Mechanical Valve

[pellicle]

Since its a movie on at the cinema again now, I can perhaps quote this nice bit of mantra penned by Frank Herbert (the author)

 

[Superman]

you know, (so for the benfit of Redone I'll say) I was diagnosed at about 5 and had my first sugery at 10.

This is what I was meaning (@Redone ) when I said " I came to the decision years ago that what didn't bother me in my childhood, should not bother me now."

Just didn’t want to assume how you felt about it as a child. Pretty much all I ever knew. The aneurysm at 36 took me a bit more by surprise as I thought I was done. Still that was more of a, “Get this thing out of here before it pops!”, rather than a dread.

 

[dick0236]

Hey Redone......I knew when I saw your earlier posts that we shared something familiar but I couldn't put my finger on it. Now I remember......1967. You were born July 11, 1967, and my one and only mechanical valve was implanted Aug. 16, 1967.......about 5 weeks later. Hopefully, that will help you put your mind at ease concerning the life of a mechanical valve.

 

[pellicle]

Just didn’t want to assume how you felt about it as a child.

pretty much just "naïve sense of adventure". I was in a kids ward of course, all the kids there were OHS patients. We just swapped stories and were usually "trouble for the nurses" as soon as we were long out of ICU ... wheelchairs were fun

I suspect this is because >>fully nobody<< had any sense of "doom and gloom" around us.

 

[Chuck C]

Being active is not why the surgeon suggested mechanical and he did because he asked me, would you like to know what I would do? Of course I said, yes!

I like your surgeon's approach. And, in my view, he gave you solid advice, based on the fact that he was aware that you wanted to be one and done.

Like you, I went into surgery asymptomatic. My cardiologist made it very clear to me that it was my decision whether to get surgery now or wait for symptoms. I pressed him a little, encouraging him to let me know what he would do in my shoes. He said it was a tough call, but he would wait for symptoms and do a follow up with me in 2 months. There is literature that suggests that the long-term outcome is much better if you get surgery before symptoms. He was familiar with it and we discussed it. He conceded that it made a strong case for getting surgery before symptoms and reiterated that it was my choice- he really had no strong recommendation eithe way. Still, I really wanted to know what he would choose if he was in my shoes and it was intesting to know.

I scheduled my consult with my surgeon and put the same question to him, as to what he would do. Without hesitation he said he would opt for the surgery now, rather than wait. He pointed out that not only might there be irreversible damage if I waited for symptoms, but the first symptom might be sudden death. I agreed with him and was 95% of that opinion before he even gave me his answer. The point being, I like the question of "What would you do if you were in my situation?"

I can't understate how important I believe that communication is with your cardiologist and surgeon. I had two consultations with my surgeon prior to surgery and each one lasted over an hour. I was fortunate that I had a surgeon who welcomed in depth discussion and was in no hurry to wrap up the appointment. My first consult was before it was even time for surgery. At that point I was set on going tissue. He was fully supportive of my choice. The second appointment was after I was diagnosed as severe and getting ready for surgery. I told him that I had changed my mind and decided on mechanical and explained why; I wanted to be one and done. Again he was supportive.

These discussions led to him knowing my desires and played a major role in a key judgement call he had to make during the surgery. It was not expected that I would need to have my aorta replaced as well as my aortic valve. My aortic diameter was only 3.6cm and well below the threshold for replacement. But, when he saw my aorta tissue during the surgery, in his experience, it had the appearance of likely progressing to aneurism eventually, as is extremely common with BAV patients. In fact this is the #1 cause for mechanical valve patients to need reoperation. For me, if I should develop an aneursism, it would mean getting another OHS in the future. From our discussions, he knew how I felt about things- he knew I switched to mechanical because I wanted this to be my first and only OHS. So, he made the judgement call to replace part of my aorta while he was "under the hood", despite the fact that the guidelines did not call for aorta replacement with a 3.6cm aortic diameter.

