its great we have a choice, and also great that most on here do well on anti coags, but i think its more than just popping a pill no problems, anti coags is a risk no matter what people say, a piece in a british paper stated a million britons are at risk from fatal bleeding,experts say numbers suffering castastrophic haemorrhages are grossly underestimated, these facts shouldnt be overlooked, now before anybody jumps down my throat am not saying mech are not an option far from it,just the full picture is sometimes not shown, bit like me saying a re op is a walk in the park no problem, BOTH choices are good and who knows when i have my re op i might get mech myself, there are good and bad in both,

I'd be interested in any actual documentation or studies that back up your statements.

Mark

 

[Fundy]

Here's a link that that was posted and discussed on another valve forum.
http://www.theheart.org/article/147...20121128_EN_Heartwire&utm_campaign=newsletter

They finding was almost a 4% annual risk of major bleed per year and 20% were fatal. so if you expect to live 25 years your probability of a major bleed would be 100%. I'd be surprised if many studies were that high. Most of what seems to be expected is 1-2% from what I've read. In which case major bleed events wover a 25 year period would be 25-50%. Or as low as 1 in 4 people.

Still that's too high for me, glad I decided on the reop risks.

 

[Mom2izzy]

Here's a link that that was posted and discussed on another valve forum.
http://www.theheart.org/article/147...20121128_EN_Heartwire&utm_campaign=newsletter

They finding was almost a 4% annual risk of major bleed per year and 20% were fatal. so if you expect to live 25 years your probability of a major bleed would be 100%. I'd be surprised if many studies were that high. Most of what seems to be expected is 1-2% from what I've read. In which case major bleed events wover a 25 year period would be 25-50%. Or as low as 1 in 4 people.

Still that's too high for me, glad I decided on the reop risks.

I really don't thing the stats add up that way. To me, 4% annually means just that. Every year you have a 4% chance...not one year at 4% and next year at 8% and so on. Statistics can be a little bit "hokey" because numbers vary depending on how the study is set up. In addition, there is almost never an exact percentage...There would always be some margin of error and without knowing that margin, it can be tough to know how reliable the information is.

I would never claim to be a real statistician, but I am required to dabble a little at work, so I have seen how numbers can be manipulated to make them give you the "right" answer.

Other weird but true statistical examples:
A woman has a child with a illness. The way this disease is "inherited" indicates there is a 25% chance of the couple having a baby with the disease. 1 in 4 right...so since she has her 1, her next 3 have a better chance of being fine, right? Actually, no. Every child she has the exact same 25% chance. The woman had 2 in a row...same problem...3rd child was fine.

There is a heart medication that has a side effect of hair growth. If you put it in a shampoo, this could help with baldness. During trials to prove it works, a higher percentage than "normal" experience heart issues. Trials are halted immediately...until a statistician reminds the company that the testing was not being done on the "normal" population. It was being done on balding men (typically in a higher age bracket). When test results were compared to the appropriate age group, there was NOT a higher risk.

 

[Fundy]

No, I don't mean you have an 8% per year chance in year two. Its 4% per year risk equates to a 8 % chance over two years.
Each year on its own is alwys 4% per year. That's how probability works.

If you have one lottery ticket in a ten ticket draw you have 10% chance of win. If you play ten times (seperate draws 1 ticket in 10 each time) the chance of winning once is 100%. But the last draw is still only a 10% chance for that draw. But still 100% chance statistically couls still mean 0,1,2,3 wins in actual occurrence.

It works similar in years, a 1% chance in one year. If you repeat the event 10 times means 10% total chance of the event happening in those 10 years. If it doesn't happen in first 9 years. The chance is still just 1% during the last year.

 

[newmitral]

Mom2izzy, you are absolutely correct.

Fundy, don't go to Las Vegas, you'll lose your shirt ;-)

Just because the odds of "red 7" on the roulette wheel are one in 38 does NOT mean that there is a 100% probability of hitting that number in the next 38 spins. The actual odds of hitting it on the next 38 spins are about 63.7%.

A quick statistics lesson...the odds of multiple events occurring is the product of their individual probabilities.

So, for the major bleed statistics, what you want to find first is the probability of NOT having a major bleed in 25 years, since these are 25 separate successive non-events that must occur in the next 25 years. So, if you have a 0.04 probability of having a bleed each year, then you have a 0.96 probability of NOT having a bleed in a given year. To go 25 years without a bleed, you multiply the annual probabilities for each of the 25 years, or 0.96 to the power of 25. This equals about 0.36 probability of NOT having a bleed in 25 years. So, the probability that you WILL have a bleed is 1.0 - 0.36= 0.64 or about 64% , not 100%. If 20% of those major bleed are fatal, then the odds of a fatal bleed in 25 years (at the high 4%/year rate) are about 12.8%.

