Going forward?????

[Gazza01]

Hi Gary - just contact Ms Yadav's secretary as the card is quite important as it will give the model number and serial number of your valve, all valves have a unique serial number for reasons of traceability. If the secretary doesn't have the card she should be able to find the model and serial numbers and then you can register the valve with Edwards Lifscience as when you say Perimount that tells us it's one of their valves: Implant patient registry | Edwards Lifesciences

Great thankyou so much.

 

[pellicle]

However, the likelyhood that we'll still be using the same tech 20 years from now is very low."

interestingly Dr Schaff makes the point in his lecture that its unlikely any company will do any additional research in the mechanical valve area. What happens in tissue valve is anyones guess, but what I see is that we are reaching an asymptote where developments are tapering off and indeed longer duration seems to be disappearing with a focus on TAVI valves now (makes the valve maker more money too) which have lower duration than any existing top flight bioprosthesis.

 

[pellicle]

Good morning (from Australia)

However, one thing struck a chord with me which has bothered me since.
if this valve lasts 10 years, and so does the next one. Well then that’ll mean having my chest cracked open in my mid 70s. If I should be lucky enough to get to that age of course.

appropriate concern .... but first let me take a step back to your earlier comment about the views of the surgeon.

My present thinking on that is that surgeons have to think statistically, for they don't know you. They specalise in Surgery not post surgical management. They genuinely don't see past 10 years because statistically that's fraught. If you look through my blog post here
http://cjeastwd.blogspot.com/2014/01/heart-valve-information-for-choices.html
you'll see some graphs like this one:

Note the years on that scale.

This is not unusual, and as you begin your research into what to do next (which should be a casual affair because you should have about a decade to need to do anything about it) you'll begin to see a pattern: Bio-prosthetic valves last longest in the oldest, who (because of age) statistically don't need the valve to last beyond 15 years.

I'm currently 57 and 15 years is on the edge of where I may live to. Back when I was 47 that would see me being concerned about this before I get to 67.

So I see your point.

Getting back to surgeons and thinking statistically, they know the stats on the surface like the back of their hand: things often don't go well for mech-valvers for the primary reason of drug compliance (they don't friggin take it) and crappy INR management (putting them at risk of harm from bleed events or clotting events. I'll come back to that).

Accordingly they look at the data surface (because digging into the psychology and mechanisms of change in INR management clinics) is not their speciality.

It can however become the patients speciality if they so choose. Personally I take my health seriously and as I once put lots of effort into things like exersize, diet, safety (at work and in recreation) I now put effort into INR management. You'll see that mentioned in that blog post too.

What we don't know so well is what the age distribution of that set of "incidents" is (because the stats choose not to present it and because there are statistically so few under 50yo patients managing INR let alone self managing INR) ... although we do now know the INR distributions of that. This graph shows where the danger areas are:

and its well known that keeping inside that green zone that you have about the "normal" level of risk.

That is the nub of the matter pure and simple: keep in the green and get a valve that will never fail and you can minimise the requirement for reoperation.

Your situation is complicated by the situation you are in and so you are not making that choice (yet).

As I see it you need to gradually and carefully evaluate the risks of the various choices which are before you. Your options of TAVR may or may not pan out as described (for many reasons, not least of which may be your own situation at that time). By that (hopefully distant) time you will have acquired the knowledge you need to make a decision which you are comfortable with on what to do then.

Or I opt for OHS again and have a mech valve, in which case I surely would have been better off having that in the first place. Any thoughts please.

hope that helps

 

[Gazza01]

Good morning (from Australia)


appropriate concern .... but first let me take a step back to your earlier comment about the views of the surgeon.

My present thinking on that is that surgeons have to think statistically, for they don't know you. They specalise in Surgery not post surgical management. They genuinely don't see past 10 years because statistically that's fraught. If you look through my blog post here
http://cjeastwd.blogspot.com/2014/01/heart-valve-information-for-choices.html
you'll see some graphs like this one:

Note the years on that scale.

This is not unusual, and as you begin your research into what to do next (which should be a casual affair because you should have about a decade to need to do anything about it) you'll begin to see a pattern: Bio-prosthetic valves last longest in the oldest, who (because of age) statistically don't need the valve to last beyond 15 years.

