Choosing St. Jude or Tissue for older people

[Guest]

This was just published.

J Heart Valve Dis. 2006 Mar;15(2):180-9;

The valve of choice in elderly patients and its influence on quality of life: a long-term comparative study.

Kurlansky PA, Williams DB, Traad EA, Carrillo RG, Schor JS, Zucker M, Ebra G.

Miami Heart Research Institute, Miami, Florida 33137, USA. [email protected]

BACKGROUND AND AIM OF THE STUDY: Mechanical heart valves are preferred for younger patients in order to avoid valve structural deterioration, but bioprosthetic valves are favored for older patients to avoid long-term anticoagulation. With increasing patient longevity, controversy persists regarding the valve of choice in the 65- to 75-year-old population. With improving patient survival, long-term quality of life (QOL) is a critical element in helping to resolve this controversy. METHODS: A retrospective analysis was conducted of 1,104 consecutive patients, aged 65-75 years, who underwent valve replacement between July 1976 and December 1999. Valves implanted were either a Carpentier-Edwards (CE) porcine bioprosthesis (596 patients) or a St. Jude Medical (SJM) mechanical valve (508 patients), with and without concomitant coronary artery bypass grafting. QOL was assessed using the Short Form (SF-36) Health Survey for both groups at the time of follow up, which was 98.2% complete. Comparable patient groups were analyzed within quintiles by propensity score analysis. RESULTS: Operative mortality was 9.4% (n = 56) for CE patients, and 5.3% (n = 27) for SJM patients (p = 0.014). Propensity score analysis revealed no significant difference in operative mortality between groups in any of the five quintiles. Actuarial survival for hospital survivors favored SJM patients (p = 0.005). However, when compared within quintiles, there was no significant difference between groups. QOL summary scores were significantly higher for physical health (p = 0.007) for SJM patients, but similar between valve groups for mental health. Comparison within quintiles revealed no significant difference between the groups in either area. CONCLUSION: When comparing the outcomes of mechanical versus bioprosthetic valve replacement, considerable care must be exercised to ensure the clinically relevant similarity of groups. When evaluating comparable patient groups, there was no advantage in either survival or QOL for patients aged 65-75 years receiving a CE or SJM valve.

 

[RCB]

I don't understand this?

I don't understand this?

It seems to me that QOL issuses like complications of drugs, falls, operations,
traval testing, would way heavily in favor of tissue at that age.

 

[Dustin]

Good news for the older McValver (aka mechanical valve recipient).

 

[Andyrdj]

Quality of life....

Quality of life....

...seems to me to be a highly indiidualistic score! If you looked at a series of individual patient records (with a preface at the start stating their attitude to warfarin vs re-operation etc) I suspect you'd get more useful data.

A summary of people's perception of their individual quality of life seems a bit of a useless measure - in either group, you'd expect to find people inclined to be happy with the choice they'd made!

 

[Guest]

But that is the point -- the people were not unhappy with the choices that they made.

 

[tobagotwo]

Interestingly, quality-of-life surveys done on over-retirement-age populations within the first two to three months after surgery tend to rate quality of life with tissue valves lower than with mechanical valves. When taken after a year, there's usually no difference, or sometimes a slight leaning the other way. Doctors are mystified as to why that is. Quantitatively, there's no functional reason for it.

In trying to figure out where the bias lies, it resolves from the mist when you consider the thing that doctors least consider in life, particularly with older people: the human side.

When you receive a tissue valve, you're operated on and pretty much dumped on the street. You're fixed and done, and no one has a reason to have a continuing interest in you. When you receive a carbon valve, you require Coumadin, which involves testing and balancing and interaction with medical staff. What people get from that is continued care and attention.

If you don't think attention is as important to older people as it is to youngsters, just take a minute to help an older person in a store reach something or find something. Share a moment, say something nice, make some pleasant conversation. Comment on something you can both laugh about.

That last paragraph isn't just about making a point. It's also making a suggestion. You've been given some extra years of time. Share a little of it. And don't go by looks: the sourer the puss, the louder the purr.

Best wishes,

 

[Karlynn]

In trying to figure out where the bias lies, it resolves from the mist when you consider the thing that doctors least consider in life, particularly with older people: the human side.

When you receive a tissue valve, you're operated on and pretty much dumped on the street. You're fixed and done, and no one has a reason to have a continuing interest in you. When you receive a carbon valve, you require Coumadin, which involves testing and balancing and interaction with medical staff. What people get from that is continued care and attention.

Very insightful idea!

 

[Guest]

I am convinced that is why people do well at my clinic. I try to make everyone laugh. One 30ish woman that has had a number of clots over the years just had her foot amputated after having the other leg amputated last year. I told her to look at the positive side -- it will be much easier to get into yoga positions now. My wife says that if she had said it, the person would have gone to the administrator demanding that she be fired but I get by with it. New people come in and tell me that their brother-in-law said to not sweat taking warfarin. You just take a pill every day and once a month you go swap a few stories with Al. It works out OK.

