Agian
Well-known member
hevishot;n871912 said:
I struggle to think of material like that. The guy is a natural.
Mechanical Valve or Tissue Valve ?
- Thread starter shah4u
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I struggle to think of material like that. The guy is a natural.
Hey Guys,
Thanks for the opinion, I am finally going with mechanical valve and surgery is scheduled somewhere next week or the week after I give my consent. Now for the most important part i would like to know is about the difficulties of warfarin and how manage INR and what problem will it pose if I go with mech valve, and also the can u guys pls tell me about the On-X valve coz one surgeon whom i consulted is happy to put On-X while another one who is a very reputed doc is a little against it stating my annulus is small of about 18-19mm since its a little heavy profile valve and he would have put that if my annulus was about 23mm and as per him St Jude fits the need better but i also read On-X do have 19mm annulus valve so i am quite confused why that doc suggested otherwise given that he has done over 7000 heart surgery.
Thanks for the opinion, I am finally going with mechanical valve and surgery is scheduled somewhere next week or the week after I give my consent. Now for the most important part i would like to know is about the difficulties of warfarin and how manage INR and what problem will it pose if I go with mech valve, and also the can u guys pls tell me about the On-X valve coz one surgeon whom i consulted is happy to put On-X while another one who is a very reputed doc is a little against it stating my annulus is small of about 18-19mm since its a little heavy profile valve and he would have put that if my annulus was about 23mm and as per him St Jude fits the need better but i also read On-X do have 19mm annulus valve so i am quite confused why that doc suggested otherwise given that he has done over 7000 heart surgery.
shah4u;n872173 said:
I have found very few "difficulties" for the past 43 years. That said, the only "difficulty" I've had occurred only 7 years post surgery when I had my first, and only, stroke......or ANY medical problem due to warfarin. It's, for me, a very simple drug to manage. Take the pill as prescribed, test routinely and maintain a normal diet, including a relatively consistent amount of vit K veggies.......that's it. Beyond that, just "eat, drink and enjoy" your new lease on life.
PS: I doubt that my early "difficulty" would have occurred had I had the information and testing protocols available to current warfarin users. My problem was mostly my fault and 99% due to my ignorance.
pellicle
Professional Dingbat, Guru and Merkintologist
Hi
I think you're looking at this the wrong way (or at least expressing it in a way that I can't grapple with, and given what's below I tend to think its both).
Did you read my blog posts? To manage your INR is about as easy as managing your stomach. If you are hungry you eat food. If your INR is low you eat warfarin. That's it ... you now have the basics.
Like eating your body can fool you into thinking you are hungry when you are not ... you eat and you get fat and its bad for you. Equally not eating enough is bad for you.
simple isn't it
If you are asking something like "tell me how many pills I must have" its a meaningless question. For if I said to you "eat one small bowl of rice every day, that will be enough it fails to account for changes. Changes like you worked harder, you are feeling sick, its colder, its hotter ... its wrong to even think that you should have a "fixed dose of food", equally most days you will probably eat the same amount. Its only occasionally it varies.
The way you tell how hungry you are is to measure your INR with the Coagucheck. As I put in my blog posts (you read and understood them right?) if your INR goes down then you need to understand if its going to go back up by itself (no change needed) or if it needs a hand ... the way to do that is to test again in a week and see what its doing.
Do not think in seconds or minutes ... you will not turn into a clot if your INR is low for a few days nor will you turn into a pool of blood on the floor if its too high for a few days. Again, as I said its on my blog ... graphs, and ranges ... if you don't understand how to read graphs by all means say that. Ask specific questions.
Unlike eating you need to wait longer to determine your INR (you feel full within minutes).
I get the feeling you are trying to micro manage this before it even happens, before you even have the experience. Its like you are asking every single traffic question possible before you go for your first driving lesson.
Before I can answer more, tell me about yourself, what do you do, what level of education do you have and what is it in. Because it seems to me that information is washing off you like water from a duck and nothing that is said is anything you can hold onto. If I know more about you perhaps I can answer better.
I have tried reading this a few times and I just don't think I understand the question.the above seems to be one sentence (perhaps a world record) ... so speak simply, make your sentences shorter and try to focus on the problem.
Remember ultimately this is not rocket science and with actual experience (not fretting with only the darkness of ignorance around you like a blanket) you will learn how.
Nobody teaches anyone how to play a musical instrument ... each person must learn them selves.
shah4u;n872173 said:
I think you're looking at this the wrong way (or at least expressing it in a way that I can't grapple with, and given what's below I tend to think its both).
