Making a tissue valve last longer
- Thread starter Ambriz
- Start date
Help Support Valve Replacement Forums:
normofthenorth
Well-known member
Ambriz, I'm waiting for a new tissue AV (Hancock II porcine) on Dec. 1, madly gathering up info 'cause I'm that kind of guy! I've also been super-active for a long time, including the first half of my 60s, and I've always enjoyed playing brutal sports (esp. volleyball) to the point of total exhaustion -- so I'm also VERY curious about your "maybe not working out quite so much"!!
It's totally clear from the evidence that tissue valves last longer in older patients than in younger ones, on average. And we all know that on average, people going through their 4th and 5th and 6th and 7th (etc.) decades of life tend to get less active. From these two factual relationships, it seems reasonable to conclude -- logical -- that more active people (=~ younger people) "use up" or "burn up" or "wear out" their tissue valves faster than less active people (=~ older people). The conclusion would be, more or less, that the tissue valves are "good for X number of beats" before they fail. (Not MY fave conclusion, to say the least!)
On the other hand, everything I've heard or read on the subject says that it's not true. It's possible that we're being sheltered from an unpleasant truth, or from a fact that might discourage us from reassuming healthy activity levels or a high quality of life. (It's probably also possible that I'm trying to avoid an unpleasant truth!)
But what I've heard (including from my prominent and smart surgeon) and read (here and elsewhere online) suggests that the main reason for the age relationship is NOT activity level, but the way our body chemistry -- and specifically our metabolism of minerals, especially Calcium -- changes with chronological age. Basically, the main mechanism of valve deterioration seems to be calcification, which is apparently not related to activity level OR to blood calcium levels or intake of calcium supplements, etc., from what I've learned so far. In fact, it's not very well understood at all, or people with a congenital BAV (like me) would be given a pill or a shot to discourage our bodies from calcifying our valves. But no. :-(
I'm still learning, and your question is one of a bunch that are high on my list! If others have info or evidence, please educate us both!
BTW, the team that's about to give me a Hancock II porcine/pig AV (and possibly a MV, too) on Dec. 1, just sent me a fax of their new study suggesting that these valves are actually more likely to make it to 15 or 20 or even 25 years post-op than the pericardial valves made from a cow's tissues. (I'd asked them why they use pig vs. cow, esp. because I'd seen some info here suggesting that the cow valves last ~5 years longer on average.)
I'm planning to post the link in one of the "sticky" posts, but for now, it's entitled "Hancock II Bioprosthesis for Aortic Valve Replacement: The Gold Standard of Bioprosthetic Valves Durability?" by Tirone E. David, MD, Susan Armstrong, MS, Manjula Maganti, MS, in Ann Thorac Surg 2010;90:775-781, abstract at ats.ctsnetjournals.org/cgi/content/abstract/90/3/775? . (I'm sure it's not the last word on the subject!)
It's totally clear from the evidence that tissue valves last longer in older patients than in younger ones, on average. And we all know that on average, people going through their 4th and 5th and 6th and 7th (etc.) decades of life tend to get less active. From these two factual relationships, it seems reasonable to conclude -- logical -- that more active people (=~ younger people) "use up" or "burn up" or "wear out" their tissue valves faster than less active people (=~ older people). The conclusion would be, more or less, that the tissue valves are "good for X number of beats" before they fail. (Not MY fave conclusion, to say the least!)
On the other hand, everything I've heard or read on the subject says that it's not true. It's possible that we're being sheltered from an unpleasant truth, or from a fact that might discourage us from reassuming healthy activity levels or a high quality of life. (It's probably also possible that I'm trying to avoid an unpleasant truth!)
