mechanical or tissue valve and an active lifestyle?

[Shobu]

@RD: I agree with all the active people here who have had a mechanical valve replacement. I also have a pacemaker. I had my second surgery to replace a tissue valve with a mechanical valve just over 6 months ago. I lift weights, swim, do martial arts, am completing SCUBA certification, am at a pretty decent bodyfat % (about 13%), eat greens daily, and shave with a blade, not mention a whole bunch of other things that you could probably fit under "being active". While I don't have regrets over getting a tissue valve initially, I will say that I have zero issues on my coumadin, and I would NEVER EVER want to back through a third OHS. While I am in fantastic shape for a 6 month post-op according to my docs, the secnd surgery was a way bigger deal than I had ever thought. Also don't be 100% sure you can have a percutaneous or other "arthroscopic-type" procedure in the future to replace a tissue valve. Mine was severely stenotic and calcified and I had a ton of scar tissue which made replacing the valve a much more difficult procedure than the first time, and having had a history of OHS, my heart wasn't too keen on being messed with a second time and I ended up with a nasty case of Dressler's. My surgeon took from about 6am to about 8-9pm or so to get me back in one piece. He did a great job, but, long story short, there would have been no way they could have gone in and replaced my valve without cutting me wide open. I am sure that probably applies to many people who have had OHS for valve replacement and are facing a second, or a third (or more!!) I was happy with my tissue valve while I had it, but, unless you are a woman who wants kids or there is some other medically compelling reason to get a tissue valve, I would pick the mechanical over the tissue with the lower risk of re-operation in the future each and every time.
Anyway, just my 2c. Good luck and hope everything goes well for you whatever your choice!!

--Dan

 

[Lily]

... However at 41 I think I am looking at a 2nd valve replacement even with a mechanical valve. I think I would rather have that at 50-55 than 65-75 ...

I found the reasoning you expressed here interesting; because at age 42, I used this same reasoning to explain my choice to a few inquisitive people

 

[normofthenorth]

Al Capshaw and OldManEmu: I've just spent 5-10 minutes "researching" the hemodynamics of percutaneous heart valves, and based on a nice-looking study (abstract) from 2009, it seems that you two, and OME's surgeon, probably have it backwards, and Lyn has it right:

J Am Coll Cardiol. 2009 May 19;53(20):1883-91. "Comparison of the hemodynamic performance of percutaneous and surgical bioprostheses for the treatment of severe aortic stenosis." Clavel MA, Webb JG, Pibarot P, Altwegg L, Dumont E, Thompson C, De Larochellière R, Doyle D, Masson JB, Bergeron S, Bertrand OF, Rodés-Cabau J., Quebec Heart & Lung Institute/Laval Hospital, Laval University, Québec City, Québec, Canada. http://www.ncbi.nlm.nih.gov/pubmed/19442889 .

OBJECTIVES: This study was undertaken to compare the hemodynamic performance of a percutaneous bioprosthesis to that of surgically implanted (stented and stentless) bioprostheses for the treatment of severe aortic stenosis.

METHODS: Fifty patients who underwent percutaneous aortic valve implantation (PAVI) with the Cribier-Edwards or Edwards SAPIEN bioprosthetic valve (Edwards Lifesciences, Inc., Irvine, California) were matched 1:1 for sex, aortic annulus diameter, left ventricular ejection fraction, body surface area, and body mass index, with 2 groups of 50 patients who underwent surgical aortic valve replacement (SAVR) with a stented valve (Edwards Perimount Magna [SAVR-ST group]), or a stentless valve (Medtronic Freestyle, Medtronic, Minneapolis, Minnesota [SAVR-SL group]). Doppler echocardiographic data were prospectively obtained before the intervention, at discharge, and at 6- to 12-month follow-up.

RESULTS: Mean transprosthetic gradient at discharge was lower (p < 0.001) in the PAVI group (10 +/- 4 mm Hg) compared with the SAVR-ST (13 +/- 5 mm Hg) and SAVR-SL (14 +/- 6 mm Hg) groups. Aortic regurgitation (AR) occurred more frequently in the PAVI group (mild: 42%, moderate: 8%) compared with the SAVR-ST (mild: 10%, moderate: 0%) and SAVR-SL (mild: 12%, moderate: 0%) groups (p < 0.0001). At follow-up, the mean gradient in the PAVI group remained lower (p < 0.001) than that of the SAVR-ST group, but was similar to that of the SAVR-SL group. The incidence of severe prosthesis-patient mismatch was significantly lower (p = 0.007) in the PAVI group (6%) compared with the SAVR-ST (28%) and SAVR-SL (20%) groups. However, the incidence of AR remained higher (p < 0.0001) in the PAVI group compared with the 2 other groups.

