Aortic Valve Choices

[Unicusp]

I'll try to keep this brief. I was diagnosed with BAV & ascending aorta aneurism at age 50. Monitored the aorta for 2 years and had replaced by dacron graft at 52 at the Cleveland Clinic. Surgeon inspected the aortic valve and confirmed it to be a unicuspid that was healthy and functioning so he left it alone. Here I am 7.5 years later with severe stenosis and need replacement soon. I'm very healthy, active and asymptomatic. Heck, I walked over 12.5k steps at the Cleveland Clinic the other day walking between the many testing area's. I've pretty much decided that I only want to do this one more time. This second time is difficult enough. I can't see installing a tissue valve with an expiration date of anywhere between 1 and 20 years. Yes, the thought of Coumadin sucks, but I feel it safer than more invasive surgeries down the road. Yes, there is TAVR but that has many potential risks as well.
So, for me it appears to boil down to either the St. Jude Regent or On-X valves. Has anyone directly compared these two valves? They are both made from the same pyrolitic carbon and are very similar in design. But, my surgeon appeared to favor the SJ as it appears a larger SJ can be installed in the same area as a On-X, and he mentioned the On-X is "Bulky" and I guess requires a larger annulus for proper installation. Which valve has better hemodynamics? They both appear to be robust enough and tested to last a "lifetime". Any thoughts/comments/experiences appreciated. I apologize if I am re-visiting an old topic. Thanks everyone! By the way, this is a great site.

 

[ottagal]

Hi Unicusp. Welcome to this wonderful forum.
I am sorry to hear that you are going through this. It is never easy to get news that you have severe stenosis again.

I , too am in severe stenosis (after 11 years with a CEdwards perimount valve) , but appear asymptomatic. Are they suggesting surgery soon although you are asymptomatic ? I'm just curious as my cardiologist is waiting for 'symptoms' before I undergo surgery again. I am on the fence as to what route to take.

Unfortunately, I don't have any advice on either mechanical valve as I have a bioprosthetic valve. There are others who are better versed in this area who will chime in.

Wishing you all the best going forward. You will get great support here. And you will get through this!

 

[ATHENS1964]

Βoth valves are good, after you made the decision to insert a mechanical aortic valve let the surgeon do the work he knows. He explained to me that they have all the options in the hospital but he chose this one for his own scientific reasons. A surgeon does not risk his reputation and put in a valve he does not trust.

 

[pellicle]

So, for me it appears to boil down to either the St. Jude Regent or On-X valves

There is also the ATS and Carbomedics, the reality is 6 or half a dozen.

Which valve has better hemodynamics?

If there was an actual difference you can be sure the owner of that would be marketing it.

St Jude has a great reputation, as to any AC therapy advances are my recent post on that.

Sorry they didn't fix the valve when they were in there last time, to me that borders on unconscionable.

I don't know if this helps but...

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

 

[DachsieMom]

I didn’t know at the time to ask my surgeon too much about brand. I was 41 so just asked whether he recommended mechanical, which he did. I mentioned brand and he said it would be st Jude as this is what he had used for 40 years and is proven. Enough for me! That was in 2015.

 

[Mark M]

[QUOTE="Unicusp ... So, for me it appears to boil down to either the St. Jude Regent or On-X valves. Has anyone directly compared these two valves? .... Any thoughts/comments/experiences appreciated.’]

First of all.. This is the first time I’ve met a person having a Unicuspid aortic valve! You are a rare & special person I would imagine. I had a plain ol’ bicuspid which served me well until I was 62 y.o., and this was 2017 when after an intense amount of research, I opted for SAVR using the relatively new On-X. Mainly for the promise of no ticking quietness and lower Coumadin/warfarin needed. My choice was validated at that time by my surgeon as an excellent bet, and I’ve never had to look back. The valve is beautifully quiet in my chest (I wonder if that’s a result of being “beefy”?), it’s easy to maintain a range of 1.5 - 2.0 INR, and I can highly recommend this valve. Of course, I would expect a person who had chosen the Regent to recommend their own choice. I pity anyone who may have had the misfortune, or need to “directly compare these two valves” inside their own chest. But SAVR and pyrrolytic carbon are a solid choices.. you are young enough to outlive a tissue valve and be forced back on the table later in life when it’s harder to bounce back. You’re on the right path. Best of all to you!!

