Is there even a choice?

[Ovie]

This isn't about mechanical vs tissue, but more or less about mechanical vs mechanical.

Both my cardiologist and surgeon recommended a certain valve for me, I don't remember what kind, or if they both agreed on the same one, probably information I should of remembered, but I think I was just more drowning the sound out because I was in aw at the fact that I had to have OHS.

That being said, information on all mechanical valves can be given, and it appears that there are really only 2 that people go with. But at the end of the day, isn't it really the surgeon who's deciding, since it's most likely he/she knows best?

I'm coming up here quick on what I should be getting, and I don't know how to make a decision? Do I just go with the flow and go with what my surgeon recommends, how did you end up deciding what was best for you? I feel this is possibly one of the most important things going into surgery and I'm completely lost.

Thanks,
Andrew.

 

[epstns]

Ovie, One aspect of the valve choice many of us chose to consider was the question of which valve(s) our surgeons were most comfortable implanting. The reasoning we follow is that if a surgeon has done many, many of Valve A, then he is very familiar with how things should go, how they should feel and what to do if the implant is not going as he feels it should. If the surgeon hasn't used Valve A before, he may miss some important yet subtle clues as to how your implant surgery is going. So, we chose the type of valve (tissue or mechanical) and then consulted with the surgeon to choose which particular make and model of valve to use.

In my case it was easy -- my surgeon had been instrumental in the design of the type of valve we chose, and he had implanted thousands (?) of them before mine. Helped me to get very confident that he knew what to expect once things got going.

 

[Cooker]

I did a little research but ultimately went with mechanical on the advice of my cardio and valve brand on the advice of my surgeon. Valve selection is personal and at times the discussions on valves gets very heated due to folks being passionate about their choice...

In the end I’m sure you will make the choice that is right for you.

 

[sarahsunshine]

Ovie,

I strongly suspect that your surgeons believe what’s best for you. On the other hand, as much as a surgeon can look at your body and decide what’s best, they can’t include things like how great you are at consistently taking your meds at exactly the same time every day…

That is one of the reasons that we picked the On-X (though we didn’t really have a choice, it’s the only kind Skyler’s surgeon will use). Our main reasons were – the chances of possibly getting a low dose warfarin later, the less “sticky” matrix that may allow for more flexibility in case a dose accidentally gets missed (historically relatively common), also because of the shape to stop pannus, and the tested high flow volumes that are higher than other valves of the same size, and lastly because it’s the newest, yet tested, heart valve. If Skyler’s going to have it for 80 years, why should he pick an out-of-date one when there are potential benefits to On-X?

But really, they are all so good these days compared to decades ago, that they will likely have you last long enough to die of something else, and that’s really the most important thing!

 

[nngbwh]

I went with a ST.Jude mechanical valve on the advice of my surgeon. I had emergency surgery the following week so I had no time to prepare.

Make sure you feel comfortable with your cardiologist and surgeon and go with your gut feeling. I knew my surgeon was the right guy for me. Good luck and keep us posted.

 

[ElectLive]

The valve selection situation is a little different for everyone, but generally speaking, most surgeons want and expect patient input into the tissue versus mechanical decision, but once that decision is made, the exact "brand" and "model" of that particular type usually becomes more surgeon driven. Now, with that said, there have been more than a few members here who absolutely wanted a particular brand and fought for it, even a few who convinced their surgeon to use a brand for the first time. I, on the other hand, spent all of my available time worrying about tissue versus mechanical, that I just let my surgeon make the call on the final brand. I was offered two choices, though, and my surgeon did give good reasons why he chose my particular valve over the other. Certainly, asking your surgeon why he's recommending what he is will probably give some reassurance.

There are all kinds of degrees of research you could do, if you have the time and the desire, ranging from literature on individual manufacturer websites (obviously, expect some bias there) to research into FDA approval data on complication rates. Even if you have the time and can make the effort to do all of this, though, will it be conclusive? Probably not.

On-X gets a lot of attention, perhaps deservedly so, perhaps not. Sarah did a good job of highlighting some of the features. Some world class surgeons think/hope it's the best. Other world class surgeons say that currently there is not data to clearly indicate that one mechanical valve (any mechanical valve) is better than any other over time. It stinks that there's not consensus, but it is what it is. But the good news is that all modern mechanical valves are exceptional.

So, whether you go with the flow and let your surgeon choose, or try and get more involved, either way you should take great comfort in the overall performance of all mechanical valves. Plus, once it's your valve, attached to your heart, no matter how the decision was made, it will be very easy to believe it's the best around, that's what we all do.

