Aortic Valve Choices

[Superman]

For anyone making their decision between biological and tissue, this article has good information on the pro biological valve option/choice.

Biological Vs Mechanical Valves – Key Points

• Long-term survival is equivalent
• Mid-term morbidity is worse with mechanical valves
• Reoperation rates are low with biological valves and are not insignificant with mechanical valves
• Reoperative aortic valve replacement has similar mortality to primary valve replacement
• Complications of mechanical prosthesis are more devastating than those of biological valves
• Mechanical valves can have substantial negative impact on daily quality of life

I hope this helps anyone deciding valve choice is best for them.

Link To Article Below:

https://www.acc.org/latest-in-cardi...c-valves-are-better-even-in-the-young-patient

The key to the whole thing is the first paragraph. They are talking about patients age 70 and above for tissue. 60 and below for mechanical. In your 60’s could go either way. At age 70 plus, the bullet points you cite are accurate. Fairly consistent with what many on this forum have been saying for a long time.

Disregard. It opens with conventional wisdom, then goes on to make the case for under 70. Still, it focuses on operation age at roughly 60. Being 48 and ticking for over 30 years already, I have a hard time relating to many or really any normal studies.

 

[Chuck C]

For anyone making their decision between biological and tissue, this article has good information on the pro biological valve option/choice.

Hi Daniel.

Thank you for sharing your thoughts. I noticed that you received the Edwards Resilia Inspiris tissue valve in 2018. At the time you said:

“According to surgeon and research, the valve’s supposed to last 2-3 times longer than previous generation tissue valves, and minimizes calcification.”

Edwards Resilia Inspiris Aortic Valve

In 2018 there was about 2 years of published human data on the Edwards Resilia Inspiris valve through the Commence Trial. I’m curious what research your surgeon provided you to support his claim that it would last 2-3 times longer than previous generation tissue valves? I wonder how such a conclusion could be supported with 2 years of human data?

I certainly hope that this valve lasts 2-3 times longer than previous tissue valves for you and others who have received it, but I'm not clear on how this conclusion could be reached with just 2 years of data. My surgeon was on the team that developed the Edwards Resilia Inspiris and he told me that at age 53 I should expect to get 10 years out of it, but there was "hope" that it would last longer than that. To be clear, it was hope and not supported by the existing studies and that was 2021. Following that discussion I decided to choose a mechanical valve, as I did not want a reoperation at age 63 and I did not feel that hope was enough for me to bank on to get longer out of it, lacking clinical data to support a longer valve life expectancy.

 

[Chuck C]

For anyone making their decision between biological and tissue, this article has good information on the pro biological valve option/choice.

Biological Vs Mechanical Valves – Key Points

• Long-term survival is equivalent
• Mid-term morbidity is worse with mechanical valves
• Reoperation rates are low with biological valves and are not insignificant with mechanical valves
• Reoperative aortic valve replacement has similar mortality to primary valve replacement
• Complications of mechanical prosthesis are more devastating than those of biological valves
• Mechanical valves can have substantial negative impact on daily quality of life

I hope this helps anyone deciding valve choice is best for them.

Link To Article Below:

https://www.acc.org/latest-in-cardi...c-valves-are-better-even-in-the-young-patient

A few things that should be noted about your linked article:

The article has no author named- just “Expert Analysis”. Would really be curious to know who this expert is. If you happen to know who he is, please share.

There is no conflicts of interest section listed below the article. Are there any? We can’t know, as it is not addressed and the author apparently is anonymous, as best I can tell.

Most important, this article is presented on the American College of Cardiology website. To be clear, The American College of Cardiology is an association and not a peer reviewed medical journal.

“The American College of Cardiology, based in Washington, D.C., is a nonprofit medical association established in 1949.”

This is not to be confused with the Journal of the American College of Cardiology or JACC. Publications in JACC are subject to peer review. This is an important distinction, because the peer review process helps to evaluate whether the conclusions reached by the authors are reasonable. An opinion piece on an association website, as I understand it, is not subject to peer review and from all appearances, this article was not peer reviewed. At the bottom of my post I link a 4 minute video explaining the peer review process and it’s importance.

