Mechanical Vs. Tissue And Atrial Fib

[David]

This is my first posting.

I am 60 year old active male (jog or otherwise work out 6 days a week) with aortic valve replacement surgery scheduled for this Tuesday, April 5 due to substantial aortic regurg (3 +)as result of endocarditus 10 years ago. I have had no symptoms (according to cardiologist, he suspects I had valve damage as kid, perhaps as result of undiagnosed rhuematic fever, and perhaps my heart had adjusted to it -- murmur was not obvious) until recently when cardiologist detected my heart size increasing and I also developed bouts of atrial fibrillation, which was discovered during a recent stress echo (had good results on stress echo in terms of output, but went into A fib afterwards, came out of it after 1/2 hour on my own). Cardiologist thought it was brought on by stress due to excercise, and was cautiously optimistic that it might not be problem once valve was replaced.

I had settled on choice of tissue valve, specifically the CEPM, as result of reading postings and communicating directly with some one of members here. I am active, planning to travel to some 3rd world countries, wanted to avoid blood thinners and was ready to accept another valve replacement when the tissue valve wore out, hopefully in about 20 years (many of my relatives have lived into their 90's).

The cardiologist performed an angiogram yesterday in order to rule out clogged arteries prior to valve replacement surgery. Good news is that my arteries are clear, so I won't need bypass surgery also. Problem is that I went into A-Fib during procedure, which cardiologist said was unusual.

I came out of A-fib after about 5 hours on my own. Now cardiologist is saying that A fib may be a permanent problem, even after valve replacement. If that is the case I'll be on warafin therapy anyway, which I was hoping to avoid by getting a tissue valve. Obviously, if I'm on thinners anyway, I might as well get mechanical valve, which will outlast me.

I'm still hoping to go with tissue valve. Since I've only had a couple of bouts with A fib (at least that have been documented, although it's possible I've had more, because I don't really have obvious symptoms when it happens), I'm hoping that the A fib was just a temporary thing, and would go away if I got tissue valve. However, I'd not want to get a tissue valve if I'm just going to have to take thinner's anyway, and face replacement in future. Anyone have any experience in this area (or thoughts or impressions?) that they can share? Thanks!

David

 

[Ross]

Hi David and thanks for coming out of the shadows

My thoughts plain and simple though your probably not going to like. I think you should just go mechanical and be done with it. It isn't a guarantee that you won't need it replaced sometime, but it sure cuts the chances considerably. Being that your already having Afib problems, honestly, I think it's going to be a chronic thing for you and you already know that means Coumadin.

My question to you is, what is your specific hang up about taking Coumadin? Is it because people have told you half truths, horror stories and urban legends as so many folks do? Believe it or not, your life isn't really disrupted any unless you want it to be by taking it. There seems to be a huge misunderstanding with this drug and lots of it come from days gone by years ago. If that's the case for you, let us help dispel this myth.

 

[tobagotwo]

Blasted stress tests...

As far as I know, I never had afib until I developed severe AS. When my valve became very stenotic and regurgitant, I had numerous bouts of afib, especially near the end. I've had none since I left the hospital.

I tend to agree with your estimation of the situation. Rhythm reactions are known to happen to some people after - and even during - catheterization, and wouldn't necessarily be indicative of anything.

However, having said that, everyone's path is different. In the end, you must choose your path based on your own estimations and your prior history.

Best wishes,

 

[Rich]

Hi David and welcome to this site,
I would have to agree with Ross on valve choice.
I was 58 at the time of my surgery and that was almost nine years ago.
My mechanical valve has been just great.
It sounds like you are in excellent physical condition, but would you be in the same condition 15-20 years from now?
That's a question nobody can answer, but if your physical condition was to go downhill for some reason, it might make valve surgery much more risky in your later years.
As Ross also mentioned there are is lot of misunderstanding regarding Coumadin.
The only times it gets to be a bit of a problem is when you require invasive procedures or surgeries, but there are ways to treat that also.
Whatever you decide I want to wish you the best and look forward to hearing how things go.
Rich

 

[RCB]

Tough one!