 

[msiwik]

interesting posts

interesting posts

I am convinced that is why people do well at my clinic. I try to make everyone laugh. One 30ish woman that has had a number of clots over the years just had her foot amputated after having the other leg amputated last year. I told her to look at the positive side -- it will be much easier to get into yoga positions now. My wife says that if she had said it, the person would have gone to the administrator demanding that she be fired but I get by with it. New people come in and tell me that their brother-in-law said to not sweat taking warfarin. You just take a pill every day and once a month you go swap a few stories with Al. It works out OK.

Al - keep them smiling at the clinic. Very interesting thread. Mark

 

[Andyrdj]

Your Choice

Your Choice

I suppose the point I was trying to make was that people who were happy with their choice might not be so happy if another choice was forced upon them.

But there again, maybe they might be resilient and get on with it. Perhaps it's only grumpy fools like me who insist of having it their way or none at all!

 

[Guest]

Andy
I think that it is pretty common for guys your age to not be happy when they are forced to admit that they are not the invincible creatures that they thought they were. I have probably never seen a guy your age who wanted to be on warfarin. However, it is like many other things in that you will one day realize that it doesn't make much difference any more - everyone you know will have some type medical problem in a few more years.

 

[Blanche]

Al:
If I ever get a valve replaced, I'm moving to Colorado Springs....Actually, I have a friend from college there and Albert has a buddy from the AirForce there. But, I would move just to go to your clinic......And, we are about the same age and I still think that I am invincible, and a creature too. (Smiles)
Blanche

 

[Guest]

COS is actually a tough place for valvers because it is 6500 - 7000 ft. Pueblo is bad enough at 4700 ft.

 

[Andyrdj]

Ouch!

Ouch!

Andy
I think that it is pretty common for guys your age to not be happy when they are forced to admit that they are not the invincible creatures that they thought they were. I have probably never seen a guy your age who wanted to be on warfarin. However, it is like many other things in that you will one day realize that it doesn't make much difference any more - everyone you know will have some type medical problem in a few more years.

Well, as stated elsewhere, in my case my surgeon is open to other options.

I was thinking more of the "2 legs amputated" case as opposed to the medication people in general. I know some people will get on with it and be happy, I just don't think I would, because I'm dreadfully stubborn and obstinate.

I've read some informative books which stress that you shouldn't base your happiness on your life situation - i.e. that the happiest people are those who choose to be happy in all circumstances.

Well, there's certainly some mileage in that, and I definitely don't base my happiness on having a bit house, a great job, or loads of material possesions.

But with health, it's a harder path to pursue. Indeed, there's a part of me which wouldn't want to be happy with no feet, because it would feel like a huge lie. I think some others have put on a similar post somewhere saying "anyone feel like getting angry sometimes?". It happens to some of us that putting on a big cheerful smile all the time can seem a terrible strain. Which is not to say we should always wallow in self pity!

Now, enough grumbling, there's also a positive side to this, if you're undeniably the sort who can't just accept fate. It does mean, though, that you have to accept risk.

In my case, I'm choosing a Bio valve option which will almost certainly mean re-operation (although that does of course have to be weighed against the lifetime risk of anticoagulation complications).

In the case of the woman who had the world's first face transplant, she's risking the face being rejected, and being on anti-rejection drugs for life (or until someone invents something better). But I'd sure as hell do the same rather than walk around with no face - the "safe" option that made some doctors dubious about the whole procedure.

In the case of your patient with no feet - I think in their position I'd be pushing to be the first person to have some experimental feet grown in vitro transplanted, or indeed receive donor feet (I know that hand transplants have been done!) no matter how risky.

But this is, of course, a highly individual thing. A good deal of people would rather accept their situation and choose long term safety as opposed to risk all for gain.

On this board, we have several younger patients who for various reasons have chosen bio valves. We also have (probably more) others who have chosen mehc valves.

allodwick, I am glad that there are people like you around to take the fear out of the choice for people. However, it is still a choice, folks, and one that is so very individual to you.

 

[Guest]

I have also posted elsewhere that "insiders" have told me that there are unpublished (as yet) studies that show that newer tissue valves are expected to last as long as (or almost as long) as mechanical valves. I can't say who these people are but they are in positions to know what is going on in several different companies. Rather than one stated fact, it is more my synthesis of bits and pieces picked up over drinks at various professional gatherings.

 

[Ross]

Rather than one stated fact, it is more my synthesis of bits and pieces picked up over drinks at various professional gatherings.

Do you think they may have seen these at those affairs too?

 

[Guest]

Maybe after I left!!!

 

[Dustin]

I have also posted elsewhere that "insiders" have told me that there are unpublished (as yet) studies that show that newer tissue valves are expected to last as long as (or almost as long) as mechanical valves.

Would it not take years for unpublished results to reach FDA approval? Meanwhile, patients in the real world have to deal with solutions that have gone through the mill of rigorous scientific verification. Tissue valves that last as long as mechanical are great to have, but I guess it will not be of any use for those needing surgery within the next 5 to 10 years.

 

[Der Biermeister]

My surgeon believes the bovine valve he used should last up to 22 years. And who can really say WHAT they will be doing in 22 years. It might be all "virtual reality" surgery or some such thing.

 

[Guest]

If those that are already being implanted are lasting much longer than the "approved" time, then people are already benefiting from them. My feeling is that this is what the people making the statements meant - not waiting for new valves.