Mechanical vs Tissue - need help deciding

[EMJEF]

I'm a 48 year old male; 6'-3" height and 275lb.

I have AVR in my very near future, and need to decide my path forward : Mechanical (On-X) valve or Tissue valve.

I'm very nervous about the prospect of hearing something tick in my chest for the rest of my life.

Is there anyone out there that can shed some light on the noise concern - and perhaps share their experience?

Any feedback / recommendations greatly appreciated


Holley650

(because I feel like I'm having a carburetor serviced on a V-8 engine)

Hi,

I have had a mechanical aortic valve (st Jude) for 35 years (since I was almost 4 years old) and am currently having to prepare to have it replaced (just spoke to cardiologist yesterday so call could be any day now). I was recommended to have to Ross procedure as that would enable them to make the cavity larger for my valve however I have opted for another mechanical as want to try to avoid future surgeries. My valve is failing due to the increased pressure on my heart during pregnancy 7 years ago (had my head buried in the sand for a while) but otherwise I’m convinced the valve would not have needed to have been replaced as prior to pregnancy there were no real issues. The ticking has never bothered me-it’s just a part of who I am. I can hear it if I choose but can also ignore it. Warfarin also never been much of an issue. Few occasions where range has gone a bit crazy (generally to do with stress or when I started uni) but having my own self test machine has been invaluable. For me, mechanical has been brilliant and served me well.

 

[pellicle]

My valve is failing due to the increased pressure on my heart during pregnancy 7 years ago

A mechanical valve?

If yes has someone explored obstructive thrombosis? As this can be cleared up with a PICC administration of tPA.

 

[Superman]

A mechanical valve?

If yes has someone explored obstructive thrombosis? As this can be cleared up with a PICC administration of tPA.

In the above individuals case, it’s also likely undersized as it was placed when she was only four years old. So the valve itself probably isn’t “failing” so much as it is no longer helpful to her. Perhaps the issues you indicate coupled with being undersized.

 

[EMJEF]

A mechanical valve?

If yes has someone explored obstructive thrombosis? As this can be cleared up with a PICC administration of tPA.

One of the leaflets is sticking at times and staying open longer than it should. I had the surgery at 3 years old so they were never sure how long it would last due to me having to grow from a very small child to an adult.

 

[Duffey]

If it were only among us I would agree with you, but we get new members who ask questions and it really is a dynamic community here not just a library.

Besides you may notice there is no black and white answers, you may notice that I at least always want to know age and situation, that I ask about other underlying conditions (like BAV) and direct my advice and thoughts based on that.

Imagine a scenario, that somone about 38 joins (you know, the age Dick was when he had his valve done) and everyone just says "go with tissue because that won't require ACTherapy" ... Dick would have by now been facing his third surgery. How would that be for him, how would that be for the family.

So re-hashing is essentially re-discussing for people who are new and who genuinely "didn't know that"

Yes, I have noticed, but unlike you, the Forum does feel to me to be more of a library. There’s nothing wrong with that. Your personal journey with valve replacement is long and varied, and your experience and knowledge is a reliable resource for new members seeking help. However when recent valve recipients, tissue or mechanical, write posts that project future scenarios which may or may not come to pass then they’re expressing opinion

not their experience. A statement such as the one that a 50 year old would probably face at least 2-3 more replacements seems to me to be fearful conjecture and offered my own experience to illustrate that there are no absolutes when it comes to our future. Surgery for valve replacement has progressed so far from the early days when Dick received his mechanical to the TAVR routinely being done today that what held true five years ago might be obsolete in five more.

 

[tom in MO]

If it were only among us I would agree with you, but we get new members who ask questions and it really is a dynamic community here not just a library.

Besides you may notice there is no black and white answers, you may notice that I at least always want to know age and situation, that I ask about other underlying conditions (like BAV) and direct my advice and thoughts based on that.

Imagine a scenario, that somone about 38 joins (you know, the age Dick was when he had his valve done) and everyone just says "go with tissue because that won't require ACTherapy" ... Dick would have by now been facing his third surgery. How would that be for him, how would that be for the family.

So re-hashing is essentially re-discussing for people who are new and who genuinely "didn't know that"

Trouble is you and some others don't believe in a tissue valve for young people and you all consistently push your mechanical valve if <60yo "diagnosis" despite that surgeons and cardiologists recommend both valve types.

This "mechanical is the best" denies the fact that despite "how easy it is" some have trouble with routine pill taking and testing, some don't have the money for test strips and there are some things for which being on warfarin makes life much more complicated and even dangerous.

I had surgery and being on warfarin extended my recovery time significantly. I cannot take NSAIDS for my arthritis. This is never mentioned by the mechanical valve "chorus." There are people with arthritis so bad, they'd rather be on NSAIDs and risk cardiac problems than live w/o their arthritis medication.

There are a variety of pluses and minuses for both valve types, that's why people are given a choice.

 

[Superman]

Trouble is you and some others don't believe in a tissue valve for young people and you all consistently push your mechanical valve if <60yo "diagnosis" despite that surgeons and cardiologists recommend both valve types.

