Best mechanical valve?

[tjay]

I'm 54 who's having AVR with root replacement (Bentall procedure) this summer. As the title suggests, I'm leaning on mechanical (although I'm open to suggestions and convincing otherwise). For example, my cardiologist was preferring tissue with future TAVR(s) since he thinks risks of internal bleeding (e.g. in head causing stroke) with coumadin increases at the age of 70-80yrs, not to mention external bleeds/cuts. Nonetheless, I'm still leaning on mechanical, thinking I may get away with 1 OHS in this lifetime.

Questions:
1) Which valve is the best among mechanical valves? If there's such a thing.

2) I'm very active physically, and plan on returning/continuing after AVR. Is a particular mechanical valve best for running, lifting weights, or all around abuse (if you plan on having serious physical/sports use of the body)?

3) Valve size: Is wider better (e.g. more blood pumped every beat and hence more cardiac output and hence better athletic/running performance)? Sorry about the stupid question.
I guess it probably depends on one's anatomy, or the size of the cavity (root perhaps) but I thought I would ask considering I'll be getting root and ascending aorta replaced (Bentall procedure), and I hear the valve will come with the aortic root/graft.

4) Low platelet count: My platelet count has always been low (~100). Am I risking by selecting mechanical (thinking it would enhance the risk of bleeding even further)? Conversely, will I need less coumadin? I also take lot of natural herbs (ginger, garlic, cayenne pepper) which are known to thin blood, can I continue those herbs thereafter, and would it require less dose of coumadin?
I guess what I'm really asking is that if I can take natural supplements and foods which naturally thin blood, and hence would require lesser dose of coumadin with mechanical valves. And if that's helpful in any way, since I will gladly do anything like that.

Thank you much.

PS: Did anyone store their own blood before surgery, in case it's needed during operation/post-op??

 

[pellicle]

Hi

I'm 54 who's having AVR with root replacement (Bentall procedure) this summer. As the title suggests, I'm leaning on mechanical

a reasonable proposition, but if you live in India you'll be fighting against the most ignorant bureaucratic petty Stalin's I've ever encountered for management of your INR.

however the alternative is a likely reoperation at your age ... I'd go mech (heck, I did, but then I was 48 and had already had two OHS before)

For example, my cardiologist was preferring tissue with future TAVR(s) since he thinks risks of internal bleeding (e.g. in head causing stroke) with coumadin increases at the age of 70-80yrs,

that's not as illogical as it sounds, but TBH if you control your INR properly its unlikely to be an issue ... unless you do some of the stupid things I see in India involving trains on TicTok (in which case warfarin won't be the deciding issue).

not to mention external bleeds/cuts.

since about 1960 we've had methods of controlling bleeds, but to be honest if you keep your INR under control it won't be an issue.

Nonetheless, I'm still leaning on mechanical, thinking I may get away with 1 OHS in this lifetime.

reasonable

Questions:
1) Which valve is the best among mechanical valves? If there's such a thing.

St Jude ... my reasoning is here:
https://www.valvereplacement.org/threads/aortic-valve-choices.887840/page-2#post-902334

read the table carefully (better than any terms and conditions or contract you've ever signed) and look for which valves meet their own claims

Now, look also at the fact that every other valve is basically a copy of the St Jude.

2) I'm very active physically, and plan on returning/continuing after AVR. Is a particular mechanical valve best for running, lifting weights, or all around abuse (if you plan on having serious physical/sports use of the body)?

don't abuse yourself and be aware of your age ... listen to your body and don't try to pretend you are what you aren't. We (should) exersize for health and fitness, I've noticed too many do it for "bulking up" and other vanity or sporting pursuits.

3) Valve size: Is wider better (e.g. more blood pumped every beat and hence more cardiac output and hence better athletic/running performance)? Sorry about the stupid question.

slightly larger than the size you have is always the go, but your surgeon will determine that.

