Just One Study (Of Many), FYI

[Superbob]

I happened across this study on the American College of Cardiology site. I was surfing just wondering what latest research might say about life expectancy of my porcine valve/root, which is going on 12 years. I decided to post it here as just another perspective in the ongoing mechanical-versus-tissue debate (or discussion or dilemma -- the bottom line being that you are better off no matter which one you choose -- and it is a very personal decision). So I am in no way presenting this as a game changer. I am sure others here have experiences and can cite research pointing in a different direction. Just thought I would share this, instead of keeping it to myself.

http://www.acc.org/latest-in-cardiol...-young-patient

 

[pellicle]

Thanks Bob

always good to have more (than less

However its important to read that carefully and recognise that they themselves say that what they wrote is an alalysis of other studies, not a new study. They also acknowledge that their data is based on older studies. They have a few premises in there which I myself don't adhere to:

For instance:

.... This is particularly important to young patients as earlier years of life are generally valued more than latter years. It may be more valuable, for example, spending the fourth and fifth decades of life, when most adults are in their prime, in excellent health free from anticoagulation, even if it meant having fair or poor health or reoperation when they are 60, as opposed to being in a fair state of health from age 40, with requirement for daily anticoagulation and attendant risks, and remaining so for the rest of their life. Most young people would rather spend their prime years free from illness, obligatory medications, and hospitals. The low event rates with biologic valves therefore make them desirable for the young patient wishing to maintain health and independence for another decade or two.

This seems to be saying "trade off good health now for worse health in your later years".

They make fair points that low event rates of bioprosthetic valves make them more desirable for people in their 40's. Myself I'd think that for a first operation as young as mid 40's its hard to discount biological prostheses from the choice.

So as long as its read carefully with those assumptions of authors viewpoint in mind.

 

[dick0236]

After reading thru this study I could, personally, take issue with much of it.....but long posts are not one of my things. I find one of their points interesting when they compare "re-ops" of 60 year olds.....and state that most 60 year old tissue valve patients will not need a reop since valve life is 15 years and life expectancy is only 12 years for this age group.....thereforea re-op is not likely to be needed before death occurs. That seems to go against what valve patients are being told......most of us expect to live a normal life span.....and some of us already have.

I do agree with the first 5 to 6 lines of the article......mechanical for the young and tissue for the old.

 

[MethodAir]

Confusing and misleading article for the most part. Clearly, their argument is motivated by economics.

In contrast, mechanical valves are associated with a reoperation rate of 0.6% per year, bleeding rate of about 1.5% per year and thromboembolism rate of 0.6% per year – in a young patient this amounts to over 20% risk of major complication in the first decade post valve replacement.

Put more accurately, it averages out to a less than a one percent chance of a negative event per year. And bleeding/thrombotic events will be lower for those who manage warfarin effectively.

It may be more valuable, for example, spending the fourth and fifth decades of life, when most adults are in their prime, in excellent health free from anticoagulation

Ridiculous to suggest you can't be in excellent health with coagulation therapy.

One aspect that has not been studied is potential economic impact of prosthesis choice over the first decade.

Warfarin therapy costs next to nothing.

Redo AVR is as safe as primary AVR

No, with increased surgery comes increased risk.

Complications specific to mechanical valves are more devastating than complications specific to biological valves

If a tissue valve suddenly breaks (I've heard numerous accounts of leaflet snaps etc), it is a very serious situation.

The negative impact of mechanical valves on day to day quality of life is significant but understated

Highly exaggerated. It is transparent in my lifestyle. When I'm about to have private time with a new woman, there is a conversation about the mechanical valve. It is weird at first to hear it, but that goes away as the night progresses.

The more I hear about the medical industry, the more I shake my head.

 

[Paleowoman]

I thought the article was rather confusing too. I especially noted this:

"The life expectancy after valve replacement varies with age, but life-table analyses of large datasets suggest the average life-expectancy of a 60 year old after aortic valve replacement is about 12 years"

12 years is neither the average life expectancy nor the valve's life expectancy (12 to 15 years and sometimes longer, the 12 years was minimum and then to have re-do, not death) that I was quoted nor would expect. I was unable to access the article from which that quote was taken. You have to wonder why the patients needed aortic valve replacement in the first place, whether they were ill or unfit in some way, whereas generally pateints with BAV are fit, especially if the BAV is replaced before health has deteriorated.

