AVR 4/23/15 - Tissue or Mechanical

[Indy Tom]

Good afternoon AVR and aneurysm repair 4/23/15. Age 62. Good health. Otherwise healthy heart.
Tissue or mechanical?
Few questions. I realize there are no exact answers:
1. Are both types of valves similar in quality?
2. Seems like every discussion is "do I want to risk having another replacement or not?". Is there another discussion to be had?
3. Coumadin seems like a drag. Is only reason to go mechanical fear of having surgery again at an older age?
4. I know I will need both knees replaced at some point. Is risk great if I am on Coumadin at that time?
5. Any real life experiences as to how long you or someone you know has had a tissue valve would be appreciated.

 

[tom in MO]

1. Quality is a relative concept. If you define it as low risk of future valve problem symptoms or re-op, then a tissue is low quality. If you define it as no warfarin, thus no new drug restrictions, no additional risk for other surgeries due to no warfarin, then a mech valve is low quality.

2. Yes. Sounds like you have arthritis. Many arthritis medications are not allowed or complicated by warfarin. Talk to your doctor before surgery. I have chronic hemoroids and went to my colorectal surgeon for a consultation before surgery. He said warfarin was no problem, but lets get a colonoscopy to make sure its all cool before OHS : )

3. Warfarin is no big deal. There are many people on it and most do not have replaced valves.

4. Ask your orthpedist. You may have to bridge which could increase your risk of stroke for a few days. However modern mech valves should not present a big problem, since they can handle lower INRs w/o problems.

5. I have had operations before this and chose mech to avoid future re-ops. Even though I have arthritis, slow valve failure followed by OHS again were not what I wanted. I was 55 when mine was replaced

Good luck, there is no wrong choice because they all result in LIFE!

 

[epstns]

Indy Tom - The current thinking is that for patients over their mid-50's, the newest generation of tissue valves are advisable. As you said, there are no concrete answers, but the scientific "opinion" now is that the second generation of tissue valves seem to be lasting up to 20 years or more for patients in their 50's onward, and that the current third generation valves should last even longer. As you've probably read by now, it is believed that the degeneration of prosthetic tissue valves happens more quickly in younger patients. This is because the younger patients' immune systems are more aggressive, so we older folks won't attack our valves as much. This seems to be borne out by statistics, but there will not be any long range statistical data on the current generation of valves for another 10-15 years.

All that said, at age 63 I had a bovine tissue valve implanted (4 years ago). At that time, the Cleveland Clinic was implanting tissue valves for almost all of their patients over the age of 50. My surgeon came to Chicago from the CC. While there is some possibility that catheter-implanted valves may become available to many patients, I'm not holding out for one. I'm just betting that my valve will last longer than I do.

 

[Bina]

At the time of my surgery I was 46 and just a few weeks away from turning 47.....my valve had heavy calcification, and I don't do well with medical procedures....So, a mech valve was my choice.
We all have our own reasons for choosing a particular path in life, and so it goes with valve choice. Best wishes !

 

[knotguilty]

A very touchy subject about which one to choose. The best one is the one you decide on. It is hard to argue with the results and success with the people who have mechanical valves here. I opted for tissue, for my own personal reasons. I am very glad I did. I figured I would sooner possibly face another surgery than the risk of Coumadin at a later age. Know there are no guarantees either way. Each way has its risks and advantages. But the one you pick is the right one for you.

 

[pellicle]

Hi

Good afternoon AVR and aneurysm repair 4/23/15. Age 62. Good health. Otherwise healthy heart.
Tissue or mechanical?
Few questions. I realize there are no exact answers:

its good that you see that point ...

1. Are both types of valves similar in quality?

very ... if you mean manufacturing quality ...

2. Seems like every discussion is "do I want to risk having another replacement or not?". Is there another discussion to be had?

That's the main discussion as well as a side serving of "can I have a Valve in Valve replacement by TAVI if I go tissue prosthetic .. Its not however a trivial discussion as your next point identifies...

3. Coumadin seems like a drag. Is only reason to go mechanical fear of having surgery again at an older age?

you think warfarin is a drag but you'd risk another surgery? In another surgery you could have all the risks of the first (infections) and added risks of damage to the heart and surrounding nerves by accident because the scar tissue blocks the view / inhibits surgery. To me this cuts to the heart of the above question. Understanding the risks. Then there is the stress for your family ... nobody will worry around your bed side because you take a tiny pill once a day (tell me you don't now anyway) but they will worry on your next surgery.

Another point is that the tissue prosthetic does not go from perfect to fail suddenly, it fails over time with a gradual change in operation Structural Valve Degredation

This is from the latest version of guidelines for aortic valve surgery (published in 2013) titled:
Aortic Valve and Ascending Aorta Guidelines for Management and Quality Measures.

4. I know I will need both knees replaced at some point. Is risk great if I am on Coumadin at that time?

it will be something that needs to be managed that's for sure. I'd discuss it with whoever will do your knees

For what its worth I've had two "debridement" surgeries which essentially are the scraping out of infected tissue and result in more trauma than a typical surgery is intended to give. I was on warfarin for both those and I managed quite well.

5. Any real life experiences as to how long you or someone you know has had a tissue valve would be appreciated.

this whole site is filled with real life experiences ... read some of them.
My summary of things is that for someone your age that the analysis of problems vs benefits sits you at having only minor differences in which way you go. To me (as you are not 30) a tissue prosthetic will probably do you just as well ... you may get 15 ~ 20 years .... there is a small chance you may get far less (as has been written in posts here).

Best Wishes

PS: I reckon if you are stuck on choice of Tissue vs Mechanical prosthetic: flip a coin. If you find that you don't like that outcome then chances are that's telling you what your gut really wants you to do. If not, then decision made.

