For reops: are you glad you started with tissue?

[neil]

bottom line is you take a slight chance whichever you choose, yes people have scar tissue with 2nd ohs and for some it can be a problem,but for most its not and re ops for most people are fine, the same can easily be said of mech with anti coags, most are fine but some do have problems, look at the threads on here about anti coags, as ive said many many times before which ever you pick is the right choice for you, all we give is our opinions thats all,

 

[Lynlw]

I recently spoke with someone who got a bovine valve put in about 7 years ago in his early 40s. His surgeon told him that it would likely last 30-35 years, and possibly longer. Is there truly evidence to support this? I understand that there have been improvements on tissue valves, and that the "3rd generation" valves are expected to last significantly longer, but 30-35 years? That would be great!

pem

Just for the sake of argument since you asked about true data to support how long any of the tissue valves in use today can/have last in patients, as far as I know the most popular, were first used in early 80s or late 70s so just now have been used 30 years..again i m NOT saying any person has had a tissue valve 30 years (like JKM I often hear 20-25 years as the number to "hope" for with a tissue valve in "younger" patients (40 and less (of course alot also depends on which valves need replaced, valve on the right side can and do usually last much longer than on the left side) in patients over 65 there ARE patients whose tissue valves were doing great at 20 years and that was probably about 5 years ago so

I'm just saying that the most popular -perimount, hanncock II, Biocore have about 30 years of data now. Unfortunately many of the first people who got valves replaced 20-25 years ago, were older so aren't still around (which is why alot of the studies following valves longterm stop, not enough patients still alive from the first groups)

But on the other side,of the most popular mechanical valves used TODAY, only 1 the St Jude has been around as many years than those 3 tissue. The other mechinical valves people are getting haven't been in use even 20 years, so even tho everyone "hopes" they will last a 'lifetime" there really isn't any data they already lasted 20 years let alone 30 etc or a "lifetime" in patients.

 

[dick0236]

In general, I conclude from this paper that someone on coumadin would do well to gradually decrease the INR levels over time so that they reach a target narrow range of 2.3-2.5 in their 70s (starting of course from a higher level when they are younger). Of course, that's just my own take-away from the study, but I encourage you to read it if you are on lifelong coumadin because I think there is some evidence that lower INR levels may be better than what today's standards indicate. Of course, one has to factor in individual differences and track record, etc. (I am not a doctor, just play one on TV, etc.)

pem

Your conclusion may be correct. However, I am in this older class (age 75) and still prefer to keep my INR around 3. My doc likes it a little under 3 and I like it a little above 3....so we settle on "around 3". My experience is that my warfarin dose has declined over the years due to aging and activity decline, in order to maintain the INR of 3. Unfortunately, INR results are far from an exact science and depend on many everchanging variables, from recent diet, activity, testing nurse protocals, machine tolerances, weather(?) etc. My range has always been 2.5-3.5 and I try to stay away from the upper and lower limits, but I do not, and cannot maintain a "close tolerance" target. My experience has been that compliance that maintains an INR within a reasonable range will minimize a nasty event. According to the docs I have talked with, NON-COMPLIANCE is the major cause of problems with warfarin....and I can personally attest to that. People who take warfarin as prescribed and test routinely normally have few, if any, problems. That said, there are always exceptions.

BTW, when I begin to experience noticeable bruising or excessive bleeding, I will probalbly reduce my INR to "under 3".....but so far, I have not noticed either of these problems.

 

[pem]

Just for the sake of argument since you asked about true data to support how long any of the tissue valves in use today can/have last in patients, as far as I know the most popular, were first used in early 80s or late 70s so just now have been used 30 years..again i m NOT saying any person has had a tissue valve 30 years (like JKM I often hear 20-25 years as the number to "hope" for with a tissue valve in "younger" patients (40 and less (of course alot also depends on which valves need replaced, valve on the right side can and do usually last much longer than on the left side) in patients over 65 there ARE patients whose tissue valves were doing great at 20 years and that was probably about 5 years ago so

I'm just saying that the most popular -perimount, hanncock II, Biocore have about 30 years of data now. Unfortunately many of the first people who got valves replaced 20-25 years ago, were older so aren't still around (which is why alot of the studies following valves longterm stop, not enough patients still alive from the first groups)

But on the other side,of the most popular mechanical valves used TODAY, only 1 the St Jude has been around as many years than those 3 tissue. The other mechinical valves people are getting haven't been in use even 20 years, so even tho everyone "hopes" they will last a 'lifetime" there really isn't any data they already lasted 20 years let alone 30 etc or a "lifetime" in patients.