PS I was 60 when I had my AVR - should have explained that and the significance of that life expectancy quote !

 

[epstns]

The other thing that the articles don't seem to consider (unless I missed something) is that the life expectancy of people, in general, has lengthened. IIRC, the current life expectancy of an American male now in his 60's is somewhere around 82 or more. If that is the case, and a patient like myself has a valve replaced while in their early 60's, what then? None of the statistics I've seen say that I would definitely need another replacement. . . only that some patients in my cohort will. Much of what is published, and even pushed out to patients, has to do with averages. In my limited experience, few of us are average.

 

[Superbob]

You guys and gals are astute. It would be well if some of these studies had to go before a vr.org review panel before being published. I came across this study -- or study of studies -- when I was in a semi-freak-out mode from feeling some mild twinges in area of my replacement device. (emphasis on mild -- probably just normal strains.) And yes reading those numbers on "average" expectancies didn't help calm me. I appreciate Steve's reminder that few of us are "average." Still, given the possibility that I might out-live my Freestyle, perhaps I should start touching bases with my original surgeon to see if he could or would do my re-op if I need one at some point.

I had planned just to post the paper for whatever value it might have, and not weigh in further. But I just wanted to say, I appreciate your analysis and comments.

 

[JulienDu]

I agree with everything that is being said above

I see 2 main issues with those studies Mech Vs Bio

-They usually do comparison over a period of 10-15 years. So they usually do not include the compulsory redo that a Bio Valver will face. A guy like Dick0236 can not even be on those stats.

-They say that mortality of a Redo is the same as a first OHS. Well maybe but they do not say that with a redo, you increase your chance of having a pacemaker, an infection, damage to your sternum, neurological damage, strokes. Also they do not mention the 6months to 1year and half reduced quality of life following an OHS ( they never talk about that). So I find funny when they say that being on AC Therapy reduces someone quality of life and do not talk about the dramatic side effects that a Redo could imply on someone quality of life...

Put more accurately, it averages out to a less than a one percent chance of a negative event per year. And bleeding/thrombotic events will be lower for those who manage warfarin effectively.

Yeah exactly.

In my job I have 5-10 percent chance per year of being disabled so possibly 100 percent chance at 10 years ( damn I am not disabled) if we follow the way they do math...I did not study much but this looks like Kinder Garden Maths.

 

[Superman]

In contrast, mechanical valves are associated with a reoperation rate of 0.6% per year, bleeding rate of about 1.5% per year and thromboembolism rate of 0.6% per year – in a young patient this amounts to over 20% risk of major complication in the first decade post valve replacement.

Maybe I missed something in statistics, but it has always been my understanding that this type of measurement is not cumulative.

Looks like JulienDu had a perfect example of why this is faulty use of statistics.

 

[MethodAir]

Maybe I missed something in statistics, but it has always been my understanding that this type of measurement is not cumulative.

Looks like JulienDu had a perfect example of why this is faulty use of statistics.

Exactly, not cumulative. The ACC must think we are complete fucking morons.

 

[pellicle]

Dude

In my job I have 5-10 percent chance per year of being disabled so possibly 100 percent chance at 10 years ( damn I am not disabled) ...

obviously you're discounting the mentally retarded bit ... but I guess that's fair as it may not have been by work related issues .
:Smile:

 

[pellicle]

expecting :Cry:
back at me
;-)

 

[pellicle]

Hi

You guys and gals are astute. It would be well if some of these studies had to go before a vr.org review panel before being published.

I often wonder about the "peer review" process ... however usually "peers" are not paid and its one of their "duties" as a researcher / professional. The biggest issue I see is that surgeons are really not trained scientists nor trained at review. Many in science use 'evidence' as clubs to defend their own views with (and thus pick and choose their data.

I came across this study -- or study of studies -- when I was in a semi-freak-out mode from feeling some mild twinges in area of my replacement device

this is the beauty of this community. You can express your concerns and when people have had a chance of answering gradually read and process their answers to see if that makes you feel better or worse.

I had planned just to post the paper for whatever value it might have, and not weigh in further. But I just wanted to say, I appreciate your analysis and comments.

in my view dialog is always good, particularly with reasonable people. We often learn to not discuss our views in life because we are confronted with unreasonable people which often leads to conflict. I think we are well endowed with reasonable people here.