After surgery, we had a lengthy discussion about his decision, during which he told me that he only went forward with the aortic replacement because he knew how strongly I desired for this to be my only OHS and that had we not had such thorough discussion about the topic, he would have not replaced it and just followed the guidelines. I am so very glad that he made the decision that he did and told him so. Now, I will not need to face surgery in the future for aneurism, which is all to reinforce my point about how important the presurgery discussion can be.

 

[Redone]

Really great solid opinions expressed here - based on personal experience...and these are the best, I reckon.
I like to keep it simple because I can think myself into a corner when I overthink things

1) You are young -> go mechanical. Can you imagine redoing OHS every 10-15 years for tissue valves? It takes a good 6 months for the sternum to heal. Forget about doing pushups till 6 months post OHS! Warfarin has not stopped me from keeping fit. Your surgeon will advise you to avoid contact sports - you can do just about anything that doesn't involve you getting bashed up.

2) Which mechanical valve? I think you have a few votes for St Jude - add mine to the list. My surgeon advised me to get this one due to the robustness and solid predictable performance. It's been a good 5 years for me so far.

I appreciate your feedback and will definitely consider the St. Jude. Thankfully, I don't like push ups, but love to bench press, tricep dip, and incline chest press and realize all this will have to wait at least for awhile until things are nice and healed. I'm glad to hear you have been able to stay fit with Warfarin. Hopefully, it won't be bad for me. We do a lot of hiking in the White Mountains and it's very rocky. Falls can happen so I'll have to watch that. The first surgeon I met said, no hiking with mechanical which I thought was odd. I appreciate your feedback!

 

[Redone]

Alternate opinion here. 56, very active, etc.

I went tissue because I'm due for a full shoulder replacement next year, and a very likely hip replacement in the next few. While not impossible, these trickier surgeries and recoveries on warfarin than without.

All of the reasons that the other members cited as reasons to go mechanical are very good ones, but everyone is different, and there are compelling reasons to go tissue.

I will likely require several future surgeries including one within a year from OHS. I see two hip replacements, hopefully no surgeries on my spine or neck but with Spinal Stenosis who knows and I still plan to go mechanical. From what I've read you go off the medication for a period before surgery limiting bleeding issues.

 

[Chuck C]

I will likely require several future surgeries including one within a year from OHS. I see two hip replacements, hopefully no surgeries on my spine or neck but with Spinal Stenosis who knows and I still plan to go mechanical. From what I've read you go off the medication for a period before surgery limiting bleeding issues.

They also typically will use a bridge anti-coagulant for major surgeries, with a short half life, such as heparin. This allows them to minimize the time that you spend in the non- anticoagulated state; taking you off heparin the day of surgery then back on again soon after surgery, as you re-establish your INR into range by resuming warfarin, at which time they would typically stop the heparin.

 

[Redone]

I like your surgeon's approach. And, in my view, he gave you solid advice, based on the fact that he was aware that you wanted to be one and done.

Like you, I went into surgery asymptomatic. My cardiologist made it very clear to me that it was my decision whether to get surgery now or wait for symptoms. I pressed him a little, encouraging him to let me know what he would do in my shoes. He said it was a tough call, but he would wait for symptoms and do a follow up with me in 2 months. There is literature that suggests that the long-term outcome is much better if you get surgery before symptoms. He was familiar with it and we discussed it. He conceded that it made a strong case for getting surgery before symptoms and reiterated that it was my choice- he really had no strong recommendation eithe way. Still, I really wanted to know what he would choose if he was in my shoes and it was intesting to know.

I scheduled my consult with my surgeon and put the same question to him, as to what he would do. Without hesitation he said he would opt for the surgery now, rather than wait. He pointed out that not only might there be irreversible damage if I waited for symptoms, but the first symptom might be sudden death. I agreed with him and was 95% of that opinion before he even gave me his answer. The point being, I like the question of "What would you do if you were in my situation?"