 

[vitdoc]

I can’t comment on the decibel level of the various valves. I can comment on the low INR that ON-X uses for promoting it’s valve. Looking at their original data and allowing the INR to drop to 1.5 suggests a higher potential for stoke. So probably the INR for either valve should be above 2.
So finally if the surgeon thinks that the St. Jude allows for a larger valve that should be the deciding factor. Bigger valve less gradient.

 

[Unicusp]

There is also the ATS and Carbomedics, the reality is 6 or half a dozen.



If there was an actual difference you can be sure the owner of that would be marketing it.

St Jude has a great reputation, as to any AC therapy advances are my recent post on that.

Sorry they didn't fix the valve when they were in there last time, to me that borders on unconscionable.

I don't know if this helps but...

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

Wow. Excellent article in that link you sent. Thanks I appreciate it. Did you write that? As an aside, I traveled to Australia on business several times back in 2007/2008. And I just loved the straight-forward honest nature of the people I met with.
I have a Marketing background and curious questioning nature. I also had thoughts that what should be a neutral "what's best for the patient" recommendation from surgeons, does not appear so. It appears to be a typical repeat business model. I am not going to mention my surgeons name, but it was on that list who did that study in the link. Last week, during my visit the first valve recommended was the Inspiris Resilia. That would virtually guarantee a future surgery for me. The surgeon mentioned I could then be a TAVR candidate in the future for valve-in-valve. No thanks! Then you're talking a smaller valve, future risk, cost and complications. Not for me!
I hope that I am not insulting others on here who have made the tissue valve choice. That is not my intention. This is a personal decision for each person.
I do regret not doing more research before my last surgery. I was busy at work right up to the day of surgery and trusted my surgeon to make the right decision. He knew that I was not excited about Coumadin but I did not make a forceful choice and left it up to him when he was able to inspect the valve. So, on the positive side I have had a really good 7.5 years with my native valve. I have a strong feeling that he would have installed a tissue valve and I'd be back here now anyway.
Thanks again. Best Regards.

 

[Unicusp]

[QUOTE="Unicusp ... So, for me it appears to boil down to either the St. Jude Regent or On-X valves. Has anyone directly compared these two valves? .... Any thoughts/comments/experiences appreciated.’]

First of all.. This is the first time I’ve met a person having a Unicuspid aortic valve! You are a rare & special person I would imagine. I had a plain ol’ bicuspid which served me well until I was 62 y.o., and this was 2017 when after an intense amount of research, I opted for SAVR using the relatively new On-X. Mainly for the promise of no ticking quietness and lower Coumadin/warfarin needed. My choice was validated at that time by my surgeon as an excellent bet, and I’ve never had to look back. The valve is beautifully quiet in my chest (I wonder if that’s a result of being “beefy”?), it’s easy to maintain a range of 1.5 - 2.0 INR, and I can highly recommend this valve. Of course, I would expect a person who had chosen the Regent to recommend their own choice. I pity anyone who may have had the misfortune, or need to “directly compare these two valves” inside their own chest. But SAVR and pyrrolytic carbon are a solid choices.. you are young enough to outlive a tissue valve and be forced back on the table later in life when it’s harder to bounce back. You’re on the right path. Best of all to you!!

Thanks I appreciate it. Yeah I'm in the .02% probability of the adult population. I recall being very short of breath as a kid and it appears that the valve adjusted and improved over time. I'm surprised that it was never heard nor diagnosed earlier.
The St. Jude & On-X valves appear to be very similar but the On-X is significantly taller and thicker. The Company seems to market it and advertise it better than Abbott does with the St. Jude. I have info from Technical at On-X where they have cycled the valve 600 million times (15 years of life) with no wear, and extrapolated the data to prove it will last 99 years with no wear. Very good news.

 

[Unicusp]

I can’t comment on the decibel level of the various valves. I can comment on the low INR that ON-X uses for promoting it’s valve. Looking at their original data and allowing the INR to drop to 1.5 suggests a higher potential for stoke. So probably the INR for either valve should be above 2.
So finally if the surgeon thinks that the St. Jude allows for a larger valve that should be the deciding factor. Bigger valve less gradient.