CONCLUSIONS: PAVI provided superior hemodynamic performance compared with the surgical bioprostheses in terms of transprosthetic gradient and prevention of severe prosthesis-patient mismatch, but was associated with a higher incidence of AR.

So, far from the percutaneous valves being narrower and tighter than the conventional valves, they seem to be bigger, more open and "looser" -- even to the point of some (usually mild) regurg.

There's still no guarantee that ANY of us will be offered a percutaneous valve if and when we outlive our tissue valve (and I don't really understand WHO these 50 PAVI recipients WERE -- are PAVIs being implanted routinely in Quebec City??), and I agree that it would be risky to choose a tissue valve on the hope that we will. But any concerns that they are naturally and logically narrower, with worse hemodynamics (higher gradients, lower effective area), seem to be without basis in fact. (Good news, eh? )

Note that the stented valve that the PAVI beat so soundly in this study is the same CEP Magma whose hemodynamics beat the socks off the Hancock II valve that I got! Also, ALL of these measured pressure gradients, while statistically-significantly DIFFERENT from each other, are VERY GOOD, and probably good enough that nobody with an average-sized AV would ever notice the difference. I was running and jumping (and playing competitive volleyball) with the 30-somethings with pressure gradients WAY higher than any of the ones they measured in any of these excellent valves. I think this is what the lawyers like to call "a distinction without difference", when it comes to real-world cardiovascular fitness and performance. But FWIW, the distinction does seem to go IN FAVOR of the Percutaneous valve, not AGAINST it.

 

[ALCapshaw2]

Norm -

Is that a Single Center Study?
Who Funded that study?
Are there any other studies to corroborate those conclusions?

Please explain to me how a valve that is inserted into another existing valve can have a Larger Effective Diameter than the Host Valve.

'AL Capshaw'

 

[epstns]

Al - I agree that it is hard to imagine getting equal flow from a cath-implanted valve that is inside a natural or tissue replacement valve, IF we are comparing the percutaneous valve to that failing valve before it started to fail. I can, however, very easily imagine how one would expect to get flow that is superior to the failing, deteriorated valve that needs replacement. I guess it is a matter of comparison point. That is probably why the percutaneous valve implants will likely be used first in older patients whose demands on the valve may be less severe. They may be of interest to the general population, but maybe not to the minority of older patients who are still athletically active.

 

[JUST-WAITING]

I have surgery Monday - 17th and I looked in depth at the Ross procedure - but after much thought and research I went with the ATS-3f- "horse valve" - I am 52 and like to be active - and I consider this the best choice- Talk to Bean counter he is a marathon runer - I am not-

 

[dick0236]

I just found a brand new "study":tongue2:. It is being published for the very first time, here on VR.org:
Study size: 3 males, all golfers, but no longer avid golfers:redface2:.
Study details:
1. Al age 80. Received tissue valve at 77.
2. Joe age 77. Received tissue valve at 43 and replaced with mechanicl valve at 52.
3. Dick age 75. Received mechanical at 31.
Study results: All doing well and "still looking DOWN at the grass":wink2::thumbup:
Study conclusion: Beats the hell outa me:wink2::biggrin2:

What does it prove? Absolutely nothing:angel::biggrin2:.....but it is another set of numbers to "ponder":confused2:.

 

[ALCapshaw2]

I just found a brand new "study":tongue2:. It is being published for the very first time, here on VR.org:
Study size: 3 males, all golfers, but no longer avid golfers:redface2:.
Study details:
1. Al age 80. Received tissue valve at 77.
2. Joe age 77. Received tissue valve at 43 and replaced with mechanicl valve at 52.
3. Dick age 75. Received mechanical at 31.
Study results: All doing well and "still looking DOWN at the grass":wink2::thumbup:
Study conclusion: Beats the hell outa me:wink2::biggrin2:

What does it prove? Absolutely nothing:angel::biggrin2:.....but it is another set of numbers to "ponder":confused2:.

