Mechanical vs Tissue - need help deciding

[Stevebav]

Hi
My choice of words may have been a little hurried - but your response is fine and the point regarding surgeons being specialists in the 'fixing' rather than management and medication well-made.

My main point was that the web page you referenced is not Edwards authored. RBHH is a NHS trust which, as is becoming common, operate a private health business ostensibly to help fund NHS facility and services within shared premises.

The content you referenced is authored by RBHH "Specialist Care" to inform/advertise to potential customers of their private health business of the 'game-changing' - in some ways I feel this is worse than if was Edwards authored!

btw "50% non-compliance" : is that 50% of reported cases or 50% of people prescribed warfarin ? either way it is seems a surprisingly high number.

As you rightly observe, as the saying goes I've ""made my bed and am laying in it" which I (almost certainly) wouldn't be if my BAV and accompanying aneurysm hadn't been discovered by chance when it was - so whichever valve type I have I'm 'winning'

all the best

 

[Croooser]

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.

Me too except I am 71, so 15 years gets me to 86... if I get that far without something else cropping up. 86 will put me well past normal life expectancy even accounting for access to excellent health care.

In my preop meeting with Dr. Johnston at CC, I asked him if I could reasonably expect 15 years with the Inspiris Resilia and then be a candidate for TAVR. He replied 'Absolutely, maybe longer." Now he is one of the biggest advocates for that valve and he clearly has a bias towards it. I get that.

My sense is that he really believes in it and that his consultant fees and studies are not driving him on this. Could I be wrong about that? Yup. But I am betting that the Inspiris Resilia will live up to expectations (a rather large bet ).

 

[dick0236]

Me too except I am 71, so 15 years gets me to 86... if I get that far without something else cropping up. 86 will put me well past normal life expectancy even accounting for access to excellent health care.

Your decision-making logic makes a lot of sense to me. If that Resilia valve is as good as they say, it should take you the rest of the way.......or, at least, to age for a TAVR to take you the rest of the way.

Next month, Feb. 21, I will reach your target age of 86.......and there is a downside in making it that far. You may outlive ALL your beer drinking, poker playing, golfing, and fishing friends.........and listening to your buddies widows gossip over dinner ain't the same as telling your friends how you made that 30' breaking downhill putt.

 

[pellicle]

Me too except I am 71, so 15 years gets me to 86... if I get that far without something else cropping up.

personally at 71 I would think you would be more likely to get longer than 15 years.

Here's to that outcome

 

[Chuck C]

In my preop meeting with Dr. Johnston at CC, I asked him if I could reasonably expect 15 years with the Inspiris Resilia and then be a candidate for TAVR. He replied 'Absolutely, maybe longer."

I've been very impressed with Dr. Johnson in several of his videos, which I have watched. My favorite was a 90 minute lecture he was giving to surgeons from other clinics. The guy knows his stuff. I think at 71, 15+ years from the Resilia is a very reasonable expectation. That is what one would expect for the Perimount Magna, and the Resilia is built on the same platform, but with the added benefit of the anti-calcification treatment. So, perhaps it will perform even better than the Magna. Also, it is designed to expand for TAVR, so that there is no need to fracture the ring. At 71, this is the valve I would have gone with.

 

[Croooser]

Your decision-making logic makes a lot of sense to me. If that Resilia valve is as good as they say, it should take you the rest of the way.......or, at least, to age for a TAVR to take you the rest of the way.

Next month, Feb. 21, I will reach your target age of 86.......and there is a downside in making it that far. You may outlive ALL your beer drinking, poker playing, golfing, and fishing friends.........and listening to your buddies widows gossip over dinner ain't the same as telling your friends how you made that 30' breaking downhill putt.

Dick,

Your valve story is a genuine benchmark and you serve as an inspiration to the rest of us - mere mortals.

But sinking 30' putts. Now you are rubbing it in!