I can't understate how important I believe that communication is with your cardiologist and surgeon. I had two consultations with my surgeon prior to surgery and each one lasted over an hour. I was fortunate that I had a surgeon who welcomed in depth discussion and was in no hurry to wrap up the appointment. My first consult was before it was even time for surgery. At that point I was set on going tissue. He was fully supportive of my choice. The second appointment was after I was diagnosed as severe and getting ready for surgery. I told him that I had changed my mind and decided on mechanical and explained why; I wanted to be one and done. Again he was supportive.

These discussions led to him knowing my desires and played a major role in a key judgement call he had to make during the surgery. It was not expected that I would need to have my aorta replaced as well as my aortic valve. My aortic diameter was only 3.6cm and well below the threshold for replacement. But, when he saw my aorta tissue during the surgery, in his experience, it had the appearance of likely progressing to aneurism eventually, as is extremely common with BAV patients. In fact this is the #1 cause for mechanical valve patients to need reoperation. For me, if I should develop an aneursism, it would mean getting another OHS in the future. From our discussions, he knew how I felt about things- he knew I switched to mechanical because I wanted this to be my first and only OHS. So, he made the judgement call to replace part of my aorta while he was "under the hood", despite the fact that the guidelines did not call for aorta replacement with a 3.6cm aortic diameter.

After surgery, we had a lengthy discussion about his decision, during which he told me that he only went forward with the aortic replacement because he knew how strongly I desired for this to be my only OHS and that had we not had such thorough discussion about the topic, he would have not replaced it and just followed the guidelines. I am so very glad that he made the decision that he did and told him so. Now, I will not need to face surgery in the future for aneurism, which is all to reinforce my point about how important the presurgery discussion can be.

Definitely excellent points Chuck! I am setting up an appointment with the surgeon for a Telehealth visit to ask him several questions. We won't be meeting twice although it would have been nice. Surgery is less than two weeks away and I want to get it done as well. I've been pushing staying in shape, hiking etc knowing surgery was approaching. Like you mentioned waiting is probably not a great idea. I feel strange palpitations from time to time and the last thing I would want is to be 6 miles from a trailhead and have an incident. My decision was made when the cardiologists I spoke to recently said, lower your exertion while strength training. That's tough to determine what that means for me. 60% exertion will likely feel like nothing so don't want to push beyond what I should. Thank you for your valuable feedback!

 

[pellicle]

From what I've read you go off the medication for a period before surgery limiting bleeding issues.

you may find this interesting then
http://cjeastwd.blogspot.com/2017/12/perioperative-management-of-inr.html
also different surgeries are done in such a way as to use a pressure tourniquet to restrict blood, typically lower limbs. So in some cases the surgeon doesn't care about it.

For what its worth I've had people doing surgery on me tell me that "if I didn't know you were on warfarin I wouldn't have guessed it by the bleeding".

this is what you can expect with a well managed INR.

Although you seem to have a bunch of other issues too, it may be nice to know them before going further, in case any of those are show stoppers for ACT / Warfarin.

 

[pellicle]

@Redone

surgeries, with a short half life, such as heparin. This allows them to minimize the time that you spend in the non- anticoagulated state;

this is correct, and it goes like this:

it works because both heparin (injected, so there's that) does not work in the same pathway of coagulation as Warfarin and so as warfarins effect falls away you can have heparin working and can cease and restart while waiting for warfarin to "kick in" again.

This is increasingly only done in cases where the patient is a high risk of clotting.

HTH

 

[Redone]

They also typically will use a bridge anti-coagulant for major surgeries, with a short half life, such as heparin. This allows them to minimize the time that you spend in the non- anticoagulated state; taking you off heparin the day of surgery then back on again soon after surgery, as you re-establish your INR into range by resuming warfarin, at which time they would typically stop the heparin.

This is good information for sure! I have read people sometimes have issues with anticoagulants and wonder what they do in instances like this?

