Mechanical vs Tissue - need help deciding

[pellicle]

Funny how the OP hasn't been on here since June 2019... I wonder what they chose....

dunno ... but its been observed (more than once) that mech valvers often stick around to discuss and learn how to manage ACT while tissue valvers usually only return to celebrate their valve anniversary for a while and then to return when the valve has gone into SVD and then discuss options.

Sadly all the options with issues relating to failed tissue valves are surgical replacement

https://www.valvereplacement.org/threads/here-we-go-again.878078/
while its true that a mechanical valve can fail its a LOT rarer.

 

[Michael O]

@pellicle

For clarity's sake, I'm not on warfarin, so I'm not even tracking my range.

"true, but as we've also discussed here that's not impossible and if its the case you know you're going to have these "serious of major invasive surgeries" then you should steer away from warfarin ... call that "contra indicated". "

I think we're saying the same thing. I expect a full shoulder replacement, a hip replacement and some degree of knee surgery (possibly a full replacement) in the next 10 years. The difficult of managing those surgeries around the discontinuation/re-establishment of the warfarin was mentioned as a factor against a mechanical valve by surgeons at Cleveland Clinic and University of Michigh (where I eventually had my surgery). The risk factor wasn't my difficulty managing the warfarin, it was the additional risk factors for the surgeries. I trust that they have sufficient line-of-sight to outcome data to make those recommendations.

The line which I see a number of times on these boards is roughly "If you're under 60, mechanical is the way to go". This is prevalent enough that if you're arguing in good faith, I don't need to link them. My point is that there are compelling reasons to get a bio valve, including drug interactions for warfarin and a substantial history of management difficulty in the population as a whole.

 

[Michael O]

Thanks @Michael O
Ok but isn't what you are saying regarding the antidepressants and contraceptives being an interaction of rather than a side effect of?

Fair point - I conflated the two.

".... compliance is easy given the possible adverse affects of noncompliance ...." Humans being humans, this statement is unfortunately not so helpful in a gigantic variety of contexts.

 

[pellicle]

Hi

The line which I see a number of times on these boards is roughly "If you're under 60, mechanical is the way to go".

I think that's pretty roughly right. I'd personally say that I believe in the main I add to that the following:

• if you don't have any contr-indications to warfarin
• if you want to have the best chance of never needing a reoperation
• I ask if you have BAV then are they repairing the aorta because aneurysm is strongly associated with BAV
• the further you are under 60 (and certainly under 50) the better it is

I will say that managing warfarin its not "as easy as sitting on the couch" but that most of the issues (like 90%) are either the patient not complying or the medical system getting in your way (I believe this to be a mostly USA issue, but as you can see there are ways around it).

However I've made the case a few times to 20y'olds that if this is your first valve then getting a tissue now may well see you through a period of your life that you may be "unreliable" in.

I believe that I start from the position of "if you are under 60 then a mech is the only choice which will realistically see you one and done" and go from there to explore the lifestyle / associated medical problems associated with that.

All too often I believe these discussions come from a simplification of what is said (probably with an eye roll) and in truth the devil is in the details. In this very thread one vociferous person (now on my growing ignore list) accused me of saying its a one stop shop, when I actually said that if they were older (and clarified that their age was not on their BIO) then a tissue >> TAVR may well serve them adequatly.

So I would say its hard to tar anyone with that brush of "If you're under 60, mechanical is the way to go" being their unthinking mantra.

Personally I wish these discussions would answer a question asked and not attack one side or the other. For clarity I do not call "correcting misinformation" attacking anyone.

Best Wishes

 

[Warrick]

Perhaps I should/could have said earler compliance is easier for people with mechanical valves because (I think) more than most they understand without it the chance of clot issues is a very real possibilty and they are already well aware of their condition due to the whole OHS experience.
Whereas someone on warfarin for afib may not have the same appreciation for potential incidence due to non compliance Im guessing.
Wouldnt it be great if the biopolymer valves pan out and there is no more mechanical or tissue or warfarin for future candidates.

 

[Michael O]

Fair points all the way through, @pellicle . Cheers and best wishes for a happy and safe holiday season.

 

[dick0236]

Perhaps I should/could have said earler compliance is easier for people with mechanical valves because (I think) more than most they understand without it the chance of clot issues is a very real possibilty and they are already well aware of their condition due to the whole OHS experience.
Whereas someone on warfarin for afib may not have the same appreciation for potential incidence due to non compliance Im guessing.
Wouldnt it be great if the biopolymer valves pan out and there is no more mechanical or tissue or warfarin for future candidates.

I think you "nailed it".

