Born-Again Valver

[pellicle]

As in, how long will a bio valve last in a 50 year old man who is getting valve replacement surgery without other underlying con

I guess you noticed that study duration is going down from 15 year follow ups to 5 years, while at the same time makers are claiming longer durations.

The information on SVD is available however and there are no radical new treatments to prevent it.

So I infer from that it's situation normal, and in the ten years I've been here I still see young people getting under ten years duration.

When I've pointed this out it's always the same answers from advocacy here; "those are last year's valves, we don't have data in the new secret sauce gluteradehyde treatments. This year's valves will last longer" (then they don't, rinse and repeat)

 

[pellicle]

Hey Dano

I hope that all goes well on the 7th as I believe it should

I am scheduled for ascending aortic aneurysm surgery and likely aortic valve replacement 2-7-22 (wow, that's just 4 days away), although my homograft continues to do its job 21 years after insertion

I dunno if 64 i I see your year of birth or not but if it then that's mine too (ahh, it is I see because the needed information wasn't in your bio it was on a "profile post"). Like you I got about 20 years from a homograft which was still functional and would probably have done another few years were it not for the 5.6cm aneurysm. But unlike you I had my homograft (almost) 10 years earlier at 28.

Unlike you my situation was that I'd already had a surgery at 10 years old to 'split the cusp" on my native bicuspid aortic valve. That functioned sufficiently to give me 10 good years and then a number of years of decline until I got my homograft.

So at that time I was facing my 3rd surgery (you are now facing your 2nd) and so that makes a difference. This means I was "one up" on surgery count.

I was advised (and I believe quite rightly) to take a mechanical because in the words of my surgeon: "good surgeons will not be lining up behind you to do your 4th"

That made sense to me (knowing what I already knew well about scar tissue, infections and what not). I think its fair to say that my childhood experiences had a strong influence on my doing biochemistry and microbiol as my Science Degree when I graduated school. It was not least to study and understand me but to try to learn about "will I pass this on to any children" (the answer was a probable yes).

So when I read this I feel vexed:

I do feel a bit defensive posting this here, given my own perception of a very strong lean towards mechanical on this site compared to what I recall from 20+ years ago.

I feel vexed about this point of being "a bit defensive" ... why is that?

I've been on this site a lot for around 10 years, I knew Ross personally (via online chats and emails, we never met of course because I was either in Australia or Finland) and have had many conversations with him and others about how toxic this site was in the past with many big fights between "the tribes" to the extent that older regulars here still have knee jerk reactions.

When I joined the site the primary sponsor was On-X valves and I would occasionally point out to rabid anti mech valve haters (yes, they were around) that before bashing mech valves as relentlessly as they were they should look up to the top banner and ask "will the sponsor feel an appropriate benefit from having their name associated with a site which was for quite a few years rabidly against mech. I was unsurprised when Hank lost that sponsorship.

In particular the most fierce arguments have come when advice for "pro tissue" people come from people who were over 60 at operation and being given to a poster who is under 50 (sometimes under 40). These people are projecting their situation and decision (or lack of it) onto a person who will then need another operation as a result of this.

Since then there has been an ongoing attack on anyone (usually me) who stands firm on their opinions, this varies from outright character assassination to hundreds of sly passive aggressive barbs over the years. Usually when arguments are demonstrated as not logical or misconceived they end in "there is no wrong choice" (so why ask) or "none of us are doctors here" (except some are).

Stepping back a bit from the past (which perhaps you missed) my view here has always been this set:

• if you're above a certain age there is no compelling reason to have a mechanical valve in the data (and the further above that age you are the less compelling it is)
• if you are not going to follow your ACT management properly then get any other valve because in the long run that will not harm you as much (from reoperation) as failure to comply with ACT will (from a stroke or an amputation)
• anyone under a certain age and who will comply with ACT then the case is very strong that (aneurysm being taken out of the equation) you will never need another surgery on that valve

If that makes me "biased" then I'll wear that shirt.

Stats suggest that the average age for AVR is over 65 and that greater than 75% of surgeries are bioprosthesis. This data fits what I see here and means that you and I (and a few others here) are data outliers.

That there are more "mech valver" participants here is also an expectable thing because unlike tissue valvers who go their merry way and fall nicely into the follow up for their next surgery, mech valvers need to manage INR and many are confronted by the biggest obstacle to that: the medical system in the USA.

