Mechanical valves in elderly patients

[Hillary]

Hi,

My husband, David had his bicuspid aortic vavle replaced with a St Jude in 1994. The valve has worked perfectly and we've been very happy with it.

He now has to go back because he has formed an aortic aneurysm on the ascending aorta - right down to the root. Apparently the vavle has to be taken out and a new one put in.

He's now 81, but in amazing physical condition. All the doctors we've consulted tell him that he should have a tissue valve put in - the dangers of coumadin in the elderly are just too great. I've looked through your forums, and I see patients taking coumadin for years and years without serious complications. We've had a few complications, to be fair, but none of them life-threatening. On the other hand, a tissue valve could well wear out in ten years or so and require another operation. One of those trans-catheter repairs. We have every reason to think David has a considerable lifespan ahead: so many medical check-ups come out with excellent results, and he comes of long-lived stock.

Any thoughts on this? Any advice? We'd probably insist on the mechanical valve if we could. :confused2:

 

[Duff Man]

Here are my thoughts. Please know I'm not a doctor and I'm just speaking from my perspective as a person in the waiting room:

If David has a considerable lifespan left, then I might lean toward the mechanical valve. Here's why I would: The bovine pericardial valve is touted to be cutting edge and it's also said to be made with transcatheter valve replacement in mind. Really, it seems like any tissue valve might work. But the transcatheter valve replacement is still in its infancy, and there's no guarantee it's going to be mainstream in the 10 or 15 years later that he'll need the bovine valve replaced. They may never get acceptable survival rates out of them.

You also have to consider that as the new tissue valve becomes progressively more stenotic, his left ventricle will begin to manifest the effects, becoming overly thick and more muscular. Left ventricular hypertrophy is a risk in itself, and you don't know how long he will need to endure that risk before relief is obtained through surgery. Being that he'll be a multiple op, older patient, well... they're going to probably be pretty conservative about go time for a 3rd operation.

It's generally accepted as fact that the more reoperations you have, the riskier the procedure. It's also generally accepted that the older you are, the riskier... but that could be debated.

I'm going to be totally honest about what I would do in your situation, but this is just me. I would find a surgeon that installs a newer mechanical valve that MAY not require ACT in the future. This valve is called the on-x valve. And to be honest, this is exactly what I'm in the process of right now.

I'm on coumadin, and it doesn't scare me.... albeit things do happen on it. One thing that does scare the hell out of me is open heart surgery. An even scarier prospect is a second or third OHS.

 

[neil]

hi hilary.......for whats its worth would defo go tissue,am suprised there have mentioned mech,but like all things the choice is yours,listen to what the docs say, there are far far more qualified than anybody on here,and thats no slight on anybodys opinion just fact,good luck and am sure he will be just fine,

 

[anita45]

Hi
I'm new in that forum .I HAD a MVRaplacement in dec.2002 and unsuccessful Maze procedure toghether..As a pharmacist i know that Coumadin could be a big problem for some people. Now FDA approuved a new drug instead coumadin RADAXA (DABIGATRAN).i think you need to speek with your doctor about this.
Good luck!
Anita.

 

[Jkm7]

Most of the top surgeons are advising they expect 20 good years (and maybe more) from the new generation of tissue valves especially when placed in patients aged 60 and over. I'm a good deal younger than 81 and was absolute about wanting tissue and all my doctors agreed it was a good choice. Also, should he require another replacement sooner, they are now beginning percutaneous replacements by cath. In the years to come, many expect that to be common and usual.

Given his age, there is more chance of other health issues arising in years to come and any procedure which might involve bleeding makes coumadin management and bridging something to deal with. There are many dentists who require coumadin be stopped before some procedures, some GI docs won't do colonoscopies while fully anti-coagulated and so many other procedures.

I think a large majority of surgeons would expect to implant a tissue valve in a man his age.
Of course, the final choice is always the patient's.
Best Wishes. This decision is never easy.