 

[user 15848]

Perspective is everything , my wish ?, i wish i was born with a perfect heart with no bicuspid valve, did not happen so, at 63 defective valve gave up and i would faint to the floor at any given moment from july/2015 to november/2015 while waiting for ohs, walking more than 50 meters was a no no, then i had to make a choice, tissue/mech; read posts in this forum and talked to my 2 sisters ( doctors ) and everybody told me go mech; i was concerned about the tick noise, about the rat poison with many years of documented background; but, no, i did not want to take the pill every day and worry about something called inr, then reality hit me; i had a bad heart, i had to go to surgery, "first ever visit to a hospital at 63", and during 4 months this was my only thought, pig/metal ..., then i started to think about the future past the ohs; and started to pay attention at how many seniors i knew that had strokes, placed on warfarin after the fact , so, i saw it was very likely that regardless of pig/metal i would have to end up taking some sort of anticoag thing, warfarin is everywhere and cheap, the others ... are very expensive and also are NOT free of "consequences"; At least 4 relatives of mine, in a very huge family of seniors and doctors got that problem, the warfarin came too late, meaning post stroke; I know the stories about hospitals not from watching TV shows, but from Medicine students and doctors, there is a lot going on inside those places we don't hear about, so the less you visit them the better for you, so, yeah, i wish i was born with a perfect heart since i do not eat Trans Fats so do not have heart decease, but no, i was not going to go plan for a second op at my 77 years of age, as told by my surgeon, and no, i will not sit an wait for the stroke to start taking Warfarin. This is MY experience, my thoughts, there is no right or wrong, just "My"
perspective".

 

[pellicle]

Fair points all the way through, @pellicle . Cheers and best wishes for a happy and safe holiday season.

thanks mate ... something to ponder. In a recent exchange here with a fellow who took a lot of coaxing to mention the KEY POINT of his age, I find that my valve (already 10) will be 20 when I get to his age "right now". Yes, so when I'm 67 my valve will be 20yo. If I'd like to get another 10 (on top of that date) without indecent it would be very very much a statistical outlier that if I'd picked a tissue prosthesis at 47 I'd get to 77 ... because you know age at operation is the primary predictor for tissue valve prosthesis durability. You did know that right?

Lastly I find it offensive that people accuse me of essentially (at best) "bias" or (more likely) "confirmation bias" because that's the valve I have. Well remember I've had

1. a repair,
2. a homograft and now
3. a mechanical

... so I have pretty much had them all to try. I call that experience ... but apparently that counts for little when the person who is in their 60's and has picked a tissue (who somehow isn't biased {or is that in denial of bias}) and calls "bull5hit" to my citation of actual scientific evidence.

Happy Holidays my friend.

 

[Michael O]

... because you know age at operation is the primary predictor for tissue valve prosthesis durability. You did know that right?

Yes - they went over that a lot as they talked about pros/cons. Anecdotally, it's interesting to hear how much better informed I was re: my choices that some friends who've had similar surgeries at lesser hospitals. I'm learning that a lot of people were told "this is what we're doing" <clap on the back> .

 

[pellicle]

The nurse who came to my house to demo the meter told me NOT to tourniquet.

I just thought I'd add something to this:

1. see that there is no discrepancy between your INR readings obtained with and without tourniquet
2. wrap lightly but sufficiently so as to gently push blood back, not like you are trying to damage the digit.
3. last (and maybe not least) make sure between wrap, lance and application you follow the 15 second rule.

First a basic point: coagulation cascade is started in either intrinsic or extrinsic pathway After I had begun doing this (having done step 1 and 2) I had a discussion (over a dinner) with an old friend of mine from school. I am fortunate to have gone to school (and later the same university) with people who have become prominent in a field. My mate Martin was previously the senior pathologist at a Base Hospital in a capital city. I asked him about this (warnings from phlebotomists) and he said that he's heard this in classes delivered to these clinicians and asked the lecturer two questions:

1. what mechanism do you think is responsible for this
2. have you ever seen an effect from it

he thinks that the answers (normally "don't know" and "never checked") suggest that this comes down the line of "truth" that is never checked. Like the story of the monkeys in a cage, that won't let the new monkey climb the ladder to get the banana.

https://www.ncbi.nlm.nih.gov/books/NBK482253/
The intrinsic pathway is activated through exposed endothelial collagen, and the extrinsic pathway is activated through tissue factor released by endothelial cells after external damage. This pathway is the longer pathway of secondary hemostasis.

As always I recommend checking for yourself (its not hard btw) if advice you find is valid or not valid. If you find its not valid perhaps challenge the advice giver to explore why?

 

[Mister_James]

Talk to your surgeon, get a second opinion. The best way would be turning the question to your doctor.
"If you were in my position, knowing what you know and have seen what, what would you do?"
If you don't trust the opinion of the dude who is going to stop your heart, slice it open, sew it up and crank it back again, what can we do?

 

[user 15848]

I just thought I'd add something to this: ee that there is no discrepancy between your INR readings obtained with and without tourniquet wrap lightly but sufficiently so as to gently push blood back, not like you are trying to damage the digit.