Tough one!

David,
This is about as tough a decision as they come. A-fib tend to get worse
as you age and the cutting that go on in heart surgery can make it worse.
Your lucky it is the aortic valve, because tissue valve implanted in that position may last you the rest of your life- no can say for sure. Some studies
suggest that increased activity can shorten the life of a tissue valve- they really aren't sure of this. If not being on warfarin is that important to you, you might check out have a Maze procedure done with your tissue valve.
Have you check out an ON-X or St. Judes Regent valve? They hold some promise of no warfarin use in the future if the clinical studies show no Warfarin is safe- again they really don't know.
Good luck and we stand ready to help you in your decision.

 

[geebee]

David,

Welcome. I would have to chime in on the side of mechanical considering your age and situation. Going into surgery with afib will mean you are more likely to come out with worse afib. Chances are it will require coumadin therapy. If you are going to need coumadin for the afib, you might as well have a mechanical valve that will probably last your lifetime.

As Rachel said, a tissue valve will require replacement when you are 75 or 80. That is fairly on in years for major surgery (not that it doesn't happen). If you did not have a choice of valves (say, tissue was the only choice) then, of course, you would face surgery as a matter of fact.

Since there are such good mechanicals out there, why not just go the route that more than likely will not require another surgery?

Good luck with everything.

 

[ALCapshaw2]

AH, the old Tissue vs. Mechanical Valve Debate,
it's one of our FAVORITES !

I too wanted a Bovine Pericardial (at age 58) but radiation damage from treatment for Hodgkin's Disease caused my surgeon to decide to put in a St. Jude mechanical instead.

For me, Coumadin has not been too big of an issue, BUT, it has caused me to put off having other invasive (diagnostic) procedures such as an upper endoscopy and a colonoscopy. I just didn't want to take the risk, even with Bridge Therapy.

The risk factors for A-Fib are:
White Male
Too Many Birthdays (over 60)
Valve 'issues'
Welcome to the Club!

A-Fib can be caused by ENLARGEMENT of the heart. IF you have surgery 'soon enough', this enlargement MAY subside with the happy result that your A-Fib also goes away. You may want to talk with an ElectroPhysiologist (a Cardiologist who specializes in Heart Rhythm issues). Beta Blockers MAY control the rapid Heart RATE but not totally eliminate A-Fib. Other drugs such as BetaPace (generic form is SOTALOL) target A-Fib but do take some adjusting to (dizzyness / headaches for several weeks were my symptoms).

The MAZE procedure is another surgical option that can be performed at the same time as your valve replacement, ASSUMING you are a candidate AND that your surgeon is experienced in this additional procedure. (Not all are)

The On-X and St. Jude Regent Mechanical valves have been designed with more attention to the principles of Fluid Dynamics. Theoretically they produce less turbulence than earlier designs and this reduces the likelihood of clot formation. Studies are underway in Europe to determine if Aspirin Therapy alone is sufficient with those valves. If not, then a lower INR may still be an option.

Bottom Line: ALL valves have their Positive and Negative attributes. Many patients end up choosing the one whose negative aspects they believe they can best live with. It is a VERY PERSONAL decision.

Best wishes,

'AL Capshaw'

 

[tobagotwo]

The AHA and the ACC have guidelines that discourage the use of exercise stress tests on valve patients for precisely this type of reason. Not only that, they point out that the tests are also inaccurate for determining the likelihood of arterial blockage specifically in aortic valve patients.

You have some enlargement, you are symptomatic, both bouts are tied to trigger events, and you came out of both yourself. I didn't even have the trigger events to blame for my afib. It happened for me mostly at night, when it (and I) should have been sleeping.

