Confused

[HarryG]

As going in for OHS, July 21st, the big debate my decision (so the doc tells me) is on aortic valve replacement, at 53 years old confused as to the many models out there (mechanical and otherwise) any suggestions to a nervous guy!

This sight is wonderful and informative, it has helped on many issues.

 

[Rich]

Hi Harry,
Valve selection is a very personal decision as I'm sure you know.
I was 58 at that time and my surgeon told me I was too young for a tissue valve.
He really didn't give me a choice but rather told me I was getting a mechanical valve.
So I received a St. Jude aortic valve and it has been great.
The Coumadin can be a little pain sometimes but has not been a big deal.
Coiumadin can be a problem when other invasive procedures or surgeries are required. You can read a lot of posts regarding some of these things.
The good news is hopefully I will never need another valve surgery in my lifetime.
When you are in your fifties and a tissue valve lasts 10-20 years ,then you might face another surgery in your seventies.
What phsyical condition might you be in at that advanced age compared to now?
Rich

 

[iparychev]

Valve choice

Valve choice

Of course this is a very personal matter, but here's the story behind tissue valve: The younger the person is, the higher metabolism. Tissue valves have a nasty habbit to calcify, and then need to be replaced. When the tissue valve will be replaced completely depends on the person's metabolism. The higher metabolism, the faster valve calcifies. Generally, older people are advised on a tissue valves, younger ones on mechanical. The statistics show that after ~40 years the metabolism slows down, and the chance of a tissue valve replacement decreases. I, personally, was a young patient(27), but I still got the tissue valve because of the coumadin. My other reasoning was that in 10-20 years these surgeries will progress and they'll come up with better valves and procedures.

 

[epstns]

Harry, You've touched upon perhaps the most personal of all the valve surgery choices. Each of us has different issues and different things that are important to us. I'm now 56, and still in The Waiting Room -- having been monitoring my (moderate) aortic stenosis for the past couple of years, and when I discuss valve selection with my cardio, his reply is "If I were in your situation, without a doubt I would opt for the St. Jude mechanical. Do it once, probably never have to touch it again. Coumadin is just something to get used to. . ."

I think that's good enough for me, right now. I'd opt for the mech. My mom had to take coumadin the last few years of her life, and although the testing can be annoying, it wasn't much of a deal to her life style.

To each, his own -- but I'd really like to minimize likelihood of a re-operation, hence the mechanical tendency at the present.

 

[ALCapshaw2]

There are some new (third generation?) mechanical valves that have better hemodynamics / flow patterns than the older (St. Jude) mechanical valves. These valves were designed with Fluid Dynamics factors taken into consideration and create a less turbulent flow. Bottom Line: you get more blood flow with less likelihood of clot formation. Check out the St. Jude REGENT Valve and the ON-X valve which offer some very interesting benefits. Do a SEARCH on ON-X, and go to their interesting and informative web site.

I was hoping to receive a Bovine Pericardial Tissue Valve (in my late 50's) which is pushing 20 years at 90% durability (i.e. 90% of the valves installed 20 years ago are still functioning). Other factors dictated a (St. Jude ) mechanical valve. The down side is that for any invasive procedures or surgery, I will have to go off Coumadin, have the procedure, and go back on Coumadin which requires either a hospital stay of 3 days each side of the procedure with a Heparin Drip IV or Lovenox Injections (to the belly) which can be done at home.

EVERY VALVE has it's positive aspects and negative aspects. Most people end up choosing one whose negative aspects they feel they can best live with.

'AL'

 

[Lisa]

EVERY VALVE has it's positive aspects and negative aspects. Most people end up choosing one whose negative aspects they feel they can best live with.

'AL'

I think Al pretty much sums it up. I'm 31 and just had my aortic valve replaced in March. I chose a homograft. I made an informed decision. At 31, the chances of having another surgery is substanstial..even with a mechanical. So I chose the valve I was most comfortable with.

 

[tobagotwo]

Valve Choice Thoughts and Thread Links

Valve Choice Thoughts and Thread Links

There are many prior threads with excellent discussion about valve types, and it would be good for you to look them over. The search function can help.

You are slightly over the border for most doctors to perform the Ross Procedure, as most like to call the line at 50. However, there are certainly those who will, if you are a candidate and it is your choice. There is a longer pump-time involved, but results at 53, if completely successfull, could well last your lifetime, with no anticoagulation therapy or reoperation.

However, the most likely candidates for you are replacements, either in mechanical or bioprosthetic form. Statistics for long-term Coumadin use (for mechanicals) and eventual reoperation (biological valves) show that they are very similar in terms of risk over time, including for stroke.

The issue then really becomes your choice of shortcomings.

Mechanicals: Coumadin (warfarin) anticoagulation therapy is a lifetime commitment. It means that you will have regular blood testing, and that you will need to watch variations to your diet that might affect vitamin K levels or accellerate the effectiveness of the warfarin. It can also complicate other physical issues, should you have to go to an emergency room, and requires bridge therapy and hospital time for some otherwise routine tests, such as colonoscopy, and any type of operation.