I came across Pellicle video about "how to" and it was very helpful for me as was wasting strips as clock timed out waiting for blood to come out, and have been doing it this way for 4 years, not sure i comply with the 15 seconds but i would say is about right , turn meter on, push strip, get ready signal, push the other button, then massage finger, put the rubber and pinch it and get the drops to the strip, sometimes it flows eassy, sometimes not so eassy , but when i used to double check my meter tests with the LAB never found a significant discrepancy. So, i Thank Pellicle for his tip and for his so many postings loaded with valid information.

Merry Xmas and Happy 2022 for all, and I pray no other Virus comes to us in 2022

 

[thos_huxley]

Sadly all the options with issues relating to failed tissue valves are surgical replacement

https://www.valvereplacement.org/threads/here-we-go-again.878078/
while its true that a mechanical valve can fail its a LOT rarer.

The prospect of valve failure is a major concern for me at the moment. Today I head back to St. Luke's for a CT scan, followed by a consult with the surgeon, at which time the valve replacement options and a surgery date will be discussed.

My age (67) places me in a "grey zone" between mechanical and bioprosthetic, where I'll have to decide which is gonna last longer: me or the valve. However, I've been reading numerous journal articles (plus comment from pellicle) re: valve-in-valve procedures. If my surgeon leans toward bio, I'll ask about the Edwards Resilia (SAVR) or Sapien 3 (TAVR). The former (not sure about the latter) is designed to be widened in situ so a TAVR valve can be placed--but that would require OHS to start. Not terribly enthusiastic about that, but I think I'd prefer implantation of a valve that can be replaced via TAVR, rather than another OHS. My uneducated guess right now suggests that would let me stay on the planet through my late '80s, maybe longer.

I'm pretty sanguine about all this, but my spouse (who 10 years younger) is nearly frantic.

 

[pellicle]

Hi

My age (67) places me in a "grey zone" between mechanical and bioprosthetic, where I'll have to decide which is gonna last longer: me or the valve.

I would agree, and that's definitely right, it's an age where I believe a tissue prosthetic will indeed get you a good 15 years, so into your 80's

I would agree that you should focus research on the ability of a valve to be amenable to a TAVR too (as well as durability).

However it's not impossible that you would require anticoagulant therapy later in life (or even from surgery itself).

It's a tough call with no obvious (to me answer) give your parameters.

I'd change dentist though, irrespective of the valve issues.

You may have noted my reference to spouse in my blog post. She was also very anxious, but as I recovered she was increasingly on side with my confidence. I'd had two by then though, so I had good understanding of what to expect.

My situation was of course being 47 (most of the way to 48) and already having two prior surgeries. As I understand it this will be your first, but nobody in their right mind wants AVR at 85. But as I say TAVR (even with reduced areas) will probably be quite suitable to the activities of a man of that age.

Best Wishes

 

[thos_huxley]

I would agree, and that's definitely right, it's an age where I believe a tissue prosthetic will indeed get you a good 15 years, so into your 80's

However it's not impossible that you would require anticoagulant therapy later in life (or even from surgery itself).

I'd change dentist though, irrespective of the valve issues.

Thanks, pellicle. Tomorrow I get scanned to determine the size of my heart's annulus and other measurements. That'll determine which procedural route(s) will be offered.

Re: the dental thing, over 20 years and more than a few dentists in different states/cities, I have yet to find one who'll cooperate on this issue. I'm now in a small town where my dental options are pretty limited. So. . . . I try to eat carefully. But I'll definitely check with my PCP to get a running supply of antibiotics.

Anti-coagulation isn't a concern for me. I'm already on several medications that require a morning/evening schedule, so adding another with frequent testing isn't a big deal. A hassle, perhaps, but I'd prefer that to the alternative.

 

[pellicle]

with frequent testing

It's only weekly, diabetics do frequent testing, more than 4 times a day

 

[gpr100rs]

The prospect of valve failure is a major concern for me at the moment. Today I head back to St. Luke's for a CT scan, followed by a consult with the surgeon, at which time the valve replacement options and a surgery date will be discussed.

My age (67) places me in a "grey zone" between mechanical and bioprosthetic, where I'll have to decide which is gonna last longer: me or the valve. However, I've been reading numerous journal articles (plus comment from pellicle) re: valve-in-valve procedures. If my surgeon leans toward bio, I'll ask about the Edwards Resilia (SAVR) or Sapien 3 (TAVR). The former (not sure about the latter) is designed to be widened in situ so a TAVR valve can be placed--but that would require OHS to start. Not terribly enthusiastic about that, but I think I'd prefer implantation of a valve that can be replaced via TAVR, rather than another OHS. My uneducated guess right now suggests that would let me stay on the planet through my late '80s, maybe longer.

