Mechanical vs Tissue - need help deciding

[Chuck C]

Morning

https://www.nps.org.au/australian-p...e-perioperative-management-of-anticoagulation
From that:

The authors argue that for every 10 000 patients with mechanical heart valves who are given perioperative intravenous heparin, three thromboembolic events are prevented at the cost of 300 major postoperative bleeding episodes. (ref Kearon C, Hirsh J. Management of anticoagulation before and after elective surgery. N Engl J Med 1997;336:1506-11.)​

seems to be supported by various other evidence too
PS: I just fixed the ref from the NPS.ORG reference to point to the right place

Thanks for linking that study. I'll take a look.

To add a little more to the comments from my cardiologist, he also said that for mechanical in the aortic position, which mine is, risk of stroke from holding warfarin for a couple of days is extremely low- more risk involved if it is the mitral position.

 

[pellicle]

risk of stroke from holding warfarin for a couple of days is extremely low- more risk involved if it is the mitral position.

agreed ... what I love about this is the way these clowns throw around terms which are qualitative not quantitative.

An example lets pretend that the risk is something like 51.8 per 100 patient years for an Aortic
so "more" could be 52.8 ...

So basically this is the technical way of saying "I don't have a clue and because I don't need to know this to keep my registration I haven't bothered reading up on stuff that was reasonably well known for over 20 years".

(facepalm) ...

(source of my conjecture on risk)

 

[Gator Chief]

Welcome back! Thank you for taking the time to share your experience.

I went with a St Jude mechanical valve 10 months ago and also self manage my INR and use the same target range as you do.

I find it interesting that two of your significant surgeries did not involve bridging. Did you bring your INR down prior to surgery?

I have an upcoming minor procedure in my thyroid to ablate a benign nodule. There is not typically too much bleeding with this procedure, but some. The surgeon, based on his experience, indicated that he does not believe that bridging is necessary, as long as I bring my INR under 1.5 for this particular procedure. I am not concerned about bringing it that low for a day or two.

My cardiologist would rather that I bridge, so I've got a decision to make. Given that there is some risk of a bleed with bridging, as you experienced, I think I'd rather bring my INR down briefly for such a minor procedure than to bridge.

That is how I have managed colonoscopy’s and the the first two surgeries. My surgeons were comfortable with INR < 1.5 so I would bring my INR down to 1.5 on the surgery day and resume Coumadin the day after surgery and never had any issues. I’ve read up on bridging and there are some Dr’s that are questioning the the practice of bridging on minor and moderate surgeries for patients on ACT. Self testing makes you a perfect candidate for those types of surgery simply because of the ability to have real time testing before and after surgery. Good luck with your surgery which ever way you go.

 

[pellicle]

That is how I have managed colonoscopy’s and the the first two surgeries.

#metoo
http://cjeastwd.blogspot.com/2017/12/perioperative-management-of-inr.html
although my surgeon wasn't even concerned on this one:

http://cjeastwd.blogspot.com/2020/10/another-example-small-procedure.html
I often gag with a mate of mine: "What's good about getting old" ... our normal black answer, to whoever says it first, is to mention a surgery or a procedure. But the truth is we're really lucky to be getting old now vs when my grandfather got old.

Self testing makes you a perfect candidate for those types of surgery simply because of the ability to have real time testing before and after surgery.

its good to see a kindred soul here

Best Wishes

 

[Chuck C]

That is how I have managed colonoscopy’s and the the first two surgeries. My surgeons were comfortable with INR < 1.5 so I would bring my INR down to 1.5 on the surgery day and resume Coumadin the day after surgery

This is definitely the direction that I am leaning right now. The surgeon is fine with <1.5 INR for the procedure and I don't see justification for bridging for such a minor operation, given the bleeding risks that come with bridging. One benefit of us self-managing is that we can test frequently and be pretty accurate for a given target. I'll make sure to consult with our local INR expert @pellicle on managing my pre-surgery dosing.

 

[pellicle]

I'll make sure to consult with our local INR expert @pellicle on managing my pre-surgery dosing.

I feel difficult with that label ...

