Choosing tissue valve but.......

[Paleowoman]

I'm choosing to have a tissue valve when I see the cardiac surgeon (a couple of weeks). The cardiologist says I will probably be able to stave off having OHS for about six months BUT although he is not critical of my choice of tissue valve he made the implications of my choice clear, ie that I will need another replacement in about 15 years time. I am just 60 so that would mean another OHS when I am 75, when I am older and not so strong. Anticipating a similar conversation with the cardiac surgeon, I am wondering how best to put my case. I know I don't want a mechanical valve because a) I have very sensitive hearing and my life would not be worth living hearing even a tiny bit of the noise, and b) I have diabetes and osteoporosis so the complications with warfarin do not bear thinking about for me, I already have complicated enough dietary requirements, plus I eat a high vitamin K diet with tons of leafy greens for the calcium, so I don't want more complications. In other words, my choice of valve is driven by what I don't want. Obviously I'd rather a valve which never needed replacing but I don't want what comes with the current mechanical valves. I know things are advancing in the valve world but I don't have time now to wait for change.

What did others say when asked why they wanted a tissue valve ?

Anne

 

[clay_from_nj]

a) I have very sensitive hearing and my life would not be worth living hearing even a tiny bit of the noise,

In my experience, the sound is nearly non-existent. I have to be in just the right position, in a totally silent place, and listen very carefully to hear it at all. The clock in the next room is louder. OTOH, YMMV, and who knows, you might get a noisy one (and your tissue valve might last 15 years or more).

and b) I have diabetes and osteoporosis so the complications with warfarin do not bear thinking about for me, I already have complicated enough dietary requirements, plus I eat a high vitamin K diet with tons of leafy greens for the calcium, so I don't want more complications.

Warfarin has nothing to do with diabetes or osteoporosis. A high K diet is really no problem at all, as the diet key with warfarin is consistency, no matter what you eat, perfect for a diabetic, who should already practice moderate and consistent eating habits. I love fresh spinach and lettuce and eat it several times a week. Some people actually take vitamin K supplements while on warfarin. And don't forget, you might wind up on warfarin anyway, and as you get older, I can almost guarantee that you'll be on other daily drugs (if not already) that have much more risk of interaction or side effects.

Really, either valve choice is a good one, and it comes down to your personal preference. But, please don't be misled by misinformation or even unintentionally misinform others.

This study actually puts forth a good argument for bioprosthetic over mechanical, in the Conclusions.

 

[knotguilty]

I asked a couple doctors if they were in my shoes (55 years old) what would they choose, and they said a tissue valve because of the possible complications from Cumadin. My surgeon did try to talk to me about mechanical, but I was never sold. There are possible new break throughs either way you go. I know they must be out there but I have not seen anyone with a tissue valve that has lasted as long as some of the mechanical valve folks here. It all depends on your tolerance and comfort level. My primary care physician told me a story of a young drug addicted woman who has had three valve surgeries because of the drugs. You can make it through multiple surgeries but I think it is important to stay healthy for when you are in the fight of your life. I would not be afraid of either valve but it all comes down to what YOU want.

 

[Paleowoman]

Thank you Clay and Knotguilty ! Thank you for replying so quickly - I saw a cardiologist for a second opinion yesterday and this is all going round in my head. He's referring me to a good surgeon but he did talk about mech versus tissue valves and I had thought I was pretty clear about what I wanted. That study, Clay, is so very interesting ! I have printed it off. It certainly helps clear up any nagging doubts I had, plus Knotguilty talking about re-ops. I had imgained I would just get weaker as I got older, but really I shouldn't live my life now for how I might be in 15 or so years time...and knowing me, once I get my fight back I will stay healthy as possible. My existing osteoporosis is a risk in the surgery, a risk of osteoporotic fracutres, but the surgeon I will have is one who often works on more complex cases (marfans and pregnant women) so she is sure to be more mindful of my bones.