(NB Reasonable = well reasoned)

One of the first things I noted was this:

1) Randomized trials show survival with biologic valves is equivalent to mechanical valves

There are three published randomized trials comparing biologic and mechanical valves in patients undergoing aortic valve replacement

it furnished references 2-4 in support, these were:

• Oxenham H, Bloomfield P, Wheatley DJ, et al. Twenty year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprostheses. Heart 2003; 89:715-21.
• Hammermeister K, Sethi GK, Henderson WG, Grover FL, Oprian C, Rahimtoola SH. Outcomes 15 years after valve replacement with a mechanical versus a biologic valve: final report of the Veterans Affairs randomized trial. J Am Coll Cardiol 2000; 36:1152-8.
• Stassano P, Di TL, Monaco M, et al. Aortic valve replacement: a prospective randomized evaluation of mechanical versus biological valves in patients ages 55 to 70 years. J Am Coll Cardiol 2009; 54:1862-8.

as soon as I read Bjork-Shilely as their comparison I just sighed ... like the fluid dynamics on that compared to modern bileaflet valves such as the St Jude or the On-X or the ATS/Medtronic valve is like comparing a Model T Ford engine with a modern 16valve double over head cam engine - sure model T's lasted till now, but how many ever did 300,000 miles without a rebuild?

Then there was the idea of ages 55 - 70 in the last reference and it became clear their idea of young (from their title) was different to the idea of young that Julien Du has or that any of the under 40's who post here have.

So I hope you are now breathing easy.

Self test, and test weekly and you will quite probably fall out of that artificial data set of bad INR related outcomes of old stroke victims who test once a month or once every 2 months (because its all they need)

Best Wishes

 

[JulienDu]

Dude


obviously you're discounting the mentally retarded bit ... but I guess that's fair as it may not have been by work related issues .
:Smile:

HAHAHAHA, yeah well now maybe cumulative stats make sense as close to 100 percent of my co-worker become mentally disable after 10 years ( well to be fair, half of them were before they started haha )

 

[neil]

it has always been my opinion that we can find stats to further our argument, none more so in the mech v tissue, the bottom line is which you prefer and imo again its the one you more or less pick from the off, off course we like to know the ins and outs of both but if your not carefull you can get bogged down with to much info which can cloud the issue, who do you believe? the cardio? the surgeon? people who have had it done? stats? people on here? people on other sites ?,

 

[neil]

one other thing is which ever valve you've picked your bound to push that more than the other, human nature I guess, all my opinion of course

 

[pellicle]

Hi

it has always been my opinion that we can find stats to further our argument

of course it is entirely possible. My point however is that as a scientist one should be attempting to find the "truth" not just seek evidence to prove your point. That's the difference between "objectively seeking" and bigoted.

one other thing is which ever valve you've picked your bound to push that more than the other, human nature I guess, all my opinion of course

I agree, its also human nature to be all manner of things that are bad (as well as good), but in science (where I was trained) we hold objectivity highly. You will note an even and consistent view that I promote is that for people over 60 that a Tissue valve is certainly not a bad choice. I often even advocate for that as a better choice for som, even though I've picked a mechanical (this time). I always attempt to draw attention "other issues" that may be of high significance in choice. I try to be objective and not just push a barrow to satisfy myself that my choice is the best choice in an attempt to gain "more support for my team". This isn't footy, its life.

 

[neil]

hi pellicle, bugger I just wrote my reply and then it got scrubbed lol, so to narrow it down some reports state over 60 tissue valve recommended other reports its over 50 some over 40, some lean towards mech others tissue, its a minefield, my point is the medical world full of experts are not sure which is better for us and depending on who you read or listen to can sway between mech or tissue,i still stick to my original thought in being tissue overall should last 10 to 20 yrs and shouldn't in general need anti coags, mechs should in general last a lifetime but need anti coags, that's imo the 2 main points, yes you could finnish up on anti coags on tissue the same as you could neep a re op with mechs but that's not common, so imo you pick the one which suits you and nobody else,

 

[neil]

on another note, hows it going pellicle ?

 

[pellicle]

on another note, hows it going pellicle ?

yeah, not bad mate. Been working on the house reno (almost finished the downstairs bathroom, just painting a few trims now)

have to work out what to do with the Kitchen (burn it sounds appealing) so that I can put it out to rent then go to Finland.

Lookin fwd to some skiing and a change of scene that's for sure!

hope all is well with you.