Accordingly they come here seeking assistance and or to vent frustration and so their population is perhaps over represented (although I don't think that's the case). Being in the main younger patients they are perhaps more articulate and well researched (*younger means median age of 50 instead).

They (I) may make a case to anyone who asks about valve choice that the decision to discount mechanical is often based on misinformation, and if you are younger than 60 that the "Surgical Guidelines" would suggest that a younger patient should consider a mechanical first and only on informed choice pick a tissue prosthetic.

So (speaking for myself) I'm here to help with them seeing that actual information and not the misinformation, because sadly there are many myths and false preconceptions about ACT. People can either accept that information or reject it. I don't mind and I stand nothing to lose or gain from their decision.

But to (all but) accuse us of being tribal is pretty unwarranted IMO.

Best Wishes on the 7th

 

[paulk]

Paulk,
Welcome back! I too am born again here, after a hiatus of almost 20 years. I am scheduled for ascending aortic aneurysm surgery and likely aortic valve replacement 2-7-22 (wow, that's just 4 days away), although my homograft continues to do its job 21 years after insertion. From my own research, perhaps limited in comparison to others, and perhaps my hopefulness in the future unknown, along with family cancer risks that took my parents too young, I am going with the Inspiris Resilia valve, even though I am 3 weeks shy of 58. I do feel a bit defensive posting this here, given my own perception of a very strong lean towards mechanical on this site compared to what I recall from 20+ years ago. The other odd factor for me is that I have never really had any symptoms whatsoever from my condition and I feel pretty good now, so I have my own definition of what normalcy looks and feels like that may not fit others. And because of my own sense of normalcy, I left this site for a long time. My surgeon softly leaned towards the bioprosthetic valve, but entirely left the decision to me. In my opinion, there are convincing studies and videos that go both ways on this. All the best for you in whatever you decide.

Thanks, and I wish you a successful outcome! I've followed up with my surgeon regarding his recommendation, and have confidence in his reasoning, based on my history and my heart condition. His expectation for me is that the Inspiris Resilia will go for 20 years, and that I have no limitations regarding TAVR. That said, I understand the risks associated with lack of long-term data, and benefits of mechanical (he uses Carbomedics) so I'm still considering my options. It's been helpful to read the many good discussions here.

 

[Dano64]

Hey Dano

I hope that all goes well on the 7th as I believe it should



I dunno if 64 i I see your year of birth or not but if it then that's mine too (ahh, it is I see because the needed information wasn't in your bio it was on a "profile post"). Like you I got about 20 years from a homograft which was still functional and would probably have done another few years were it not for the 5.6cm aneurysm. But unlike you I had my homograft (almost) 10 years earlier at 28.

Unlike you my situation was that I'd already had a surgery at 10 years old to 'split the cusp" on my native bicuspid aortic valve. That functioned sufficiently to give me 10 good years and then a number of years of decline until I got my homograft.

So at that time I was facing my 3rd surgery (you are now facing your 2nd) and so that makes a difference. This means I was "one up" on surgery count.

I was advised (and I believe quite rightly) to take a mechanical because in the words of my surgeon: "good surgeons will not be lining up behind you to do your 4th"

That made sense to me (knowing what I already knew well about scar tissue, infections and what not). I think its fair to say that my childhood experiences had a strong influence on my doing biochemistry and microbiol as my Science Degree when I graduated school. It was not least to study and understand me but to try to learn about "will I pass this on to any children" (the answer was a probable yes).

So when I read this I feel vexed:


I feel vexed about this point of being "a bit defensive" ... why is that?

I've been on this site a lot for around 10 years, I knew Ross personally (via online chats and emails, we never met of course because I was either in Australia or Finland) and have had many conversations with him and others about how toxic this site was in the past with many big fights between "the tribes" to the extent that older regulars here still have knee jerk reactions.

When I joined the site the primary sponsor was On-X valves and I would occasionally point out to rabid anti mech valve haters (yes, they were around) that before bashing mech valves as relentlessly as they were they should look up to the top banner and ask "will the sponsor feel an appropriate benefit from having their name associated with a site which was for quite a few years rabidly against mech. I was unsurprised when Hank lost that sponsorship.