I keep feeling okay followed by awful waves of doom and despondancy about this...I suppose that's normal. The cardiologist asked me if I was mentally prepared for surgery and I said yes but I wonder how anyone really can be

 

[dick0236]

........although he is not critical of my choice of tissue valve he made the implications of my choice clear, ie that I will need another replacement in about 15 years time. I am just 60 so that would mean another OHS when I am 75,

Anne

Hi Anne, you have been on this forum long enough to read the pros and cons of both valve choices.....and you have the tools to make a "considered" decision for your situation. I can understand his concern about heart surgery at 75, and I agree that OHS at that age would be tuff, but your concerns regarding your other health issues and warfarin are also understandable. You seem to be at the age that valve choice becomes a "coin flip", so make your case to your docs....listen to their responses.....and make your decision.

 

[Agian]

I just read the article that Clay linked to. I wonder what others think about it.

 

[Paleowoman]

Hi Anne, you have been on this forum long enough to read the pros and cons of both valve choices.....

And I want to say THANKGOODNESS for this forum ! There is not one like this in the UK so I am so grateful for my American 'friends' here :smile2: And for the UK ones too

Aglan - re that article, the other thing that stood out for me in it was that there is also a choice of what kind of tissue (and presumably mechanical) valve a person has. I don't know how surgeons choose which kind.

 

[pellicle]

I don't know how surgeons choose which kind.

from what I have read, based on what they prefer to work with, what their mentors taught them (meaning perhaps out of date ideas) and what the sales folks push on them. I have a friend who works in sales of valves as it happens. Its a small world in that field so I'll say no more there.

I would wonder did you read the link I've posted from the Mayo presentation? That may open you up to thinking more about this subject.

http://mayo.img.entriq.net/htm/MayoPlayer1.html?articleID=4071

summary:
- mechanical valves have longer lifespans than tissue
- mechanical valves confer longer lifespans to patients, that increases with age group
- tissue chosen by patients and or surgeons because of
belief that will not require anti-coagulation (warfarin) [which is false when evidence is considered]
- over a longer time frame over half of tissue patients require anticoagulation
30% require it within 2 years
- anticoagulation itself confers benefits to patients increasingly as they fall into
older age groups

There were studies cited in that presentation where they dealt with elderly and the results were a small but better outcome for tissue.

Mostly I find that people have made up their minds before asking here and asking here is to make them feel better about their choice. I don't mind because it is their choice.

 

[pellicle]

I just read the article that Clay linked to. I wonder what others think about it.

Personally (as one with some experience in reading research papers ableit in a different academic domain) I would ask further questions about their 'conclusions'.

For instance in their conclusions they say

because of increased awareness of the associ ated lifetime
risk of major thomboembolic and hemorrhagic complications,particularly stroke, that occur with mechanical valves despite optimal anticoagulation.

yet make no significant analysis of this aspect in their paper. I would get bollicked for that in an academic paper at my uni... But my training area is science and Medicine often seems to act more like Arts in their ways.

The statement:

By contrast, mechanical valve technology and antithrombotic treatment options have remained
relatively static.

would seem to ignore the points (found elsewhere) that other studies show that self monitoring and self testing (which I understood represents about 1% of warfarin patients in the USA) brings the data on thromboembolic events to quite equal to that of tissue valve recipients (who may in fact need to go on warfarin anyway before a valve failure requiring reoperation due to the degeneration of the tissue valve).

A quote from the Mayo presentation:
a 77yo who had previously had a tissue valve replacement was presented in sever heart failure. It could be said that this was 'Gods hand' for 77 year olds. Its not true that tissue valves don't
thrombose, they do. If not identified it can be confused with heart failure. Patient is now anticoagulated
This patient would have died for lack of diagnosis of thromboembolism.