You've got me Laughing Out Loud Dick!

And your study does prove that a Heart Valve Replacement Survivor can still have a Sense of Humor 8=)))

'AL'

 

[nngbwh]

The Three Stooges.:biggrin2::biggrin2:

 

[dick0236]

The Three Stooges.:biggrin2::biggrin2:

Great conclusion and very appropriate:tongue2:.....but we got a problem:confused2:. Nobodey has enough hair to be called "Curly":redface2:.

 

[normofthenorth]

Norm -

Is that a Single Center Study?
Who Funded that study?
Are there any other studies to corroborate those conclusions?

Please explain to me how a valve that is inserted into another existing valve can have a Larger Effective Diameter than the Host Valve.

'AL Capshaw'

Al, if you clicked on the link, you know as much about that study as I do. I assume it's all from one center, the Quebec Heart & Lung Institute/Laval Hospital, Laval University, Québec City, Québec, Canada.

You may have also noticed (I just did) that there's also a "Comment" on the following 2 pages of the journal, after the article. Me, I'm too cheap to look at any of it except that one abstract, so I can't tell you the rest of the info, sorry. Maybe there's a Prof here or a librarian, or somebody else with free access to the full text versions. [Edit: I've just found the TITLE of the Comment: "Hemodynamic evaluation of heart valve prostheses paradigm shift for transcatheter valves?" by Walther T, Falk V. FWIW.]

I haven't looked for other studies, since this one seemed to be methodologically solid and "spot on" to the question at hand. Google's free for everybody, so have fun!

About your last question: My understanding is that all replacement valves are essentially inserted inside something, like the Aorta or Aortic Root or some such. And they all take up space inside that "something" before you get to the part that actually opens. Stentless valves (like the Medtronic Freestyle they included) are supposed to minimize that loss of area, and the CEP Magna (which they also included) is touted to have "stentless performance in a stented valve", so it's also supposed to minimize the loss of area.

I don't know what part of the pre-existent stenotic valve was removed, but since we're talking about stenosis = narrowing here, it seems obvious to me that some was either removed or somehow stretched, like with a stent.

Here's what I know for sure:
1) When my theory conflicts with facts, it's usually my theory that needs to be adjusted. and
2) The underlying reasons and explanations for the vast majority of facts that are generally acknowledged to be true in modern science are at least partly mysterious. I take a baby Aspirin every day, and the last I heard, we STILL don't actually understand the mechanism through which AcetylSalycilic Acid (ASA = Aspirin) actually DOES what it DOES! But we've done the studies to prove that it DOES those things, and we WANT those things, so we take the Aspirin.

If you want to continue to cling to your theory because there's only one study showing unequivocal (apparently factual) results that shoot it out of the water, do whatever you've got to do. I'm not the boss of you. For me, I'm not going to believe that percutaneous AVs have inferior effective areas any more, unless and until I see some better evidence that it's true. Having multiple AVers repeat the old theory, or explain why they think or believe or imagine that it makes sense, also can't compete with facts when I make up my mind -- nothing personal, folks!

 

[epstns]

Hey, Dick - I know what your study proves. . . Patients having successful valve replacement do as well as they would have if they never needed the valve. Your sample proves it!

Also, I can sign up to be one of the stooges (although my surgery isn't until March 1) - I've got plenty of curly hair, although most of it is grey now. Remember, there were actually four stooges, but only three of them appeared at any one time or in any one film. They were Moe, Larry, Shemp and Curly. So you never really got more than 3 out of 4.