I'm pretty sanguine about all this, but my spouse (who 10 years younger) is nearly frantic.

Thos - I'm 63 and underwent SAVR in April 2021 at Cleveland Clinic. I opted for the Resilia based, in large part, on its design feature which allows for the ring to expand facilitating a TAVR. I was also impressed with Edwards proprietary process to treat the leaflets which, it is hoped, will slow the calcification/deterioration process. So, if I can get 15 years out of the Resilia and then have a TAVR at 78 or so, I should be able to get to the finish line without another OHS. Of course, like many on this forum, you have a condition which could cause your demise in short order. You trade that inevitability for an artificial valve (tissue or mechanical) which brings with it a prolonged life, but issues continue nonetheless -- future surgery, blood thinners, clicking, etc. For me, my surgery included resection of my ascending aorta and graft placement to deal with an aneurysm and bypass of my LVAD. My main problem afterwards was a bout of a-fib and PAC's (premature atrial contractions - essentially a strong intermittent early heart beat which felt like my heart wanted to jump out of my chest). Thankfully, everything has settled down and my heart beats normally now and I have no restrictions. Yes, OHS is tough as is the recovery, but for the most part now I feel "normal" now. All the best with your decision-making.

 

[Stevebav]

hey @le19555 , I had a look over at the resilia site

https://www.rbhh-specialistcare.co....t-patients-benefit-new-inspiris-resilia-valve
very interesting and for anyone over 50 well worth a look (assuming you fully trust the sales lines, none of which seem unrealistic at all)

"This new valve is an absolute game-changer because it lasts three times as long as conventional valves."​

​

...The valve is estimated to last 30 years; reducing the chance of patients requiring additional operation in later years.​

I myself will not be around to know. but that sort of implies that "conventional valves only last 10 ... interesting.

The procedure​

In total the surgery takes up-to two hours.​

wow ... so they say up to when the accepted figure is between 2 and 4 ... assuming everything goes right. So to me this suggests they might be being a bit optimistic with the sales pitch rather than offering "just the facts ma'am"

Thank god its friday

This is an observation - nothing more. I underwent AVR and aortic graft at Harefield 18 months ago, following 6 years of monitoring etc.. the link above caught my eye and I though some may find it interesting that when discussing valve type my surgeon (who operates private practice and NHS) over three separate conversations:
- made clear the (usually) one & done flavour of mechanical ;
- talked through risk scenarios of mechanical (mainly areas where blood thinning medications may not mix well with other treatments/health conditions
- made sure I understood that I was almost certain to outlive a tissue valve;
- observed that the 'plan' if I went tissue was likely to be a second tissue valve via TAVR (or whatever technical procedure evolves over the next decade or so.

The evening before my OHS I confirmed my choice as tissue and enquired about manufacturer - he stated very firmly that (assuming that the pre-op measurements etc were close enough to what he found the next day) he would be using a Edwards Perimount MagnaEase as there was ~15 years track record compared to the 3 years or so the history Inspiris Resilia had built up at that point. He was also very clear that a) he would have a range of valve sizes available in theatre, including mechanical, b) would use whichever valve was best fit to where it needed to be seated and c) the operation would last between 4 & 6 hours.

All of this seems if not rather 'contra', definitely miss-aligned, with the information on the web page referenced - which is from the Private Health area of the RBH&H web-site aimed at those in the UK (or from elsewhere) who would be paying for their treatment. It is a commercial world.

 

[pellicle]

Hi Steve

firstly I don't mind what you chose, and what I chose was driven by this being my third surgery and a risk of a fourth was far greater than what you faced. However, with respect to this:

mainly areas where blood thinning medications may not mix well with other treatments/health conditions

it is very seldom that any surgeon has any actual interest in the detailed facts about managing warfarin, because its just not their job.

They see the stats, which are driven by ignorance and mismanagement (even your "blood thinning" line underscores that ignorance, its not thinning the blood at all). The stats however show the following

• people come to harm on warfarin in the main due to failure of compliance, the rate of failure stuns me, and is about 50%
• management of INR is managed miserably by cost based centers who employ more dim followers and clinicians than ACT experts (or it would be too dear)
• almost every issue can be managed, indeed every issue has other management issues
• most of the issues raised will never present to the majority of people
• words like "burden" are used when in fact its only trivial

again, I don't mind because you have already made a choice and the time for "being informed" has passed in terms of decision making. I'm not replying to you for your benefit, I'm replying to other readers for theirs.

There could be many other issues that you have that I don't know about (I checked your bio before I replied), however as I said above its not really important because the time for informed choice has gone.

The is nothing wrong with the choice you have made and I hope you get a good 15 years out of that valve before you face TAVI or reoperation. At 56 if you aren't an athletically oriented person then you very well may,

Best Wishes