Long-term success of ON-X aortic valve?

[attagirl_MN]

My St. Jude Regent aortic valve needs to be replaced 1 year after initial replacement due to pannus and a blood clot. ON-X is a possibility and wondered if anyone has developed pannus with the valve in the aortic position? Of course the literature claims 0% pannus ... just want to be sure.

 

[Juli]

I am so sorry ro read about this - have my surgery in two weeks and are also planning for a ON-X. I assume that this came as a total surprise without any warnings - hope all goes well with your replacement.

 

[pellicle]

Hi

My St. Jude Regent aortic valve needs to be replaced 1 year after initial replacement due to pannus and a blood clot.

very sorry to read this ... I assume that you've not been down the replacement path yet, so can I ask some questions:

What tests have been performed to be certain that its pannus and not clot obstruction?

I ask this because there are therapies available to reverse clot obstruction and pannus so soon seems like "crazy fast".
I suggest you read this thread carefully and discuss these specific issues with your team.
http://www.valvereplacement.org/foru...air-or-replace

I can't be sure that is your issue with the lack of information I have but it does seem a good candidate to explore and a PICC line insertion is a better option if it succeeds if you ask me. Any good risk analysis by a surgeon will support that.

ON-X is a possibility and wondered if anyone has developed pannus with the valve in the aortic position? Of course the literature claims 0% pannus ... just want to be sure.

I know of one other person here RobThatsMe who has had a valve replacement due to pannus, but I didn't think it was so quickly after surgery. I hope that he sees this mention in his alerts and comments.

I understood that the On-X has a "panus guard" but to be honest we see far far less of them in the market than the St Judes ... so saying they have 0% rate is a bit like saying "I went to a mexican restaurant once and didn't get food poisoning" so with a zero %age experience you should be safe. We just don't know how effective it will be.

 

[RobThatsMe]

Hi



very sorry to read this ... I assume that you've not been down the replacement path yet, so can I ask some questions:

What tests have been performed to be certain that its pannus and not clot obstruction?

I ask this because there are therapies available to reverse clot obstruction and pannus so soon seems like "crazy fast".
I suggest you read this thread carefully and discuss these specific issues with your team.
http://www.valvereplacement.org/foru...air-or-replace

I can't be sure that is your issue with the lack of information I have but it does seem a good candidate to explore and a PICC line insertion is a better option if it succeeds if you ask me. Any good risk analysis by a surgeon will support that.




I know of one other person here RobThatsMe who has had a valve replacement due to pannus, but I didn't think it was so quickly after surgery. I hope that he sees this mention in his alerts and comments.

I understood that the On-X has a "panus guard" but to be honest we see far far less of them in the market than the St Judes ... so saying they have 0% rate is a bit like saying "I went to a mexican restaurant once and didn't get food poisoning" so with a zero %age experience you should be safe. We just don't know how effective it will be.

Hi Pellicle,

Yes, I did have my St. Jude mechanical aortic valve replaced due to pannus. My St. Jude lasted 10 yrs before the pannus became so bad the St Judes Valve would not function properly.
My doctors said the pannus restricted the valve to only 4% blood flow, and yet I was still asymptomatic. This may be due to my very active workout routine, Gym 5 days a week, and jogging.
They also told me that it needed too be replaced within 4-6 months, or I would not be around for much longer.
So, I elected to go with the On-X valve as my new replacement back in 2010. So far I have no issues with my On-X valve.

I do wish they still had all the member bio's like they had in the older version of the site.

Cheers,
Rob

 

[pellicle]

Hi Rob

thanks for the reply..

... My St. Jude lasted 10 yrs before the pannus became so bad the St Judes Valve would not function properly.
My doctors said the pannus restricted the valve to only 4% blood flow, and yet I was still asymptomatic. This may be due to my very active workout routine, Gym 5 days a week, and jogging.

to perhaps assist the OP, how long after your surgery was it before identifying pannus?

 

[RobThatsMe]

Hi Rob

thanks for the reply..


to perhaps assist the OP, how long after your surgery was it before identifying pannus?

It was around 8 yrs after surgery, when they found that my valve was getting restricted, and began testing me every 6 months instead of annually.

 

[Catie]

Attagirl, so sorry to hear this. I hope everything is going to go extra smoothly with selecting and implanting a new valve.

 

[attagirl_MN]

I had my 1-year follow-up echocardiogram which indicated increased outflow over the new valve. Then I had a CT angiogram which showed that the leaflets are still functioning but the doctors still couldn't determine if it was pannus or a clot. Then I had a TEE test, which indicated that pannus developed at the back of the valve and a blood clot was attached to the pannus. My surgeon gave me a 2-month window for the next replacement. I'm going to be sending my records out for second opinions. My surgeon, Dr. Robert Farivar, is the Chief of Cardiothoracic surgery and seems to have a good reputation. The explanation is my body just aggressively healed after the replacement.

I appreciate everyone's support and information. Thank you!