 

[MarkU]

In response to the OP, I was a very active 47-year-old ten years ago when I had my AVR. Both my surgeon and cardiologist strongly recommended a mechanical valve to minimize the possibility of future re-ops.
I went with a St. Jude valve and have never regretted my decision. My surgery was 'textbook' and I didn't need to do any formal rehab: they just told me to go home and walk as much as I could.
The only real issue I've had with Coumadin (other than dealing with ignorant dentists) is having to do Lovenox bridging when having colonoscopies. Not really a big deal once you get used to giving yourself the injections.
I had been an avid weightlifter prior to my surgery, but post-op my cardiologist urged me to cut back on the heavy lifting and focus more on aerobic exercise. One thing led to another and I did my first triathlon three years post-op and have been hooked on triathlon training ever since ( I love the cross-training aspect which is easier on my body as I get older). Ironically, my cardiologist now is urging me to add more weightlifting back into my regimen in order to maintain muscle mass as I get older (I'm now 57).
Again, my surgery was ten years ago, and the technology of both mechanical and tissue valves has advanced significantly since then. If I was having to make a decision today it would probably be more difficult, though I still think I would pick a mechanical valve. Even though my surgery went well, it's not something I would ever want to go throught again if I could avoid it.
Best of luck to you.
Mark

 

[ski girl]

Welcome RD!

I had an AVR three months ago at 39 and I went with tissue valve. This was because my 'active lifestyle' doesn't just involve walking and riding a bike where I'm unlikely to get hurt, mine involves being out in the middle of nowhere in the Australian bush and doing sports such as whitewater paddling where if I did get hurt, it would be literally HOURS before anyone could get me to medical treatment. Whether or not I'd bleed to death before I could get out, I didn't want to be thinking about that possibility and I certainly didn't want to put my friends through that additional strain!

My surgeon agreed with that assessment. I'll have to go through at least one more OHS in my life (assuming something else doesn't get me first!) and then I'm likely to go mechanical - but for this next 10-15 years I just wanted to have absolutely no restrictions and be able to compete at the highest level I was able to.

Good luck!!!

 

[RDISH]

Thanks for all the information, point’s of view, and well wishes!

I had a consultation visit with a surgeon last week, (I met with this same surgeon 15 yrs ago after a knee jerk recommendation from a new cardiologist, and at the time there were a few numbers that pointed to the condition being present but at that consultation this same surgeon said I did not need surgery at that time.) long story short, he now is very sure I need surgery, sooner rather than later. In the consultation we discussed options and the benefits of each valve most all of them have been discussed here. The one area that I had hoped for more promise from was the surgical technique, he did not give me much hope for the minimally invasive surgery and even warned me about other surgeons that may promise otherwise even though he does not see any evidence that the aortic root would need repair. (anyone have any experience or opinions on minimally invasive surgery?) In the end I think based on my life style in combination of the very positive indicators that through catheter replacement is the future of valve replacementand the subsequent replacemrnts, I think I am going with a tissue valve. Both the surgeon and I agree that this is the direction to go for me, however I do still plan to see another surgeon to get a second opinion, if there is a dissenting opinion I would like to discuss it before surgery. I have a cath appointment on 1/25, a follow up with the original surgeon on the 27th and surgery shortly there after.

Again, thanks for all the feed back!
-RD

 

[olefin]

I had stenosis for ten years before surgery was required, had no symptoms. My surgeon and cardiologist both highly recommended mechanical for my young age of 56. Even with my history of a bleeding duodenal ulcer. They both said, if at all possible!, you don't want but one heart surgery. They were so correct, for I had major complications from the surgery. 21 days in the hospital, even back then the normal stay for AVR was 5 days. But I was very fortunate, other people have had for worse complications and people do die from heart surgery.
Active... I had jogged 3 miles daily for 15 years up to the month before AVR, since then I've walked 3 miles a day.
Warfarin has not been a problem, luckily I've not had another bleeding ulcer. I was familiar with warfarin for my wife had taken it.

Best of luck to you on what ever you go with.

 

[Glenda]

I received my tissue valve in 2004. I go to see my cariologist every six months and have a echo and for the last three years he has said that I will have to have this valve replaced in the very near future. He always tells me when I leave that he'll see me in his office in another six months or he'll see me in ER. My replacement was three years ago and I'm still kicking, now I will have to admit here lately I've been having some signs that maybe the replacement is now far off. Shortness of breathe, getting dizzy at weird times, some pounding and hurting in my chest area. I go to see my doctor this Friday so I'm anxious to see what the echo reads this time. I will go with a cow's valve the next time. The cardiologist said it would out last me. The reason I went with a tissue valve the first time was becasue I have CML (chronic myloid leukemia) and I have to the take the chemo drug "Gleevec" for the rest of my life and it doesn't mix with Coumadin which you have to take with a mechanical valve. I also have a very noticable heart mummur which seems to getting worse. So time will tell, what or when I go under the knife again. I am a secretary at our major hospital in Joplin and I work on the cardio floor so I am around my cardiologist and surgeon every day. I told them here while back, what a great place to be if something happens! Let's just hope it happens at work. My job is very fast paced and very stressful but because of economic reasons I have to continue to work. The majority of the time I love my job but sometimes it gets to me and I ask myself "what in the world am I doing here?" But again, I can related to the patients because I've been there and done that. I feel God has put me here.