In that this anonymous expert reached some questionable conclusions, in that his conclusions appear to not be peer reviewed, the author is not named, conflicts of interest are not disclosed and his credentials are not disclosed so that we can evaluate his level of expertise, in my view, this opinion piece should be viewed with a great deal of skepticism.

As an example, here is another expert analysis put up on the American College of Cardiology website- see link below.

Notice, that even though this also appears to not be peer reviewed and does not list conflicts of interest, the author is named. So, if somebody really wanted to understand if the author has conflicts of interest, they can click the hot link of the author, which will take you to their bio page, which includes their conflicts of interest, see her bio page, bottom link.

https://www.acc.org/latest-in-cardi...from-the-new-acc-aha-valve-disease-guidelines
Bio page of Mirvat Alasnag

https://www.acc.org/Membership/Person?id=a3b546c8-e548-4839-9186-4c308b1a4138
The article also includes the following information about the author:
Mirvat Alasnag, MB, BCh, Director of Catheterization Laboratory Military Hospital, Jeddah-Saudi Arabia, member of the American College of Cardiology (ACC) Interventional Leadership Council

I’m editing my post to add this 4 minute video briefly explaining the peer review process and why it’s important:

 

[cldlhd]

Maybe I'm a cockeyed optimist but I'd like to live a long , healthy life and in that scenario I view a tissue valve in my 60's (52 now and hopefully won't need another surgery) as either planning on dying relatively early or a guaranteed surgery.
My grandmother is 93 and still kicking so ..

 

[nobog]

That article should be removed from the web - good grief ...

 

[user 15848]

There are many opinions about the subject, make and educated decision with your doctors, this article below is a informative one from June-2021, touches on some main points,and could be of interest. Regardless of choice, tissue WILL have to be replaced since the human body attacks any foreign tissue by design; so no tissue valve will last , and that is the reason young people waste them faster, their inmune system is stronger;

https://www.heart-valve-surgery.com/learning/mechanical-heart-valve-replacements/

 

[pellicle]

Complications of mechanical prosthesis are more devastating than those of biological valves

From your source

However, for mechanical prosthesis, even though the rate of valve related complications may be low, these may be devastating, and sometimes irretrievable, and typically require emergency surgery.​

Indeed so low as to be insignificant

 

[pellicle]

That article should be removed from the web - good grief ...

I'm sort of surprised it got published. Very little actual data or evidence. Seems like a beat up.

 

[Chuck C]

That article should be removed from the web - good grief ...

This article cherry picks existing studies to argue the author's bias and would not survive the peer review process in my view.

Much of his conclusion is based on this argument - from his article:

".. many patients will die before the valve degenerates "

Really? Even young patients?

In support of this he claims:

.".the average life-expectancy of a 60 year old after aortic valve replacement is about 12 years10"

12 years life expectancy for a 60 year old? I believe there was some cherry picking of data in this claim. The study which he cites to support this used data from 1982 to 2003, which does not account for improvement in valves, surgery, or aftercare that have occurred in the past 20-40 years.

Other published studies have found longer life expectancy:

This study found that those who have undergone aortic valve surgery have only slightly lower life expectancy than the general population:

https://www.jacc.org/doi/full/10.1016/j.jacc.2019.04.053?rss=1
This study found that life expectancy for those with BAV following valve surgery was similar to the general population:

" Conclusions The survival of patients with BAV following aortic valve surgery was excellent and similar to that of the general population. "

https://heart.bmj.com/content/107/14/1167
And, in some situations, there may be no loss in life expectancy, as was suggested in this study regarding the Bentall Procedure:

" Discharged patients enjoyed survival equivalent to a normal age- and sex-matched population and superior to survival reported for a series of patients with aortic valve replacement alone. "

https://pubmed.ncbi.nlm.nih.gov/178...al was 93,with aortic valve replacement alone.

I guess that if I was planning to just live 12 years that I would not care which valve I choose. But, I plan to live a lot longer than that, and I would hope that someone who is aged 60 or even 65 plans to live a lot longer than that.

 

[Superman]

Much of this stuff just smacks of Monday morning quarterbacking where we want to feel better about our decisions. Bottom line I keep going back to is if you can sleep well and not worry about it, you made the right decision for you. Regardless of the choice made, it is a better choice than doing nothing if you’re eager to just get on with life.

 

[pellicle]

Bottom line I keep going back to is if you can sleep well and not worry about it, you made the right decision for you.