 

[pellicle]

oops, forgot to cover this

One benefit of us self-managing is that we can test frequently and be pretty accurate for a given target.

not only that, but we can actually gain data from ourselves and our own metabolism on:

1. how our INR falls
2. how long it takes to come back from said "fallen level" to "chosen therapeutic range"

all that data goes towards knowing and a feeling of certainty about the decisions we make in the management of our health.

Knowledge is power.

Best Wishes

 

[tom in MO]

Welcome back! Thank you for taking the time to share your experience.

I went with a St Jude mechanical valve 10 months ago and also self manage my INR and use the same target range as you do.

I find it interesting that two of your significant surgeries did not involve bridging. Did you bring your INR down prior to surgery?

I have an upcoming minor procedure in my thyroid to ablate a benign nodule. There is not typically too much bleeding with this procedure, but some. The surgeon, based on his experience, indicated that he does not believe that bridging is necessary, as long as I bring my INR under 1.5 for this particular procedure. I am not concerned about bringing it that low for a day or two.

My cardiologist would rather that I bridge, so I've got a decision to make. Given that there is some risk of a bleed with bridging, as you experienced, I think I'd rather bring my INR down briefly for such a minor procedure than to bridge.

The cardiologist is your valve and INR expert, not your surgeon. If you think your cardio is wrong, ask another cardio's opinion. I've had one surgery on warfarin and the surgeon told me what he thought should be done, but stated he wanted the cardio to make the final decision since they know the valve and warfarin therapy.

My mil on warfarin suffered a stroke during a surgery even though she bridged.

 

[Chuck C]

My mil on warfarin suffered a stroke during a surgery even though she bridged.

Sorry to hear that. I hope that she recovered fully.

 

[user 15848]

Same choice at 62 with OnX, i use the 2.0 -2.5 range as target, works for me, did use the 1.5 - 2.0 first year, but got concerned about how it easy it could fall below 1.5 at times, so with 2-2.5 my fail safe is wider, just my experience.

 

[AZATADINE]

I'm 4 months post AVR (Carpentier-Edwards Magna Ease) and had my follow up with my cardiologist yesterday. Everything went great. My gradient is now 12 mmHg (I was almost 90 mmHg pre op) and the valve itself is working very well. I was able to see it on the Echo as well. My heart is good and ECG normal.

She took me off warfarin and also off the beta blocker (Bisoprolol 1.25mg). I'm also good to go in terms of normal activities such as bike riding and, when I'm strong enough..... , horse riding again. My only medication is 75 mg Aspirin going forward.

She also said that the surgeon removed my left atrial appendage when he was in there. Never heard of that piece of kit till yesterday but apparently, it can be where clots can start.

So, looks like I'm all set and I feel great again. Went back to work a month ago.

Of course, being 52, the question is how long this my new valve will last before it'll need replacing. No way of knowing that but at least I'm up and going and reset again so I'll take that for now.

In terms of my native bicuspid valve it was highly stenotic and heavily calcified so it looks like getting it changed (although I was asymptomatic at the time) worked out well in terms of the timing.

Maybe the Foldax valve will be the way to go by the time I need another....

 

[pellicle]

No way of knowing that

well, actually, there is a reasonable way of knowing the bounds (its called the accumulated evidence).

I'm up and going and reset again so I'll take that for now.

true and that's great. If (as I think it is) this is your first OHS, then you'll be something like 68 when you need another. I would suggest at that time you take a 2nd tissue and not a TAVR ... so that when they need to do the TAVR you'll actually be a high risk patient and it will then serve you well.

Even then you won't be where I am now with #3 10 years ago.

 

[AZATADINE]

Thanks. Yep, this was my first OHS.

 

[Eva]

I'm 4 months post AVR (Carpentier-Edwards Magna Ease) …

She also said that the surgeon removed my left atrial appendage when he was in there. Never heard of that piece of kit till yesterday but apparently, it can be where clots can start. …

My surgeon also removed my left atrial appendage when I had my surgery in 2008. I laughed then as I had not heard of that before! He loved Carpentier-Edwards for they proved to last about 12-15 years!

Good luck with yours and enjoy your new you!

 

[TomD]

Hi Holley650, welcome aboard!