This "mechanical is the best" denies the fact that despite "how easy it is" some have trouble with routine pill taking and testing, some don't have the money for test strips and there are some things for which being on warfarin makes life much more complicated and even dangerous.

I had surgery and being on warfarin extended my recovery time significantly. I cannot take NSAIDS for my arthritis. This is never mentioned by the mechanical valve "chorus." There are people with arthritis so bad, they'd rather be on NSAIDs and risk cardiac problems than live w/o their arthritis medication.

There are a variety of pluses and minuses for both valve types, that's why people are given a choice.

All good points. But some don’t allow for the fact that doctors and surgeons are only human. They take an oath to do no harm. They do not take and oath to help the patient make the best choice for them among several good options.

My last open heart surgery was nearly 12 years ago. It was due to an aneurysm. At that point I had a mechanical valve for 19 years already. Since they had to open me up again, it made sense to look at the sizing as I was fairly young when I received.

I was perfectly comfortable with a mechanical valve and warfarin. Being my second surgery and in my 30’s I was very interested in staying with mechanical. But if I had left the choice to my surgeon, he was a tissue valve guy. Never took warfarin, but didn’t like operating on patients on warfarin- so he always pushed for tissue.

And tissue meets the, “do no harm” standard. But it didn’t meet what was best for me in my specific situation. So I had to advocate for my own choice. That said, he was fine and didn’t fight me on it. Just if left to his devices, everyone would get a tissue valve.

Many times people come here to get real experiences from tissue, mechanical, ross, and now TAVR patients. I think everyone is fairly consistent in recommending mechanical if potential future operations is a concern of yours and the idea of managing warfarin isn’t a concern (and there are some misconceptions about that that warrant clarifying) - or tissue if the idea of INR management is a bigger concern to you than the likelihood of revisiting everything down the road.

I would say the reason mechanical recipients are more vocal in speaking about misconceptions is because there are more misconceptions to speak about. (“I’m going with tissue because my doctor said no more green veggies and no more beer.” - Sorry, but the chorus will arise!)

Tissue is, for the most part, replace the valve and get your checkups. When and if the time comes to intervene again, then make a decision based on available information.

 

[EMJEF]

In the above individuals case, it’s also likely undersized as it was placed when she was only four years old. So the valve itself probably isn’t “failing” so much as it is no longer helpful to her. Perhaps the issues you indicate coupled with being undersized.

Yes, that is part of the issue. I have a 19mm St Jude as it was the largest they could give me at the time. Quite large for a tiny three year old. I’m not particularly tall so chances are it might have lasted.

 

[pellicle]

However when recent valve recipients, tissue or mechanical, write posts that project future scenarios which may or may not come to pass then they’re expressing opinion

And thats entirely fine and I never say people should not express opinions. However I feel (as this is something that has deeply and enduringly effected my life) its important to follow those opinions up with greater defining information.

For instance the usual lame answer of "there is no bad decision" is lame because it specifically does nothing to answer the question asked. Its inoffensive and ineffectual.

If the person asking is 40 my answer will be different to 50 and different to 60.

I personally feel that's being responsible. Reciting what happens to you in your situation requires the background of age at surgery, present situation. Without that the information is pretty well like saying "well I go fishing every day" without saying "I live on the ocean shore".

A statement such as the one that a 50 year old would probably face at least 2-3 more replacements se

Are you saying I said that?

I believe I wrote

Imagine a scenario, that somone about 38 joins (you know, the age Dick was when he had his valve done) and everyone just says "go with tissue because that won't require ACTherapy" ... Dick would have by now been facing his third surgery. How would that be for him, how would that be for the family.

and Dick was around 31 at that time.

With respect to a 50 year old I would say that you will face at least on OHS in your time if you choose a tissue valve now. I would say this based on what we know now of the average time for a tissue prosthesis being 15 years. So lets say that a 50 year old gets 17 years (to lean in your direction rather than my direction of going with known statistical data) then at 67 they'll be probably facing SVD and a replacement. If they go TAVI to replace that (if they are a candidate) they'll get (lets be generous here) 10 years from that ... 77 ... would YOU want to be facing another OHS (because I doubt that there'll be valve in valve in valve options.

I think you should also examine the direct replies to your conjecture too, that new member DO want to talk about this.

I would ask if you are bringing to bear your personal feelings about this and not simply considering others situations and replying with what is your personal experience and knowledge.

 

[pellicle]

Yes, that is part of the issue. I have a 19mm St Jude as it was the largest they could give me at the time. Quite large for a tiny three year old. I’m not particularly tall so chances are it might have lasted.

ok, I had anticipated that 19mm would be around the size a female would get as average size is smaller.

I understood that with smaller valves and female as criteria that pannus is also an issue ... is that causing the obstruction?

Because I'm quite surprised to hear that a St Jude is in any sort of structural failure ... even given 35 years of operation.

I'm just working through this because

• I'd like to see you avoid a surgery if possible
• I'm personally interested in gathering data which never emerges in the stats (due to the homogenisation of collected data)

Best Wishes

 

[pellicle]

Tissue is, for the most part, replace the valve and get your checkups. When and if the time comes to intervene again, then make a decision based on available information.

and as I often also add mechanical is managed by the patient complying with ACTherapy, and Tissue is managed surgically (in the main).