Did you read my blog posts? To manage your INR is about as easy as managing your stomach. If you are hungry you eat food. If your INR is low you eat warfarin. That's it ... you now have the basics.
Like eating your body can fool you into thinking you are hungry when you are not ... you eat and you get fat and its bad for you. Equally not eating enough is bad for you.
simple isn't it
If you are asking something like "tell me how many pills I must have" its a meaningless question. For if I said to you "eat one small bowl of rice every day, that will be enough it fails to account for changes. Changes like you worked harder, you are feeling sick, its colder, its hotter ... its wrong to even think that you should have a "fixed dose of food", equally most days you will probably eat the same amount. Its only occasionally it varies.
The way you tell how hungry you are is to measure your INR with the Coagucheck. As I put in my blog posts (you read and understood them right?) if your INR goes down then you need to understand if its going to go back up by itself (no change needed) or if it needs a hand ... the way to do that is to test again in a week and see what its doing.
Do not think in seconds or minutes ... you will not turn into a clot if your INR is low for a few days nor will you turn into a pool of blood on the floor if its too high for a few days. Again, as I said its on my blog ... graphs, and ranges ... if you don't understand how to read graphs by all means say that. Ask specific questions.
Unlike eating you need to wait longer to determine your INR (you feel full within minutes).
I get the feeling you are trying to micro manage this before it even happens, before you even have the experience. Its like you are asking every single traffic question possible before you go for your first driving lesson.
Before I can answer more, tell me about yourself, what do you do, what level of education do you have and what is it in. Because it seems to me that information is washing off you like water from a duck and nothing that is said is anything you can hold onto. If I know more about you perhaps I can answer better.
I have tried reading this a few times and I just don't think I understand the question.the above seems to be one sentence (perhaps a world record) ... so speak simply, make your sentences shorter and try to focus on the problem.
Remember ultimately this is not rocket science and with actual experience (not fretting with only the darkness of ignorance around you like a blanket) you will learn how.
Nobody teaches anyone how to play a musical instrument ... each person must learn them selves.
Superman
Well-known member
shah4u;n872173 said:
The only thing I can say for certain about On-X is that they market heavily on this site and people that have them seem happy with them. It sounds like the one doctor is making an informed recommendation about valves with reasoning behind it. I haven't heard that reasoning before - but all that means is I haven't heard it. I have a St. Jude. I've had a St. Jude for over 26 years. I feel perfectly safe with it and sleep just fine. I could be mistaken, but I seem to recall that it was former St. Jude employees who created the On-X to compete. Someone will correct or affirm shortly, I'm sure.
Regarding "difficulties" with warfarin. I guess I'm not sure what you're looking for here.
- Take prescribed dose daily
- Test INR with home monitor weekly
- Adjust dose if needed based on test results
- Rinse / Repeat
You can take your meds and test machine with you on vacation. It's battery powered, so no worries if the power goes out. Warfarin comes in many strengths. For me, I keep 5 mg and 1 mg pills on hand, which allows me to dose anywhere from 1 mg - 10 mg or more daily as needed depending on pill combo's. For me, 5 - 6 mg daily is the typical dose with most days at 5. I don't even think about food / meds anymore really. I eat what I want to when I want to.
Not sure if this helps but I had my valve replaced November 1 and the operating room head nurse told me they were using a St. Jude. I came out with an On-X. I had done my research and would have been as comfortable with the St. Jude. Some things you just have to leave to the professionals I think. I also ended up with a bypass. Not positive if the difference in valves warranted that but no blockages were found pre-surgery testing.
I am getting settled in with warfarin and testing and think it will be pretty easy to manage. I like the analogy made by Superman............"rinse/repeat "
I am getting settled in with warfarin and testing and think it will be pretty easy to manage. I like the analogy made by Superman............"rinse/repeat "
good luck shah, hope all goes well,
cldlhd
Well-known member
jwinter;n872193 said:
If there were no blockages then why a bypass?
Agian
Well-known member
I find it disturbing that people tout 'life-saving technology' like car salesmen. They all do it: pharma, the stent guys. Really confronting. There's even been a shill on the forum before (reading old posts).Superman;n872192 said:
Bodhisattva
Member
shah4u;n872173 said:
Hi shah4u,
This is my first post and I wanted to comment on this part of your post asking about On-X vs St. Jude quoted above - very very important question!