A good saying ...

 

[pellicle]

his article cherry picks existing studies to argue the author's bias and would not survive the peer review process in my view.

sadly (having experience with Peer Review) it would. Peer Review only guards against invalid assumptions, false citations and incorrect data.

The biases and cherry picking is left as is as that would somehow be "a reviewer bias" ... the appropriateness of citations is left to the reader. Which is why at Uni we teach strongly Critical Analysis, but seemingly mainly focused on Hon and Masters level leaving undergrads to be nothing more than modern day Certificate holders) . These could include being:

• inquisitive and curious, always seeking the truth
• fair in their evaluation of evidence and others’ views
• sceptical of information
• perceptive and able to make connections between ideas
• reflective and aware of their own thought processes
• open minded and willing to have their beliefs challenged
• using evidence and reason to formulate decisions
• able to formulate judgements with evidence and reason.

Critical thinking experts describe such people as having “a critical spirit”, meaning that they have a “probing inquisitiveness, a keenness of mind, a zealous dedication to reason, and a hunger or eagerness for reliable information” (The Delphi Research Method cited in Facione, 2011, p. 10).

however most people just want to use research to justify their biases and ignore conflicting evidence or evidence which does not make them feel happy (cherry picking). Routinely done with the Bible for instance.

Such critial failure of "grave danger" also occur to bioprosthese ... conveniently ignored when drumming up fear as in the above

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3461687/

Aortic valve replacement using stentless biological prostheses offers the benefits of good hemodynamics, without the requirement of prolonged anticoagulation. Although their major drawback—structural degeneration in the long term—is well documented, bioprostheses rarely fail early, and, when they do, rapid calcification of the valve leaflets is the usual cause.​

​

We report the successful management of a rare case of early failure of a stentless aortic bioprosthesis within 4 months of implantation. The patient presented with severe noncalcific aortic regurgitation secondary to prolapse of the noncoronary leaflet.​

please note that I left in the point that its rare (just as it is with Mech valves)

Also Intraoperative Bioprosthetic Valve Dysfunction Causing Severe Mitral Regurgitation
DEFINE_ME

https://www.researchgate.net/public...of_Bioprosthesis_by_Preserved_Mitral_Leaflets
https://www.acc.org/education-and-m...ia-detail?id=c2360eeba07647b7b245058329ced312

The data is out there if you actually honestly want to know it

 

[Chuck C]

sadly (having experience with Peer Review) it would. Peer Review only guards against invalid assumptions, false citations and incorrect data.

Clearly it has flaws and limitations and your points about critical analysis are excellent.

But, doesn't peer review also guard against overreaching conclusions? The very title of said article seems an incredible overreach that was not well supported by the references.

 

[vitdoc]

First of all this was written 6 years ago. Fewer people were self testing their coagulation levels. Secondly there are some statements in this that I really don’t agree with. For example: but life-table analyses of large datasets suggest the average life-expectancy of a 60 year old after aortic valve replacement is about 12 years.
This is used to justify tissue valves at a younger age than 70 since the individual will likely die before the tissue valve dies. 12 year life expectancy at age 60? Really? Statistics cherry picked from all over the place used to justify the author‘s bias.
So for me a worthless article.

 

[pellicle]

First of all this was written 6 years ago.

I'm not sure that much has changed ... particularly with respect to valve failures (NB they don't).

Self testing and indeed self management could probably step up in the USA, but that's a thorny issue. You'll note that this form has a long history of self testers and self managers, much longer than 6 years. I'm glad I do it and of course it essentially demolishes the arguments about anticoagulant related risks

Statistics cherry picked from all over the place used to justify the author‘s bias.
So for me a worthless article.

agreed, but it appears to be sufficient to push at least one person into believing it. I would ask questions about the actual motivations of the Author, it can't simply be "well AC Management is so crap you should suffer further surgeries for your own sake"

 

[pellicle]

But, doesn't peer review also guard against overreaching conclusions?

I don't believe so, especially when the presented facts apparently justify the conclusion. It becomes a difficult job to then be sure that the literature review is inadequate or biased.

https://www.biomedcentral.com/getpublished/peer-review-process
This is exactly why in medicine you have the situation that there is no "consensus" and the whole thing is run on "opinions"

 

[cldlhd]

This article cherry picks existing studies to argue the author's bias and would not survive the peer review process in my view.