 

[Lynlw]

My Dad is 81 and IF it were him I definately would suggest he get a tissue (bovine valve). The perimount Bovine already have a track record of 85% (or 90) of the people 65 and above are still doing well at 20 years. I can't imagnine IF a tissue valve he got now needed replaced, it not being done in the cath lab. The next group of people thay are discussing right now to do the Trials for are all patients in their 80, wether they are high risk or not. Also even IF the percutaneous valves are not mainstream, whenever your husband MAY need this valve replaced, chances are even if it only lasted 10 years, as a 90 year old needing his 3rd surgery, chances are very high he would be a candidate to have it placed in the cath lab. Altho percutaneous is only an option to replace a tissue valve (for any time in the foreseeable future) so IF he got a mechanical valve and for some reason needed it replaced, that would have to be by surgery.
YES the risks of coumadin ARE higher in the elderly. Many (not ALL) elderly people are a little more fraglie, their skin and bones weaker, sometime their balance is off and they fall more often (which is why so many elderly die after broken hips)
There are a couple elderly members on VR, but for the most part the members are middle age. IF I were researching the different stats, to help make this decisions, I would start by doing a search on www.pubmed.com Its the site that list many of the studes and articles about everything medical. Search things like Elderly + valve replacement Coumadin and elderly, ect
The On-X valve may NOT need coumadin some time in the future, but as far as I know it WILL need some from of anticoagulant, like plavix that also has risk (and the Pradaxa is ONLY for Afib, it has NOT even been discussed starting trials on it for valve patients * added I JUST read they "are organizing a trial that will involve mechanical heart valves in patients who ALSO have atrial fibrillation.* http://www.theheart.org/article/1142899.do



FWIW, more centers and surgerons, are using tissue valves in younger (40 and up) patients these days.

 

[catwoman]

If your husband's been OK on warfarin since 1994 and he's got a good ACT manager, you may want to go with another mechanical valve, perhaps an On-X.
Another thing to consider is his overall health condition and the longevity of his immediate family.

Otherwise, go tissue.

Hi
I'm new in that forum .I HAD a MVRaplacement in dec.2002 and unsuccessful Maze procedure toghether..As a pharmacist i know that Coumadin could be a big problem for some people. Now FDA approuved a new drug instead coumadin RADAXA (DABIGATRAN).i think you need to speek with your doctor about this.
Good luck!
Anita.

Pradaxa is currently only for use by a-fib patients, not for valvers. No doubt it will be a while before it could be considered for use with mechanical valves.
It's also a pricey drug in comparison to warfarin.

 

[watson524]

FWIW - we're dealing with the same question here. My mom is waiting to get a date for MV replacement. She's 71. Has been on coumadin almost 30 years with no issues (other than easier bruising). Her local cardio and GP are saying no question, mechanical given that she's in otherwise good health, deals with the coumadin well and comes from family that tends to live into their 90s. Also, it's expected due to her constant a-fib that she'd always need ACT. She'll be going to Cleveland Clinic where tissue valves seem to be more prevalent so now we're waiting to get out there and talk to them about what they recommend and then make our final decision. If there's anything we know, we want to limit the chance of resurgery and only do this once (pending any other issues).

 

[ALCapshaw2]

Hi
I'm new in that forum .I HAD a MVRaplacement in dec.2002 and unsuccessful Maze procedure toghether..As a pharmacist i know that Coumadin could be a big problem for some people. Now FDA approuved a new drug instead coumadin RADAXA (DABIGATRAN).i think you need to speek with your doctor about this.
Good luck!
Anita.

As a Pharmacist Anita, I'm surprised that you are apparently NOT aware that Pradaxa is ONLY approved for patients with Atrial Fibrilation. It has NOT been approved for patients with Mechanical Heart Valves. It is also my understanding that there is NO Antidote for Pradaxa.

'AL Capshaw'

 

[ALCapshaw2]

Hilary,

You may want to do some more research on the Risks of Coumadin in Elderly patients.
I'm thinking that the Major Concern with Elderly Patients is Bleeding in the Brain.

To my mind, the Best Two Options are the Bovine Pericardial Tissue Valve (which has the longest proven durability of the Tissue Valve Options, especially when implanted after age 65) and the On-X Mechanical Valve which 'may' be approved for 'reduced anticoagulation' after their NO/Low AntiCoagulation Study is complete in a few more years.

I am a big believer in the benefits of the On-X mechanical valve, BUT, for a patient in his 80's, I can't help but think that the Bovine Pericardial Tissue Valve is a Very Good option.

 

[Jkm7]

As a Pharmacist Anite, I'm surprised that you are apparently NOT aware that Pradaxa is ONLY approved for patients with Atrial Fibrilation. It has NOT been approved for patients with Mechanical Heart Valves. It is also my understanding that there is NO Antidote for Pradaxa.

'AL Capshaw'

I've asked this before but if it was answered, I missed the response. Sorry if that is the case.

Is there an antidote for Plavix? I am not the best researcher but cannot find info about one.
Thanks.