Here’s what I understand, please anyone correct me if I’m wrong:
Your native valve opening is about 18-19mm. But your replacement valve will not have the same size opening. The inside opening will be smaller. This is because the vast majority of replacement valves have stuff that takes up space on the inside. The valve leaflets are attached to this foundation no matter whether the leaflets are bio or mechanical. So what is important is not the outside opening size of the replacement valve but the inside effective orifice area or EOA.
The EOA is very important because of what is called Patient-Prothesis Mismatch or PPM. This is when the effective orifice area of the valve is too small so the heart still has to work too hard to get enough blood through the valve opening since the replacement valve opening is too small relative to body size metabolic requirements. This relativity between opening and body is the most tricky with smaller annulus.
The St. Judes Regent (I’m assuming your doctor is thinking about the Regent?) seems to be the best valve design with regard to dealing with PPM. Look at Tables 1 & 2 in this article http://circ.ahajournals.org/content/119/7/1034#F6 for the normal reference valves for EOA for all the most commonly used prothetic valves, both bio and mechanical. You’ll see how the St Judes Regent design is by far the best on the EOA critera and On-X not so much.
When someone’s annulus is 23mm or so, maybe no problem with putting in On-X. But when you get into the smaller size annulus like 18-19mm, it’s a whole different story apparently. Because the benefits of a little less warfarin or a pannus barrier are nothing compared with downside of dealing with PPM 24/7 if someone ends up with an effective orifice area index that is too small for their body. This is basically like replacing native stenosis with replacement valve stenosis.
So in this case, it looks like your second doctor has a good reputation for a reason! I’d go with their recommendation for sure. Whereas the first doctor seems to be less knowledgable about PPM since they are willing to implant On-X in the context of 18-19mm annulus assuming your body isn’t especially petite. And even with a petite body, things can change down the road. So going for the largest effective orifice size possible might be the best bet in general and especially when we are talking mechanical.
I sure hope this is fairly clear and helps the next time you talk with your doctors about your valve choices. Good luck and all the best to you and everyone!
pellicle
Professional Dingbat, Guru and Merkintologist
Hi
Great first post, very informative
And especially with a small diameter valve
Great first post, very informative
Bodhisattva;n872211 said:
And especially with a small diameter valve
Bodhisattva
Member
pellicle;n872213 said:
Here's the effective orifice index table for St Jude Regent valves. It's at the bottom of the page. Looks like they do pretty well with the smaller diameter valves indeed!
https://www.sjm.com/en/professionals...t/evidence#tab
Here's how folks can figure BSA (body surface area) so you can plug your annulus size x BSA into the Regent index table: http://www.globalrph.com/bsa2.htm
Now the table only goes down to 19mm valves. But not worries it looks like Regents are available as small as 17mm. It's incredible really.
https://www.ncbi.nlm.nih.gov/pubmed/19101276
The 17-mm St. Jude Medical Regent valve is a valid option for patients with a small aortic annulus.
Article abstract:
BACKGROUND:
When aortic valve replacement is performed in patients with a small aortic annulus, prosthesis-patient mismatch is of concern. Such prosthesis-patient mismatch may affect postoperative clinical status and survival. We investigated the outcomes of isolated aortic valve replacement performed with a 17-mm mechanical prosthesis in patients with aortic stenosis.
CONCLUSIONS:
Aortic valve replacement with a 17-mm Regent prosthesis appears to provide satisfactory clinical and hemodynamic results in patients with a small aortic annulus. Remarkable left ventricular mass regression during follow-up was achieved irrespective of the effective orifice area index at discharge.
And here's the full article as a pdf in case someone wants to dive deeper
http://www.annalsthoracicsurgery.org...08)02047-X/pdf
A quote from the full article:
Castro and colleagues [8] performed aortic root enlargement procedures in 114 patients to avoid moderate to severe PPM. Del Rizzo and associates [9] reported that a stentless valve resembled the native aortic valve and provided a larger internal diameter and good flexibility, leading to superior hemodynamic performance and improved left ventricular function. However, aortic annulus enlargement and implantation of the stentless valve have been shown to result in prolonged cardiopulmonary bypass and ischemic times [8, 10]. Such surgical modification is now seldom necessary because advances in the design of prostheses have improved hemodynamic performance considerably. The 17-mm St. Jude Medical Regent valve with an effective orifice area of 1.30 cm2 can be applied in patients with a BSA of less than 1.5 m2, resulting in an EOAI of more than 0.85 cm2 /m2.