In particular the most fierce arguments have come when advice for "pro tissue" people come from people who were over 60 at operation and being given to a poster who is under 50 (sometimes under 40). These people are projecting their situation and decision (or lack of it) onto a person who will then need another operation as a result of this.

Since then there has been an ongoing attack on anyone (usually me) who stands firm on their opinions, this varies from outright character assassination to hundreds of sly passive aggressive barbs over the years. Usually when arguments are demonstrated as not logical or misconceived they end in "there is no wrong choice" (so why ask) or "none of us are doctors here" (except some are).

Stepping back a bit from the past (which perhaps you missed) my view here has always been this set:

• if you're above a certain age there is no compelling reason to have a mechanical valve in the data (and the further above that age you are the less compelling it is)
• if you are not going to follow your ACT management properly then get any other valve because in the long run that will not harm you as much (from reoperation) as failure to comply with ACT will (from a stroke or an amputation)
• anyone under a certain age and who will comply with ACT then the case is very strong that (aneurysm being taken out of the equation) you will never need another surgery on that valve

If that makes me "biased" then I'll wear that shirt.

Stats suggest that the average age for AVR is over 65 and that greater than 75% of surgeries are bioprosthesis. This data fits what I see here and means that you and I (and a few others here) are data outliers.

That there are more "mech valver" participants here is also an expectable thing because unlike tissue valvers who go their merry way and fall nicely into the follow up for their next surgery, mech valvers need to manage INR and many are confronted by the biggest obstacle to that: the medical system in the USA.

Accordingly they come here seeking assistance and or to vent frustration and so their population is perhaps over represented (although I don't think that's the case). Being in the main younger patients they are perhaps more articulate and well researched (*younger means median age of 50 instead).

They (I) may make a case to anyone who asks about valve choice that the decision to discount mechanical is often based on misinformation, and if you are younger than 60 that the "Surgical Guidelines" would suggest that a younger patient should consider a mechanical first and only on informed choice pick a tissue prosthetic.

So (speaking for myself) I'm here to help with them seeing that actual information and not the misinformation, because sadly there are many myths and false preconceptions about ACT. People can either accept that information or reject it. I don't mind and I stand nothing to lose or gain from their decision.

But to (all but) accuse us of being tribal is pretty unwarranted IMO.

Best Wishes on the 7th

Thanks Pellicle. I expect I would have a mechanical now too if I had your history. From an older and yet newer eye here, I don't disagree with you, but you do tend to come off a bit strong-handed in your opinions. And you are correct that my normal with the homograft did not keep me on this site. I was never informed in 2001 of the strong association of BAV and aneurysms developing. In fact, I first learned of my aneurysm just 3.5 years ago, so I was not informed for many years, but I am certainly glad that I, as a young 37-year-old, chose the homograft, as I enjoyed many good years that would have continued further but for the aneurysm. I was told then that 15-20 years was what was expected of homografts. I guess I would say that younger people who have BAV should study up on the risks of future aneurysms too when choosing a valve. I admittedly have missed many discussions here, so I can only go on some of the more recent ones. I mean no offense, but I have read both sides of the argument and my brain seems to keep me in the bioprosthesis lane. If a third surgery hits me too quickly, I expect my brain will change.

 

[pellicle]

don't disagree with you, but you do tend to come off a bit strong-handed in your opinions.

that could be as much about cultural differences (I'm Australian) and I have found that if one even replies to the contrary that some folks call that a fight.

I grew up doing debating and public speaking at school and if I have a point of view then I need to address it with evidence or abandon it. I am always willing to abandon a point of view which is not supportable.

That's what I call "reasonable"

anyway as mentioned my views are consistently stated as per my bullet points above.

I hope this doesn't sound "strong handed" its just I believe what I say or I don't say it.

For example

... I mean no offense, but I have read both sides of the argument and my brain seems to keep me in the bioprosthesis lane. If a third surgery hits me too quickly, I expect my brain will change.

I find the need to say you mean no offense sort of strange (well totally strange) because what is wrong with that (you stating your position)? (unless you are accusing me obliquely of not reading both sides of the argument, which I can address if you were and or wish).

Best wishes

 

[pellicle]

PS

but I am certainly glad that I, as a young 37-year-old, chose the homograft, as I enjoyed many good years that would have continued further but for the aneurysm.