[ oops - correction on the fatal rate - since early fatality takes you out of the running for subsequent years, a more accurate calculation for fatal bleeds would give 18.2%]

More germane to the original question, all the studies I have seen on the subject indicate that taking the proper anti-coagulation drugs with a mechanical valve - and staying within the target INR range - reduces the overall risk of bleed/stroke events for a mechanical valve patient to about the SAME risk per year as that with a bio-prosthetic valve. I have seen numbers ranging from just under 1%/year to about 4%/year in various studies depending on the type of valve (bi-leaflet, tilting disc, ball & cage) and position (mitral versus aortic).

Although I had no time to research any of this prior to my own valve replacement, which was an emergency situation caused by endocarditis of my native valve, my thoughts in the hospital at the time were that I did not want to go through the operation again, and I elected to go mechanical.
Having done a massive amount of research AFTER my valve was replaced, I am quite comfortable with my choice in retrospect.

 

[MarkU]

I really don't thing the stats add up that way. To me, 4% annually means just that. Every year you have a 4% chance...not one year at 4% and next year at 8% and so on.

Exactly. The risk is not cumulative; it's just a flat 4% every year. Just like if you flipped a coin once a year; the odds are always going to be 50/50.

I hate seeing threads where people make arguments against a certain choice. As I mentioned earlier, there is "no one-size-fits-all" solution. Each option has pros & cons and in the end it comes down to making an informed decision on a individual basis. Hopefully rationally, not emotionally.

I'm certainly happy with the choice I made, but would never criticize or second-guess someone else's decision. Any decision that either prolongs or improves one's quality of life is a good decision. The only bad decision is doing nothing when there are options available.

That being said, I think I'd have a much tougher time making a decision today, as the technology of both tissue and mechanical options have advanced significantly since I had my surgery twelve years ago. And that's a good thing.

Mark

 

[tom in MO]

Most of what I've read indicates a risk of a bleeding event was about 1-2% for a replacement valve patient (irrespective of age) and the cause was "excessive anticoagulation". http://circ.ahajournals.org/content/119/7/1034 What I have seen indicates that INR management with home monitoring (I took this to mean tests about every 2 weeks) was the way to address the bleeding risk in valve patients. Personally, I am willing to believe that every year 1% of us are not up to date on our INR and thus suffer a bleeding event.

 

[Fundy]

I'm actually right. Your misinterpreting.

In the 25% chance of a baby with disease. If the woman said she expected to have 4 children and another woman says 8 children in the 25% chance per child scenario. Each child is a 25% chance no matter how many children are born.

But in the first case 4 x 25% would indicate that after four children there is a 100% statistical probability of having one child with the disease. Meaning she should expect to have 3 disease free and one with the disease.

In the 8 child scenario, 8 X 25% means 200% statistical prrobability of having one child with disease. Which means she should expect two children with the disease and 6 disease free. If however she has 7 children disease free, the last child still has just a 25% chance of being diseased.

 

[MarkU]

Most of what I've read indicates a risk of a bleeding event was about 1-2% for a replacement valve patient (irrespective of age) and the cause was "excessive coagulation". http://circ.ahajournals.org/content/119/7/1034 What I have seen indicates that INR management with home monitoring (I took this to mean tests about every 2 weeks) was the way to address the bleeding risk in valve patients. Personally, I am willing to believe that every year 1% of us are not up to date on our INR and thus suffer a bleeding event.

I think you meant to say "excessive anticoagulation"


Mark

 

[dick0236]

I really don't thing the stats add up that way. To me, 4% annually means just that. Every year you have a 4% chance...not one year at 4% and next year at 8% and so on. Statistics can be a little bit "hokey" because numbers vary depending on how the study is set up. In addition, there is almost never an exact percentage...There would always be some margin of error and without knowing that margin, it can be tough to know how reliable the information is.

I would never claim to be a real statistician, but I am required to dabble a little at work, so I have seen how numbers can be manipulated to make them give you the "right" answer.
.

It has been a long, long time since I studied college statistics but I do not remember this type of "event" having a cumulative risk. It's like "flipping a coin"....you have a 50/50 chance of getting a "head" on the first, second or 100th flip and your odds of getting a "tail" do not get better 'cause you get 5 "heads" in a row......nor do I believe that the added risk is anywhere close to 4%, maybe 2%???/yr.

Lets use me as a "test subject" since I have been on warfarin continuously for over 45 years. Using the cumulative logic, my current chance of a stroke would be at, or close to, 100% per year. This is simply not the case. My current risk is still about 2%/yr. Although my risk may be a little higher than when I was young, it is not even close to 100%.

BTW, I had my one, and only, stroke only 8 years after surgery and there was a 100% chance it was due to poor INR management. Fortunately, I am a quick learner and it hasn't happened again.....and I am confident that "taking warfarin as prescribed and routinely testing" will keep my odds low.

 

[Fundy]

Yeah , **** on a yearly basis its just 2% a year still. However back when you were 31 and if you expect to live to 81. Then that 2% risk would statistically mean you should experience 1 stroke by the time you reach 81.
However at 76, your new expected lifetime would be 5 years and you'd expect only a 10% probability over the rest of your life. Next year and each subsequent year by itself is still just 2%. The annual percentage never increases.