4) Low platelet count: My platelet count has always been low (~100). Am I risking by selecting mechanical (thinking it would enhance the risk of bleeding even further)?

not as I understand it, but you may wish to discuss the use of aspirin (which is antiplatelet) but you will of course need warfarin

Conversely, will I need less coumadin?

no, the amount of warfarin has fully nothing to do with platelets, its about thrombin ...

I also take lot of natural herbs (ginger, garlic, cayenne pepper) which are known to thin blood, can I continue those herbs thereafter, and would it require less dose of coumadin?

no ... and ALWAYS be guided by your INR.

I guess what I'm really asking is that if I can take natural supplements and foods which naturally thin blood,

mostly its not of any measurable effect, like most of this its only "believers" who think this way. Most of medicine dismisses it for what it is. My background is biochemistry and so I really like this guys approach (he's a PhD candidate, poor bastard)



if you follow that to the end and see that there is an "exception" my advice is TO NOT DO THAT. Really you want medicine or you want witchdoctors ... but you can't do both. So if the magnetic attraction to Tumeric is "blood thinning" then baby, you've got it in spades with warfarin. Don't double up

PS: Did anyone store their own blood before surgery, in case it's needed during operation/post-op??

haven't heard of that since stories of things in the pre 1960's but then I live in Australia (which is just a penal colony after all).

HTH

 

[nobog]

3) Valve size: Is wider better (e.g. more blood pumped every beat and hence more cardiac output and hence better athletic/running performance)? Sorry about the stupid question.

By "wider" you mean larger diameter. In general, the size of the valve does not affect the cardiac output - the difference is that in a smaller size valve the fluid velocity through the valve will be greater. Too small and it becomes a problem as the resistance to flow becomes a problem and that is called pressure drop or pressure gradient, this is usually measure in mmHg but your surgeon will try to put in the largest valve possible.

Personal opinion, don't worry so much about the valve size, I would sacrifice a valve size to get a nice sized cuff - this allow the surgeon much more room for error and helps prevent paravalvular leakage (leakage through the cuff/tissue interface).

 

[dick0236]

IMO, if you want a "probable" one and done surgery get a mechanical valve. If you keep your INR within a reasonable range (such as 2-3 or 2.5-3.5) internal bleeding should not be an issue.......and external bleeding is treatable........unless you cut a leg off and then all bets are off.

I still have the mechanical valve that was implanted in 1967 when I was 31 years old and have been on Warfarin since that time. My only issue (stroke) came in the mid-1970s......before the INR system was introduced.

I have never had a serious bleed (internal or external) that was not controlled by first aid.....and/or a few stitches. As a matter of fact, I fell earlier this week and it took four stitches to close the head wound. My mechanical valve has allowed me to grow old(88) and prone to suffer old age medical issues (falls, etc.)

If I had to go thru this "all over again" at a younger age, I would go with a mechanical valve .

 

[vitdoc]

The two most competitive mechanical valves used in the US are the St. Jude and the On-X. Probably they are both very similar. On-X has been pushing for lower INR as a selling point for their valves. St. Jude has not done as far as I know, similar studies so does not recommend very low INR levels. At this site there has been significant discussion about this with the preponderance of feeling that the low INR might predispose one to have a higher incidence of stroke and a lower incidence of bleeding. You take your choice.

To me the interesting issue that you have is the low platelet count. At 100,000 you still usually have pretty normal coagulation studies. (primarily bleeding time) But if your platelet count were to drop in the future say to 50,000 than bleeding from a low platelet count becomes more likely. So being on warfarin might be more problematic if that were to occur. Nobody can predict the future and your platelet count could be stable or not. The only fairly predicable forecast for you at your age is that you will likely need another procedure of some kind with a non mechanical valve. TAVR might take you to the finish line or it may not. No perfect solution.