I would agree with that and if you actually knew my posts you'd find:

1. I've said the same
2. I've said to younger people (early 30's to 50's) that exactly because of aneurysm there is absolutely nothing wrong with picking a tissue, or a cryo preserved homograft to "kick the can down the road" and enjoy some "freedom"
3. that when I had a homograft the monitoring and understanding of warfarin management was quite poor compared to now.

I feel people are very quick to make a judgement about me based on one or two posts that may not have been as sweetly phrased as it could be.

I personally have always had the views that I would rather be honest and forthright than obsequious and reserved at telling the truth. I'm often told that "honey attracts more flies than vinegar" and to that I always respond that "bullshlt attracts even more flies".

I don't bullshit and I (as you can see) genuinely engage with discussion. More than most do I find. Further I actually go out of my way to give up my time assisting those I can, both with phone calls to support them and actual management guidance with INR management. How many of the "pro tissue" crowd do more than say "prayers for you"

I'm a pragmatist and to be honest I've been through a LOT and seen a LOT. If anyone doesn't value that its really no skin off my nose.

Best Wishes

 

[Superman]

PS

I would agree with that and if you actually knew my posts you'd find:

1. I've said the same
2. I've said to younger people (early 30's to 50's) that exactly because of aneurysm there is absolutely nothing wrong with picking a tissue, or a cryo preserved homograft to "kick the can down the road" and enjoy some "freedom"
3. that when I had a homograft the monitoring and understanding of warfarin management was quite poor compared to now.

I feel people are very quick to make a judgement about me based on one or two posts that may not have been as sweetly phrased as it could be.

I personally have always had the views that I would rather be honest and forthright than obsequious and reserved at telling the truth. I'm often told that "honey attracts more flies than vinegar" and to that I always respond that "bullshlt attracts even more flies".

I don't bullshit and I (as you can see) genuinely engage with discussion. More than most do I find. Further I actually go out of my way to give up my time assisting those I can, both with phone calls to support them and actual management guidance with INR management. How many of the "pro tissue" crowd do more than say "prayers for you"

I'm a pragmatist and to be honest I've been through a LOT and seen a LOT. If anyone doesn't value that its really no skin off my nose.

Best Wishes

You don’t have to yell.

 

[pellicle]

You don’t have to yell.

yeah ... sorry about that, was too lazy to hit bold.

 

[pellicle]

once upon a time there was a philosopher whom I have great respect for his teachings. He taught about a few things like forgiveness, not judging, and a few other things which I do try to adhere to. I don't expect others to know of that philosophy or abide by it (even if they declare that they are members of such a group of students of that philosopher).

Like many of that period he never wrote down his own works, but those who he taught did (Epictetus and Socrates, for instance, of the Greek school did not write their teachings but their students did) and we must trust that they wrote honestly. Those teachings are still available in various publications now.

My bedside manner may be considered abrasive by some, but I reckon you've all met more abrasive medical practitioners or surgeons. If I must appeal to *"smiles and soap" then probably I really don't have anything to offer

(*reference:

"'You may seek it with thimbles—and seek it with care;
You may hunt it with forks and hope;
You may threaten its life with a railway-share;
You may charm it with smiles and soap—'")

 

[tom in MO]

Thanks Pellicle. I expect I would have a mechanical now too if I had your history. From an older and yet newer eye here, I don't disagree with you, but you do tend to come off a bit strong-handed in your opinions. And you are correct that my normal with the homograft did not keep me on this site. I was never informed in 2001 of the strong association of BAV and aneurysms developing. In fact, I first learned of my aneurysm just 3.5 years ago, so I was not informed for many years, but I am certainly glad that I, as a young 37-year-old, chose the homograft, as I enjoyed many good years that would have continued further but for the aneurysm. I was told then that 15-20 years was what was expected of homografts. I guess I would say that younger people who have BAV should study up on the risks of future aneurysms too when choosing a valve. I admittedly have missed many discussions here, so I can only go on some of the more recent ones. I mean no offense, but I have read both sides of the argument and my brain seems to keep me in the bioprosthesis lane. If a third surgery hits me too quickly, I expect my brain will change.