But what I've heard (including from my prominent and smart surgeon) and read (here and elsewhere online) suggests that the main reason for the age relationship is NOT activity level, but the way our body chemistry -- and specifically our metabolism of minerals, especially Calcium -- changes with chronological age. Basically, the main mechanism of valve deterioration seems to be calcification, which is apparently not related to activity level OR to blood calcium levels or intake of calcium supplements, etc., from what I've learned so far. In fact, it's not very well understood at all, or people with a congenital BAV (like me) would be given a pill or a shot to discourage our bodies from calcifying our valves. But no. :-(
I'm still learning, and your question is one of a bunch that are high on my list! If others have info or evidence, please educate us both!
BTW, the team that's about to give me a Hancock II porcine/pig AV (and possibly a MV, too) on Dec. 1, just sent me a fax of their new study suggesting that these valves are actually more likely to make it to 15 or 20 or even 25 years post-op than the pericardial valves made from a cow's tissues. (I'd asked them why they use pig vs. cow, esp. because I'd seen some info here suggesting that the cow valves last ~5 years longer on average.)
I'm planning to post the link in one of the "sticky" posts, but for now, it's entitled "Hancock II Bioprosthesis for Aortic Valve Replacement: The Gold Standard of Bioprosthetic Valves Durability?" by Tirone E. David, MD, Susan Armstrong, MS, Manjula Maganti, MS, in Ann Thorac Surg 2010;90:775-781, abstract at ats.ctsnetjournals.org/cgi/content/abstract/90/3/775? . (I'm sure it's not the last word on the subject!)
So far there is nothing you can do or not do to make a tissue valve last longer. How active you are doesn't play part in it, (it doesn't only last a certain amount of beats or wear out) but as you said the body's chemistry plays a big role. It is kind of related to bone/ grow and repair, The reason tissue valves don't last as long in younger people is related to their bones are still growing and usually strong/dense if they are very young, but even how a fractured bone heals faster /better in younger adults then people in the 60s .
it's a little confusing because "valve calcification" isn't really calcium, it is mainly apatite. Tobagotwo has a couple good post explaining, but I can't find them by searching since he didn't start the threads.
i wonder, would a beta blocker help?
hi ambriz, yea i agree with above posts about tissue, theres nothing you can do apart from look after yourself ,keep to a good diet and exercise etc, but i suppose you can say that about everbody lol,its nice to hear positive reports on tissue valves,and questions just ask ambriz, you will be fine........................
Ambriz,
From what I've read the answer is no, there are no things that you can do to extend the life of a tissue valve, but you can do things that improve your chances for a successful outcome of the future surgery that may be required if you choose a tissue valve and if you are young enough to likely require another surgery to replace that valve in the future.
Things that should improve your outcome during a second, redo surgery to replace a tissue valve, might include: a heart-healthy diet, exercise, a healthy weight, a well-adjusted, positive attitude in life, a competent surgeon that does lots of redo surgeries and a high-volume surgical center, and in countries that have private health insurance, try to maintain good insurance to keep you from going broke paying for the reop.
Best,
John
DuffMan,
My cardio put me on a Beta Blocker and said it helped the heart "not work as hard", but he said nothing about any benefits to my tissue valve. I think it does something to moderate adrenaline, and may also help reduce incidence of A-fib. With his approval, I've stopped taking my beta-blocker (Atnenolol) to see if it was the cause of my fatigue.
John
This is a logical and reasonable question -- of course using a heart-healthy diet and getting an appropriate amount of exercise are important for overall heart health. But from everything I've read, there is, unfortunately, nothing that can be done specifically to extend the life of your tissue valve. Tobagotwo has posted a lot of great info on this subject in the past. If I find some of it, I will repost, or hopefully he will come along and respond to this.
Edited: I did find this fairly recent thread. There have been others, I think:
http://www.valvereplacement.org/for...ighlight=tobagotwo+and+tissue+valve+longevity
Edited: I did find this fairly recent thread. There have been others, I think:
http://www.valvereplacement.org/for...ighlight=tobagotwo+and+tissue+valve+longevity
Last edited:
I think I can safely say that working out hard does not help. My homograft had calcification and I understand it had a torn cusp. I just assumed that working out would be good for it.
I believe it is just luck of the draw on how long it will last.