Much of his conclusion is based on this argument - from his article:

".. many patients will die before the valve degenerates "

Really? Even young patients?

In support of this he claims:

.".the average life-expectancy of a 60 year old after aortic valve replacement is about 12 years10"

12 years life expectancy for a 60 year old? I believe there was some cherry picking of data in this claim. The study which he cites to support this used data from 1982 to 2003, which does not account for improvement in valves, surgery, or aftercare that have occurred in the past 20-40 years.

Other published studies have found longer life expectancy:

This study found that those who have undergone aortic valve surgery have only slightly lower life expectancy than the general population:

https://www.jacc.org/doi/full/10.1016/j.jacc.2019.04.053?rss=1
This study found that life expectancy for those with BAV following valve surgery was similar to the general population:

" Conclusions The survival of patients with BAV following aortic valve surgery was excellent and similar to that of the general population. "

https://heart.bmj.com/content/107/14/1167
And, in some situations, there may be no loss in life expectancy, as was suggested in this study regarding the Bentall Procedure:

" Discharged patients enjoyed survival equivalent to a normal age- and sex-matched population and superior to survival reported for a series of patients with aortic valve replacement alone. "

https://pubmed.ncbi.nlm.nih.gov/178...al was 93,with aortic valve replacement alone.

I guess that if I was planning to just live 12 years that I would not care which valve I choose. But, I plan to live a lot longer than that, and I would hope that someone who is aged 60 or even 65 plans to live a lot longer than that.

It's weird now that I'm 52 I have a much different perspective on what I consider to be old.... We have a guy here at work who's 21 who probably thinks I'm ancient, and my stupid brain still thinks I'm 30. But when I look at evidence like that it's hard to get much out of it because saying that someone who has "aortic valve replacement at age 60 lives 10 to 12 years on average afterwards" doesn't really tell you why they had the valve replaced. Or what kind of valve it was. Did it end up getting replaced because they were morbidly obese, didn't exercise at all, and smoke two packs a day? Well yeah then I could see it working out that way. But were they generally healthy person who gets a decent amount of exercise, eats pretty well, doesn't smoke etc? Then it's a different story.

 

[Chuck C]

but it appears to be sufficient to push at least one person into believing it.

Which is why I believe it is important for us to call out bad science when it is presented on the boards as reasonable evidence which supports a certain choice.

 

[Daniel758]

Well it looks like this article has stirred up quite a few people. This was not my intention but it was no doubt my result.

First, I want to say I have vey much enjoyed this forum, the people posting their experiences are great and the information shared is valuable.

That said, I'd like to share a story...

I have family members that are members of a very conservative fundamentalist Christian church. Very good people who truly believe in their churches' teachings.

One day at a cookout, a couple of them began discussing how "liberalism" was destroying America and leading to the destruction of America's children.

Their example was that in San Francisco, the bastion of Liberalism in America, there's a law that allows people to ride the city busses naked.

And what could be more traumatizing and moral decaying to America's children than seeing someone riding the bus naked, right?

I couldn't think of anything.

I was a little taken aback by this, though, so I questioned the existence of this "Law".

Their response: Everyone knows this is true. One relative turned to the other, both shaking their heads and confirming that everyone in their church knows this. It's been talked about many, many times. In fact, it's common knowledge everywhere, except the "Main Stream Media", and to prove it, I could just go to San Francisco myself and ride the bus and I would indeed see naked people.

They were so confident in their answers that I actually googled this to find out if somehow this could possibly be true.

It wasn't.

Now back to this forum...

I'm sure the following will probably stir up a lot more people but it seems this forum is beginning to have an echo chamber vibe that will eventually stifle an otherwise good, supportive place to discuss heart valve issues and lead to disinformation that could harm people.

And I don't think it's intentional. I think it just happens when a few people discuss over and over their beliefs. The beliefs then become solidified and unquestionable.

I see time after time people telling others that "no valve choice is the wrong choice" and then ithey mmediately proceed to tell them why their choice is/was wrong. I'm not sure they realize what they are doing this but this is what I see happening.