 

[Mentu]

The Patient's Dilemma

The Patient's Dilemma

The basic problem we all confront is that there is no way for any of us to know that a particular valve type is "the best one for me". There is a lot of convergence in heart valve construction so many of the differences are impossible to evaluate because there is no body of performance records that allow straight forward comparison. In the end, you choose a valve type based upon your special circumstances, your life style, and what will give you the greatest peace of mind. Your surgeon assists in this. Perhaps one question that should be asked is "If you trust this person to hold your heart in his hand, should you not also trust his guidance in valve selection?" Like it or not our surgeon's are the experts and in the time available we cannot become expert. The choice works best, however, if you have done your homework and have learned enough to participate in the conversation when you and your surgeon sit down to make that decision of which valve is to be used. In that conversation, if you have doubts or preferences, it is your time to voice them but in the end you are advising your surgeon not directing him. Once the operation is underway, you must trust your surgeon to do what he believes is best for you. It is necessary to acknowledge that your span of control is limited. There are no back seat drivers in the operating room.

Larry

 

[Shirley Dickey]

I let my surgeon be the one to decide which was best for me...And he did a wonderful job for both surgeries

My aortic valve is a St Jude (tissue) due to other health prob. that prevented mechanical at the time of surgery in which my surgeon said was the best for me at that time.. However when it came time for the MVR surgery my surgeon went with On-X due to the fact that previous health prob fixed I could have mechanical now and I grow scar tissue like a factory and he said that the scar tissue would not build up on the on-x like it did on my avr which is why I had to have a double bypass at the time of mvr..Anyways he made the right choice for me and my body after taking many things in to consideration. He has implanted all kinds of valves tissue/mechanical in people of all ages from babies to older people and many in betweens and he seems to know which ones to use on who and at what times to use them...

 

[onxvalvefan]

Ovie

All of the replies to your post so far are right on. When you are looking at mechanical valves there are basically three things to look at; flow pattern and rate, pannus growth potential, and whether or not you will have to be on coumadin for life.

I need to be ultra clear on the next point. It is up to you which valve you use. The surgeon can choose whether or not to use the one you want and if they don't like your choice they can refer you to a surgeon that implants your choice. My original cardiologist wantd me to use a St. Jude valve but after a huge amount of investigation I went with an ON-X valve. I also had to find a new cardiologist, surgeon and hospital.

One other thing to consider, strictly from vanity perspective, is that the ON-X valve is quieter than the others. You're going to be able to hear a clicking sound with any you use but the ON-X is a little less noisy.

Good luck with everything and I hope your surgery goes without a hitch!

 

[Luana]

I wouldn't get too attached to one particular valve over another. I was supposed to get an On-X valve, but it was not fitting right in surgery, so got a St. Jude instead. I may be one of few that this has happened to, but I would trust the surgeon to do what's best for you.

 

[Tom Berning]

Both of the surgeons I interviewed said they thought most of the mechanical valves were very similar. The surgeon I ultimately chose said he thought the On-X aortic valve did have slightly better flow, but if he had to implant a valve/conduit combo he liked the St. Jude version better. You do really want your surgeon installing a valve that they are very familiar with and have used many times before. My On-X is pretty noisy so far at 8 weeks. IMHO On-X has a very aggressive marketing dept so don't get sucked in by all the advertising claims.

 

[RealtorRick]

I agree with Tom. When my surgeon saw MRI's that indicated I might need a conduit, he said St Judes was his recommendation. When he opened me up, he confirmed that I needed a conduit and I got a St Judes Masters 33mm with a dacron aortic graft. I hear the valve very clearly at certain times and hardly at all others. I am less than 4 weeks post op and fell great. Coumadin has not been an issue and the local clinic is near my home. A little finger prick and 10 seconds later the INR is read and I get my dosage for another week. I do not record my diet, only think every other day to eat a salad or green veggies. I looked up vitamin K levels of foods and decided if I stayed away from the real high ones it would be easier.

 

[OldManEmu]

My first surgery was ever only going to be short term as my heart function was to poor to have a reasonable chance of surviving an ascending aorta repair so a straight AVR with a tissue valve was done to allow my heart function to recover; a redo was triggered by the aortic aneurysm crossing 5cm. The second surgery I made the decision between mechanical or tissue, however left the decision of which make of valve to the surgeon.

