Mechanical/Tissue Valve - Redo Surgery on Sept 21st

[Guest]

My wife had a mechanical aortic heart valve done in 2011. She was hospitalized earlier this year for 63 days with Infective Endocarditis. She had stroke, bursitis, kidney failure just to name a few things. Since then her kidneys have recovered nicely, but she still has some issues (trouble walking & fatigue are the main issues she is dealing with). She found out about a month ago from her TEE that there is some leaking due to a ruptured abscess. Her BP is good and her heart rate is just a little high (Resting BPM = 86-90). They surgeon scheduled her heart valve replacement on September 21st. A big question we have is should we do the mechanical valve or tissue valve? For her to be off the Coumadin will be nice, but we know that with a tissue valve another surgery will be looming. Just want to get thoughts. This really stinks that she has to go through this again. Has anyone gone through this a second time? Thanks in advance.

 

[pellicle]

Hi

it does indeed stink that you have to go through it all again. The risks of endo are there ... I've had 3 open heart surgeries over my life.

As to mech or tissue a lot depends on her age. Of course you should also consider that she will then have had 2, which (assuming your wife is young enough) a third operation may be likely.

Getting of warfarin may be a benefit if (say) you don't self manage and your clinic has been "difficult". Much of the problems with warfarin (you mention the brand Coumadin) is caused by the management of dose and INR (or shoud I say the failure of management). Myself I am glad that I manage myself and I know that I do a much better job than any clinic, even in the face of ongoing antibiotic treatments. So if you are able to self manage then it really becomes no more problem than learning to drive.

Again, depending on age the choice is more or less "flip a coin" or "whatever you feel happy with" , but if your wife is under 50 I'd suggest you look carefully at a mechanical

 

[honeybunny]

As pellicle's said, your wife's age may factor into your decision. I'm presuming she is on the younger side since you mention her having to have a third surgery if she goes with tissue. I chose tissue at 61 in part because of not looking forward to warfarin therapy. I anticipate only one more OHS in my life time. I think if I was looking at two or more I would opt for mechanical. Either way it is not an easy decision. Best wishes in reaching the best one for her.

 

[Agian]

Welcome to the forum. Firstly, did they find the cause of the endocarditis? We're told that dental work and other procedures can be a cause. If they have found what caused it, you may be able to 'neutralise' the future risk, making the decision simply one of valve choice, for a second AVR. In which case, I would personally agree with Pellicle. For example, if it was caused by a bronchoscope, then you might be able to look at it as an unfortunate one-off accident.

Is one type of valve more prone to ongoing endocarditis risk than another? You've got to wonder. It may be something worth investigating. In other words, does the endocarditis, or it's cause, complicate the decision? You mentioned stroke and kidney failure. Were these due to the endocarditis, and if they remain an ongoing problem, what impact would Warfarin have on them?

I'm someone who has only gone through it once. I'd have so many questions. Good people here with a wealth of collective wisdom.

 

[Heartvalvefix]

Hi
I also had endocarditis and a tissue valve. I did not want lifetime anticoagulation therapy. My understanding is that the current research is showing that the tissue valves are lasting longer than traditionally thought. In addition, a redo can be done via a catheter vs . OHS. I feel for your wife and wish her/you all the best.

 

[pellicle]

Hi
.... My understanding is that the current research is showing that the tissue valves are lasting longer than traditionally thought.

the marketing is making such claims but there is zero evidence supporting any significant changes. Some anecdotes:

http://www.valvereplacement.org/foru...fter-the-first

After a long hiatus from the board i find myself back where i first started. I had my valve replaced 10 years and 3 months ago with an Edwards 29mm bovine valve, i was 34 at the time.

http://www.valvereplacement.org/foru...=&p=793746

Dr Miller replaced my failed tissue valve after 7 years.

http://www.valvereplacement.org/foru...ly-lasted-2yrs

http://www.valvereplacement.org/foru...after-6-months

I had OHS 6 months ago and received a St jude biocor 21 mm valve. It now seems that the valve is not working properly. It is still unclear what the exact problem is but my surgeon thought the leaflets of the valve appeared to be thickened which could be caused by calcification

youth is the issue ... no two ways about it.

 

[Agian]

If youth is the only issue, then yes, I agree with you. There may be other factors involved. We don't know enough about this lady, to make a 'call'; not that we're experts anyway. If I have a colonoscopy and get a complication because of it and get endocarditis that's different than it just happening with no cause ever found. The anaesthetist told me that in his experience most of the endocarditis they see is in failing native valves.

