Best valve for Mitral positon?

[ALCapshaw2]

Well it seems that I will have the 'opportunity' to have another OHS (Strike THREE or Third Time is the Charm?).

My mitral valve has shown a linear negative progression in effective valve area over the last 2 years. The surgeon I saw for a second opinion actually reviewed the echo tapes and told me that my 'REAL PROBLEM' was that the leaflets were so stiff that they barely moved. His conclusion was that a Valvuloplasty would NOT provide any benefit and that my best option for an improved quality of life is to replace the Mitral Valve and perhaps have a MAZE procedure at the same time to eliminate my A-Fib and PAC/PVC episodes (which have now strangely gone into remission...something is changing...who knows what).

SO, my fellow and sage VR experts, here is your chance to chime in on your recommendation for a Mitral Valve Replacement. I already have a St. Jude Mechanical Valve in the Aortic position and am on Coumadin, BUT, I keep reading that a mechanical valve in the Mitral position is more prone to clot creation, hence the dilema.

The 'call-in' line is OPEN.

'AL' (Bypass X3 and AVR with Radiation Damage)

 

[PapaHappyStar]

Well it seems that I will have the 'opportunity' to have another OHS (Strike THREE or Third Time is the Charm?).

My mitral valve has shown a linear negative progression in effective valve area over the last 2 years. The surgeon I saw for a second opinion actually reviewed the echo tapes and told me that my 'REAL PROBLEM' was that the leaflets were so stiff that they barely moved. His conclusion was that a Valvuloplasty would NOT provide any benefit and that my best option for an improved quality of life is to replace the Mitral Valve and perhaps have a MAZE procedure at the same time to eliminate my A-Fib and PAC/PVC episodes (which have now strangely gone into remission...something is changing...who knows what).

SO, my fellow and sage VR experts, here is your chance to chime in on your recommendation for a Mitral Valve Replacement. I already have a St. Jude Mechanical Valve in the Aortic position and am on Coumadin, BUT, I keep reading that a mechanical valve in the Mitral position is more prone to clot creation, hence the dilema.

The 'call-in' line is OPEN.

'AL' (Bypass X3 and AVR with Radiation Damage)

Al, Sorry to hear the bad news.
The problem in the mitral position as far as I understand is: mechanical valves seem to produce more clots and tissue valves dont last as long as in the aortic position.
Dont know if it makes the magnitude of the choice harder -- perhaps take the mechanical and up the coumadin?
What do your doctors suggest and what are their reasons?
Regards,
Burair

 

[Bryan B]

Al,

You asked for it...so here goes. Given that this is your 3rd OHS I would go with the mechanical in hopes of reducing the odds of requiring a 4th. I too would be concerned about the increased risk of clotting, but I believe we have several members with mechanical mitral valves doing well today.

I'm sorry to hear you have to go through another surgery, but I have faith that you will come though it fine.

 

[Nancy]

Hi Al-

Well, I'm so sorry to hear that OHS is on the horizon. As you probably know, Joe has two mechanicals, aortic and mitral. The only problem that can be attributed to the two mechanicals in his case is hemolysis. And he takes Procrit for that. But all of his doctors seem to agree that it is caused by his very old Bjork-Shiley valve. The hemodynamics of that valve are just not up to today's level.

I seriously don't think he'd ever want to have another OHS surgery. It just takes too much out of you when multiple past surgeries are in the history.

His surgeon said, "you're on Coumadin anyway, so go with the St. Jude".

How does your surgeon feel about mixing tissue with mechanical when the tissue would be in the mitral position. I guess engineers could have fun with that one, different stresses, pressures, cavitations etc., etc.

Tough thing to face.

 

[geebee]

Al,
I am sorry also to hear of your pending surgery. I have a St. Jude in the mitral position that has been implanted for almost 11 years. Prior to that I had a Bjork-Shiley (one of the infamous recalled ones) that was in for almost 14 years.
I have had problems with tiny TIAs (never any permanent damage that we could find - I've always been a bit crazy ) in the past. The doctors can't determine the cause but they say it COULD be the result of a mechanical in the mitral position because it is more prone to clotting. However, they could not say for sure as some folks don't have such problems.
The INR range is usually a bit higher for mitral valves so you would probably have to up your coumadin. I am also on low dose aspirin which has eliminated the TIAs (knock on wood).
Just wanted to give you all viewpoints. I would go with a St. Jude again if I ever needed another surgery (unless I was old enough to consider a tissue).
Best of luck in your research.

 

[Emma]

Hi Al,
Sorry to hear you need more surgery! I asked about this once before when Chloe had had her mechanical mitral valve for a while. We were told there is a slightly increased chance of clots in the mitral position but that is why they raise the INR range a bit more, to take that into account. Chloe has now had her mitral ON-X for almost 4 years and it's ticking strongly away still (touching wood!). Strange, but i wasn't aware there was a choice between tissue and mechanical in the mitral position - we were told it was mechanical or nothing - no choice, although having said that, (and with hindsight) I'm sure i would have gone for mechanical because they last so much longer and seem to be very effective (especially if you're on warfarin already so starting on that won't be an issue!).
Not sure i was any help - but good luck!
Emma
xxx

 

[ALCapshaw2]

Thanks to all for your inputs. As usual, you have helped me put this all in perspective. Pretty much as I expected, namely mechanical. I 'think' that's what the second opinion surgeon had in mind since I'm already on Coumadin. We glossed over that to place the emphasis on the nature of the problem and timing for surgery which he said will be determined by when I decide my quality of life has reached an unacceptable level (or slightly before).

My AVR surgeon told me in a previous meeting that when my effective area reaches 0.1 sq cm that I should be "highly symptomatic". If the linear progression continues at the same rate, that should come sometime later this year.