I'm currently 57 and 15 years is on the edge of where I may live to. Back when I was 47 that would see me being concerned about this before I get to 67.

So I see your point.

Getting back to surgeons and thinking statistically, they know the stats on the surface like the back of their hand: things often don't go well for mech-valvers for the primary reason of drug compliance (they don't friggin take it) and crappy INR management (putting them at risk of harm from bleed events or clotting events. I'll come back to that).

Accordingly they look at the data surface (because digging into the psychology and mechanisms of change in INR management clinics) is not their speciality.

It can however become the patients speciality if they so choose. Personally I take my health seriously and as I once put lots of effort into things like exersize, diet, safety (at work and in recreation) I now put effort into INR management. You'll see that mentioned in that blog post too.

What we don't know so well is what the age distribution of that set of "incidents" is (because the stats choose not to present it and because there are statistically so few under 50yo patients managing INR let alone self managing INR) ... although we do now know the INR distributions of that. This graph shows where the danger areas are:
View attachment 888106
and its well known that keeping inside that green zone that you have about the "normal" level of risk.

That is the nub of the matter pure and simple: keep in the green and get a valve that will never fail and you can minimise the requirement for reoperation.

Your situation is complicated by the situation you are in and so you are not making that choice (yet).

As I see it you need to gradually and carefully evaluate the risks of the various choices which are before you. Your options of TAVR may or may not pan out as described (for many reasons, not least of which may be your own situation at that time). By that (hopefully distant) time you will have acquired the knowledge you need to make a decision which you are comfortable with on what to do then.



hope that helps

Thank you very much for taking the time. Very interesting. Time will tell.

 

[carolinemc]

Hi Gazza and welcome to the forum.

You ask good questions and yes, you will face reoperation- almost certainly more than one reoperation. It is for this reason that most guidelines call for a mechanical valve if the patient is under 60 years old.

" Or I opt for OHS again and have a mech valve, in which case I surely would have been better off having that in the first place"

This is a possibility, but whether this is the best option will largely depend on how long your tissue valve lasts. If it lasts far longer than average- say 20 years, then perhaps you consider going tissue again. If it only lasts another 4 years, then maybe going mechanical is a reasonable choice to discuss with your cardiologist.

Having said that, it would be best to just to enjoy life and not worry about this until the imagery indicates that the time is approaching for your next procedure. Perhaps you are one of the fortunate ones and that date is many years away. It really does no good to worry now. However, it is good that you do due diligence, as you are, so that you come into the situation with some foundational understanding of the pros and cons of the choices before you when the time comes.

I have the St. Jude's leaflet valve for the last 20 years this month. No problem adjusting to the warafarin and still alive. The Bovine valve are not as recommended these days since much research has been done for the alternatives. Best choice, Mechanical valves, which last more than ten years and reoperation rates are lower. Might discuss the changes with the Cardio Surgeon. Good luck at least you have a choice this time.

 

[Chuck C]

interestingly Dr Schaff makes the point in his lecture that its unlikely any company will do any additional research in the mechanical valve area.

longer duration seems to be disappearing with a focus on TAVI valves now (makes the valve maker more money too)

It is very understandable from a business standpoint. Why invest in one and done technology, when TAVI and other tissue options offer repeat customers? Thus, investment and advertising dollars will continue to flow in this direction.

 

[Michael O]

The Bovine valve are not as recommended these days since much research has been done for the alternatives. Best choice, Mechanical valves,....

Note carefully that this is only true for people who do not expect to have additional major surgeries post-OHS. There are absolutely good reasons to get tissue valves.

 

[Chuck C]

There are absolutely good reasons to get tissue valves.

Very much true. Many reasons to choose a tissue valve, some of the reasons being: age, anticoagulation contraindication, female who is still in child bearing years and plans to have children, professional athlete in a contact sport who wishes to continue after recovery, likelihood of future OHS reoperation for another reason or if the patient for some reason is unlikely to be compliant with taking warfarin.

 

[pellicle]

Very much true. Many reasons to choose a tissue valve, some of the reasons being: age, anticoagulation contraindication, female who is still in child bearing years and plans to have children, professional athlete in a contact sport who wishes to continue after recovery, likelihood of future OHS reoperation for another reason or if the patient for some reason is unlikely to be compliant with taking warfarin.

pretty much the perfect summary