 

[Dano64]

I am now 9 days away from my second surgery and I am two months shy of 58. I had a BAV with what one tech called "the biggest clump of calcification" she ever saw and that's what prompted me to have my first surgery in March 2001. I had a homograft which, if not for the ascending aneurysm, has more life to live coming up on 21 years. So, although I was 37 at the time of my first surgery, I have been thrilled with my choice. There will be no bashing of anyone from me ever, although I am a lawyer, but I am going with a tissue valve again in the hopes of similar success to what I have experienced in the past. Right now, I just want to get past my surgery and recovery. I admit I am guilty of leaving this forum since 2003 due to my own sense of normalcy after my first surgery. I was here for a few years before that. I have been studying both tissue valves and mechanical valves recently, as I did many years ago, and I think I understand the risks and rewards of both. I wish it was easier, but I am ready to get past it. As for how life changes, my wife in 2001 was a rock for me through my first surgery - God Bless her - but she was diagnosed with breast cancer in 2011 and passed away in 2015. I am now re-married to a wonderful, new rock of a wife who gets to go through this for the first time. So, I understand the fact that other life issues can get in the way of a period of 10, 15 or 20 years when considering a valve choice. I cannot see a right or wrong with either choice. There are going to be risks.
My current brother-in-law is a primary care physician in Ohio who sees many patients on Coumadin, some with mechanical valves, and also sees some patients who have tissue valves. He feels that most of his patients handle the Coumadin issues well. He also has a couple of patients who had the TAVR procedure and they have come out of that doing well physically and cognitively. I understand that this is a small sample, certainly from a statistical standpoint, but this provided me some comfort with either choice. If anyone says there are easy answers, I would probably get into that debate, but I will only wish everyone Godspeed with whatever choice they make for a valve, and I sincerely hope it is the best possible choice for that individual going forward.

 

[pellicle]

Hi

... I had a homograft which, if not for the ascending aneurysm, has more life to live coming up on 21 years.

indeed and as you know I had an excellent run with mine. Aneurysm drove my replacement (which while the valve was still working it was quite calcified according to the surgeon and the data from the ultrasound reported this was starting too), as well as other members here (such as @Superman)

...but I am going with a tissue valve again in the hopes of similar success to what I have experienced in the past.

well firstly you know that the homograft is living human tissue and the bioprosthesis isn't. However that not withstanding one of my close personal friends made a similar call (at the same age as you), he called me up to ask my view and I said that it will be close and that he would likely get the 15 years (plus or minus) from it (he is a long distance runner) if TAVR is available will likely be able to get perhaps another 10 from that which would max him out at about 85 years old if all goes to plan.

He somehow had the misapprehension that I had found management of INR difficult.

none the less (unlike you) he is facing his first surgery, which doesn't effect durability of the prosthesis but does effect the complications of his (and your) next redo.

Right now, I just want to get past my surgery and recovery.

quite a common reaction.

I have been studying both tissue valves and mechanical valves recently, as I did many years ago, and I think I understand the risks and rewards of both.

that's good, but ultimately you must make a choice and now you have no matter what you should not look back and go "I wish I'd chosen" or "really? I didn't know that"

As for how life changes, my wife in 2001 was a rock for me through my first surgery - God Bless her - but she was diagnosed with breast cancer in 2011 and passed away in 2015.

mine passed away with a brain tumor killing her less than a year after my surgery, so she missed my infection hassles.

http://cjeastwd.blogspot.com/2012/12/chest-wound-progress.html
I won't say it was easy having nobody to support me (in either the difficulties of the infection or the grieving) but here I am and I'm still standing.

If anyone says there are easy answers, I would probably get into that debate,

I think you've made your choice and now is no longer the time for debate.