I believe it is just luck of the draw on how long it will last.
There isn't anything to extend the valve life in an otherwise normal heart, as far as any science or studies can tell. That includes statins (the SEAS trials and other studies back this up) and other supplements. Fortunately, there is no evidence that being physically active reduces the valve's lifespan either. It's your active chemistry that does it, and it's predictably much less damaging to your valve if you are over 65 when you receive it. The best you can do with what is known right now is to make sure your heart is in the best condition it can be, so it will withstand whatever you request of it, including another valve implantation, if eventually required.
There is mention of vitamin K2. K2 - in combination with vitamin D and other chemicals - is involved with blood calcium levels, bone growth and density, as well as calcium deposition into joints and other unfortunate places. It would make sense that it and/or vitamin D (or a lack of either) could be a factor in some apatitic valve calcifications. It has been shown that an unusually high number of people with senile calcification (like I have, not specifically associated with bicuspidism) have a higher incidence of the B allele of the gene that controls vitamin D use than the A allele, which is linked to calcium control. But it gets very fuzzy right after that drop-off point. There is no understanding of whether more or less of either of these would be helpful, harmful, or pointless. There is even some evidence that added vitamin D is not good for pregnant rabbits, causing calcium deposit issues in their young. However, rabbits don't get either atheromae or calcified valves in nature, so I tend not to trust them as representative study animals for coronary artery disease or valve calcification issues.
As far as the seven-year-itch for tissue valves, the context here for that conjecture is inadequate, as has been posted a number of times. Real studies of large groups of people with tissue valves don't reflect such a pattern. Most people here who have tissue valves are either long-time forum members or people who are on the unhappy end of the curve, needing a replacement soon. Those expecting surgery are the people who are apt to seek the forum for company and information. Because of this, the incidence of people with short-lived valves on the forum is predictable and not representative of general tissue valve results over time. Decisions on what type of valve people want to receive can depend on many things, and usually there's no "right" answer, except for the satisfaction of the recipients themselves. But a seven-year theory would not be a valid input into such a decision.
Best wishes,
There is mention of vitamin K2. K2 - in combination with vitamin D and other chemicals - is involved with blood calcium levels, bone growth and density, as well as calcium deposition into joints and other unfortunate places. It would make sense that it and/or vitamin D (or a lack of either) could be a factor in some apatitic valve calcifications. It has been shown that an unusually high number of people with senile calcification (like I have, not specifically associated with bicuspidism) have a higher incidence of the B allele of the gene that controls vitamin D use than the A allele, which is linked to calcium control. But it gets very fuzzy right after that drop-off point. There is no understanding of whether more or less of either of these would be helpful, harmful, or pointless. There is even some evidence that added vitamin D is not good for pregnant rabbits, causing calcium deposit issues in their young. However, rabbits don't get either atheromae or calcified valves in nature, so I tend not to trust them as representative study animals for coronary artery disease or valve calcification issues.
As far as the seven-year-itch for tissue valves, the context here for that conjecture is inadequate, as has been posted a number of times. Real studies of large groups of people with tissue valves don't reflect such a pattern. Most people here who have tissue valves are either long-time forum members or people who are on the unhappy end of the curve, needing a replacement soon. Those expecting surgery are the people who are apt to seek the forum for company and information. Because of this, the incidence of people with short-lived valves on the forum is predictable and not representative of general tissue valve results over time. Decisions on what type of valve people want to receive can depend on many things, and usually there's no "right" answer, except for the satisfaction of the recipients themselves. But a seven-year theory would not be a valid input into such a decision.
Best wishes,
I agree that conventional wisdom says that beta blockers do not help the valve itself, but I have to believe that reducing (via slower heart rate from beta blockade) the number of times the valve is put under pressure via systole would be beneficial. If I concentrate the stream of my power washer on one small area on my deck, eventually the fibers of the deck will disintegrate. I may even be able to blow a hole in the deck if I stand there long enough spraying the same spot. IF I reduced the pressure/frequency of my power washing, perhaps I could extend the life of my deck... no?