I REALLY like and am impressed with this second surgeon (Dr. McGiffin at UAB in Birmingham, AL.). His diagnosis seems to be the 'best fit' between cause and effect and he took the time to explain how he arrived at that conclusion.

These meetings took place in December and I'm now 'getting my ducks in a row' to prepare for the inevitable procedure. This includes checking out who will be willing and able to assist with follow-up care once I'm back home and getting other medical concerns taken care of beforehand (dentalwork, possible upper endoscopy and
colonoscopy, and that pesky ingrown toenail).

I'll tackle the MAZE procedure recovery in a later post. The 'info sheet' makes that process sound even more rocky than what we all know to expect for 'normal' valve replacement! I may need to take an appartment near the hospital for followup care for a few months.

I want to thank Emma for reminding me about the ON-X valve. I guess I had always thought of that one in terms of aortic replacement. That is an interesting idea worth discussing with the surgeon for it's lower 'turbulence' and possible lower level of clot formation.

Well, I guess I'm now a both a VR graduate and new member of the 'virtual waiting room' at the same time. VR.com is the BEST!

'AL'

 

[gadgetman]

Al,

In my opinion (based on ONE operation), Dr. McGiffin is the best. Just saw him today (see post in Post Op). He is one nice fellow. He takes the time to explain what is going on and gives you all the details you want. UAB was the best.

Add to that is I'm sorry you've got to face this again. Dr. McGiffin explained the pros and cons of my valve choices and I had decided on the mechanical. I was fortunate that he was able to repair the one I was born with. Of course, my X-Ray does look strange. I've got 6 wires holding my sternum together, this wire leading from my heart back up to my AICD, which looks like a small transistor radio. I am also able to see the ring they used around my valve. Busy place in there.

Hope everything goes well on your second walk and you know our prayers and thoughts will be with you throughout it all. Best of luck.

vr.com rocks!!!!!!!

Danny

 

[SHerrin Hutt]

Sorry to hear you have another surgery but there alot of us that have two or more and our life is better for it. Not to mean that it is not a stressful thing to have to deal with. I wish you are the luck.

 

[Johnny Stephens]

Sorry to hear that you're up against this again, Al. I can see that I haven't been around here enough lately

Your concerns about the mechanical mitral valve and clotting seem to mesh well with what I have heard from my doctors and their teams. My team wants my INR range to be 3.0 - 4.0, with ideal being 3.5. The lower pressure and "washing" of the mitral valve seems to be the area of concern when dealing with this supposed higher incidence of clotting. So, while you're already up to speed on anticoagulation therapy, the number you have to manage to is higher, and frankly, you'll bleed and bruise more (mostly bruise).

Since our hearts have been irradiated for Hodgkin's, I'm left wondering what else may be lurking out there as a late effect from the radiation treatments. It's not a simple answer, but I still feel that even if my mechanicals don't "last forever," over the course of my life I will hopefully have had fewer operations. If my heart hadn't had irradiation thrown into the equation, reoperation would be much less of an issue.

The other obvious aspect of having 2 mechanicals is the sound - most times you would sound like a watch; "tick tick" instead of "tick". I have noticed that sometimes I can't hear the mitral because it closes so gently, but can still hear the aortic.

So at the risk of stumping for "what I have," if it were me, I'd go with mechanical.

Sorry I didn't see your post earlier - I'll be pulling for you whichever route you decide to take.

Johnny

 

[tobagotwo]

I can't believe you're going through all this, just to get a refresher course. You're so dedicated, Al...

I would agree that a mechanical mitral makes sense for you, something that you undoubtedly already realized at some level before you ever posted. You are adjusted to the lifestyle (which you must continue regardless), and already have a valve installed whose chief asset is extended service. Use of a tissue valve would compromise that value without apparent gain. The more recent studies seem to indicate that having more than one valve doesn't meaningfully increase the liability to fatal TE events. And irradiated heart tissue should be disturbed as infrequently as possible.

In the functioning of the mitral valve, the blood sticks around momentarily in the ventricle, where the outflow is, so there isn't as good a "flushing out" as happens at the aortic end. That temporary stasis is probably one of the factors that adds to clotting at the mitral site. The dynamics are different enough that the tilting-disk type of mechanical valve, considered less clot-free in the aortic position, posts results as good as the bileaflet type in the mitral position. (Okay, interesting, but probably useless information...)

As far as specific valves, the On-X you mentioned in a previous post has been getting good press lately. If you like what you've read, they have a mitral version: http://www.onxvalve.com/ (click on Valve Information, then on Specifications and Catalog, then page down past the aortic version). Or you could go for a set of St. Jude cardiac bookends. The On-X intrigues me the most, specifically due to possibly reduced clotting potential, but I'm not the one who'll have to wear it.

I wish you success and minimal downtime, my friend.

Very best wishes,

 

[Nancy]

Al-

If you do have to get an apartment for post surgical follow-up, I hope you are looking into computer hookup or have a laptop.

We'll all be there to help you through this.

 

[KathyH]

Al, Sorry to hear you will need a third OHS. heres my two cents. If it were me, I would look into the ON-X. Since so far it has not had a problem with clot formation and you are on coumadin anyway, I'd say the third time would be ther charm. It would be interesting to hear the hearbeat with two different mechanical valves. GoodLuck Al.
Kathy H

 

[Barry]

" I keep reading that a mechanical valve in the Mitral position is more prone to clot creation..."

Can you provide more info, links? I've got a vested interest in this because I've got a St. Jude's mechanical mitral valve. Had it for a couple of years, works OK I guess since I'm here to tell the story, but I'm thinking that if there's more clotting risks with a mitral mechanical I then should speak with my cardiologist about getting my Warfarin dose and INR up some.