 

[Madsometimes]

Before my operation, my surgon discussed tissue vrs mechanical with me. She felt mechanical would be best for me, because I am 39 and have completed my family. We didn't discuss brand at all. I felt that was something for her to choose. I was quite surprised when I found that I had an ATS valve, I had never heard of that make before. In a similar way, I did not discuss what brand of pacemaker I had fitted, hoping that my doctors would make the best choice for me.

 

[Ovie]

I have complete faith in my surgeon, after talking to a couple cardiologists I was so overwhelmed, they made it out to just be horrible, so for 2 months I felt like I was just watching the clock count down to something terrible. Than I met my surgeon in person, Dr. Burkhart at Mayo, and he didn't sugar coat anything, he was direct, exceptionally knowledgable, and even had a little sense of humor, but came out of the consultation extremely confident and more at ease. So I knew just about right away that he was the one.

I was fortunate enough to find someone on this site that had the same surgeon as I'll have and have heard nothing but great things. Also reading articles on him helped.

I'm 25 so that's why I'm being pushed towards mechanical, obviously if I wanted a tissue valve I think I could get it, but I think I'd rather take my chances at not having to go through this again, or at least hopefully not for awhile. But the day before when I meet with him I'll be sure to ask about the valves. This is a scenario where I don't feel bad for talking or asking too many questions on the matter because I think I have the right to know everything I can obtain.

With alot more knowledge from this site I have a better understanding of what to ask and maybe understand more of what he tells me. Thanks for the replies.

 

[Lynlw]

Ovie

All of the replies to your post so far are right on. When you are looking at mechanical valves there are basically three things to look at; flow pattern and rate, pannus growth potential, and whether or not you will have to be on coumadin for life.

I need to be ultra clear on the next point. It is up to you which valve you use. The surgeon can choose whether or not to use the one you want and if they don't like your choice they can refer you to a surgeon that implants your choice. My original cardiologist wantd me to use a St. Jude valve but after a huge amount of investigation I went with an ON-X valve. I also had to find a new cardiologist, surgeon and hospital.

One other thing to consider, strictly from vanity perspective, is that the ON-X valve is quieter than the others. You're going to be able to hear a clicking sound with any you use but the ON-X is a little less noisy.

Good luck with everything and I hope your surgery goes without a hitch!

I just wanted to say the ON-X valve is not always quieter than other mech valves, as with all things you'll never know until after surgery how loud your valve is, but some people have valves of every brand either very loud or very quiet. There also are people whove had different brands of mech vales and their ON-X valve was louder than their older one.

 

[Gail in Ca]

I have had 3 surgeries, and I think, ultimately, it is the surgeon who decides what you get once he gets in there. My 1st surgeon, Dr McFadden, wanted to give me porcine along with a dacron graft, as I was only 34 and he thought I might want another child. He did present my case to a round table of surgeons at Stanford and told me it was 50/50 as to how they all felt about giving me tissue vs mechanical. I didn't know much about valve choice since it was my 1st surgery. So, 11 yrs later, I needed another surgery to replace the porcine. My surgeon, this time Dr Miller, world renowned surgeon, basically told me my only real choice was mechanical due to my age,46 yrs. I was fine with his choice. All was going well for 8 1/2 yrs til I got bacterial endocarditis, and had to have another surgery to replace my mechanical and repair/replace my mitral, both had been screwed up due to the bacteria. I again went with Dr Miller. He came in to talk about my choices as I was then 54. He said he would use a St Judes mechanical, and would try to repair the mitral. However, when he got in there I might need a homograft to replace the aorta and old dacron graft if my tissue was too badly damaged by the staph and wouldn't accept a mechanical. I did get the feeling that I could've chosen the homograft if I had really wanted it, but he said to only expect 10 yrs out of it. In surgery, he found he couldn't use the St Judes which was already sewn into a graft, it wouldn't be the right fit for where he wanted to place it. He had to create a back table valve inside a graft to the specifications he needed. He used a Carbomedics top hat valve. I feel fine about leaving this important stuff to the surgeon. He knows what he's doing and I trusted him completely! I know how you must be feeling. The first surgery seems like it can't be really happening until it does, then you know so much more than you did before. Best to you!

 

[Bill B]

Everybody here has been confronted with the valve choice issue and almost everybody here does not have the training or expertise to evaluate the marketing claims and clinical data available to really make an educated choice. You do have a choice. Some surgeons leave the choice TOTALLY up to the patient with very little professional input. In most cases surgeons have a preference, often a strong one. What you will find is that equally qualified surgeons have totally different preferences. So, who is right? The guy at the Cleveland Clinic or the one at the Mayo who would use totally different approaches? Which is the best valve? Should you alone make that determination? That's a heavy burden beyond nearly all of us, no matter how much medical knowledge and smarts we may think we have and I suggest you might as well use a Ouija board.