 

[neil]

Do your homework discuss with your cardio and surgeon and choose what's best for YOU . good luck and am sure you will do just fine

 

[gregjohnsondsm]

Neil. I disagree. The problem is that the five or so cardiologists I've delt with were not all that knowledgeable about this issue. In fact a couple were completely wrong about a few details. So relying on a single dr or cardiologist just isn't a satisfactory approach - for me. Discussions here and at other user forums. Research. The society for thoracic surgery and other sources of information really helped me come to a decision that I could be at peace with.
For some this is too much effort and for those I would recommend going with your surgeons recommendation. But not your cardiologists.

 

[epstns]

Or. . . you could do as I did. I consulted with my cardio (who is well educated on valves, in my opinion), THEN I consulted with two surgeons. All three of them had the same recommendation, with which I agreed. So, is mine the best decision? For me, it is. I'm a happy camper.

Also, if I interpret the stats pellicle posted correctly, since my valve was implanted at age 63, I have roughly a 9% chance of needing another by age 78 (and by extrapolation, maybe 20% by age 90?). That's about what Dr. McCarthy described to me prior to implant. I can accept those odds - but that's just me. YMMV

 

[tom in MO]

I always get three opinions before major surgery. My GP, surgeon and cardio all told me surgery was absolutely needed based upon my echo results even though I thought I had no symptoms. Not one of them suggested a valve to me at age 55; they told me it was my choice. Both said to not make my choice based upon possible future developments and my surgeon is involved in clinical trials.

 

[Heart Of The Sunrise]

Indy Tom: It is a very personal choice....plus and minuses to both... however they both save your life!
I started out thinking tissue.
But for many reasons went mechanical.
Coumadin not a problem.
I home test..consistently in range.

 

[kentuckyed]

Good morning Tom.
AVR and aneurysm repair scheduled 4/14/15 just down the road in Louisville. Age 64. Good health (with 10 yr old steel hips). Otherwise healthy but enlarged heart.
Going with tissue valve and Dacron sleeve for aneurysm.
My surgeon says 20 yrs is doable with today's tissue valves and who knows what may be available 20 yrs down the road.
It is a personal choice that YOU have to be satisfied with but as stated above no choice is wrong.
Good Luck on your surgery.

 

[kentuckyed]

Good morning Tom.
AVR and aneurysm repair scheduled 4/14/15 just down the road in Louisville. Age 64. Good health (with 10 yr old steel hips). Otherwise healthy but enlarged heart.
Going with tissue valve and Dacron sleeve for aneurysm.
My surgeon says 20 yrs is doable with today's tissue valves and who knows what may be available 20 yrs down the road.
It is a personal choice that YOU have to be satisfied with but as stated above no choice is wrong.
Good Luck on your surgery.

 

[skeptic49]

My surgeon is convinced that by the time I might need a tissue valve replacement, that TAVR, even multiple TAVRs, will be the norm. Based upon his strong recommendation I went with tissue valve at age 66.

 

[Duffey]

5. Any real life experiences as to how long you or someone you know has had a tissue valve would be appreciated.
My real life experience is that I had a tissue valve implanted at the age of 53, and I will hit the 10 year mark in early June. No problems so far. I had to have my tonsils removed last November so they could be biopsied for cancer. I was very relieved that I had a tissue valve. The surgery would have been much more problematic if dealing with anticoagulants.

 

[Indy Tom]

Thank you Thank you Thank you. For what it's worth, Cardiologist told me that within the past few days USA has approved INR levels of 1.5-2 for Onyx mechanical valves. Down from around 2.5 I think.
Does that "improve" the use of Coumadin - making it less troublesome?

 

[scott.eitman]

I'm sure this discussion is just getting started. It is always a good hot subject.

I received a Homograft in 1998 and had that replaced 12 years later with a mechanical valve. I hate the mechanical valve as it thumps in my chest day and night. Yes, I feel it, not all day every day, but enough of the time. However, I love the valve as I am reasonably certain I will never have to have my chest opened up again because of it. The real problem with a mechanical valve is that you cannot play hide and seek with children as they can hear it and know where you are.

In 2010, there was little talk of the Trans-catheter VR (TAVR). If there had been, I may have picked a prosthetic valve instead. Now with that said, today, you would have to be in pretty bad shape to be eligible for TAVR, but I hope that they will someday be doing TAVR for all patients.

As for coumadin, I have found it to not be that big of a deal...yet. I am lucky that I live about 1.5 miles from my coumadin clinic and it is on my way to work...and they see me at 7:45am. Food is not a big deal, however consistency in what amounts of vitamin K is. We should medicate for the amount we eat, not eat based on medication.

 

[pellicle]

Hi

Does that "improve" the use of Coumadin - making it less troublesome?

well personally I don't find it troublesome, but it just could be that it takes some of the concerns out of going under. As you may have seen my graph of INR there is some variation and there is a reasonably wide region where being within poses little trouble. This is last years data:

and you can see from that there was a few ups and downs (perhaps contributed to by me altering my dose a bit attempting to control it) none the less you can see that there is some natural variation. As long as one is under 4 there seems to be little danger and so it would seem that if you identified a dose which kept you within that range then you would be fine. I guess it all comes down to "how much do you want to be involved".

On my blog post here (http://cjeastwd.blogspot.com/2014/05...ocks-dose.html) I identified that my metabolism variations were such that if I took 7mg that I'd be no higher than 3.5 and no lower than 1.8 if I just did nothing. Of course those were my 'extreme ranges' and most of the time I'd be hovering around 2.5 ... so in that sense it could make it less troublesome in that you'd just need to check now and then.

up to you however, but it sure gives some "fudge factor" safety on being under 2 and not worrying about it.