 

[pellicle]

Hi

.... but the doctors still couldn't determine if it was pannus or a clot. Then I had a TEE test, which indicated that pannus developed at the back of the valve and a blood clot was attached to the pannus. .... I'm going to be sending my records out for second opinions.

to me there is little to be clear that its pannus ... the imaging is remarkably unclear (have you ever tried to look at it?) and subject to MUCH conjecture and intrerpretation. One may say "clearly a clot" another may say "could be pannus" ... I would raise my above points about an attempt at dissolving a potential clot with a PICC administration of TPA. (Tissue Plasminogen Activator) as in my earlier referenced post (I hope you read it carefully) when you meet your next opinion.

Remember ... surgeons specialise in surgery ... not other techniques. You can imagine if they get it out and go "oh, it was a clot" they'll just tell you it was a clot and pannus (but not if the pannus was an issue). There are also catheter treatments for pannus if I recall correctly.

Also, have a read of these articles ... take your time, read carefully

http://content.onlinejacc.org/article.aspx?articleid=1125451

http://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/1749-8090-7-62

... because you probably aren't wanting a 2nd surgery IF there is a viable alternative.

 

[attagirl_MN]

Thank you, Pellicle. I had my consultation with my original surgeon. Turns out I don't have a blood clot. It's strictly pannus. My obstruction is about 1cm. He said I could wait a while before the second replacement, but not too long that I get symptomatic. He also recommended (later via email) that I have the Perceval sutureless valve. I am not convinced that I want to subject myself to the complications related to the valve, as well as the mysteries associated with such a new valve.

I am having a second opinion with a surgeon at the U of Minnesota Medical Center today. Apparently, my situation is rare and complicated. So ... trying to get answers wherever I can. I may eventually also get feedback from Mayo Clinic. Just a very surreal situation. I'm in my mid-40s so I am not looking forward to TAVR in the future (another reason my original surgeon recommended the Perceval) or another replacement if this second one fails.

 

[Catie]

Attagirl, I hate that you're having to deal with rare complications--my heart goes out to you. I hope you can get some very good answers that will help guide you to the best possible solution.

 

[Agian]

You take care sweetie.
They say the bigger the valve, the less likely you'll get pannus. They might be able to put in a biggie with a conduit. I got a 27mm on-x and was told I wouldn't get pannus.
I spoke to someone from on-x and they told me that whenever someone claimed one of their valves had pannus, it was actually a clot under the microscope.
The Pelmeister raised the issue of pannus removal via catheter. That may also be something worth exploring.

Anyways, have a chat with the on-x nurse. I think her name is Burkett(?) lovely lady.

 

[MethodAir]

Hi

to me there is little to be clear that its pannus ... the imaging is remarkably unclear (have you ever tried to look at it?) and subject to MUCH conjecture and intrerpretation. One may say "clearly a clot" another may say "could be pannus" ... I would raise my above points about an attempt at dissolving a potential clot with a PICC administration of TPA. (Tissue Plasminogen Activator) as in my earlier referenced post (I hope you read it carefully) when you meet your next opinion.

Remember ... surgeons specialise in surgery ... not other techniques. You can imagine if they get it out and go "oh, it was a clot" they'll just tell you it was a clot and pannus (but not if the pannus was an issue). There are also catheter treatments for pannus if I recall correctly.

Also, have a read of these articles ... take your time, read carefully

http://content.onlinejacc.org/article.aspx?articleid=1125451

http://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/1749-8090-7-62

... because you probably aren't wanting a 2nd surgery IF there is a viable alternative.

Great post.

 

[Heart Of The Sunrise]

Attagirl_ Best of luck with your upcoming surgery. I just had my three year follow-up. Now 40 months out. Pictures say perfect no pannus. It looks and sounds great!
I am very happy with my choice of the On-X valve.

 

[Agian]

So am I. On-X has a pannus protection thingy.

By the way, does anyone remember a guy who used to frequent the forum that everyone thought was a shill for On-X? I came across an old post of his, and Ross pipes in and says: Look it's raining dogs in the garden.' That was funny as batshit. Is that an Americanism or did he make that up? Made my day, anyway.

 

[GA Mom]

Hello, all. I'm new to the forum but have been reading the posts for awhile now. I'm a 51 y/o with a congenital BAV. My pre-op was today and my OHS is Tuesday 9/6. I'm beyond stressed about which valve - and I must give the dr my final answer tomorrow. My cardiologist was adamant that i go with the tissue valve. My cardiothoracic surgeon discussed the pros and cons of both but ultimately left it up to me. I also have a blood clotting disorder, Factor V Leiden, that makes me at risk for developing blood clots - deep vein thrombosis. I do not take any aspirin or anticoagulant therapy for the Factor V, with the exception of when having two other surgeries (gall bladder and hysterectomy.) In my mind, I think it's inevitable that I'll be on a blood-thinner in the future due to my Factor V - so may as well go ahead and get the mechanical valve and not worry with a second surgery. However, could it be possible that my Factor V makes me an ever higher risk for blood clots with the mechanical valve - therefore, I should go with the tissue valve to lessen that risk?? I have no clue what to do!!!

 

[pellicle]

Hi and welcome

your post is a "curly one" ... but I'll ask a few questions as well as give some thoughts ... I'm a discussive sort.