Best Wishes and I wish you an uneventful recovery

 

[Chuck C]

I am now 9 days away from my second surgery and I am two months shy of 58. I had a BAV with what one tech called "the biggest clump of calcification" she ever saw and that's what prompted me to have my first surgery in March 2001. I had a homograft which, if not for the ascending aneurysm, has more life to live coming up on 21 years. So, although I was 37 at the time of my first surgery, I have been thrilled with my choice. There will be no bashing of anyone from me ever, although I am a lawyer, but I am going with a tissue valve again in the hopes of similar success to what I have experienced in the past. Right now, I just want to get past my surgery and recovery. I admit I am guilty of leaving this forum since 2003 due to my own sense of normalcy after my first surgery. I was here for a few years before that. I have been studying both tissue valves and mechanical valves recently, as I did many years ago, and I think I understand the risks and rewards of both. I wish it was easier, but I am ready to get past it. As for how life changes, my wife in 2001 was a rock for me through my first surgery - God Bless her - but she was diagnosed with breast cancer in 2011 and passed away in 2015. I am now re-married to a wonderful, new rock of a wife who gets to go through this for the first time. So, I understand the fact that other life issues can get in the way of a period of 10, 15 or 20 years when considering a valve choice. I cannot see a right or wrong with either choice. There are going to be risks.
My current brother-in-law is a primary care physician in Ohio who sees many patients on Coumadin, some with mechanical valves, and also sees some patients who have tissue valves. He feels that most of his patients handle the Coumadin issues well. He also has a couple of patients who had the TAVR procedure and they have come out of that doing well physically and cognitively. I understand that this is a small sample, certainly from a statistical standpoint, but this provided me some comfort with either choice. If anyone says there are easy answers, I would probably get into that debate, but I will only wish everyone Godspeed with whatever choice they make for a valve, and I sincerely hope it is the best possible choice for that individual going forward.

Best if luck with your upcomming procedure Dano! It sounds like you did a good job with your due diligence heading into the procedure, weighing the pros and cons of each choice. You are making an informed choice- well done!

On Monday, if I understood your post correctly, your surgeon was going to wait and see what your homograft valve looked like at the time of your aneurism repair before deciding whether to replace it. Is the plan now to replace the valve regardless? Given that it is 21 years old and has already lasted longer than the average homograft, I do believe that it is the right call- taking care of it while the hood is open, so to speak.

 

[thos_huxley]

As Denjun recently posted, "my time has come." I've returned from St. Luke's in Kansas City, where I met with my surgeon and one of his structural cardiology colleagues (same guy who did my cardiac cath). Both are extremely knowledgeable and garrulous. (For me, a retired professor, their published research was impressive, and they were pleased I had read their stuff.)

We had a lengthy discussion about appropriate valve selection, surgical procedure, and recovery for about 45 minutes. Good news is that my ascending aorta is not grossly dilated, so replacement of that is unnecessary. I've mentioned in a previous post that I suspected the surgeon would push TAVR, but he did not, noting that my recent CT scan and cardiac cath indicated no stenosis. Rather, both docs agreed that SAVR is the indicated procedure, with implantation of a tissue valve.

I pushed back on this some, noting that my age and health didn't entirely warrant a tissue valve, and that anti-coagulation therapy wasn't an issue for me. The cardio countered with, "sure, but will that still be true in 5, 10, 15 years?" He had a point; I can't say what my health and mental state will be into my 70s-80s, and anti-coagulation--from what I've read here--does require fairly close attention. Both docs advised I should take daily aspirin as a precaution. I was also quite firm in my desire to avoid future major surgery and asked if the Edwards Resilia was appropriate for a future TAVR valve-in-valve procedure. Yes, it is, but the surgeon cautioned that the Resilia's expandable cuff still requires compressed air to widen it, and that that function hasn't yet been approved by FDA.

So, that's the route I'm going to take, and I'm hopeful the valve will last at least 10 years before redo surgery. It would be helpful to know if there's any way to prolong the life of these things, but everything I've read so far about the Resilia valve suggest very good long-term operation. Additionally, I asked for (and will get) use of the Sternaloc Blu rigid fixation devices for sternal closure, so post-surgical recovery should be faster than with wire cerclage.