 

[EMJEF]

ok, I had anticipated that 19mm would be around the size a female would get as average size is smaller.

I understood that with smaller valves and female as criteria that pannus is also an issue ... is that causing the obstruction?

Because I'm quite surprised to hear that a St Jude is in any sort of structural failure ... even given 35 years of operation.

I'm just working through this because

• I'd like to see you avoid a surgery if possible
• I'm personally interested in gathering data which never emerges in the stats (due to the homogenisation of collected data)

Best Wishes

Thank you. I definitely know I need the surgery as I’m struggling a lot more with walking without becoming breathless and certainly couldn’t even give jogging a go. I know when the leaflet sticks too as I feel a rush around my body. Dizzy spells have increased even when sitting down as well. Surgery is something I wish I could avoid but I’m hoping that by getting another mechanical valve (rather than Ross procedure that the surgeon has recommended) I will avoid future surgeries.

 

[pellicle]

go. I know when the leaflet sticks too as I feel a rush around my body. Dizzy spells have increased even when sitting down as well. Surgery is something I wish I could avoid

But you haven't addressed if this is a valve related thrombosis obstruction. I have seen exactly those symptoms.

Please read this thread, particularly the outcome
https://www.valvereplacement.org/threads/st-judes-valve-repair-or-replace.850001/post-850389
They were going to do surgery, but Donna pushed back and asked for further investigation. Knowing how difficult repeat surgeries are, and how eager many surgeons are to do surgery I am really just trying to (for your sake) make sure all these bases are covered before the knife

 

[hevishot]

It appears that the biggest concern about selecting a tissue valve is the possibility of a second surgery. I have had both open heart valve replacement and open rotator cuff surgery and I can tell you that the rotator cuff surgery was much much worse in terms of pain and recovery. Most of what you hear on this site is a lot of "Blue Sky". Most of the posters hear that advocate for mechanical are not trying to convince you to go mechanical but are trying to convince themselves that they made the right decision. My advice to you if you decide on tissue it to stay in shape, join a gym, eat right, don't smoke, and keep your weight down. Good advice for anybody.

 

[Michael O]

I have had both open heart valve replacement and open rotator cuff surgery and I can tell you that the rotator cuff surgery was much much worse in terms of pain and recovery.

This. I had closed shoulder arthro and that recovery was way worse than the last 7 weeks of OHS recovery. I'm heading for a full replacement, so I chose tissue valve.

 

[Superman]

Most of the posters here that advocate for tissue are not trying to convince you to go tissue but are trying to convince themselves that they made the right decision.

Yup. Just as silly the other way too.

Most of the people here are just relaying real world experience trying to answer people’s questions, correct misconceptions, and share their reality regardless of choice.

 

[pellicle]

My advice to you if you decide on tissue it to stay in shape, join a gym, eat right, don't smoke, and keep your weight down. Good advice for anybody.

Totally agree

 

[pellicle]

Most of the posters hear that advocate for mechanical are not trying to convince you to go mechanical but are trying to convince themselves that they made the right decision.

well that's a bit like what the tissue valvers do too you know. I think you're projecting what you do on others

I would plead not guilty on that charge however because what I usually say is that it depends. on the following points

• a mechanical valve will give you the best chance of never needing a reoperation
• if ACTherapy is contra-indicated you can only choose tissue
• the difficulties of managing ACTherapy are overblown and are most commonly (at best) exaggerated or false
• choosing a tissue valve at a young age will make it a certainty that you will need a reoperation
• if you are over 60 and its your first I say that either choice is good but its simply up to you if you prefer the idea of ACTherapy and sticking with that properly then you can manage the performance of the valve. If you can't then Tissue will not require you to do anything and will be managed surgically
• I caution on relying on future advances as "may be available"and go with decisions based on now
• I always ask about BAV because if you are younger BAV may drive a redo operation in the future because of aneurysm; meaning nothing wrong with picking a tissue on that premise

Further, that is pretty much rewording the actual surgical guidelines NOT just what your surgeon said to you. Everything I write is on public record and you can check my words.

I speak as one who has (unlike you) been around this most of my life and had 3 valve surgeries.

 

[tom in MO]

... My advice to you if you decide on tissue it to stay in shape, join a gym, eat right, don't smoke, and keep your weight down. Good advice for anybody.

There is no experimental data that points to what's in a person that causes implanted tissue valves fail or how to extend their life. Ironically, some have lived for 50 years with a damaged valve and their new one fails in <10 years.

 

[EMJEF]

ok, I had anticipated that 19mm would be around the size a female would get as average size is smaller.

I understood that with smaller valves and female as criteria that pannus is also an issue ... is that causing the obstruction?

Because I'm quite surprised to hear that a St Jude is in any sort of structural failure ... even given 35 years of operation.

I'm just working through this because

• I'd like to see you avoid a surgery if possible
• I'm personally interested in gathering data which never emerges in the stats (due to the homogenisation of collected data)

Best Wishes

Thanks for the info. I will look into this further.