... I'm a 51 y/o with a congenital BAV.
...I'm beyond stressed about which valve - and I must give the dr my final answer tomorrow.

I'm sure ...

My cardiologist was adamant that i go with the tissue valve.

and indeed I would wonder why your cardio is "adamant" ... sounds like an arse without knowing more.

I would love to read the reasons for such a stance ...

My cardiothoracic surgeon discussed the pros and cons of both but ultimately left it up to me.

how kind of them ...

I also have a blood clotting disorder, Factor V Leiden, that makes me at risk for developing blood clots - deep vein thrombosis... In my mind, I think it's inevitable that I'll be on a blood-thinner in the future due to my Factor V - so may as well go ahead and get the mechanical valve and not worry with a second surgery.

indeed, I would agree with your logic. Unless there is something you have not mentioned it would seem that your cardio's only looking worse. The normal "reasonable" justfification to avoid a mechanical prosthesis is to avoid AntiCoag therapy ... which you may not be avoiding long term anyway.

Are there (for instance) any issues in your blood disorder that makes determining INR difficult?

My view also would be tending towards a mech for the above stated reasons that you'll

• reduce the likelyhood of a second op
• need to be on AC anyway (thus they are not part of the equation)

do you know what size diameter your aortic valve is? I ask because about the only other factor I can think of (given what I know) is that females with small diameter aortic valves are more prone to pannus. (https://en.wikipedia.org/wiki/Pannus)

This is not as bad as it may sound because its only a small margin more and indeed exactly how much more I'm unable to say. However its important to point out there are non valve replacement surgical interventions available now to remove pannus.

This (perhaps confusing to you) article discusses the findings which suggest a greater possibility of pannus for females:

http://content.onlinejacc.org/articl...icleid=1125451

The first issue is that the study group is small:

The study group consisted of 23 consecutive patients with obstruction of mechanical prosthetic valves detected by Doppler echocardiography at the echocardiography laboratories of The Methodist Hospital, Houston, Texas, or The Hippokration Hospital, Athens, Greece, who underwent a TEE within 4 weeks prior to redo valve replacement. Patients with suspected endocarditis were excluded. There were 17 women and 6 men, with a mean age of 60 ± 12 years. In the 23 patients, there were 24 malfunctioning mechanical prosthetic valves: 13 bileaflet St. Jude Medical valves, 7 tilting disc, 3 caged-ball and 1 caged-disc valve. All patients had surgical and pathologic confirmation of pannus and/or thrombus as the underlying cause of the prosthetic valve obstruction. Demographic information, clinical data, operative details and pathologic results were obtained from medical records

so straight up women were over represented (which may also say something too).

This study:
http://link.springer.com/article/10.1007/s10047-006-0334-3

takes the view that diameter is important

Seven of a total of 390 patients (1.8%) required reoperation for prosthetic aortic valve obstruction due to pannus formation. All seven patients were women; four patients underwent resection of the pannus and three patients needed replacement of the valve. The frequency of pannus formation in the early group was 2.4% (6/253), whereas it was 0.73% (1/137) in the late group (P < 0.05). Pannus was localized at the minor orifice of the Björk–Shiley valve in the early group and turbulent transvalvular blood flow was considered to be one of the important factors triggering its growth. We also consider that small bileaflet valves have the possibility of promoting pannus formation and that the implantation of a larger prosthesis can contribute to reducing the occurrence of pannus.

hope that isn't too confusing.

Happy to discuss if you wish.

 

[GA Mom]

Pellicle, thank you for your reply. To the best of my knowledge, I have no other issue that could cause my INR to be difficult to determine. The PA drew quite a bit of labs today and will discuss and analyze my clotting disorder (again) with the surgeon. As to the size of valve I'll need, I don't know that yet but I plan to ask tomorrow. As to pannus, I think I read that the On-X valve has a coating to help reduce the risk of the development.. Both of the articles were informative. What about my last theory: If I decide on the mechanical valve, am I increasing my odds to have blood clotting issues since I am already predisposed to them? A blood clot could still form even though I would be taking Coumadin, correct? In that case, the tissue valve might be the best choice. Thank you again.

 

[Paleowoman]

Hi GA Mom - it's always very stressful coming up to surgery. It's a shame that the issue of what type of valve to go with wasn't discussed some time ago (my cardiologist asked me to look into it two years before surgery as he had an idea I'd be heading that way in that time frame and I don't have any blood disorders !) but not everyone has the luxury of 'notice'.

I would have thought that with a blood clotting disorder the question of whether to go with tissue or mechanical valve should have been discussed thoroughly with a doctor knowledgable about blood disorders by now and not at the pre-op stage. It's good your PA is discussing this with the surgeon.

Whatever valve you go with, the surgeon won't know what size to implant it is until he's actually in there during surgery and can measure the size of the annulus accurately. He might have an idea from your echocardiogram or angiogram but it's not accurate till surgery.

I hope you get some more good advice from your docs soon - sounds like your cardiologist is sure which way to go - is he knowledgeable about your blood clotting disorder ?

 

[Agian]

I would INSIST on an opinion from a haematologist.