So even if someone has a small annulus and larger BSA, there are ways to get around it by choosing stentless valves (which remove the foundation that takes up space) or doing annulus enlargement (cutting a larger hole to fit a larger valve). Neither is ideal because both require much more bypass time of course as well as more special surgeon skill. So this Regent valve design is really great since it incorporates various methods which increase the effective orifice as much as possible which gives more BSA wiggle-room.
Finally, on a more general note, here's an Oxford Journal article presenting a 30year study of mechanical bileaflet St Jude valves with very good results to show:
Bileaflet mechanical valve replacement: an assessment of outcomes with 30 years of follow-up
http://icvts.oxfordjournals.org/cont...ts.ivw196.full
Agian
Well-known member
I've learned something new. Thanks!
cldlhd
Well-known member
Perhaps the On-x is a bit heavy for its orifice size due to the pannus guards?
Bodhisattva
Member
cldlhd;n872222 said:
hi cldlhd, I don't know for sure. I've not read the term "heavy" in the literature regarding orifice so not sure how to define that. But I hear On-X is very responsive? Maybe they'd send over the On-X effective orifice area index table? I haven't seen it online on their website but that makes sense since On-X seems to be focusing its public materials more on the lower INR thing and the pannus barrier addition.
Bodhisattva
Member
And this 2009 article is very comprehensive, seems well researched and is amazingly easy to read for a medical article. It lays out all the different types of valves and touches upon all the major issues.
Prosthetic Heart Valves
Selection of the Optimal Prosthesis and Long-Term Management
The introduction of valve replacement surgery in the early 1960s has dramatically improved the outcome of patients with valvular heart disease. Approximately 90 000 valve substitutes are now implanted in the United States and 280 000 worldwide each year; approximately half are mechanical valves and half are bioprosthetic valves. Despite the marked improvements in prosthetic valve design and surgical procedures over the past decades, valve replacement does not provide a definitive cure to the patient. Instead, native valve disease is traded for “prosthetic valve disease,” and the outcome of patients undergoing valve replacement is affected by prosthetic valve hemodynamics, durability, and thrombogenicity. Nonetheless, many of the prosthesis-related complications can be prevented or their impact minimized through optimal prosthesis selection in the individual patient and careful medical management and follow-up after implantation. The purpose of this article is to provide an overview of the current state of knowledge and future perspectives with regard to optimal prosthesis selection and clinical management after valve implantation.
http://circ.ahajournals.org/content/119/7/1034#F6
Prosthetic Heart Valves
Selection of the Optimal Prosthesis and Long-Term Management
The introduction of valve replacement surgery in the early 1960s has dramatically improved the outcome of patients with valvular heart disease. Approximately 90 000 valve substitutes are now implanted in the United States and 280 000 worldwide each year; approximately half are mechanical valves and half are bioprosthetic valves. Despite the marked improvements in prosthetic valve design and surgical procedures over the past decades, valve replacement does not provide a definitive cure to the patient. Instead, native valve disease is traded for “prosthetic valve disease,” and the outcome of patients undergoing valve replacement is affected by prosthetic valve hemodynamics, durability, and thrombogenicity. Nonetheless, many of the prosthesis-related complications can be prevented or their impact minimized through optimal prosthesis selection in the individual patient and careful medical management and follow-up after implantation. The purpose of this article is to provide an overview of the current state of knowledge and future perspectives with regard to optimal prosthesis selection and clinical management after valve implantation.
http://circ.ahajournals.org/content/119/7/1034#F6
cldlhd
Well-known member
Bodhisattva;n872228 said:
Sorry I misread in my haste.
Interesting stuff
Agian
Well-known member
I'm just starting to wade through the article. It implies that the gradient across the prosthetic valve is at least partly dependent on body size / weight. I've not heard this before, but it makes sense. So my thinking is that losing weight might decrease the pressure gradient across the valve. Do people think this is right? Would a smaller pressure across the valve mean less haemolysis (reduced LDH)? My mother is overweight and when she had her echo initially they said she had stenosis, but then they did some calculation and said nup. I'm wondering whether this more weight = bigger gradient applies to native valves as well. Extraordinary concept. Thanks again for making me think.Bodhisattva;n872211 said:
The difference in effective orifice area between the On-X and Regent is significant, especially as the valve size increases. I've got a 27/29 On-X. I guess the 'pannus guard' comes at a 'price'.