Agreed. Larger valve should be more beneficial. INR's will most likely be the same for either valve in my opinion.

 

[Unicusp]

Hi Unicusp. Welcome to this wonderful forum.
I am sorry to hear that you are going through this. It is never easy to get news that you have severe stenosis again.

I , too am in severe stenosis (after 11 years with a CEdwards perimount valve) , but appear asymptomatic. Are they suggesting surgery soon although you are asymptomatic ? I'm just curious as my cardiologist is waiting for 'symptoms' before I undergo surgery again. I am on the fence as to what route to take.

Unfortunately, I don't have any advice on either mechanical valve as I have a bioprosthetic valve. There are others who are better versed in this area who will chime in.

Wishing you all the best going forward. You will get great support here. And you will get through this!

Thanks for your reply. I guess that I am still in the "anger denial" mode. So, yesterday (and almost everyday) I walked 3.2 miles at an avg pace of 3.6mph (up to 4.3mph) in nice hilly terrain. Heart rate goes up to 150. No pain but some chest tightness.
I also do various weight exercises and abdominals. But.......I am getting more tired and sleeping longer.
One year ago; my AVA was 1.0 and and peak velocity was 3.5 so I was in the "Moderate" category. Now, my AVA is 0.78 and peak velocity is 4.3 both in the "Severe" category. So, it appears that valve degradation is accelerating. Sucks.
What do you experts think of these numbers?? Thanks!

 

[pellicle]

Hi

Excellent article in that link you sent. Thanks I appreciate it. Did you write that?

yep ... by me

As an aside, I traveled to Australia on business several times back in 2007/2008. And I just loved the straight-forward honest nature of the people I met with.

I'm glad you had a good time, if you came to Queensland we're even more "direct" than New South Welshmen or Victorians. Unless you went to the West coast and I have no idea.

I also had thoughts that what should be a neutral "what's best for the patient" recommendation from surgeons, does not appear so. It appears to be a typical repeat business model.

I chalk this up to the role being so specialised (by the demands of complexity) and mistakes are not taken kindly. So due to that surgeons develop a preference for what they have worked with.

I'd add to that (having talked to quite a few people in the various waiting rooms over the years (before phones allowed for infinite distraction and "socialising") because it was common to be waiting for an hour or so in the public system before seeing anyone. I observed from those interactions that many "don't want to know" and want to get on with it and "get back to being normal". Like this comment on my blog post: " and I freely confess that I loathe being reminded of my condition "

I have come to the view that many people just want to be like Cypher:


and pretend there is nothing wrong or anything to learn.

guarantee a future surgery for me. The surgeon mentioned I could then be a TAVR candidate in the future for valve-in-valve. No thanks! Then you're talking a smaller valve, future risk, cost and complications. Not for me!

that is also my view. People have often had conversations with me about how many heart operations are done (on the public purse here in Australia) on the very elderly (over 70) and how this seems a waste. I remind them that those operations have enabled the development of the techniques (both surgical and ICU) to enable me to have heart surgery (now three times) and live a good and full life. For that I'm grateful. As a young adult I always allowed any curious doctor or imaging specialist (had a few reasons to go to hospitals which include bicycle and motorcycle mishaps) and wish to do as much as I can (within reason) to spread knowledge (even if I'm the walking example).

I hope that I am not insulting others on here who have made the tissue valve choice. That is not my intention. This is a personal decision for each person.

it is my view that we are all adults (or should be) and anyone insulted by your choices and your reasons is not worth being concerned about. Over the years people have unwittingly said intensely painful things to me (because some people are fully idiots) and it took me a while (till adulthood) to get to a point where it (mostly) didn't bother me.

I do regret not doing more research before my last surgery.

I did none in my first two, and indeed in the lead up to the second I actually was doing Uni (again) and negotiated to have it done (it was deemed pressing) after my exams. So I was pretty busy right up till I walked in too. I had the same team (although the head surgeon had retired) on all three and as its literally the best cardiac hospital in the state just went along.