My surgery date is 7 February, barring any Covid-related delays. That leaves plenty of time for y'all to try to change my mind .

 

[dick0236]

[QUOTE="thos_huxley, post: 913467, member: 17150]
My surgery date is 7 February, barring any Covid-related delays. That leaves plenty of time for y'all to try to change my mind .
[/QUOTE]

Why would we try to change your mind? You seem to have done your research and have come to a logical conclusion. Your age and "retired" lifestyle seem to fall into the range where valve material won't make that much difference.

However I'm gonna "push back" at your Cardios argument that warfarin might be a problem in "5, 10, 15 years when your physical and/or mental health might make INR management difficult. I'm already 86 (well, almost) and I find my warfarin no more difficult than the handful of other cardiovascular drugs I take each day. In fact, like you, I currently take the BP med Losartan. My GP, who prescribed the Losartan, suggested I take my BP weekly.......but he never askes me what it is......so I am very lax about following his suggestion of "weekly BP testing". I never forget to get my INR checked every two weeks. I actually give credit to the warfarin ACT regimen with my doc for helping me get 54+ years out of my valve.

 

[Chuck C]

My surgery date is 7 February, barring any Covid-related delays.

Wishing you the best of luck with your upcoming procedure.

It would be helpful to know if there's any way to prolong the life of these things

Dr. Philippe Pibarot and his colleagues in 2018 published a longitudinal study on markers for early SVD, as well as a review on this subject. I am attaching both here if you are interested.

" Several clinical, imaging, and circulating biomarkers may help to predict or indicate the presence of SVD of aortic bioprosthetic valves. The most important biomarkers of SVD are: for patient-related clinical biomarkers: diabetes and renal failure; for the valverelated biomarkers: absence of antimineralization process and severe prosthesis–patient mismatch; for imaging biomarkers: the presence of valve leaflet mineralization on MDCT or sodium fluoride uptake on PET-CT; and for circulating biomarkers: increased levels of HOMA index, ApoB/ApoA-I ratio, PCSK9, Lp-PLA2, phospho-calcic product "

But, important to note:

"Although further studies are needed to determine if these factors are only markers of SVD or factors that contribute to SVD"

So, while further research is needed to determine whether these are markers or causative, a healthy lifestyle, involving regular exercise and eating a whole foods diet can help improve your metabolic profile and insulin sensitivity (HOMA index), which will have positive health benefits for you regardless, and possibly could reduce your risk of early SVD.

Also, ApoB/ApoA ratio have to do with having a good lipid profile, so living a healthy lifestyle and controlling lipids with medication if necessary would probably be a good idea for not only heart health in general, but possibly better chances at extending the life of your bioprosthetic valve.

Lastly, PCSK9 was correlated with faster SVD development. With the caveat that, like the other markers, it is not known whether this is causative, it might be good to keep the following in mind. Statins are widely used for lipid control, but they raise PCSK9. Recently, PCSK9-inhibitors have been approved, which have a much more significant impact on lowering LDL cholesterol than statins, but also lower PCSK9. For patients needing lipid management, there have been remarkable published results with significantly lower events for those using the combination of statins and PCSK9-I; look up the Fourier Trial. So, particularly if you need lipid control medication, you might want to have a discussion with your medical team about considering a PCSK9-inhibitor, such as Repatha.

 

[pellicle]

@thos_huxley

Why would we try to change your mind?

My thoughts exactly.

Although I wonder what the _uck your cardio is on about with "The cardio countered with, "sure, but will that still be true in 5, 10, 15 years?" He had a point;"

I wonder what the state of US health will be like in 20 years and if people who aren't wealthy will be able to afford heart surgery.