Sometimes it just happens and they never find a cause. Is avoiding Warfarin simply a lifestyle choice, or are there other concerns?

I can understand why someone might think 'Well you got endocarditis on a mechanical, let's try a tissue valve.' Not that this would necessarily be the right decision.

I'm rambling... I empathise with the anxiety. IF it was me I'd have a thousand questions.

Marketing works both ways btw. I wouldn't be game to drop my INR to 1.5, despite the On-X marketing.

ALL things being equal, IF it was me, I would be leaning towards mechanical. Age????

 

[Agian]

Gotta say one more thing, or my head will explode:
The gentleman's wife is found to have endocarditis, then they discover a bursitis (? Bacterial ? Same bug).
Which came first? How can we be sure?
Antibiotics + Warfarin = PITA
However, I've done it twice since my operation 7 weeks ago. Definitely doable with self-monitoring.

Point 2: I'm GUESSING a failing tissue valve is more susceptible to endocarditis (just like a stenosed native valve)

Sorry, if I've offended anyone or have been too nosey with my questions. The gentleman is not obliged to answer personal questions.

 

[pellicle]

If youth is the only issue, then yes, I agree with you.

I was speaking only on the topic of tissue prosthetic valves longevity , not to this persons choice.

Her age is as yet unknown.

 

[pellicle]

Antibiotics + Warfarin = PITA
However, I've done it twice since my operation 7 weeks ago. Definitely doable with self-monitoring.

Ahh young padawan, you are still learning the ways of the living force. Give it a few more years and you won't even break stride

 

[Agian]

Ahh young padawan, you are still learning the ways of the living force. Give it a few more years and you won't even break stride

Feckin Yoda. LOL

 

[cldlhd]

Is endocarditis more likely once you've had it? Also is it more likely with a mechanical valve?

 

[briacunn]

Hello Everyone. I am the one that wrote the initial topic - I just registered after I posted. I appreciate all of the time you took to reply. My wife will be 53 in February. We don't know how she developed endocarditis. She did have a dentist appointment (cleaning) about a month and half prior to developing her illness. She was on Clindamycin for her cleaning. She also told me she was cleaning her teeth pretty good a few days prior to her dentist appointment and her gums were bleeding pretty good. We also got two dogs about a month prior to her illness and I was able to get a used crate from a co-worker. She cut her hand when we were putting it together. Not real bad, but it did draw blood. I go crazy trying to figure it out. I believe her kidneys failed due to all the contrast she had. She had a lot of CT's and x-rays. Her creatinine is 1.17 which we just found out today. It was over 4 when she was in the hospital.

I by no means am even close to a doctor, but if there is leaking then aren't they going to have to use some sort of graft to act as solid tissue? If this is the case I would think mechanical is the way to go. My thought process is that hopefully this will last the rest of her life. If a tissue valve then I would think a greater risk of even more complicated procedure with the graft. The only real issue she had with the Coumadin was a lot of bruising.

I was a nervous wreck during her first surgery. I am a nervous wreck now and I will be beside myself on Sept 21st.

 

[pellicle]

Hi

... My wife will be 53 in February.

well from what I know at that age (rather than if you'd said 33) you're likely to get 15 years or perhaps 18 years from a good tissue prosthetic. So that's in her 70's ... I wouldn't think that's a bad thing and the way things are going a TAVI may well be a viable "fix" to that by then ...

also, from what I know, if she has a small diameter valve size then that would put her in the risk group for pannus which (as far as I know) is not a significant problem for tissue prosthetics but is a problem for female + small diameter valve.

We don't know how she developed endocarditis. She did have a dentist appointment (cleaning) about a month and half prior to developing her illness. She was on Clindamycin for her cleaning.

its a possibility, but as you had antibiotic cover I'd be feeling its a very small risk

We also got two dogs about a month prior to her illness and I was able to get a used crate from a co-worker. She cut her hand when we were putting it together. Not real bad

both of those are such insignificant risk factors that I'd more or less rule them out

...

but if there is leaking then aren't they going to have to use some sort of graft to act as solid tissue? If this is the case I would think mechanical is the way to go.

in situ repair of prosthetic valves is not viable (and to my knowledge just not done) so it would be replacement.

My thought process is that hopefully this will last the rest of her life. If a tissue valve then I would think a greater risk of even more complicated procedure with the graft. The only real issue she had with the Coumadin was a lot of bruising.