The majority of those using Coumadin feel it is not really a problem to them. However, there can be side effects for some, and it can be difficult for some others to adapt to the requirements of the lifestyle.

With a mechanical, your risk of reoperation for that valve is very low. If you have no reason to believe you will be having other surgery, it can be a good choice.

Tissue Valves: Tissue valves have a useful lifespan limitation. The better models arguably have a twenty-year run for someone over the age of forty to fifty (younger people burn them up - calcify them - faster). That means that a 53-year-old will be looking at eventual reoperation eventually. A good-faith estimate with the newest tissue valve types is about 20 years.

However, barring atrial fibrillation or other very dangerous rhythm abnormalities, there is no long-term anticoagulation requirement. A successful replacement can mean just a yearly echo and cardiologist visit for many years. Although tissue valvers, like mechanical valvers, premedicate with one, 2-gram dose of amoxicillin before dental work and some other infection-risk procedures, there are basically no other differentiations between a tissue-valved patient and a "regular" patient.

There are a number of good posts about this (some are mine, of course...). This points to a particular post, but page back and forth in the thread it comes up in for many other useful and interesting posts:

http://www.valvereplacement.com/forums/showthread.php?p=77609#post77609post77609

and here is a post listing some other threads and posts:

http://www.valvereplacement.com/forums/showthread.php?p=81697#post81697post81697

Best wishes,

 

[Mary]

Bob

Bob

Bob,
Besides the threads you listed, Peter Easton had an excellent thread that ran and chronicled the variables that come with making the valve choice.
I read it after a member suggested that it was a good idea to look under Peter's name and bring it up.
It's very interesting, and you might want to check it out if you haven't all ready. It's informative and shows a great deal of reflection about the entire process.
Mary

 

[RayinSF]

~This was a difficult decision for me as well. I just decided, 100%, to go with a homograft about a week ago. After changing my mind about 100 times in the last 2 weeks, I feel its the best valve for me. I among young, {35} but if I can go through this surgery once, I can do it again. I think, as everyone else has already said, its a very personal decision, and YOU have to make the decison that YOU feel is best for YOU.

~Ray

 

[tobagotwo]

If Not Ross, What?

If Not Ross, What?

Mary, the CarlaSue thread (one of the threads I posted a link for) does talk about accessing that thread by Peter, in a post by GrandBonny. I'll bet that's where you saw it yourself. However, it should also be borne in mind that some of the variables have changed over the last three years (even in the last year), and there is new risk information that was not available then -some of it since I had my own surgery, twelve weeks ago. There is very little "permanent" information regarding valve surgery.

My personal belief remains that tissue valves offer the greatest overall benefit in most cases that are not good candidates for the Ross Procedure, unless the person has other medical issues, such as prior major surgeries. The main weakness of tissue valves overall is that they have a limited useful lifespan of about twenty years, and sometimes considerably less than that in young patients (less than 40 or so). However, for those over 40, reoperation is not necessarily the bugaboo that has been depicted: http://www.valvereplacement.com/forums/showthread.php?t=7339

The only concern I have with the homograft is that it is the only type of valve that I have ever read of having any rejection factors come into play, albeit I do not know the percentages. Originally, that had been my second choice, as I had been pushed away from the Ross Procedure based on what I now believe to be inaccurate statistics.

Mechanical valves have improved greatly, but some of the things I have been reading lately seem to indicate that the life on them may not be infinite in everyone, may be more like 25-30 years in some cases. The main reason for getting a mechanical valve is to avoid reoperation. Its main weakness is the requirement for anticoagulation therapy.

Although many people here have little or no difficulty with Coumadin (warfarin anticoagulation therapy), there are others who do, either with the regimen or with the side effects that it can cause in some people. And there's no going back, once the valve's in. Coumadin also opens one up to other risks that do not show up in fatality statistics, and definitely complicates many medical situations (see the thread on colonoscopy and bridge therapy). A link regarding side effects and interactions with other drugs: http://www.accessmednet.com/prescription-drug-information/coumadin-warfarin.html#side-effects

Again, there are as many opinions as there are members, and almost as many valid arguments. You will find many people on this site who live with and are thoroughly satisfied with each of the valve options. This is just my take on it - and a very abbreviated version at that.

Each person's health situation is different, and knowledge about valve issues grows and is modified continuously. For example, it is now being proposed that a percentage (again, no real numbers) of people with bicuspid aortic valves will later encounter aortic aneurisms, as they can be "part of the package." If there is an indication that that might be the case, a mechanical valve and coumadin use will not keep that person from having reoperations.

As well, if a heart has multiple issues, or if htere are other major organ problems, the benefits can sway in different directions.
Best wishes,

 

[Mary]

Bob,
I sent you a PM about this.
Mary