Getting a tissue valve...which one?

[oscarsonthepond]

My wife and I have decided that she'll be getting a tissue valve for a variety of reasons (please no debate over tissue vs. mechanical). My question is, which is the latest/greatest one? I just watched that Ross Procedure video which is only a year or two old and they seemed like they were really big on the Mosaic valve. Any opinions would be much appreciated. If it matters, my wife is 23 years old, it's her pulmonary valve being replaced, and we plan on having a couple more kids. Also, we're meeting with the surgeon on Wednesday, so I know we'll have a lot better idea after talking to him...but just wondering if anybody has any suggestions so we can go in asking about particular valves? I know St Jude's, Edwards, and Medtronic are all options....and then I know there are many valves manufactured by each of them. Is it just anybody's guess as to which will be the best since not all the data is there? Or are some better for certain situations? Thanks in advance for the responses.

 

[Lynlw]

welcome, does your wife just need her pulmonary valve replaced, or does she have one of the CHD repairs that also has a conduit? My 17 year old son had his pulm replaced in 05 and got a carpentier edwards bovine valve but his is in his dacron conduit. I don't know if you are aware, because i wasn't when i first started looking but usually the pulmonary valve is replaced with a valve made for the aorta. do a search here for CE perimount valve and there is quite a bit of info on them, Lyn

 

[geebee]

Hi,

I think you will find that there is never a debate on valve choices with those who have made their decision as you and your wife have. Congratulations on getting to that point. The fact that you want more children pretty much rules out a mechanical anyway.

My understanding is that a pulmonary valve replacement will last much longer than a mitral or aortic so your wife is lucky from that standpoint.

I am partial to St. Jude since I have their mechanical so feel confident of their quality. I have a couple of friends that have St. Jude tissue valves in various positions.

I am sure you will hear more information soon but I am also sure your surgeon will have some thoughts as well. Go in armed with your research but be sure and take advantage of his experience.

Best of luck to your wife and you as well.

 

[oscarsonthepond]

She just needs a PVR as far as we know. We're doing a cath on tuesday so we'll find out for sure if there are any other problems, but she needs a PVR as a result of repair of pulmonary stenosis 20+ years ago.

 

[Lynlw]

She just needs a PVR as far as we know. We're doing a cath on tuesday so we'll find out for sure if there are any other problems, but she needs a PVR as a result of repair of pulmonary stenosis 20+ years ago.

Ok, since her surgery was for PS and no other chd then I would e pretty sure she doesn't have a conduit.
I believe one of the newer/improved valves is the CE perimount magna here's a link to their site, http://www.edwards.com/products/heartvalves/magna.htm
I don't know if you would be interested but there is also a great forum at the Adult w/ CHD org http://achaheart.org/ you have to register (it's free) but there are quite a few members in their 20's and 30's that post.
so between the 2 groups there is a lot of knowledge and support.
I'm just curious, since it is a newer field, but does your wife go to a doctor that specalizes in adults with CHD?
Lyn

 

[oscarsonthepond]

I'm just curious, since it is a newer field, but does your wife go to a doctor that specalizes in adults with CHD?
Lyn

Not currently...you had recommended it to me before. We might get a second opinion from one, but at the same time we really like our current cardiologist and out of the dozens of doctors we've seen we trust him pretty much more than anybody else. Having said that, we will likely get a second opinion either from another cardiologist (one at an ACHD clinic) or from a surgeon who specializes in valve jobs.

 

[Lynlw]

I was just rereading your post from a few months ago, you had afew questions, were you every able to get them answered? if not ask away maybe someone can help, lyn

 

[oscarsonthepond]

Yeah some of them have been answered (mostly by you - thanks! - most people don't seem to know much about pulmonary problems since it's not all that common). Also we've figured out some answers through talking to our doctor and doing other research. Of course with each answer comes many more questions. Our big issues now are:

1) Making sure 100% we want the surgery, even though we're not sure her
symptoms are being caused by her heart problems. We were set on it until our cardio told us he wasn't sure that he'd get it if he was in our position.

2) Getting a second opinion, and by whom.

3) Picking a surgeon - right now it's between the one who our cardiologist always works with and highly recommends and who's been on his own for 9 years and the one who is an hour away, our cardio doesn't know much about, has only been on his own for three years, but was the chief resident at John's Hopkins and whose first interest on CTSnet is "xenograft and homograft valve replacement" (which is what she'll be getting). Right now I'm thinking we'll just stick with our cardio and get a consultation from both surgeons to make sure they both recommend the surgery and to figure out which one to go to.

4) Picking which tissue valve.

 

[Lynlw]

me again, I'm not sure if you are talking about surgery right away or in the future, but if it is a future thing, I would ask was her pressure gradient is, or what the pressure in the right ventricle is, that is what we followed for Justin to decide when it was time for surgery or an intervential cath. also sorry if I am confusng instead of helping, I saw in your first post you were waiting for her old records to see exactly what your wife's CHD/repair was. Do you know if they replaced her pulmonary valve when they did her first surgery as a baby or left it out? I know that since the pulmonary valve is the one valve you don't necessarily "need' alot of tmes they didn't replace them, Justin didn't have a pulmonary valve until ast year, snce he needed surgery anywa and was close to full grown, he hasn't had one since his surgery at 18 months, Lyn

 

[oscarsonthepond]

You're not being confusing at all...this is all *very* helpful. When she was younger they just repaired it not replaced it....she has a valve, it was just stenotic. I don't know what exactly they did to open it up, but they did do OHS. I asked the cardio about the pressure gradient (although the first time I asked I couldn't remember what it was called so I sounded really dumb and just said 'is there something that we should be watching for that should be under 65'? ) and he said we'll find out on tuesday after the cath what it is. He said he doesn't expect it to be as high as 65, but it will probably be higher than it should. I've seen others post who said 50 is a point at which some doctors suggest replacement as well. We'll see what happens.