Love & God Bless, Glenda

 

[MarkU]

Welcome RD!

This was because my 'active lifestyle' doesn't just involve walking and riding a bike where I'm unlikely to get hurt

I guess you've never crashed on a triathlon bike at 25 mph.

There's no wrong answer when picking a valve, but a lot of it has to do with an individual's personal risk tolerance or perception of risk.

In ten years on this board I can't remember anyone bleeding to death as the result of leading an 'active lifestyle', but if the psychological worry bothers you, then it's not worth it.

It reminds me of the old saying about investing money: If you can't sleep at night then the investment is too risky.

Mark

 

[njean]

I just found a brand new "study":tongue2:. It is being published for the very first time, here on VR.org:
Study size: 3 males, all golfers, but no longer avid golfers:redface2:.
Study details:
1. Al age 80. Received tissue valve at 77.
2. Joe age 77. Received tissue valve at 43 and replaced with mechanicl valve at 52.
3. Dick age 75. Received mechanical at 31.
Study results: All doing well and "still looking DOWN at the grass":wink2::thumbup:
Study conclusion: Beats the hell outa me:wink2::biggrin2:

What does it prove? Absolutely nothing:angel::biggrin2:.....but it is another set of numbers to "ponder":confused2:.

Hey,don't forget me, Dick!

Norma: Age 59, received mechanicals at age 24, swapped out an old one in 2006, mitral valve mis-firing but still gettin' around! :biggrin2:

 

[normofthenorth]

There are some studies (and here I mean REAL ones, in peer-reveiwed journals ) on the additional ACT risks of "trauma", which generally confirm that there is a real added risk. Of course, they don't answer the question of whether or not somebody wants to give the risk enough weight to change their lifestyle (or change their valve choice and accept the risk and OMG/Yee-Yikes of future re-ops).

I've linked to one from 2007 recently -- ncbi.nlm.nih.gov/pubmed/18073596 -- that grouped a series of consecutive trauma patients into 3 groups: No ACT, Said they were on ACT but INR tested <2, and Said they were on ACT and INR tested >=2. The first two groups had identical likelihood of comas, cerebral hemorrhage, and the other nasty end-points they measured, and the third group had 2.5-5 times the likelihood of those nasty end-points (varying with the specific end-point).

There are legit questions about what that study really means -- e.g., I only looked at the abstract, and it doesn't say what the ACTUAL AVERAGE INR was in their ">=2 INR" group. It might have been 5, for all I know, which is a very different thing from "anything over 2" if they were mostly in a normal therapeutic range. The study also mostly dealt with old folks who fell down and hit their heads, rather than young fit mountain-bikers or skiers who crashed on the slopes; maybe the risk profile is different in the two groups (or not). And while the study is pretty clear on the additional RELATIVE risk, between the no-ACT groups and the ACT group, it's not clear to me how large the ABSOLUTE risk is -- e.g., how many times would I have to go over the handlebars wearing a helmet, on average, before I got a nasty outcome with INR >=2 versus INR=1 (with a tissue valve -- and no A-Fib, etc.!!). Several of the mech-valve folks here have posted stories about people on ACT (themselves or friends) who've fallen off roofs etc., etc., and been A-OK. Just anecdotes, but we know that "trauma + ACT" doesn't assure sudden death, by any means.

One other relevant data point from my own experience: I just told my top-rated (and older) Cardiologist that I'm planning to ski a week in Whistler starting in less than 2 weeks (~8-9 weeks post-OHS), while I'm still in my 3-months-post-op ACT period for my MV repair. After determining that I was going with or without his blessing, he told me that he doesn't think that ANYBODY who's on Warfarin/Coumadin should ever do downhill skiing. That's his professional opinion -- Period.