On this last operation I made no explorations of warfarin because the case for a mechanical was so compelling that to my mind it was a done deal (reasons: 42, third OHS and attendant complications caused by scar tissue, complicated aneurysm repair, and last but not least considerations of my wife {whom as I mentioned was in inner turmoil about this})

When you get to managing your warfarin and INR reach out (or search my blog under INR in the tag cloud) and I'm happy to help you bed into that.

Best Wishes

 

[pellicle]

One more point @Unicusp recently brought up on choice of valve is that there are definitely clear cases (such as a propensity to bleed as Harriet suffered) through to "risks" to orient one to avoid a Mechanical in favour of a Tissue (aside from the usual ones of age) Katherine brought up this point recently in another thread recently

Sometimes, we must kick the can, especially with underlying or additional medical issues where warfarin or similar drugs are contra indicated. Macular degeneration for example.

so these are factors to think about as well as the usual ones of "compliance" (failing to take your warfarin) and monitoring. I can certainly see why some surgeons just push people (who are undecided) towards a tissue prosthesis.

The reality is for us valvers however is that there are no (to my knowledge) broad statistical analyses of the choices as a matrix with a "what if" sort of interface. Perhaps one day with better use of neural networking and systematic reviews there may be a case for that (or even maybe the direction for me to move from only holding a research Masters to a PhD.. . God help us all Dr Pellicle ....

Best Wishes

 

[Unicusp]

Hi


yep ... by me



I'm glad you had a good time, if you came to Queensland we're even more "direct" than New South Welshmen or Victorians. Unless you went to the West coast and I have no idea.



I chalk this up to the role being so specialised (by the demands of complexity) and mistakes are not taken kindly. So due to that surgeons develop a preference for what they have worked with.

I'd add to that (having talked to quite a few people in the various waiting rooms over the years (before phones allowed for infinite distraction and "socialising") because it was common to be waiting for an hour or so in the public system before seeing anyone. I observed from those interactions that many "don't want to know" and want to get on with it and "get back to being normal". Like this comment on my blog post: " and I freely confess that I loathe being reminded of my condition "

I have come to the view that many people just want to be like Cypher:


and pretend there is nothing wrong or anything to learn.



that is also my view. People have often had conversations with me about how many heart operations are done (on the public purse here in Australia) on the very elderly (over 70) and how this seems a waste. I remind them that those operations have enabled the development of the techniques (both surgical and ICU) to enable me to have heart surgery (now three times) and live a good and full life. For that I'm grateful. As a young adult I always allowed any curious doctor or imaging specialist (had a few reasons to go to hospitals which include bicycle and motorcycle mishaps) and wish to do as much as I can (within reason) to spread knowledge (even if I'm the walking example).



it is my view that we are all adults (or should be) and anyone insulted by your choices and your reasons is not worth being concerned about. Over the years people have unwittingly said intensely painful things to me (because some people are fully idiots) and it took me a while (till adulthood) to get to a point where it (mostly) didn't bother me.



I did none in my first two, and indeed in the lead up to the second I actually was doing Uni (again) and negotiated to have it done (it was deemed pressing) after my exams. So I was pretty busy right up till I walked in too. I had the same team (although the head surgeon had retired) on all three and as its literally the best cardiac hospital in the state just went along.

On this last operation I made no explorations of warfarin because the case for a mechanical was so compelling that to my mind it was a done deal (reasons: 42, third OHS and attendant complications caused by scar tissue, complicated aneurysm repair, and last but not least considerations of my wife {whom as I mentioned was in inner turmoil about this})

When you get to managing your warfarin and INR reach out (or search my blog under INR in the tag cloud) and I'm happy to help you bed into that.

Best Wishes

Thanks! Will do. I'll be back. It was Sydney.