I went through the On-X data as carefully as I could before surgery and came to the opposite conclusion of "onxvalvefan". A good number of On-X recipients do not find the valve particularly quiet and some complain about it here. In fact, On-X's only actual study published on this subject found no difference at all between the SJM and On-X valve. Here's a link; see for yourself. http://www.ncbi.nlm.nih.gov/pubmed/10616244. 34 patients with SJM or On-X valves were assessed for perceived audio level. There was no statistically significant difference in perceived sound from the two valves. My SJM valve happens to be very quiet. Go figure.

At this point there is no published information on potentially no or low warfarin requirements and the press releases about the trial in progress, a process which brings up some ethical and trial integrity issues, were worded so circumspectly they raised more questions than they answered.

I read and reviewed nearly all of the professional references On-X provides on their website: http://www.onxlti.com/heart-valves/medical-professionals/references-and-bibliography/. You can see my comments here: http://billsworkshop.com/Some_AVR_lit/On-X refs.htm My basic conclusion is there is very, very little published data to substantiate any of their marketing claims. Does that mean it's a bad valve? Of course not, but most of the claims of superiority still remain to be substantiated. Having spent 30 years involved in "big pharma", I learned to have a substantial suspicion of all company marketing claims about the superiority of their products. In the end I concluded that like most of the medical literature, the data comparing valves is so lacking and unclear, that it is rather useless to surgeons, let alone mere mortals undergoing surgery.

Ovie, find a surgeon you can trust and ask him to help you make this decision. You do have a choice. My surgeon had a very strong preference, but he opened up the can of worms by adding he would implant any valve I wanted. He thought I was smarter and had a lot more medical expertise than I have. I went on a several month search of the literature before I finally saw the light and went with his recommendation.

 

[normofthenorth]

Ovie

All of the replies to your post so far are right on. When you are looking at mechanical valves there are basically three things to look at; flow pattern and rate, pannus growth potential, and whether or not you will have to be on coumadin for life.

I need to be ultra clear on the next point. It is up to you which valve you use. The surgeon can choose whether or not to use the one you want and if they don't like your choice they can refer you to a surgeon that implants your choice. My original cardiologist wantd me to use a St. Jude valve but after a huge amount of investigation I went with an ON-X valve. I also had to find a new cardiologist, surgeon and hospital.

One other thing to consider, strictly from vanity perspective, is that the ON-X valve is quieter than the others. You're going to be able to hear a clicking sound with any you use but the ON-X is a little less noisy.

Good luck with everything and I hope your surgery goes without a hitch!

Like Lynn, the one claim I'd NEVER heard for the On-X valve before -- from On-X or anybody else -- is that it's the quietest mechanical valve. In fact, I've seen it compared to others in a few studies, and it seems not to be the quietest. In virtually all the studies, the quietest is made by Medtronics, with a name something like the ATS Free Pivot. If you start at the Medtronics site, you'll find a number of fairly solid documents -- including referreed articles and official submissions to the US FDA for licensing -- that suggest that the ATS is superior to the On-X in a number of other ways as well. That even includes anti-clotting, an area where On-X is often granted superiority on this forum and elsewhere. We've had some lively discussions here about how to read the evidence, etc.

But again, I've never even heard or seen anybody claim that On-X was the quietest until I read that claim right here. (And we've had some bloggers here who were very frustrated with how loud their On-X valves were, too, though that's just anecdotal.)

Do you have a source for the claim, onxvalvefan?

 

[Ovie]

@Bill B.

I've met my surgeon once, and came out of the meeting feeling very good about it. Unfortunately I'm 2 weeks out from my surgery, I'm going to try and dig into information on both and get what I can. Correct me if I'm wrong, but what i got out of everything other than, yes it is my decision, and that there is really no proof of a superior valve. It's just like everything else that's advertised, it's more of a marketing skeem between valves, just as if Wendy's says their fries are good, but Burger King says they're better. Which I believe to make sense considering in this modern day age everything is marketing tactics, why should the medical field be any different.

Now that being said, I also got that different valves work for different people. I'll end up speaking to the surgeon the day before and ask his opinion on both, and why he feels the way he does about the particular one he wants to use, and go from there, but I trust him. I also see my cardiologist, Thursday..so I'll get his input also.

BTW, if I went the completely wrong way on what you were explaining, I do apologize, I'm new to this matter if you couldn't already tell