You’ll find MANY previous threads here about valve choice and many different opinions!
My thoughts are that your cardio and your surgeon (if you trust them) will be the best to advise which valve is best for you, as they know your heart’s condition and your overall heath better!
To answer your question about clicking, also some members hear it, others don’t.
I personally have two St. Judes mechanical valves that I very rarely hear! And when I do, it’s comforting not bothersome!

Good luck.

after 13 years of my mechanical valve the ticking sound is a complete non-issue. After about a month my brain just tuned it out and you will find that the only people that can hear it are grandchildren with great ears. At your age the valve decision is a tough one. I was 64 and knowing how long a bovine valve would last I did not want to go through another operation when I was in my 80’s. I do my own warfarin management with a home tester so that is also a non-issue for me. So the question I would ask is number one how long will a mechanical valve typically last? And then if I go bovine and it fails in 15 or 20 years what will be the likely procedure to fix it? Perhaps by then it will not be nearly as traumatic and invasive

 

[pellicle]

Hey Tom (and whoever else)

So the question I would ask is number one how long will a mechanical valve typically last?

this is a vexed question because it has both a simple and a complex answer.

Simple answer: it will outlast you

Complex answer: there may be requirements to re-operate in the future which will despite the valve functioning perfectly may require its removal. Such events are things like aneurysm of the ascending aorta; this will depend on parameters like age at operation (younger means more time to have this happen) and if you are BAV (which increases the chances of aneurysm in later age). Other more rare things can occur such as pannus ingrowth (which can often be treated without conventional surgery) and if the patient has consistently failed at anticoagulation control a blockage of the operation of the valves by thrombosis (a big clag of scab has formed) which can also in many cases be treated without surgery.

In my own case had I had a mechanical fitted in 1992 (instead of a homograft) I would have likely had the valve changed when they did the OHS in 2011 to repair my aneurysm. I would not be the only younger patient (I was 28 at the time of my 1992 OHS) to have something like that happen.

However I would in the main counsel a younger patient to seriously consider a mechanical valve as you can get 30 years or more out of them, but as a person under 40 you won't get that possibility from anything else.

 

[carolinemc]

It is the slightest risk we

The cardiologist is your valve and INR expert, not your surgeon. If you think your cardio is wrong, ask another cardio's opinion. I've had one surgery on warfarin and the surgeon told me what he thought should be done, but stated he wanted the cardio to make the final decision since they know the valve and warfarin therapy.

My mil on warfarin suffered a stroke during a surgery even though she bridged.

take when we skip dosages or bridge for procedures. But she was in good hands and I assume she is much better.

 

[carolinemc]

Hey Tom (and whoever else)



this is a vexed question because it has both a simple and a complex answer.

Simple answer: it will outlast you

Complex answer: there may be requirements to re-operate in the future which will despite the valve functioning perfectly may require its removal. Such events are things like aneurysm of the ascending aorta; this will depend on parameters like age at operation (younger means more time to have this happen) and if you are BAV (which increases the chances of aneurysm in later age). Other more rare things can occur such as pannus ingrowth (which can often be treated without conventional surgery) and if the patient has consistently failed at anticoagulation control a blockage of the operation of the valves by thrombosis (a big clag of scab has formed) which can also in many cases be treated without surgery.

In my own case had I had a mechanical fitted in 1992 (instead of a homograft) I would have likely had the valve changed when they did the OHS in 2011 to repair my aneurysm. I would not be the only younger patient (I was 28 at the time of my 1992 OHS) to have something like that happen.

However I would in the main counsel a younger patient to seriously consider a mechanical valve as you can get 30 years or more out of them, but as a person under 40 you won't get that possibility from anything else.

I was 36 when I had my bypass and got St. Judes' aortic, in 2001. No hurry for another surgery.

 

[tom in MO]

It is the slightest risk we

take when we skip dosages or bridge for procedures. But she was in good hands and I assume she is much better.

She never fully recovered from the stroke but she was ~80 and the effects were not too dramatic. The irony per this board's discussions was she went off warfarin to have a tissue valve installed. About 25% of older patients with a tissue valve wind up on anticoagulants for reasons other than their valve.

 

[ATHENS1964]

Novel Technology Could Prevent Repeat Operations to Replace a Faulty Bioprosthetic Heart Valve
https://www.dicardiology.com/conten...ions-replace-faulty-bioprosthetic-heart-valve