Thanks, Lyn - very well taken. I guess any newer valve is somewhat "sight unseen" in terms of its longevity. I have to say, if I had a crystal ball that told me I could keep a tissue valve for exactly 20 years, I might be sorely tempted to get that. 10-15 years at my age doesn't seem like enough for my personal choice. I know others differ on this.

pem

 

[pem]

Your conclusion may be correct. However, I am in this older class (age 75) and still prefer to keep my INR around 3. My doc likes it a little under 3 and I like it a little above 3....so we settle on "around 3". My experience is that my warfarin dose has declined over the years due to aging and activity decline, in order to maintain the INR of 3. Unfortunately, INR results are far from an exact science and depend on many everchanging variables, from recent diet, activity, testing nurse protocals, machine tolerances, weather(?) etc. My range has always been 2.5-3.5 and I try to stay away from the upper and lower limits, but I do not, and cannot maintain a "close tolerance" target. My experience has been that compliance that maintains an INR within a reasonable range will minimize a nasty event. According to the docs I have talked with, NON-COMPLIANCE is the major cause of problems with warfarin....and I can personally attest to that. People who take warfarin as prescribed and test routinely normally have few, if any, problems. That said, there are always exceptions.

BTW, when I begin to experience noticeable bruising or excessive bleeding, I will probalbly reduce my INR to "under 3".....but so far, I have not noticed either of these problems.

Thanks for this - I defer to your extensive experience!

 

[Jkm7]

Your conclusion may be correct. However, I am in this older class (age 75) and still prefer to keep my INR around 3. My doc likes it a little under 3 and I like it a little above 3....so we settle on "around 3". My experience is that my warfarin dose has declined over the years due to aging and activity decline, in order to maintain the INR of 3. Unfortunately, INR results are far from an exact science and depend on many everchanging variables, from recent diet, activity, testing nurse protocals, machine tolerances, weather(?) etc. My range has always been 2.5-3.5 and I try to stay away from the upper and lower limits, but I do not, and cannot maintain a "close tolerance" target. My experience has been that compliance that maintains an INR within a reasonable range will minimize a nasty event. According to the docs I have talked with, NON-COMPLIANCE is the major cause of problems with warfarin....and I can personally attest to that. People who take warfarin as prescribed and test routinely normally have few, if any, problems. That said, there are always exceptions.

BTW, when I begin to experience noticeable bruising or excessive bleeding, I will probalbly reduce my INR to "under 3".....but so far, I have not noticed either of these problems.

After a great deal of reading re: ACT prior to my replacement, I came to think the biggest risk with life long coumadin is dealing with professionals who are woefully uninformed regarding coumadin/bridging/performing procedures on patients who require ACT. Seems a great many of the 'nightmare' stories we read about ACT involve a coumadin manager or dentist or doctor who needs an intensive ACT course. Many of the problems could be avoided with proper coumadin management.

That was one of the factors that decided me to opt for tissue valve....... certainly not the only one.

 

[pem]

After a great deal of reading re: ACT prior to my replacement, I came to think the biggest risk with life long coumadin is dealing with professionals who are woefully uninformed regarding coumadin/bridging/performing procedures...

That was one of the factors that decided me to opt for tissue valve....... certainly not the only one.

Well taken! I guess if one goes the mechanical route, one needs to be prepared to self-advocate in these matters, which is admittedly a burden, though perhaps more for some than for others.

Thank you!
pem

 

[pem]

After a great deal of reading re: ACT prior to my replacement, I came to think the biggest risk with life long coumadin is dealing with professionals who are woefully uninformed regarding coumadin/bridging/performing procedures on patients who require ACT. Seems a great many of the 'nightmare' stories we read about ACT involve a coumadin manager or dentist or doctor who needs an intensive ACT course. Many of the problems could be avoided with proper coumadin management.

That was one of the factors that decided me to opt for tissue valve....... certainly not the only one.

Follow-up question: in these cases, wouldn't you have your cardiologist in consultation for bridging, etc?

Thanks,
pem

 

[dick0236]

....... one needs to be prepared to self-advocate in these matters, which is admittedly a burden, though perhaps more for some than for others.
pem

This is certainly true. Prior to the INR system (early 1980s although I think it was closer to 1990 before it was used locally), the old Pro-Time lab test was much more cumbersom and relied, to some extent, on subjective interpretation and since a single, universal INR number was not generated, it made it more difficult for a patient to follow his/her history. The new system(INR) makes it easy to track your results. I keep a simple log of date, dose and INR in my computer and periodically review my log with my PCP. A good doctor, once he knows the patient is knowledgeable and interested, will encourage the patients input. If he/she maintains a "my way or the highway" attitude, it's time to find a new doc. Like all professions, half the MD graduates, were in the bottom half of their class.....and its usually those, that feel threatened by a patients knowledge.