 

[Lynlw]

that sounds like a good plan, I hope you get clear ct answers not those iffy ..well you can now or you can wait type of things. Feel free to email me at anytime if I can help w/ anything [email protected] sometimes when i'm not online as much, i still check at least my email a few times aday, just put vr.com in the subject. i'll keep you in my prayers, lyn

 

[tobagotwo]

There are actually three tissue valves that I would consider, were it for myself or my wife.

One is the Edwards bovine pericardial line (Carpentier-Edwards Perimount series). It has a long-life pedigree that is hard to match in tissue valves. There are a variety of them to chose from. so your wife's needs can be accommodated. It's a stented, manufactured valve, stitched together from the tough tissue that surrounds a cow's heart, which apparently is quite naturally resistant to calcification to begin with. The Magna is the current favorite among the CEPs, but I am unsure if its mounting technique works the same in the pulmonary position. http://www.edwards.com/products/heartvalves/perimountaortic.htm

Another is the Medtronics Mosaic, which has been referred to as the Cadillac of biological valves. It's the most expensive of the lot, due to the care required in its processing. I have one in my aortic position. It's a complete, natural porcine valve, thin-stented for shape and attachment. It hasn't been in circulation (sic) for as long as the Edwards valves, but is also expected to have a long useful life. http://www.medtronic.com/cardsurgery/products/mosaic_index.html

The third is the Medtronics Freestyle, which is a stentless porcine xenograft that would be individually styled to fit your wife during the procedure. This valve includes the root it's attached to, so a stent is not required to help it hold its shape. This generally improves bloodflow through the valve. Again, it hasn't been around as long as the Edwards valve, but is expected to have a very long useful life. (A very similar type called the Toronto SPV has a 15+ year average useful life, without anticalcification treatments.) http://www.medtronic.com/cardsurgery/products/free_index.html

All three of the valves above have anticalcification treatments and special fixation techniques that avoid damaging the tissue of the valve when curing them. Any of them would be an excellent choice.


PLEASE NOTE:

I've had to update this, because I note that the St. Jude Lynx anticalcification treatment is now available on some of their tissue valves in the US. I can't speak to their expected longevity yet, because I don't have enough information. However, St. Jude's porcine valves did not have as long a life as their competitors before anticalcification treatments were involved. Their lackluster earlier performance would make me lean toward the more established current-generation brands above until I could find something that would dispute that. The Toronto Stentless Porcine Valve is also sold by them, but doesn't boast anticalcification treatments. (St. Jude does have one interesting "mixed grille" type biological valve in Europe that may debut stateside soon, but it's not approved here yet.)

Best wishes,

 

[Lynlw]

sorry hijacking

sorry hijacking

Bob, I just want to thank you for all the research you do and not only your willingness to share, but ability to write things that make it easy to understand. I have learned more about individual valves from you than anyone else, I call you my valve guru, Lyn

 

[oscarsonthepond]

Lyn - thanks so much for the help - I may take you up on your e-mail offer at some point and I really appreciate it!

Tobagotwo - Thank you! That is exactly what I was looking for! We'll talk w/ the surgeon about those options on Wednesday.

 

[Keithf]

Expected lifespan for Medtronic Freestyle tissue valve?

Expected lifespan for Medtronic Freestyle tissue valve?

Does anyone know of any studies that can guess at the lifespan of the Medtronic Freestyle valve? I've looked and don't find anything.

In contrast, it's pretty easy to find curves showing the expected lifespan for the Carpentier Edwards valve.

Thanks!

 

[tobagotwo]

The reason for that is that the direct predecessors to the CEP valves have been in production longer. You can't give 20-year statistics for a valve that hasn't been out for 20 years. Note that the 20-year CEP statistics are based on the valve before Edwards added their anticalcification and tissue-preserving fixation processes.

The functional parts of the Freestyle are basically the same as the Toronto SPV, a valve that has been in production for a long time (sold by St. Jude). The TSPV has a useful life of over 15 years. However, the Freestyle has more aorta available with it, and has anticalcification treatments and a non-damaging fixation process that the TSPV doesn't claim to have. Its predecessor, the Hancock II, shows over 80% still implanted after 15 years without valve breakdown. The Hancock II is not a one-for-one with the Freestyle as the CEPs are to the CEPM, but they are the same tissue from the same company and have the same treatments and fixation techniques. The freestyle has a lower pressure gradient and no flow obstructions, being non-stented, so there is reason to feel the valve leaflets should last longer. The Mosaic and the Freestyle are Medtronics' top-of-the-line valves because their expectations for these two valves are very high.

Best wishes,

 

[oscarsonthepond]

Just got back from first consultation w/ a surgeon - we loved him! I was expecting, however, that he would recommend either the Perimount or the Mosaic. Instead, he very much suggested a homograft. I asked him about a backup just in case something was wrong w/ the homograft, etc. and he said that they use Medtronic valves and that he would use a Freestyle in that (unlikely) event. I'm sure I've seen some studies showing that homografts need replacement sooner/more frequently than xenografts (at least I think I remember seeing them), but I do know that for the pulmonary valve they always use a homograft for Ross procedures. Anybody have any info/data/suggestions on xenograft vs. homograft for pulmonary valve replacement?

Thanks in advance,
Blake