You are correct in that there is a loud tribe of mechanical valvers on this forum. I've been here 10 years and 10 years ago there was a softer gentler tone than in the last 5 years or so. Too many people who know the "truth" and like playing internet doctors

You have obviously shown that a young person can get 20 years out of a bio-valve. Most mechanical valve boosters ignore the problems with warfarin, such as more risk with surgery, removal of a lot of arthritis therapies, restrictions on surgery (can't get two knees replaced at the same time) and even the most in-your-face problem, traumatic injury. I'm a mechanical valver and don't regret my choice, but find the restrictions limiting as I seek treatment for comorbidities.

 

[Chuck C]

You have obviously shown that a young person can get 20 years out of a bio-valve.

He had a homograft. This is very different than a standard bioprosthetic. Homografts are from human donors and have a significantly longer valve life expectancy for young people and 15-20+ years is not at all uncommon.
Typical bioprosthetic valves are made from bovine or porcine tissue. 20 years from one of these non-homograft bio-valves is very rare for young people.

 

[pellicle]

Homografts are from human donors and have a significantly longer valve life expectancy for young people and 15-20+ years is not at all uncommon.

This is a good point Chuck and I was going to mention it in my discussion with @Dano64 in adding more detail about his case (but my post was already getting long and he already nolonger needed this data).

This is the study published by the hospital (single institution) which did my homograft, mine was a cryo-preserved homograft but it seems that antibiotic solution preservation was also successful. Note the duration of the follow up is nearly 30 years 99% complete ... in all probability one will never see the likes of this again

BACKGROUND AND AIM OF THE STUDY: The study aim was to elucidate the advantages and limitations of the homograft aortic valve for aortic valve replacement over a 29-year period.​

​

METHODS: Between December 1969 and December 1998, 1,022 patients (males 65%; median age 49 years; range: 1-80 years) received either a subcoronary (n = 635), an intraluminal cylinder (n = 35), or a full root replacement (n = 352). There was a unique result of a 99.3% complete follow up at the end of this 29-year experience. Between 1969 and 1975, homografts were antibiotic-sterilized and 4 degrees C stored (124 grafts); thereafter, all homografts were cryopreserved under a rigid protocol with only minor variations over the subsequent 23 years. Concomitant surgery (25%) was primarily coronary artery bypass grafting (CABG; n = 110) and mitral valve surgery (n = 55). The most common risk factor was acute (active) endocarditis (n = 92; 9%), and patients were in NYHA class II (n = 515), III (n = 256), IV (n = 112) or V (n = 7).​

​

...​

​

Freedom from reoperation for structural deterioration was very patient age-dependent. ​

​

For all cryopreserved valves, at 15 years, the freedom was ​

• 47% (0-20-year-old patients at operation),
  • 85% (21-40 years),
  • 81% (41-60 years) and
  • 94% (> 60 years).

​

Root replacement versus subcoronary implantation​

reduced the technical causes for reoperation and re- replacement (p =​

0.0098).​

​

CONCLUSION: This largest, longest and most complete follow up demonstrates the excellent advantages of the homograft aortic valve for the treatment of acute endocarditis and for use in the 20+ year-old patient. However, young patients (< or = 20 years) experienced only a 47% freedom from reoperation from structural degeneration at 10 years such that alternative valve devices are indicated in this age group. The overall position of the homograft in relationship to other devices is presented.​

That anyone would confuse the written word "homograft" with a bioprosthetic is in itself a good indication for why people would say to not trust what you read on a forum filled with just people (who aren't doctors or aren't scientists). However the benefit of a large public forum is that you will also encounter people who are doctors, surgeons or scientists and they can contribute to clear up misapprehensions or misinformation.

To @Dano64 , I say that whoever advised you to have a homograft at your age was on the ball and it was good advice. I hope you get equal life from the valve you choose next.

Best Wishes

 

[Dano64]

Pellicle, you post fine examples of things I have missed in my years away. I appreciate your posts in response to me. I wish homografts were readily available and easy to use. I have grown to love mine and I will certainly miss it. Cheers!

 

[pellicle]

Hi Dano

thanks for the kind words.