Also, from their conclusions:

Patients undergoing valve replacement with a mechanical valve can expect a linear annual risk of major hemorrhagic or embolic events, including stroke, of 2–4% per year for life compared with around 1% per year for bioprostheses

which given their light examination of the literature on anticoagulation I can only assume that would be assuming the 99% who are not on self care or self monitoring, which has been established (in other studies) to bring down the risks to within the bioprosthesis group. Again quoting from the meta-analysis review done by the Mayo

another study showing TIR for UC vs PSM showed
PSM was in range 78% and total related events dropped from 4.7% (UC) to 2.9% (PSM)

It showed also that PST reduced the bleed complications from 11% to 4.5% and Thromboembolic from 3.6% to 0.9%

UC = Usual Care
PSM = Patient Self Monitoring
PST = Patient Selft Testing

Those drops in complication rates suggest strongly otherwise than the conclusions in that paper. Given how few in the USA are doing PSM or PST I guess its easy to pull together modern data and present it as current when in fact the patients in the USA are not being treated in a modern way with respect to warfarin care.

I'm not going to do a full analysis on this, but to me it was just one more 'paper' with predominately a meta-analysis approach and confusing presentation of data. Probably done because in academic circles you have to get your publications count up as part of your KPI's. One of my fellow students had this on his door while writing up his PhD ...

Personally I've seen at least one academic who has such cut and paste approach to his papers that I have to print them and have them on the desk to see which is which. Remember its not plagiarism if you copy your own work!

 

[Paleowoman]

Hi Pellicle,

Oh yes, I take your point about mechanical valves lasting longer etc which is one thing which I feel is in their favour, and that warfarin might be prescribed too for a tissue valve. The noise is a very big thing for me - I have a very thin chest wall with depressed sternum (my pericardium is touching my sternum, I've seen it on CT scan) and I have very sensitive hearing. Once had a hearing test done because I get pulsitle tinnitus in my left ear, and the test showed that my hearing is well above normal. I know what my dh or ds are eating in the next room to me from the sound the food in their mouths make. A wrist watch in the bedroom will keep me awake and has to be removed. It is a blessing and a bane to have such sensitive hearing. I have read quite a few people complaining about the noise of the clicking mech valve here, I know some people don't hear it but are they very thin chest walled and do they have extra good hearing ? And what if I take a chance on one that it will be quiet and it isn't ? There is no turning back and getting the valve undone ! To choose a mech valve solely on it's durability for the next 15 years rather than on my quality of life......

I read the other day here about a new tissue valve being developed that will last very much longer than current tissue valves BUT I am too early for that one

 

[pellicle]

Hi

To choose a

I wish I could do or say something useful for you, but only you can choose. I know that sounds like a cop put on my part, but , well only you have to live with the result.

All you have said makes sense and so I say to you go with what you feel is right

There are no wrong choices.

 

[Paleowoman]

Thanks Pellicle. I think things are quite tricky for us valve replacement patients - it's not like we're shopping for clothes and have to choose between two items.

 

[big_L]

Hey - You decide what type of valve you want! It's your body. The doctors are there to help you. You've made your mind up. Tell them what you've decided, stand your ground. I don't think that you should have to worry about what you're going to tell them. Tell them you've done your research and your mind is made up. Tell them you understand the risks involved and you accept that. If the doctor won't back off after you tell them this, then you have a Dr problem.

My impression after meeting with my doctors on this subject was that they just wanted to be sure that I understood the implications of my decision. Yes - I went mechanical (I'm younger than you). One of the Drs wanted to make sure that I understood that re-operation could be a possibility even with mechanical. Which is fine.

 

[epstns]

Let's keep one thing in mind about statistics. You can say anything you want to say with statistics, and you can prove it.

That said, the 15 years proclaimed as the life span of a tissue valve is misleading. That is the average for the second generation valves. That means that half last less, half last more. It is also not representative of the newer third generation valves now being implanted. In addition, none of these statistics are age-adjusted. Tissue valves deteriorate faster in younger patients. The 3 leading hospitals I considered for surgery (Cleveland Clinic, University of Chicago and Northwestern Memorial) all implant more tissue valves than mechanicals in total. They recommend tissue for patients over the age of 55 or so, routinely. If that were to mean that they expected these patients to all need re-ops or die by age 70, I would be very surprised.