I'd tend towards the view that management of bruising is easier than management of a tissue prosthesis, however at her age it may well be "flip a coin" ... to my mind the knowledge of her valve diameter would ease my mind about pannus, which is a small but not dismissable risk with a mechanical.

I have read that research suggests that pannus is linked to lower than 2.2 INR ... so if you made your AC target 2.8 then that may minimise risks there.

I was a nervous wreck during her first surgery. I am a nervous wreck now and I will be beside myself on Sept 21st.

I think I understand ... my wife was a mess during mine ...

If you want to chat about things, PM me and I can call ... if you're in the USA or UK I can call for no charges on my phone plan at the moment. That is if you want to just "talk" to someone.

 

[Agian]

She also told me she was cleaning her teeth pretty good a few days prior to her dentist appointment and her gums were bleeding pretty good.

Did her teeth bleed when she brushed, before the appointment? How long had she been cleaning her teeth regularly? Was it just for the few days before the appointment?
Do you know the name of the bacteria they discovered? It might indicate the cause. Then it's a matter of minimising her risk factors. She must've seen an infectious diseases guy in hospital.
Knowledge is power. If you can narrow it down to poor oral hygiene (for example), you can take more control of the situation.
Again, I apologise for being nosey.
They say oral hygiene is an important factor in the development of endocarditis.

 

[Agian]

I have read that research suggests that pannus is linked to lower than 2.2 INR ... so if you made your AC target 2.8 then that may minimise risks there.

Interesting. Do you still have the paper?

 

[pellicle]

Interesting. Do you still have the paper?

yes, and I just re read it ...

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

... Adequate anticoagulation was defined as International Normalized Ratio (INR) = 2.5 at the time of diagnosis. Eleven patients (48%) were considered to have adequate anticoagulation, 8 in the pannus group and 3 in the thrombus group.

Adequate anticoagulation was more frequent in patients with pannus compared to thrombus. Pannus formation was more common in the aortic position compared to the mitral position (70% vs. 21%, p = 0.035).

my mistake it seems as I was thinking it said "inadequate" and thus had remembered it wrongly

they go on to say:

There are no reports in the literature assessing the level of anticoagulation in patients with pannus formation. In the present study, suboptimal anticoagulation was present in 78% of valve thrombosis and in only 11% of pannus formation, further confirming the clinical suspicion that patients with valve obstruction in the setting of therapeutic anticoagulation are more likely to have pannus formation.

which is a little unclear (like hedging their bet) and not really very conclusive but suggestive.

I'd dug for this in the past because my surgeon was of the view that > 2.2 was significant at reducing pannus ... thanks for pulling me up as I don't like spreading misinformation!

My reference on female & small diameter and pannus is this one:
http://link.springer.com/article/10....047-006-0334-3

Pannus formation after aortic valve replacement is not common, but obstruction due to chronic pannus is one of the most serious complications of valve replacement. The causes of pannus formation are still unknown and effective preventive methods have not been fully elucidated.

We reviewed our clinical experience of all patients who underwent reoperation for prosthetic aortic valve obstruction due to pannus formation between 1973 and 2004. We compared the initial 18-year period of surgery, when the Björk–Shiley tilting-disk valve was used, and the subsequent 13-year period of surgery, when the St. Jude Medical valve was used.

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.

 

[OldManEmu]

Cldldh

Is endocarditis more likely once you've had it? Also is it more likely with a mechanical valve?

Endocarditis is more likely once you have had it once. My endocarditis was with a native valve.
When the AHA guidelines for antibiotic coverage for dental work with prosthetic valves was changed a few years ago I asked my cardio if I still needed coverage and was told that because I had already had endocarditis I was therefore in the high risk group for reoccurrence and should always have antibiotics before dental work, colonoscopy and gastroscopy procedures.

Mechanical valves are not used on patients that require emergency valve replacements and still have active endocarditis; Homographs (human donor) are the first preference if available or a tissue valve.

 

[Agian]

1) When I was researching valve types, I spoke to an RN from On-X. Of all the Pannus reported for On-X, further investigation revealed it was actually a clot. This implies that it's often difficult to tell the two apart.
2) My surgeon told me the valve he implanted was the biggest size, making future pannus unlikely. This fits with the smaller valve = higher pannus risk theory (and therefore women getting it more than men).

 

[Agian]

My endocarditis was with a native valve.

Was it a normal, healthy valve though? No rheumatic fever, stenosis etc?