I wish homografts were readily available and easy to use.

as I see it there are a few primary issues with why homograft is not more main stream:

1. availablity, someone has to die and then that person has to have an order allowing organ harvesting and then the hospital has to be equipped to properly excise that and not damage it
2. the ideal comes from appropriate tissue typing
3. surgeons need to specialise in that as its much more delicate than regular bio or mech valves

I would also wonder how much problem there is with exclusion criteria for being a donor (as some diseases could potentially be transferred by the tissue {hepatitis comes to mind immediately}).

Either way we were both fortunate enough to have the opportunity to get that at the right time in our lives.

I have mentioned also that a good friend that I grew up with recently (last year) reached out to me to ask about valves. He too was a 1964 kiddo and was in need of a valve and an aortic graft.

He chose a bio-prosthesis and holds hope that when his starts to fail that a valve in valve TAVI will suffice. Like you his situation is different to mine because I had my AVR in 2011 and my valve has now done already 10 years service before his was implanted. Then there is the issue that TAVR was not even remotely common place in Australia for low risk patients ten years ago.

So its also about the technology available at the time (as well as ones personal risk evaluation preferences too ;-)

Best Wishes

 

[TomM]

I had a homograft AVR at 17 years old. It lasted 5 years. I choose another homograft AVR at 22 that lasted 16 years. It corresponds somewhat I think with the data in @pellicle's post. Without any proof, only my own intuition, I put the homograft I had at 17 lasting 5 years down to teenage (and early 20's) strife with life in that I think being contented was good for my heart whereas not being contented was not. Again to emphasise, I've no medical proof of this.

 

[cooperman]

I had the Ross procedure at age 21 in 2001. I was able to go 20 years with the autograft and homograft, but both were deteriorated when I had my second surgery a year ago. This time I have another homograft for the pulomonary valve and the On-X for my aortic valve. I wish it made sense for tissue valves only again, but I did not want to risk having another surgery in 5-10 years with a bioprosthetic aortic valve. I do not expect to have to be opened up again, assuming the pulmonary homograft lasts 20 years again. TAVR should resolve any issues with it.

Warfarin therapy has certainly changed my life some, but I had a pretty adventurous life before compared to most people, traveling the world and physically pushing myself. I have settled back down in the USA and am more careful about risk taking. I may resume traveling again, but I will have to make sure that I always have testing equipment on hand as well as an adequate supply of warfarin (or good access to it). I do worry about quality of care should I get in a car accident or something like that. No sense in being in a third world country and bleeding out because the hospital there is not equipped to deal with my situation. On the other hand, I am over 40 now and it's not like I could keep up what I was doing forever. May have been time to slow down a little ayways.

There is no right or wrong answer for these decisions. As Phil Conners said in the movie Groundhog Day, "We make choices, and we live with them." Key word being "LIVE".

 

[pellicle]

Hi Tom
Sorry you got a bum run.
I hope it didn't impact your life and health now.

I've no medical proof of this.

Nothing that we experience is proof, it's just one more but of evidence. Certainly it does not contradict the evidence of that study.

Best Wishes

 

[pellicle]

Hi

... and the On-X for my aortic valve. I wish it made sense for tissue valves only again, but I did not want to risk having another surgery in 5-10 years with a bioprosthetic aortic valve. I do not expect to have to be opened up again, assuming the pulmonary homograft lasts 20 years again. TAVR should resolve any issues with it.

seems a rational decision

Warfarin therapy has certainly changed my life some, but I had a pretty adventurous life before compared to most people, traveling the world and physically pushing myself.

that sounds like a good life lived, may I ask how warfarin has changed your life? Are you self testing?

...I may resume traveling again, but I will have to make sure that I always have testing equipment on hand as well as an adequate supply of warfarin (or good access to it).

I've had a coaguchek from very early on and it has not only allowed me to avoid clinic waiting lines (and time out of work as a result, which became unacceptable when I was getting weekly testing) but has come with me to places I've travelled since surgery (Finland, Sweden Czech Republic, UK ...) I had more planned but life choices (and COVID) put the brakes on that.

I always travel with a supply of Warfarin for the trip and my coaguchek and strips. Fortunately its not heavy.

...On the other hand, I am over 40 now and it's not like I could keep up what I was doing forever. May have been time to slow down a little ayways.

I was investigating emigrating to Finland (I have an EU citizenship) but decided that despite the many things I love about Finland that being back in Australia would be better for my health. It has turned out to be a reasonably wise decision because the health care here is noticeably superior to Finland even out in the countryside of Australia its at least a par with Helsinki (I lived in Joensuu). A case in point was the elective surgery I had on arthritis on my big toe (preventing me from Skiing at first, walking later).