Also, you may find that your fatigue is worse when you stop taking the beta blockers. If that's the case you should consider going back on them. Listen carefully to your body. There are other BB's out there now that may have a more tolerable side effect profile.
Good points Duff.
Say, I've got some cleaning to do, can I borrow that power washer?
John
normofthenorth
Well-known member
Nobody's mentioned smoking, but I'd be shocked if it was NOT a short-cut to a redo. Anybody seen any evidence?
Jkm7
Well-known member
Smoking is a short cut to early death.
Some of the 'big name' surgeons are refusing to operate on smokers. They will not take their cases.
I'll add my support for what the others have already told you. Because the process of valve calcification is poorly understood, no one knows how to prevent or slow it down. The best thing one can do is exercising to maintain good cardio vascular fitness. Since the mechanism of calcification is not understood, taking random supplements or modifying one's diet or exercise habits based upon speculation does not seem wise. Hopefully, now that tissue valves are being used in greater numbers research will finally identify the underlying process and provide us with guidelines as to how we can preserve our valves. Sadly, we are not there yet.
Larry
Larry
Study providing average durability data on bioprosthetic valves for younger patient
Study providing average durability data on bioprosthetic valves for younger patient
RE: "7 year itch for valves"
Not sure if this is the correct thread to place this info under, but here goes:
A recent study that provides data on: LONGEVITY OF HEART VALVE BIOPROSTHESES ACCORDING TO AGE AT IMPLANTATION: NEW COMPILED AGE-SPECIFIC DATA FOR PATIENT DISCUSSION AND DECISION-MAKING
V Chan, H Lapierre, M Boodhwani, B Lam, F Rubens, P Hendry, R Masters, W Goldstein, TG Mesana, M Ruel
Ottawa, Ontario
http://www.pulsus.com/ccc2010/abs/245.htm
BACKGROUND: Evidence supporting the use of bioprostheses in young patients is steadily accumulating. We and others have shown that young patients who select a bioprosthesis at the time of initial valve replacement have an increased reoperation risk, but suffer no long-term survival detriment. However, the median durability of bioprostheses in younger adults, where accelerated structural failure may occur, remains poorly defined in the literature. This information is important for young patients who may choose a bioprosthesis and for their physicians, thus forming the basis for the present study.
METHODS AND RESULTS: We examined bioprosthesis durability in 4131 patients who underwent first-time bioprosthetic valve replacement in the aortic (AVR) (N=3157), mitral (MVR) (N=823), or in both the aortic and mitral positions (DVR) (N=151).
All implants were performed after 1976. The mean age of patients at initial valve surgery was 68.8+/-13.4 years, 65.0+/-13.4 years, and 66.4+/-12.2 years for patients in the AVR, MVR, and DVR groups, respectively.
There were 937 patients below the age of 60 years at bioprosthesis implant (AVR 636, MVR 259, DVR 42).
The median durability, with respect to reoperation from any cause, of isolated stented aortic bioprostheses was 11.2 years (95% confidence interval [CI] 10.1-12.4 years) for patients between 40 and 60 years of age, and 8.5 years (95% CI 7.3-10.3 years) for patients less than 40 years old at implantation.
The median durability of isolated mitral bioprostheses was 11.3 years (95% CI 10.3-12.5 years) in patients between 40 and 60 years of age, and 9.5 years (95% CI: 7.6-14.3 years) in patients less than 40 years old at implantation. The use of 2 bioprostheses in the context of DVR significantly increased reoperation risk (hazard ratio 1.9, 95% CI 1.2-2.8; p=0.004).
CONCLUSION: These data provide new age-specific prognostic information for young patients in need of heart valve replacement, who may want to know their expected time frame to reoperation if they choose a bioprosthesis. This information may help guide clinical decision-making and allow patients to better estimate their personal long-term outcomes.