When I had my second surgery in 1983 I collected two units of blood for possible transfusion after surgery. I did not want to risk getting a blood born disease such as hepatitis. AIDS was just starting and was just being recognized at that time. I lost blood with the surgery and should have been transfused back but the surgeon I think wanted to pad his statistics on doing surgery without needing transfusions. So it took me a few months for my body to bring back my blood count naturally. Currently blood is checked for a variety of potential contaminates such as various types of hepatitis and AIDS. But if you want to be as certain as possible that you won't get something from the blood, you could have a few units taken and be used if needed.

 

[Protimenow]

IIRC, in 1991 when I got my St. Jude valve in the aortic position, I did bank a liter of blood pre-op.

 

[tjay]

I really appreciate you all for responding. I learnt so much from each response.

Pellicle, I'm in California, USA, not in India. I will be watching the video on mechanical valve you sent. Watched the other one on Curcumin, I get your point ... Now, the chart you sent, there are 2 St Jude valves, you're referring to the SJR (St Jude Medical Reagent) valve, correct? There's so much good info in your message. You completely explained how INR works, irrespective of any supplement intake, and has no relation to platelets.

nobog, Thanks for explaining where to focus (i.e. cuff) rather than the absolute valve size/diameter, and the fluidics.

dick0236, your success story is truly inspirational. I hope I live anywhere close to that age, and so does my new upcoming valve

vitdoc, my platelet has been fairly consistent thus far (~100-110) for the last 2 decades I became aware, and primary physician thinks that it's low because of my bad aortic valve itself (it chops down the platelets as blood passes through the valve or something like that)... Does it mean, it would improve after the new valve, who knows... And if On-X has lor INR (i.e. requires less coumadin?) but still "might predispose one to have a higher incidence of stroke". I'll search and read pertaining information on this platform.

Protimenow/vitdoc, another reason I'm thinking of banking my blood is to ensure they would have my blood type. I'm O-ve. I'm over reading into it too much I guess. Blood banks will have any types if needed. I read in one of the books on OHS, but will ask my surgeon too.

Thank you all. I'm sure I'll have more questions. Now I know, I would get some useful information and advice here anytime

 

[pellicle]

Hi

glad anything was useful however:

You completely explained how INR works, irrespective of any supplement intake, and has no relation to platelets.

I think I've scratched the surface on 1% of it ... but in the main all you need to know is to take your pills, don't get them out of the bottle (so use a pill box) because missing and double dosing are the biggest reasons why your INR will be all over the place.

If you are managing your own INR then there's even more to learn, but for now avoid grapefruit and maybe cranberry (it varies).

Its a good starter to just know that being organised is important.

Best Wishes

 

[tom in MO]

I asked by surgeon and was told there was no need to bank a pint of blood for my AVR. Ask your surgeon that question. They will know.

I eat what I want but don't binge. Per garlic, cayenne pepper and ginger, no problem. Dose the diet, don't diet the dose

My cardio wants me to tell them if I decide to routinely take an over the counter treatment or get prescribed a new medication. Their nurse calls me back to tell me if it will effect my INR. Usually "no problem" but sometimes I'm told to check my INR a little bit more often to see if there is an impact.

The non-therapeutic effect of warfarin that I dislike the most is the inability to take arthritis drugs such as NSAIDs due to their prevalence to cause internal bleeding. The second most annoying effect of warfarin is needing to stop warfarin for some surgical procedure. However, I've done that 4 times w/o any problem.

 

[carolinemc]

I asked by surgeon and was told there was no need to bank a pint of blood for my AVR. Ask your surgeon that question. They will know.

I eat what I want but don't binge. Per garlic, cayenne pepper and ginger, no problem. Dose the diet, don't diet the dose

My cardio wants me to tell them if I decide to routinely take an over the counter treatment or get prescribed a new medication. Their nurse calls me back to tell me if it will effect my INR. Usually "no problem" but sometimes I'm told to check my INR a little bit more often to see if there is an impact.