There is no right or wrong answer for these decisions. As Phil Conners said in the movie Groundhog Day, "We make choices, and we live with them." Key word being "LIVE".

well the issue I see is that while all give you an extra 10 years or maybe 20 years on life its the full understanding of the possibilities that helps one to see the possibilities of the future decisions with greater clarity.

Best Wishes

 

[cooperman]

that sounds like a good life lived, may I ask how warfarin has changed your life? Are you self testing?

Yes, I am now. Certainly more convenient. I am just more mindful about what I do mainly- avoid contact sports, drive a bit more defensively, etc. I do physical work still. I get my share of scrapes and bruises- more so now, but nothing major. The biggest change is that I was living in Thailand and had planned on continuing to live overseas indefinitely (semi-retired). I have lived in developing countries (Costa Rica, Mexico, Albania) that did not have good health care available in many places. I have pretty much accepted that it would now be wise to live in a developed country where there are capable doctors should I have an accident or a stroke. Generally speaking, such places are more expensive to live. So I am working much more again out of necessity. I'm not unhappy, but it is not what I planned when I started my journey of being more minimalist and selling my business years ago.

I am very jealous of your EU citizenship and that you are living in Australia. I am considering moving to western Europe (perhaps Spain or Italy) next year if Covid slows down more. If I could somehow figure out how to get residency in Australia or New Zealand without being an actual multi-millionaire, I would be thrilled. We will see.

 

[pellicle]

Hi

Yes, I am now.

Excellent, and I hope you are documenting and tracking your INR range and that you are in range more than 80% of the time. That's a really important indicator right there.

...The biggest change is that I was living in Thailand and had planned on continuing to live overseas indefinitely (semi-retired). I have lived in developing countries (Costa Rica, Mexico, Albania) that did not have good health care available in many places. I have pretty much accepted that it would now be wise to live in a developed country where there are capable doctors should I have an accident or a stroke.

agreed ... a "thing" I often see is people who live in the city have a fantasy view of what its like living in the country, so when they initially retire they prowl around the countryside within a few hours drive of their capital city and eventually select a lovely little cottage and plant flowers. Then the reality of the distance dawns on them (their kids and grandkids stop visiting, they get sick of 3 hour each way drives to see their preferred heart specialist or endocrinologist) and they sell up, loose dozens of thousands of dollars and have to buy back in to a now more expensive city.

I think recognising that early is wisdom.

Generally speaking, such places are more expensive to live. So I am working much more again out of necessity.

myself personally I grew up splitting my time in old school farming areas and small fishing village (which grew with the same cancer that Florida has). So I'm the kind of guy who does this:
https://cjeastwd.blogspot.com/2022/01/two-sheds.html
and lives like this:
https://cjeastwd.blogspot.com/2020/04/distancing.html
and so the FIRE concept works well for me ...

but it is not what I planned when I started my journey of being more minimalist and selling my business years ago.

it can be very rewarding, I value my time more than I value any money. I believe that once I have sufficient (that's properly invested) I can live humbly but happily.

I am very jealous of your EU citizenship and that you are living in Australia. I am considering moving to western Europe (perhaps Spain or Italy) next year if Covid slows down more. If I could somehow figure out how to get residency in Australia or New Zealand without being an actual multi-millionaire, I would be thrilled. We will see.

well that's courtesy of being born in Australia and having Irish Ancestry and a desire to live in Finland with my wife. So I have a small list of wonderful women to thank for where I am now.

As I see it US citizens live in Australia reasonably commonly, and the only issue you have is getting access to our "free" medical system. I would also advise you budget for about AU$300 a month for health insurance (you're free to select one as they are not tied to employer {indeed that's illegal here}) and can afford you to pick a surgeon and get some small procedure done here and there as needed as you age.
https://cjeastwd.blogspot.com/2020/10/another-example-small-procedure.html
stuff like that ...

Anyway, best of luck with plans, if you have any skills that are desired here then you'll have no trouble with a VISA ... just wait till COVID has settled ...

Best Wishes (and shout out if you aren't over 80% in range and wish some guidance on managing INR)