Study providing average durability data on bioprosthetic valves for younger patient
RE: "7 year itch for valves"
Not sure if this is the correct thread to place this info under, but here goes:
A recent study that provides data on: LONGEVITY OF HEART VALVE BIOPROSTHESES ACCORDING TO AGE AT IMPLANTATION: NEW COMPILED AGE-SPECIFIC DATA FOR PATIENT DISCUSSION AND DECISION-MAKING
V Chan, H Lapierre, M Boodhwani, B Lam, F Rubens, P Hendry, R Masters, W Goldstein, TG Mesana, M Ruel
Ottawa, Ontario
http://www.pulsus.com/ccc2010/abs/245.htm
BACKGROUND: Evidence supporting the use of bioprostheses in young patients is steadily accumulating. We and others have shown that young patients who select a bioprosthesis at the time of initial valve replacement have an increased reoperation risk, but suffer no long-term survival detriment. However, the median durability of bioprostheses in younger adults, where accelerated structural failure may occur, remains poorly defined in the literature. This information is important for young patients who may choose a bioprosthesis and for their physicians, thus forming the basis for the present study.
METHODS AND RESULTS: We examined bioprosthesis durability in 4131 patients who underwent first-time bioprosthetic valve replacement in the aortic (AVR) (N=3157), mitral (MVR) (N=823), or in both the aortic and mitral positions (DVR) (N=151).
All implants were performed after 1976. The mean age of patients at initial valve surgery was 68.8+/-13.4 years, 65.0+/-13.4 years, and 66.4+/-12.2 years for patients in the AVR, MVR, and DVR groups, respectively.
There were 937 patients below the age of 60 years at bioprosthesis implant (AVR 636, MVR 259, DVR 42).
The median durability, with respect to reoperation from any cause, of isolated stented aortic bioprostheses was 11.2 years (95% confidence interval [CI] 10.1-12.4 years) for patients between 40 and 60 years of age, and 8.5 years (95% CI 7.3-10.3 years) for patients less than 40 years old at implantation.
The median durability of isolated mitral bioprostheses was 11.3 years (95% CI 10.3-12.5 years) in patients between 40 and 60 years of age, and 9.5 years (95% CI: 7.6-14.3 years) in patients less than 40 years old at implantation. The use of 2 bioprostheses in the context of DVR significantly increased reoperation risk (hazard ratio 1.9, 95% CI 1.2-2.8; p=0.004).
CONCLUSION: These data provide new age-specific prognostic information for young patients in need of heart valve replacement, who may want to know their expected time frame to reoperation if they choose a bioprosthesis. This information may help guide clinical decision-making and allow patients to better estimate their personal long-term outcomes.
Last edited:
normofthenorth
Well-known member
More interesting stuff. It seems strange that the abstract seems to make no mention of the mix of types of tissue valves, which many of us are understandably curious about.
Also, this study is "age-specific" only in the same imprecise, large-tranche (big-basket) way as the new article on Medtronic Hancock II (pig) aortic valve longevity that I've been mentioning -- i.e., they give results for only 2 or 3 big "baskets" of patient ages. That's not very meaningful to a patient, really. E.g., if you're 39 and they give you the overall results for the "under-40" group, you can be pretty sure you're not an average member of that group, so the median numbers don't apply to you directly. But it takes more than a little counting on fingers and toes to figure out what your own best-guess numbers are. (The Hancock II study abstract is at ats.ctsnetjournals.org/cgi/content/abstract/90/3/775? .)
I would THINK -- having forgotten most of the statistics I ever learned -- that it would be relatively straightforward for a fancy statistician (or a good piece of software) to invert the data, to present (e.g.) the % confidence of being SVD-free at 5, 7, 9, 11. . . years, for each year of age (or each small age "slice") at surgery. Or the number of years post-op to reach 75% and 50% confidence of being SVD-free for each year of age (or each small age "slice") at surgery. I think that kind of presentation would require more "smoothing" and interpolation than what they presented (and the error bands might well expand as the age tranches shrank), but I also think it would be much more directly meaningful to any patient. Heck, we each have a specific age, and we each know it; what we DON'T know is how long we can expect a tissue valve to last, given the evidence to date! That sounds exactly like the question they set out to answer -- as they said, "the median durability of bioprostheses in younger adults. . . is important for young patients who may choose a bioprosthesis and for their physicians, thus forming the basis for the present study." I certainly don't find their abstract (or the data presentation in the otherwise impressive Hancock II study) to be responsive to that need.