I've also seen many postings that question cardiologist's motives by saying cardiologist's are probably taking money from valve makers when they recommend someone choose a valve the poster doesn't agree is best.

These same cardiologists that have dedicated their lives to saving our lives are now not to be trusted because they are obviously on the take for a few dollars if they recommend something other than what the poster "knows" to be best? To me this is a huge turn off.

The reality of this is that people who have the drive, intelligence and the skill to become world class heart surgeons are surely talented enough to go into any field they want and make as much money as the wish. I just don't believe it's about the money with them.

And before anyone says, "Yeah, but a study showed a cardiologist was on the take once", yeah, probably, but overall I'd bet 99.9% of world class heart surgeons are not "on the take" and I'll take my chances with their experience and knowledge over any internet forum poster.

One poster here questioned who my heart surgeon was how he could recommended my specific Inspiris Resillia valve, here's the link to his bio:

https://providers.keckmedicine.org/provider/Vaughn+A.+Starnes/205280
Point being that I think it's obvious that these surgeons/people, who we have placed our lives in their hands and they gave us many more good years of life than we would have ever had without them, are much more qualified and much more knowledgable than anyone posting on an internet forum.

I think it's actually dangerous for new people coming to this forum when making their decisions to be told to disregard the opinions of people like the above Dr. Starnes and be sidetracked by internet researchers or forum posters telling readers they know more than their Drs.

Now, if people are still open to hear the "other side" after reading the above, I believe the article I posted has value in many ways:

1. Many posters on this forum are often perplexed about why their cardiologist recommended a biological valve over a mechanical.

Read the article, maybe this is why?

Maybe trust your cardiologist or surgeon knows more than an internet poster?

2. If the statistics show only 45% of people receiving a biological valve at 50 and 25% at 60 will ever end up having a re-operation for another valve or that less than 20% of people under age 70 who receive a biological valve will have a redo within 15 years, then that's just what the numbers say.

Will you fall somewhere close to these figures? Probably.

Will you be an outlier? Probably not, but who knows. Dick is living proof it can happen and everyone wants to be Dick and go 50 years. I know I do.

Will I be as lucky and seriously as tough as Dick? Hopefully, but probably not. It's just reality.

People also go to Las Vegas by the millions all planning to win big. Do they end up winning big? Yeah some do, but the vast majority don't.

3. If warfarin is no big deal, there would not be literally thousands of posts here and hundreds of thousands of posts all over the internet trying to help people figure it out. Enough said.

If you're en engineer or someone with the mindset of one, great, it probably is no big deal at all.

For the average person, judging by the sheer number of postings, it does seem to be a big deal.

And there are many more "average" people than engineers. There just are.

4. As far as quality of life issues, I'll give an example from my own experience:

A month or so after I had my valve replacement, my wife of 35 years placed her head on my chest in bed for the first time since the surgery and then pulled away a few minutes later. When I asked her what was the matter, she said, "It doesn't sound like you". That bothered both me and her. It's real.

Luckily, it has since quieted down but I don't know how it would have affected both of us if there was a constant and even more "foreign" ticking sound 24 hours a day.

If it doesn't bother you or yours, great, but it may bother others. Again, reality.

5. Another thing that stuck out to me in this article that I think is very valuable to know in making your valve choice is the claim that the average quality of after surgery health with mechanical valves is "Fair" and with biological valves is "Good".

I know posters will tear into the article"s claim with "peer review" questions, how the study was set up, etc., etc. and how the claim is not true because they can climb mountains, etc. (which I have no doubt is true, I just question how typical that is for the average replacement valver)

NOW HERE'S WHY IT'S IMPORTANT:

If cardiologists and actual heart valve researchers are correct, I think that knowing the difference in quality of health after surgery is very important information to know when deciding and weighing tradeoffs between both valve types.

Let's say the cardiologists and researchers actually do know what they are talking about and you get 15 years out of a biological valve and "good" health before a replacement re-operation.

Let's also disregard the 10% re-operation rate on mechanical valves and say a mechanical valve will give you "fair" health and will never wear out.

Now you're basically weighing 30 years +- of "good" health plus one more high success rate operation against an undetermined number of years of "fair" health plus daily warfarin, etc. and no more operations.

Maybe not so cut and dry when you look at it like this?

Was this valuable information in a heart valve forum?