Best Wishes

 

[pellicle]

Hi

I've mentioned in a previous post that I suspected the surgeon would push TAVR, but he did not, noting that my recent CT scan and cardiac cath indicated no stenosis. Rather, both docs agreed that SAVR is the indicated procedure, with implantation of a tissue valve.

ok, here are my more full thoughts

1. your bio says you are 67 (change that to a year of birth if you want people to know it, because you may change over the years) at 67 and living in the USA my view is you should go SAVR and a tissue. This is because the system is geared that way (and all the horsehockey about choice is pretty much bs as you've discovered, its an illusion of choice)
2. because you live in the USA the system is not supportive of modern patient methods of self management, if you want to have the best results with INR management it has to be self management. Now this is not to say that any given person will do well on self management, only most of them.
3. the illusion of choice meets a hard wall in the USA when people want to do something a bit different, then they face the policies of their insurance companies who will dicatate things to them. If you doubt this just read enough threads here over time and you will see this again, and again ... and again. Here is just one such thread about the strife people have with clinics. This sort of stuff just doesn't happen in Australia because we don't have the same system as you

The stats show that for a male of your age you will enjoy at least 10 years before any signs of SVD occur in the valve (77) it will be a few years more (lets say 7) before the next intervention needs to occur (84) and you go with a valve and your situation is amenable to TAVR, this will give you a good 5 more years (probably trouble free) (89). After that its either a miracle or you're up for another SAVR

Only you can know your family history, but for me most of my family were pretty rough around the edges at 89 (well all their lives really). Myself I recognise I'll die and have made good friends with that (although most people seem to repeat it like a movie but when they suddenly get actual evidence for it freak out as if was a consensual fiction).

So given all of the above I believe you will be best served by SAVR and bioprosthetic.

Best Wishes

 

[thos_huxley]

Dr. Philippe Pibarot and his colleagues in 2018 published a longitudinal study on markers for early SVD, as well as a review on this subject. I am attaching both here if you are interested.

Thanks for the helpful info. Actually, I'm already on Simvastatin (20mg) for slightly higher-than-normal LDL. I'll definitely inquire about PCSK9-inhibitors.

I also appreciate the articles. In that vein, I wonder if you've seen/read the following:

 

[pellicle]

I wonder if you've seen/read the following:

yes, it and similar articles get posted here (including by me and Chuck) often.
This is the online verison
https://www.ahajournals.org/doi/10.1161/JAHA.120.018506
most recently I posted it here:
https://www.valvereplacement.org/threads/tissue-valve.888317/post-913068
most of us who are data driven and serious are aware of this, but if you start saying this sort of thing to people the flaming torches and pitch forks and chants of "mech valver" come out. So I mainly only focus on this message to younger people.

I assume you are familiar with my posts ... I can produce another view of my above post points but to be honest I wrote what I think is the majority of my views (with respect to your situation) in that post

 

[Dano64]

Best if luck with your upcomming procedure Dano! It sounds like you did a good job with your due diligence heading into the procedure, weighing the pros and cons of each choice. You are making an informed choice- well done!

On Monday, if I understood your post correctly, your surgeon was going to wait and see what your homograft valve looked like at the time of your aneurism repair before deciding whether to replace it. Is the plan now to replace the valve regardless? Given that it is 21 years old and has already lasted longer than the average homograft, I do believe that it is the right call- taking care of it while the hood is open, so to speak.

It seems more likely that the valve will go also. We shall see. I am preparing for it to go.

 

[Chuck C]

I also appreciate the articles. In that vein, I wonder if you've seen/read the following:

Yes, Lynn posted that last month. That is an excellent review of the current literature on the subject.

 

[pellicle]

Yes, Lynn posted that last month.

Thanks for that, I couldn't remember who reposted that up-to-date one. Nothing much had changed, but having current stuff heads off the claims of "old research"

 

[Chuck C]

Thanks for that, I couldn't remember who reposted that up-to-date one. Nothing much had changed, but having current stuff heads off the claims of "old research"

You also posted it more recently in another thread. I recall that someone came out of the woodwork and slammed you for it, apparently because it was a Russian review, which is really a silly criticism. It was peer reviewed and published in the AHA Journals.