 

[MarkU]

I'm actually right. Your misinterpreting.

In the 25% chance of a baby with disease. If the woman said she expected to have 4 children and another woman says 8 children in the 25% chance per child scenario. Each child is a 25% chance no matter how many children are born.

But in the first case 4 x 25% would indicate that after four children there is a 100% statistical probability of having one child with the disease. Meaning she should expect to have 3 disease free and one with the disease.

In the 8 child scenario, 8 X 25% means 200% statistical prrobability of having one child with disease. Which means she should expect two children with the disease and 6 disease free. If however she has 7 children disease free, the last child still has just a 25% chance of being diseased.

Hate to burst your bubble, but you're the one who's wrong. In your example the probability is always going to be 25%, it's not cumulative. Three negative outcomes does not guarantee a positive outcome the fourth time.

Mark

 

[newmitral]

I'm actually right. Your misinterpreting.

But in the first case 4 x 25% would indicate that after four children there is a 100% statistical probability of having one child with the disease.

Sorry Fundy, but you are still wrong.

If each child has a 25% chance (0.25 probability) of having a disease. Then the probability of each child NOT having the disease is 0.75
If you expect to have 4 children then the probability of having 4 children ALL without the disease is 0.75*0.75*0.75*0.75 = 0.316 or about 31.6% probability that all 4 children will be disease free, or about 68.4% probability that AT LEAST one of the children will have the disease, never 100%.

You still seem to want to ADD probabilities when you should be MULTIPLYING them.

Consult a local mathematician/statistician for further details.

 

[MarkU]

Yeah , **** on a yearly basis its just 2% a year still. However back when you were 31 and if you expect to live to 81. Then that 2% risk would statistically mean you should experience 1 stroke by the time you reach 81.
However at 76, your new expected lifetime would be 5 years and you'd expect only a 10% probability over the rest of your life. Next year and each subsequent year by itself is still just 2%. The annual percentage never increases.

Nothing personal, but you need to go read a book on statistics before you keep making incorrect statements.

Mark

 

[Fundy]

Personally, I was great at math and statistics. I know I'm right. What I'm saying is exactly what mom2izzy is saying.
newmitrals algorithm is incorrect. as the total statistical wins don't add up to the number of actual wins that will occur.
In my lottery draw example. there is 10 draws and statistical wins of each person totaled must equal the number of draws. So there must be 10 statistacal wins in total as there is 10 draws.

Same as for 20 draws there must be statistical win total of each person equalling 20. With 10 people that is 2 statistacal wins per person.
My math of 10% chance per draw multiplied by 20 draws equals 200% or 2 wins statistacally. 2 wins per person equals 20 wins as it should.

If the totals don't add up as it would in newmitrals algorithm, there is something unaccounted for. Or possibly the formula is used to describe chance of occurring twice rather than once, I don't know.

Using my math for just one draw. is 10% multiplied by one results in 10% or 0.1 statistical wins.
0.1 wins of each person adds to total wins of 1, which is what is expected.

I've read lots of statistical books. Score A's in most math and stats courses. The problem is many people spin what I'm saying into something totally different.
I never imply that annual risk ever increases. For some reason everyone assumes that I am. And I never am.

 

[tom in MO]

Thanks MarkU, I fixed it.

 

[MarkU]

Personally, I was great at math and statistics. I know I'm right. What I'm saying is exactly what mom2izzy is saying.
newmitrals algorithm is incorrect. as the total statistical wins don't add up to the number of actual wins that will occur.
In my lottery draw example. there is 10 draws and statistical wins of each person totaled must equal the number of draws. So there must be 10 statistacal wins in total as there is 10 draws.

Same as for 20 draws there must be statistical win total of each person equalling 20. With 10 people that is 2 statistacal wins per person.
My math of 10% chance per draw multiplied by 20 draws equals 200% or 2 wins statistacally. 2 wins per person equals 20 wins as it should.

If the totals don't add up as it would in newmitrals algorithm, there is something unaccounted for. Or possibly the formula is used to describe chance of occurring twice rather than once, I don't know.

Using my math for just one draw. is 10% multiplied by one results in 10% or 0.1 statistical wins.
0.1 wins of each person adds to total wins of 1, which is what is expected.

I've read lots of statistical books. Score A's in most math and stats courses. The problem is many people spin what I'm saying into something totally different.
I never imply that annual risk ever increases. For some reason everyone assumes that I am. And I never am.

As several people have tried to politely explain to you, your fundamental error is that you are assuming that the individual independent probabilities are cumulative over time. Going back to your example, something having a 25% annual probablity, does not have a 100% probability after four years as you tried to suggest. You're adding the annual probabilities together (25%+25%+25%+25%=100%), which is incorrect. newmitral is correct in his explanation that the probability is multiplicative, not additive

With all due respect, you don't understand statistics as well as you think you do. As I suggested before, you need to go back and review statistical probabilities again, if nothing else for your own knowledge and understanding.

Mark