 

[Superman]

I appreciate your feedback and will definitely consider the St. Jude. Thankfully, I don't like push ups, but love to bench press, tricep dip, and incline chest press and realize all this will have to wait at least for awhile until things are nice and healed. I'm glad to hear you have been able to stay fit with Warfarin. Hopefully, it won't be bad for me. We do a lot of hiking in the White Mountains and it's very rocky. Falls can happen so I'll have to watch that. The first surgeon I met said, no hiking with mechanical which I thought was odd. I appreciate your feedback!

Some Dr’s are certifiable. Seriously, “Never leave the house and surround yourself with pillows. Then you should be safe on Warfarin. Oh, and no more shaving or clipping your fingernails!”

The only real hiking I’ve done has been on Warfarin. Allow me the liberty Of adding some of my favorite hiking pictures:

As far as other surgeries, I’ve had another open heart while on warfarin and Gallbladder and appendix removed. I bridged with Lovenox and went back on warfarin later. No issues.

 

[drleng]

with

Cross the bridge when you come to it
I'm just 1 week postop sinus surgery. I was put on heparin bridging before and after surgery.
The heparin preop was no issue. And yes, you are free of anticoagulation for 24-48 hrs perioperatively (I have not been off warfarin since my Bentall op and it felt a bit like I was let out of jail for a couple of days
Postop I had some annoying oozing because 1) I was overdosed on heparin 2) the hematologist advising didn't know much about fine tuning warfarin, although he was the go to doctor for the job.
Anyway, I compared notes with Pellicle (do ask him for advice on this - he has heaps of personal experience) and also based on my own experience, decided on my own dosing and prevented potentially troubling postop bleeding. Trust me, doctors don't know everything unless they have personally been through it themselves.
If you ever need help with perioperative management of anticoagulation, just holler. In the meantime, just get through your first surgery. Slim fit people recover quickly in the hands of a good surgeon. Postop,
take enough painkillers and keep good posture to 1) expand your lungs - you will get chest physio 2) prevent cervical nerve compression.
All the best!

 

[drleng]

Some Dr’s are certifiable. Seriously, “Never leave the house and surround yourself with pillows. Then you should be safe on Warfarin. Oh, and no more shaving or clipping your fingernails!”

<They aren't certifiable . They just have no clue how their patients cope in real life because they have not experienced it. In short, they are not qualified to give advice in this department.>

The only real hiking I’ve done has been on Warfarin. Allow me the liberty Of adding some of my favorite hiking pictures:
View attachment 888222View attachment 888223View attachment 888224View attachment 888225View attachment 888226View attachment 888227

As far as other surgeries, I’ve had another open heart while on warfarin and Gallbladder and appendix removed. I bridged with Lovenox and went back on warfarin later. No issues.

 

[stephenismycopilot]

I had pretty much settled on mechanical when I had my AVR at 37... until 5:30am the morning of my surgery at UCLA Reagan when my surgeon said (his words), "You'd be crazy to do mechanical." His thinking was that the Inspiris Resilia would have a few more years on previous biological valve longevity and that he'd be able to put in a valve large enough to accommodate one or even two TAVR down the road. We had a rough time stabilizing my INR during the three months post-op that I was on warfarin, so I'm glad I made the choice that I did, and I am now more active and feel physically better than I have since I was a teenager.

That said, it's a personal choice which way to go. I'm grateful for my surgeon's advice and feel this was the right choice for me. Might I choose differently if this valve needs to be replaced sooner than we hoped... maybe! But like Pellicle says, there are no wrong decisions here, and to the extent we can, we should focus on what a blessing medical science is that we can be cracked open like crab legs and be up and walking around days later.

 

[Lynn]

Redone, I agree with you, Knowing your going to need open heart surgery “one day” and knowing you need it ”now” are to complete different things lol. I was also shocked by how quickly my stenosis progressed the last couple of years prior to surgery.