Another weakness in this study -- which seems to be a "poster session" paper from a conference, rather than a formally peer-reviewed publication, at least so far -- is that it presents "Freedom from [Aortic or Mitral] Valve Reoperation" as the key variable, apparently equating it with valve "durability". As the Hancock II study points out, those freedom from Reoperation numbers almost always overstate valve durability, because some patients with failed valves are not suitable candidates for surgery. In effect, they represent failures, but they show up in the "success" column! In that study, they presented the data both ways -- e.g., they documented Structural Valve Deterioration (SVD) in 87 patients (of 1134), but only 74 underwent reoperation, since 13 were inoperable. (Once the difference is pointed out, you can't ever ignore it again!)
I initially found the graphs under the Abstract almost illegible. But when I right-clicked on the graphic and opened it in a separate page (then expanded it), it was much clearer. I'm sure that saving it on your computer, then opening it with a good image viewer, would also help.
Also, this study is "age-specific" only in the same imprecise, large-tranche (big-basket) way as the new article on Medtronic Hancock II (pig) aortic valve longevity that I've been mentioning -- i.e., they give results for only 2 or 3 big "baskets" of patient ages. That's not very meaningful to a patient, really. E.g., if you're 39 and they give you the overall results for the "under-40" group, you can be pretty sure you're not an average member of that group, so the median numbers don't apply to you directly. But it takes more than a little counting on fingers and toes to figure out what your own best-guess numbers are. (The Hancock II study abstract is at ats.ctsnetjournals.org/cgi/content/abstract/90/3/775? .)
I would THINK -- having forgotten most of the statistics I ever learned -- that it would be relatively straightforward for a fancy statistician (or a good piece of software) to invert the data, to present (e.g.) the % confidence of being SVD-free at 5, 7, 9, 11. . . years, for each year of age (or each small age "slice") at surgery. Or the number of years post-op to reach 75% and 50% confidence of being SVD-free for each year of age (or each small age "slice") at surgery. I think that kind of presentation would require more "smoothing" and interpolation than what they presented (and the error bands might well expand as the age tranches shrank), but I also think it would be much more directly meaningful to any patient. Heck, we each have a specific age, and we each know it; what we DON'T know is how long we can expect a tissue valve to last, given the evidence to date! That sounds exactly like the question they set out to answer -- as they said, "the median durability of bioprostheses in younger adults. . . is important for young patients who may choose a bioprosthesis and for their physicians, thus forming the basis for the present study." I certainly don't find their abstract (or the data presentation in the otherwise impressive Hancock II study) to be responsive to that need.
Another weakness in this study -- which seems to be a "poster session" paper from a conference, rather than a formally peer-reviewed publication, at least so far -- is that it presents "Freedom from [Aortic or Mitral] Valve Reoperation" as the key variable, apparently equating it with valve "durability". As the Hancock II study points out, those freedom from Reoperation numbers almost always overstate valve durability, because some patients with failed valves are not suitable candidates for surgery. In effect, they represent failures, but they show up in the "success" column! In that study, they presented the data both ways -- e.g., they documented Structural Valve Deterioration (SVD) in 87 patients (of 1134), but only 74 underwent reoperation, since 13 were inoperable. (Once the difference is pointed out, you can't ever ignore it again!)
I initially found the graphs under the Abstract almost illegible. But when I right-clicked on the graphic and opened it in a separate page (then expanded it), it was much clearer. I'm sure that saving it on your computer, then opening it with a good image viewer, would also help.