 

[drivetopless]

For this reason, and because I think I would manage my ACT well, I have decided to get a mechanical valve (did I just put that in writing??). Now I'm trying to decide between On-X and ATS. I think I prefer the latter from a technical standpoint, but with the On-X there's the more immediate prospect of Aspirin/Plavix or lower INR in a few years. I think the same prospects exist for the ATS valve, because if the ON-X is successful, I don't see why they wouldn't follow suit, but there would be a longer wait.

Thanks for your reply!

Congrats on your decision, Pem. No matter which valve you get it will be better than the one you have.

I had surgery at 47 and went with the On-X. I wasn't too worried about the ACT because I am a good pill taker. I'm almost 5 months post op and the ACT has really not been a big deal at all. Everyone is different, but I've been pleasantly surprised at how steady the INR is now that I've stablized after surgery. Because INR changes slowly (a change in meds takes 2 or 3 days to show up) , you really don't have to panic if you keep it "between the lines" and are consistent with your lifestyle most of the time. I eat spinach and broccoli every week. In fact, I find that my INR is better maintained when I eat veggies every day! I will hopefully get approved for my home INR tester soon and it will be even less of a hassle. ACT has not turned out to be the scarey beast. I am also lucky to have an INR nurse who is open to my suggestions.

RE reduced warfarin dosing or the Plavix/aspirin dosing that may be possible with the On-X-- That is exactly the same reasoning I had for choosing an On-X. But now that I've been on warfarin, I don't know that I would be the first to jump on the Plavix/aspirin bandwagon. Warfarin is cheap and has been around a lot longer than Plavix, so I think I will let others establish the safety of Plavix/Aspirin instead. By the time I'm old and maybe more warfarin sensitive THEN I might change away from warfarin. I was initially prescribed a target INR of 1.5-2.5 which is .5 lower than published guidelines. I was thrilled at first, but let me tell you when you get down below 2 it becomes much harder to maintain a consistent INR in my experience. And I"ve read the margin of error is +/- .3 so if your reading is close to 1.5 you might not be anticoagulated at all! So now I have a target of 2.0-3.0 and it has been MUCH easier to maintain with the meds.

I don't know much about the ATS, but it sounds like a good optoin. I would go for the quietest valve, though the ticking has a lot to do with body composition. The ticking noise from the mechanical valve has been noticable. It doesn't intefer with life or keep me awake at night, but it is a near-constant presence that takes some getting use to. I sort of like the ticking now. I just wanted to mention it, because I think that is the biggest change you will adjust to with your mechanical heart valve-- you tick tock.

 

[pem]

This is certainly true. Prior to the INR system (early 1980s although I think it was closer to 1990 before it was used locally), the old Pro-Time lab test was much more cumbersom and relied, to some extent, on subjective interpretation and since a single, universal INR number was not generated, it made it more difficult for a patient to follow his/her history. The new system(INR) makes it easy to track your results. I keep a simple log of date, dose and INR in my computer and periodically review my log with my PCP. A good doctor, once he knows the patient is knowledgeable and interested, will encourage the patients input. If he/she maintains a "my way or the highway" attitude, it's time to find a new doc. Like all professions, half the MD graduates, were in the bottom half of their class.....and its usually those, that feel threatened by a patients knowledge.

That all seems reasonable! How often does one check with the home testing? I suppose there's another forum for that, or perhaps a sticky... I think I saw elsewhere, someone seemed strongly opposed to home testing, which I don't understand. If anything, I have heard it is more reliable and results in better outcomes (?)

Thanks,
pem

 

[pem]

Thanks a lot. I really appreciate your feedback on this. Hearing about actual coumadin management as well as specific experience with a particular valve is very helpful. I didn't realize it is more difficult to manage INR in the lower range. In any case, it sounds like you've had good experiences with the On-X, with a little ticking

pem

 

[Gail in Ca]

Some that have chosen tissue for 2nd surgery like to jump all over my comments. I also didn't have major scarring issues with my 2nd surgery. It was the 3rd one that was problematic. And my surgeon is one of the best in the world, thank you. Also, about the 10 yr tissue valve expectancy: I was told this by my surgeon and cardiologist just 2 yrs ago. I recently looked online about tissue life expectancy, looking for the 20+ yrs many here have been told, and I couldn't find anything definitive.
I guess many here think I am trusting my surgeon's opinion too much, but this is his job, and he does alot of redos. When he told me expect about 10 yrs, I asked about all the valves you all think will last so much longer and he kept answering, 10 yrs! This is Stanford, not some Podunk hospital. Of course it will be wonderful if his opinion is proved wrong in the yrs to come, because we all want our valves to last as long as possible. OHS is no picnic. I also wanted to comment about scarring. I have a beautiful scar on the outside, no keloid tissue, almost invisible, so I expected that I wouldn't have much scarring on the inside, either. But, I was off on that, too. All I know is my surgeon was concerned going into this 3rd surgery. I made sure I had a trust made beforehand, because this was the 1st time I saw concern on his face.