I have told my children all their lives that feeling fear doesn’t mean something is wrong, it usually just means we are being pushed our of our comfort zones. They also heard over and over that the best things I have done in my life have almost always been the scariest. When I was nervous before surgery my two daughters, and my daughter in law (who has been been with my son for so many years that I feel as if I raised her as well) all coached me through my fear by reminding me that the best things in life are often the scariest lol. I guess sometimes they were actually listening.

I also think as a personal trainer you will have a leg up during rehab. My cardio was fine after surgery but it was working with a kinesiologist, doing the right exercises in the right way that moved from feeling good to feeling great.

 

[Redone]

Redone, I sympathize with how you are feeling. I found the decision between tissue and mechanical to be one of the most difficult I have ever had to make. Like you and many others I was initially leaning tissue and was very concerned with taking warfarin. I am 58 so I could have gone either way and I thought my mind was settled on tissue. My surgeon, however, was very adamant that if I went tissue I would be facing another surgery at some point in my life and was strongly advocating mechanical which sent me crashing back to the drawing board and completely confused as to which way to go.

The surgeons case was that even if I did get 20 years from a tissue valve (which he felt was unlikely) I would be facing a redo of some kind in my life-at an advanced age. My deliberations went like this: If I did get 20 years and TAVR was a possibility and a was able to squeeze another few years out of that it could work out. If my tissue valve failed after 7, 10 or 12 or even 15 years (which is a real possibility) I would face another surgery as TAVR could not be relied upon to get me through-even if I was a candidate.

The other side of the coin is of course anti coagulants for the rest of my life. As others have said, this board helped a great deal in my ability to overcome my reluctance to warfarin. I think without reading people’s real life experiences on this board I would have been to afraid to chance the warfarin and gone tissue despite my surgeon and cardiologists recommendations.

In the end I went On-x because that is the mechanical valve my surgeon uses most often. Am I happy with my choice? Yes I am. I feel great (surgery April 1) warfarin really is no big deal. I home test and I eat what I want. My hair hasn’t fallen out (knock wood) and I don’t bleed very much if I cut myself. I don’t feel the mechanical valve or the warfarin limit any of my activities.

Whatever choice you make, I am sure everything will work out for you. Really, both choices are great options. We are so lucky to have these choices and to live in a time when medical science can give us a new lease of life. Good luck.

Thank you for your experiences Lynn. Our situations sound similar in many ways. I'm grateful your surgeon recommended the mechanical valve. That's exactly what I liked about the surgeon I chose. It's also very encouraging to know you feel good! I love hearing this and am really happy for you! My general practitioner thought it was a great idea too! This forum has taught me a lot and I'm grateful for what I've learned. Thank you so much! It's right around the corner.

 

[Redone]

Some Dr’s are certifiable. Seriously, “Never leave the house and surround yourself with pillows. Then you should be safe on Warfarin. Oh, and no more shaving or clipping your fingernails!”

The only real hiking I’ve done has been on Warfarin. Allow me the liberty Of adding some of my favorite hiking pictures:
View attachment 888222View attachment 888223View attachment 888224View attachment 888225View attachment 888226View attachment 888227

As far as other surgeries, I’ve had another open heart while on warfarin and Gallbladder and appendix removed. I bridged with Lovenox and went back on warfarin later. No issues.

Fantastic to hear!! I wasn't too concerned. We definitely have area's where falls can occur, but it wasn't really a deterrent from choosing mechanical. Thank you for your feedback and beautiful pictures!

 

[user 16827]

@Redone , just to offer a little real world perspective on Warfarin;

The INR value of 2 means you will take twice as long to clot ( INR ~ 1 in an uncoagulated person )

if a person cuts their hand and takes 15 seconds to stop bleeding you will take around 30 seconds,
you do not bleed to death, your clotting just takes longer that is all.

I'm mechanical, very active and competitively race mountain bikes, i have had numerous crashes
on rocks and jumps over the years and i have never bled to death .

Best of luck with the surgery

Just to add , my driver on mechanical was also ( like you ) to have just the one OHS, both for myself and my family