 

[tom in MO]

I'll try to keep this brief. I was diagnosed with BAV & ascending aorta aneurism at age 50. Monitored the aorta for 2 years and had replaced by dacron graft at 52 at the Cleveland Clinic. Surgeon inspected the aortic valve and confirmed it to be a unicuspid that was healthy and functioning so he left it alone. Here I am 7.5 years later with severe stenosis and need replacement soon. I'm very healthy, active and asymptomatic. Heck, I walked over 12.5k steps at the Cleveland Clinic the other day walking between the many testing area's. I've pretty much decided that I only want to do this one more time. This second time is difficult enough. I can't see installing a tissue valve with an expiration date of anywhere between 1 and 20 years. Yes, the thought of Coumadin sucks, but I feel it safer than more invasive surgeries down the road. Yes, there is TAVR but that has many potential risks as well.
So, for me it appears to boil down to either the St. Jude Regent or On-X valves. Has anyone directly compared these two valves? They are both made from the same pyrolitic carbon and are very similar in design. But, my surgeon appeared to favor the SJ as it appears a larger SJ can be installed in the same area as a On-X, and he mentioned the On-X is "Bulky" and I guess requires a larger annulus for proper installation. Which valve has better hemodynamics? They both appear to be robust enough and tested to last a "lifetime". Any thoughts/comments/experiences appreciated. I apologize if I am re-visiting an old topic. Thanks everyone! By the way, this is a great site.

I asked about St. Jude vs. On-X and my surgeon said if I cared he'd do either. When I pressed him for what he preferred, he said the St. Jude. He said the St. Jude has a longer positive track record than the newer On-X. Your surgeon is the expert...

 

[Unicusp]

Thanks. After more thorough research, multiple discussions, and thought, I've decided to go with the SJM Regent. It is also the one my surgeon initially recommended, but I needed to come to that conclusion on my own since I have to live with the decision. Thanks again.

 

[NorthWoods]

Interesting topic indeed. My cardiologist recommended the On-X valve, and my surgeon said both are great valves. He has implanted more SJM valves as they have been around longer. My surgery is coming up on the 25th of this month and I have chosen the On-X valve. Mainly due to it's pure carbon construction, it is 100x smoother under a microscope and runs a less chance of blood clotting with proper INR levels. It also has a slightly higher outflow lip, so during the healing of the tissue, less chance of blockage from what I read.
If my surgeon feels strongly about the SJM, then that is what I will ultimately go with.

 

[Superman]

I apologize if I am re-visiting an old topic. Thanks everyone! By the way, this is a great site.

Welcome to the forum, and don’t apologize for this topic. It’s why the forum exists. Everyone should visit this topic on their own as it is a very personal decision.

You and I are opposite in that I received my valve first and graft later. Back in 1990 I don’t recall there being much choice offered as a teenager. It was either St. Jude or ball and cage model. Tissue wasn’t offered. That lasted until an aneurysm was discovered when I was 36. The valve itself would still be going strong, but I went with a one piece valve/graft from St Jude the second time. So 30 plus years in warfarin. I’m 48 now. Hope it lasts a good long time.

As far as brand recommendation- I don’t know that there’s a wrong brand. On-X wouldn’t pass my sleep at night test, regardless of approvals I would not want an INR below 2 and a take comfort in a full 1.0 window for therapeutic range. I’m still managed at 2.5 - 3.5. But others are more comfortable with a lower INR and would lose sleep worrying about bleeding risk.

To each their own. As we say around here, regardless of what you choose, it’s better than what you have!

Best wishes and keep us posted.

 

[Unicusp]

Sorry. my reply to Northwoods. Tough decision! I thought that too. On-X is very good at Marketing. I have a Marketing background and challenge everything. The following is what I've been able to gather and understand. The On-X and SJM valves are made of the same material so same "smoothness". The design of the SJM allows for better hemodynamics and laminar flow. I've been told (by my surgeon who has installed thousands of valves) that generally a larger sized SJM can be implanted in the same location as a On-X due to the taller and bulky nature of the On-X design. Depends upon the size of the aortic valve annulus. They can't know specifically until they are in there. To me, SJM appears to be a conservative Company, does not make unsubstantiated claims, and lets the product "sell itself". That's my opinion. Others can chime in. I'm always open to new information. I have 2 weeks to finalize my decision. I'm scheduled for 2/19. Thanks!

 

[Rapidman]

I had the On-X placed with conduit 6 years ago, it was what my surgeon recommended. Despite the claim of only needing to keep your INR between 1.5 and 2.0 I still keep it at 2.5 to 3.0. Warfarin has not been a problem for me, easy to self monitor. After researching both valves I felt they were comparative, so I went with the surgeons suggestion.