If you have surgery soon enough for your heart to recover its normal size, there is still a very good chance that you will not have afib after surgery. If you want to take a shot at it, the "worst" result would be that you wind up on warfarin, at a somewhat lower INR than most mechanical valve recipients. The folks here are saying that's not so bad. At least you would get to find out.

If you're 82 and you need a replacement, it will likely be done through a catheterization procedure, as has recently been done to a 71-year-old with multiple heart problems. They said he was back to work in four days. Probably has to work to pay for the surgery, poor fellow.

Your requirements on a valve will be less by then, and their valves will be two decades better than they are now. There are a number of companies in percutaneous-valve clinical trials phases, including Edwards and some new, start-up companies. The valves to this point are not in the same league as those installed the hard way, but they seem to be the next wave for delicate patients. It's hard not to see them expanding from there.

Just food for thought.

Best wishes,

 

[inlaguna]

David,

I expereienced A-fib several times prior to my valve replacement in November. These bouts almost always occured as a result of exercise. I chose a tissue valve ( knowing I will have to get another op in my lifetime).

I had two other episodes after surgery ( kept me in the hospital for 4 additional days). At four months plus post op, I have not had any other problems and I am exercising harder than I have in years. After that first week post op, I think my heart settled down and the a-fib went away.

I did consider the fact that I would have to go on coumadin despite having the tissue valve , but I chose to take the chance.


Dan

 

[Guest]

The older you get, the higher the risk of getting a - fib.

It seems that the biggest risk factor for having a - fib is having already had an episode.

 

[bvdr]

David, welcome!

Bouts of atrial fib is what finally got my attention that something was really wrong with my heart. I too would go in and out of it but it got to the point I needed drugs or electricity to convert me back into sinus rhythm. I went on coumadin prior to surgery even though I was in sinus rhythm most of the time. Knowing it was a real possibility that it would remain a problem needing long term anti-coagulation made the choice of a mechanical valve easy for my doctors and me.

It is now about 18 months since I had surgery and even on flecainide (a powerful anti-arrhythmic) I still slip into atrial fib at times. For me, I'm glad I have a mechanical.

 

[Barry]

I've got a mechanical valve and atrial fibrillation. My understanding is that the more recent the atrial fib is, the more readily it's reversed - they can do it through electroshock, or through amiodarone. I guess because they figured my had been chronic, they didn't try electoshock, but did try amiodarone.

I'll spare you the details, but amiodarone is pretty toxic and has potential for some really weird side-effects - my favorite being "smurf syndrome" in which your skin turns permanently blue-grey. And docs aren't big on informed consent these days for some reason, so I wasn't informed of its side-effects, found out by asking the pharmacist for the medication insert and by reasearch on the 'net. Even knowing its side effects, I still gave it a shot for a few months. Didn't help, so I discontinued.

Serendipity in a weird way: With the mechanical valve I'm stuck with dealing with Warfarin, anyway, and as you note Warfarin is often given for atrial fib to diminish the possibility of throwing clots.

FYI, despite the horror stories, I find Warfarin to really be no more than just an annoyance. I did have to give up my hobby of knife-fighting...

 

[David]

Thanks

Thanks

Thanks for all the responses. They were really helpful.

I'm going into surgery tomorrow and have decided to go with a St. Jude's Regent. I'm just not willing to take chance that A fib will reverse after surgery and if I'm going to being taking thinners, I'd rather avoid a second surgery.

I really appreciate everyone's help, the time you took to answer my questions and your willingness to share your experiences.

David.

 

[geebee]

David,

My thoughts and prayers are with you. I wish you well and look forward to hearing from you after surgery.

Can you try and get someone to post for you tomorrow after your surgery so we know you're alright?

Hugs to you.

 

[Glenda]

David I probably posted this too late for you to see before you go into surgery but you will be in my prayers today. We'll be seeing you on the other side of the mountain before you know it. I hope someone can post for you to let us know how you are doing.