The choice of valve is a complex decision. Tissue valves are not to be merely relegated to the women of child-bearing age. They are indeed a viable alternative. I find it aggravating that people seem to "sell" one valve or the other by saying things like "Mechanical valves are bad. Warfarin is dangerous." or "Tissue valves are bad. You always need another."

Good, bad, always, never. These are words of opinion that I think should used carefully when new members are struggling with valve choices.

I'm a tissue valver, and I'm perfectly happy with that.

 

[Rachel]

It is a blessing and a bane to have such sensitive hearing. I have read quite a few people complaining about the noise of the clicking mech valve here, I know some people don't hear it but are they very thin chest walled and do they have extra good hearing ? And what if I take a chance on one that it will be quiet and it isn't ? There is no turning back and getting the valve undone ! To choose a mech valve solely on it's durability for the next 15 years rather than on my quality of life......

I read the other day here about a new tissue valve being developed that will last very much longer than current tissue valves BUT I am too early for that one

Just wanted to say that the possibility of noise was a big factor for me when I decided to go tissue.....I think you put it well in your above statement - it's also how I felt about the whole thing. For me, I'm very happy to even have the option to get a valve replacement because it does extend our lives (either way, mech or tissue) - but I don't think there is one perfect solution yet and that is why we're all still talking about the what-ifs......I hope that in the future we'll have an option that is as good as our native valves.

Good luck to you whatever you decide!!!

 

[Paleowoman]

I feel really happy that there has been so many contructive replies to my question - thank you so much everyone. Thinking more and more about it, trying to see it from both angles, being objective as I can be....I have decided that a tissue valve is most definitly the way I want to go

I see that both Steve and Rachel had bovine valves (am I correct ?). Does that mean there's a further choice ? Bovine or porcine ? Did you choose or is that up to the surgeon ?

 

[neil]

agree totally steve, i can say any rubbish on here and back it up, the point is you pick the valve what suits you best not anybody else, yes listen to opinions but go with what you choose, sometimes reading on here can muddy the waters for people theres so much stuff wrote it makes my head spin, yet most times theres also a lot of good stuff and most of that is short and to the point,i have friends who have picked mech and tissue and we often pull each others leg about the pros and cons, hopefully one day there will be just one valve which will last a lifetime and with no anti coags,

 

[neil]

anne now you are getting into dangerous ground, a porky pig or a mo cow ? hail the pig lol,

 

[Jkm7]

Let's keep one thing in mind about statistics. You can say anything you want to say with statistics, and you can prove it.

That said, the 15 years proclaimed as the life span of a tissue valve is misleading. That is the average for the second generation valves. That means that half last less, half last more. It is also not representative of the newer third generation valves now being implanted. In addition, none of these statistics are age-adjusted. Tissue valves deteriorate faster in younger patients. The 3 leading hospitals I considered for surgery (Cleveland Clinic, University of Chicago and Northwestern Memorial) all implant more tissue valves than mechanicals in total. They recommend tissue for patients over the age of 55 or so, routinely. If that were to mean that they expected these patients to all need re-ops or die by age 70, I would be very surprised.

The choice of valve is a complex decision. Tissue valves are not to be merely relegated to the women of child-bearing age. They are indeed a viable alternative. I find it aggravating that people seem to "sell" one valve or the other by saying things like "Mechanical valves are bad. Warfarin is dangerous." or "Tissue valves are bad. You always need another."

Good, bad, always, never. These are words of opinion that I think should used carefully when new members are struggling with valve choices.

I'm a tissue valver, and I'm perfectly happy with that.

[My underline.]

Add Boston's Massachusetts General Hospital and Brigham and Women's Hospital (both always included in top ten if not top five heart centers in U.S.) to the list. The surgeons in both of those very fine hospitals implant a great many tissue valves each year in patients of all ages ...... not just women of child bearing age.

 

[Paleowoman]

anne now you are getting into dangerous ground, a porky pig or a mo cow ? hail the pig lol,

But the porky pig isn't Kosher and my dh is Jewish - if I get a porky pig, he'll not only have married a shiksa but I'll definitly be un-kosher too