The non-therapeutic effect of warfarin that I dislike the most is the inability to take arthritis drugs such as NSAIDs due to their prevalence to cause internal bleeding. The second most annoying effect of warfarin is needing to stop warfarin for some surgical procedure. However, I've done that 4 times w/o any problem.

I am able to take NSAIDS. But you have be monitored more carefully when you are on them on a daily basis. I can only take Tylenol and only when there is pain. I have to talk to my doctor soon about the neuropathy pain. Can't just take anything. Yuck. Keep hanging in there.

 

[tommyboy14]

@tjay

There is four major valve manufacturers. They are all the same, but also all slightly different.

1) St Jude. This is the original bileaflet valve model, which all current ones are based on. This valve has been around since 1979, so has by far the longest history in studies. There are many people on his board which have had their St Jude for over 30 years.

2) ATS or now Medtronic open-pivot. This is similar to the St Jude. However, there are some studies which suggest that it is quieter than St Jude.
https://www.annalsthoracicsurgery.org/article/S0003-4975(99)01302-8/fulltext
There is also some evidence that this valve allows for low intensity INR with a target of 2
https://academic.oup.com/icvts/article/24/6/862/3060336?login=false

3) On-X valve. This is the one with the most active marketing department. It is the only one approved for INR target at 1.8, but this approval was done on a study that was very dodgy. The clinical performance of this valve if the same as St Jude: https://pubmed.ncbi.nlm.nih.gov/36590733/
But this valve also has something called Panus protection. This means that if your body decides to grow on your valve, this valve has a feature to prevent that from happening. The risks of Panus are low, but it can happen nevertheless.

4) Carbomedics. The clinical performance is the same as St Jude, but apparently some surgeons find it easier to fit this valve in patients with tricky anatomy.

What is the conclusion: all these valves are broadly the same. The best valve is the one your surgeon is comfortable with and that best fits your anatomy. So state your preference to the surgeon, but let him decide.

 

[nobog]

What is the conclusion: all these valves are broadly the same.

"broadly" in that they are all bi-leaflet valves - otherwise they are significantly different - the pivot area, the opening angle, overall height, leaflet stability, (claimed) carbon composition, & available sizes.

 

[Unicusp]

I am able to take NSAIDS. But you have be monitored more carefully when you are on them on a daily basis. I can only take Tylenol and only when there is pain. I have to talk to my doctor soon about the neuropathy pain. Can't just take anything. Yuck. Keep hanging in there.

How is one "monitored" safely while on NSAIDS? I would think that the only sign is internal bleeding which if it happens, it's too late. I'm curious because I'd much prefer Naproxen if it were safe to use. Thx.

 

[tommyboy14]

@nobog

My point was that the clinical results are the same.

Randomised control trial says ON-X and St Jude show that clinical results are the same
https://pubmed.ncbi.nlm.nih.gov/36590733/

Randomised control trial showing carbomedics, ATS and St Jude showing the same clinical results
https://www.ahajournals.org/doi/10.1161/circ.102.suppl_3.III-1

St Jude and Carbomedics randomised control trial shows the same clinical outcomes
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1524677/

 

[pellicle]

Randomised control trial says ON-X and St Jude show that clinical results are the same
https://pubmed.ncbi.nlm.nih.gov/36590733/

The occurrence of valve thrombosis was also related to a younger population possibly due to anticoagulation compliance based on record review.​

a notworthy point backing up what I bang on about "all the time"

 

[tjay]

Thank you all again.
Great, useful info

 

[carolinemc]

How is one "monitored" safely while on NSAIDS? I would think that the only sign is internal bleeding which if it happens, it's too late. I'm curious because I'd much prefer Naproxen if it were safe to use. Thx.

By going to the lab when the doctor orders it. And it will show on the protime blood draw. And Naproxen can cause bad bleeds. There is nothing we can take that will be safer. But I have been a heart patient since birth and since 2001, have used warfarin and one time did use naproxen, but no longer. And you can hurt yourself where you can bleed out from a knife cut on the finger. Takes forever to stop the bleed.