 

[pem]

When he told me expect about 10 yrs, I asked about all the valves you all think will last so much longer and he kept answering, 10 yrs!

IMHO, they just don't know yet. The data don't exist yet to support either claim. The Stanford surgeon might reasonably argue that in the absence of new data, we should expect tissue valves to last as long as they always have. But another surgeon might reasonably argue that new advancements in the treatment of the tissue could lead to longer-lasting valves. I am aware of a study that reports a 20-year median tissue life expectancy when implanted in people over 65 years old. When implanted in people under 65 years old, it is closer to 15-years. But they don't stratify it beyond that. I would guess someone my age (41) might get about 10-12 years out of it, on average. But also keep in mind that these are statistics, and individuals can vary greatly from means and medians.

For now, I think we each have to place our bets and our trust where it makes sense to us individually. The good news is that the technology on both the tissue and mechanical fronts seems to be improving, so wherever we place our bets, we're better off now than ever before.

Thanks for your note!
pem

 

[pem]

I am aware of a study that reports a 20-year median tissue life expectancy when implanted in people over 65 years old.

Oops - I meant to say that study was specifically about the Medtronic Hancock valve.

 

[neil]

well said pem.........theres to much negativity on here, agree with you totally both tissue and mech are improving,lets concentrate on the positives,.............right wheres my choclate

 

[pem]

right wheres my choclate

Just had some nice dark chocolate with almonds, myself

 

[mainframe]

well said pem.........theres to much negativity on here ...

Neil, I hardly think that pointing out the fact that many members aren't getting the life expectancy from tissue valves that keeps getting talked about on this forum is "to much negativity [sic]". It's a reality.

I'm just curious. Has anybody on this forum had their tissue valve of any kind last 20 years? I can't remember ever reading this to be true.

 

[neil]

mainframe...........pointing it out.........mmmmmmmmmmmm well that maybe you way of putting it, and maybe you have a point,as i could go on about all the negatives on other types of valves and stuff, who knows whats round the corner for any of us,maybe its my fault for just trying to be positive on all counts,we can all point out the negative stuff,but at the end of the day we are blessed with whatever we choose,i know what you are saying is true but i guess i just believe in looking on the bright side...........

 

[tobagotwo]

I've not seen anything on 30-35 years for a tissue valve. If I were a surgeon, I might be tempted to tell that to all my patients over 90. It could happen, may have even already happened, but it would be an absolute fluke. Certainly nothing to even consider as a possibility for the average patient. A person may be a great surgeon and also be startlingly gullible.

I'm another who's had two surgeries and opted for a tissue valve the second time, too. Different strokes for different folks. The surgery may go very well for you, and it may go poorly. For me, both times I was out in three days. Some folks get to take the shortcut through like me. For some others, complications and weeks in the hospital. You just cannot know. Most are out within a week, some of them with various levels of discomfort and complications (such as arrhythmias, intercostal pain, etc.) There are also issues with health professionals who are ignorant about ACT, and issues with dental work, minor procedures, colonoscopies, etc. The farther away from a city (which provides more choice of professionals), the more difficult it may be to get simple treatments without bridging or lowering your protection.

The stats are still that there is little difference in survival, no matter which way you decide. The odds are slightly better for younger people, probably 40s and below, for a mechanical valve (sheer number of surgeries for tissue valves). Slightly better for older people, probably 60s and above, for tissue valves (additional bleeding risks for coumadin users). And people in their fifties have the Devil in between.

Either choice has good or disappointing aspects. As they are equivalent in survival, my own belief is that you must choose your valve type based on your personality: what can you live with best? Can you deal with knowing you will have another surgery in your future? Can you live with knowing you are dependent on a prescription the rest of your life?

Right now, percutaneous replacement is still somewhat problematic. The valve openings aren't as big, the catheter is "huge" (courtesy of my interventional cardiologist) and very difficult to manipulate without causing damage, the valves often have difficulty being set in place properly or opening correctly, and the clock is ticking the whole time. But the science of it is moving along. They are, so far as I know, all tissue valves at this time.

Best wishes,