(Note also that if you choose the Inspiris Resillia, it's supposed to last longer (but who knows for sure yet) and it's made to accept a TAVR valve in valve that would probably give you another 8-10 years. Depending on my health at the time and whether or not a material like the FOLDEX is available, I would probably go new valve in 15 years and then do a TAVR later as TAVR seems to reduce capacity. That would bring me up to potentially 40 years with "good" health, and one additional operation.}

Quality of health for me was/is a huge issue. I do know that I was ready for some "good", worry free health when my time came after a number of years of tough sledding and I'm very thankful for it. It has changed my life tremendously.

I also think of posters like Paleowoman and her problems with a mismatched valve and her resulting "poor" health she's had to endure for many years. I think she would probably be very interested in and eager for a chance at as many years of "good" health as she could possibly get.

So moral of the story, which option is best?

Individuals need to choose for themselves but it's not as cut and dried as many here make it out/are convinced it to be. Both are valid options.

I also see a danger in this forum becoming an echo chamber and new people coming here for information and answers only to be told that their cardiologists and surgeons are not to be trusted and that warfarin will not be problem for them when it may be.

SO TO THE NEW PEOPLE READING THIS FORUM: The posters on this forum, while well-meaning and knowledgable, are not cardiologists or surgeons. Your decision is life altering, please listen to your cardiologists and surgeons when they tell you something and take these posters advice and experience for what it is, advice and experience from well meaning people, not cardiologists and surgeons.

 

[pellicle]

Hi

Well it looks like this article has stirred up quite a few people. This was not my intention but it was no doubt my result.

discussion is always good ... well unless those in the discussion have no intention of changing their minds

That said, I'd like to share a story...

...
Their response: Everyone knows this is true.

my view is represented by this quote

They were so confident in their answers that I actually googled this to find out if somehow this could possibly be true.

It wasn't.

well done ... veracity

Now back to this forum...

I'm sure the following will probably stir up a lot more people but it seems this forum is beginning to have an echo chamber vibe that will eventually stifle an otherwise good, supportive place to discuss heart valve issues and lead to disinformation that could harm people.

how so?

I see time after time people telling others that "no valve choice is the wrong choice" and then ithey mmediately proceed to tell them why their choice is/was wrong. I'm not sure they realize what they are doing this but this is what I see happening.

what I see is people saying "no choice is wrong" then giving their opinion about the choices.

see above quote

The reality of this is that people who have the drive, intelligence and the skill to become world class heart surgeons are surely talented enough to go into any field they want and make as much money as the wish. I just don't believe it's about the money with them.

I would agree ... and just to make a point, there are no "hacks" in Cardiothoracic surgery. Its a long process to get there.

This does not mean howerver they are not human and not without personal biases.


you say:

Read the article, maybe this is why?

which article?

Point being that I think it's obvious that these surgeons/people, who we have placed our lives in their hands and they gave us many more good years of life than we would have ever had without them, are much more qualified and much more knowledgable than anyone posting on an internet forum.

of course ... and if you read my posts for example you'll often see me suggesting that the person use the advice here to formulate a question set to take to their surgeon and ask about it

I think it's actually dangerous for new people coming to this forum when making their decisions to be told to disregard the opinions of people like the above Dr. Starnes and be sidetracked by internet researchers or forum posters telling readers they know more than their Drs.

interesting ... who actually said that?

I also see a danger in this forum becoming an echo chamber and new people coming here for information and answers only to be told that their cardiologists and surgeons are not to be trusted and that warfarin will not be problem for them when it may be.

that's interesting and not so long ago it was the exact opposite ... also what do you have to say to the posters who are on warfarin and it isn't a problem?

Also have you noted that people like me regularly say "its an equation which is driven by parameters" first of which is age, then if you are contra indicated for warfarin, then if you are unlikely to be warfarin compliant?

The older you are the more a tissue prosthetic is quite the right choice. Especially over 65 and more.

SO TO THE NEW PEOPLE READING THIS FORUM: The posters on this forum, while well-meaning and knowledgable, are not cardiologists or surgeons. Your decision is life altering, please listen to your cardiologists and surgeons when they tell you something and take these posters advice and experience for what it is, advice and experience from well meaning people, not cardiologists and surgeons.

which should also apply to you too ... no?

Best Wishes