 

[ShezaGirlie]

Hi Hillary and welcome..!

Hi Hillary and welcome..!

Hi,

My husband, David had his bicuspid aortic vavle replaced with a St Jude in 1994. The valve has worked perfectly and we've been very happy with it.

He now has to go back because he has formed an aortic aneurysm on the ascending aorta - right down to the root. Apparently the vavle has to be taken out and a new one put in.

He's now 81, but in amazing physical condition. All the doctors we've consulted tell him that he should have a tissue valve put in - the dangers of coumadin in the elderly are just too great. I've looked through your forums, and I see patients taking coumadin for years and years without serious complications. We've had a few complications, to be fair, but none of them life-threatening. On the other hand, a tissue valve could well wear out in ten years or so and require another operation. One of those trans-catheter repairs. We have every reason to think David has a considerable lifespan ahead: so many medical check-ups come out with excellent results, and he comes of long-lived stock.

Any thoughts on this? Any advice? We'd probably insist on the mechanical valve if we could. :confused2:

Welcome Hillary and we're glad you found us. Sounds like you are an excellent health advocate for David..:thumbup:

My thoughts on the best type of valve for David would be to listen and digest the info your doctors are giving you. They have the experience and knowledge shared among colleagues as to the best course of action for David.

I'm also of long-lived stock since my Mom just celebrated her 95th birthday and actually has no physical health problems other than normal aches and pains of 95 years of wear and tear. But, if required I'd choose a tissue valve in a heartbeat!

I echo the opinions of Neil, JKM7, Lynlw, and Al Capshaw2 and their reasoning for choosing a tissue valve. It's certainly true that warfarin is more difficult and more dangerous for the elderly. Simply getting older exaserbates that for a mechanical valver.

 

[kfay]

For an 81 year old, tissue, hands down. There are reasons that his Dr's are recommending tissue to an 81 year old, just like there are reasons that they recommend mechanical to a 35 year old male. To be fair, the people who you see posting on here who have not had a problem with coumadin are not in their 80's.

 

[dick0236]

IF I were to need a reop at my age (74+), I would almost certainly choose a tissue valve, if feasable, with the hope I would not be on warfarin. I am a big believer in mechanical valves for the young to lessen the need for multiple surgeries. However, in advanced ages, the risks of warfarin may outweigh any benefits of a long lasting mechanical valve....but this is a very personal choice.

 

[RobThatsMe]

Hi,

My vote for a person 81 years old would be with a "tissue" valve.
There are no guarentees with either type of valve. I had a St Judes mechanical put in back in 2000. I got 10 years out of it due to pannus or scar tissue buildup under the valve. I had to either replace it or face a life threatening major cardiac event within 12 months. They also found that the root had to be repaired, and that I also had an aneurysm that needed repair.

So, my point it this, we all hear that mechanical valves will last a lifetime. That may be true, but other heart related issues can cause issues in themselves to a person.

Also, My mother passed away from a brain hemmorage. She was 81. She had come down with dimentia, and even though her pills were managed by a daily pill box, and my dad monitoring her, she still had these "moments" that she thought she forgot to take her pills, and ended up over medicating herself.

So, for someone who has lived so far to 81 years of age, another 10 to 15 years from a tissue valve sounds, at least for me, like a great "Low Risk" deal.
Life comes at ya fast...

Wishing you husband a healthy life, no matter which valve type he selects..

Rob

 

[anita45]

hi,
in our country is not approuved yet;i can only hope that one day i will also,change my warfarin??

 

[Lionheart]

Hi Hillary,
The American Heart Association along with other professional cardiac medical societies have established a set of guidelines that provide recommendations to cardiologist and surgeons about standards for care related to valve disease and treatment. I believe those guidelines would recommend a tissue valve for someone your fathers age in order to avoid anti-coagulation therapy, unless there are other underlying issues or reasons that would alter that decision. I think you should generally listen to the recommendations from his cardiologist and surgeon, but also remember that it is elective surgery and your dad can select the type of valve that he wants even if it overrides the standard protocol for someone his age. Most surgeons will honor his choice unless that decision severely undermines your dad's health.

Take care,
John

 

[anita45]

To AL"
your sarcastic answear , maybe want to say:Anita ,Welcome to our forum????????

 

[Kathy McCain]

I have to agree. Tissue valve

 

[Kathy McCain]

Anita, WELCOME TO OUR FORUM!!!! We are ALL certainly glad that you found us!