Mechanical vs Tissue - need help deciding

[Lucker]

whoa ... loathe? Wow ... what causes that?

Anticipation of living in fear of strokes, internal bleedings and hardships with future possible surgeries.
Yes, the mechanical valves were a great achievement, but we deserve something better in 2020-s after 60 years.

I mean how would YOU personally feel to get a valve which you hope to last 15 or 20 years (not sure of your age) and find that it was inferior in some way to the existing products?

cheated?

The possible gains that the polymeric valves promise seem to me so dramatic, that yes, I seriously consider taking the risk of a valve with only 8-10 years history (hopefully I have 5 years ahead before surgery). I'd feel very cheated having a mechanical, when the better cure was there. Yeah, cheated, but alive.

 

[pellicle]

Anticipation of living in fear of strokes, internal bleedings and hardships with future possible surgeries.

I suspect you've been misinformed. The risk of stroke with properly maintained INR is about the equaivalent of the age related general population.

Having had 3 surgeries, a repair, a homograft and finally a mechanical I do not feel cheated, indeed I'd feel cheated if I'd been il-advised into getting a tissue prosthetic at my age of 48 and would most likely now be facing my 4th surgery soon.

The evidence is pretty clear. If you wish to minimise your risk of reoperation, and you want to take an actual hand in the outcomes of your health; then a mechanical valve and self management of INR gives you the best opportunity to live without reoperation (which brings risks I'm suspicious that you're unaware of) and with essentially no risk of stroke or bleed.

but we deserve something better in 2020-s after 60 years.

indeed we do have something better now, its called point of care INR systems, these just like the revolution in managing diabetes allow individuals to manage their own INR far more carefully than a Lab would be able to do and with less injury to your veins.

I recommend you read my blog post on that
http://cjeastwd.blogspot.com/2014/09/managing-my-inr.html
If you follow up on that you'll even see some great actual examples of managing INR around surgeries.

http://cjeastwd.blogspot.com/2017/12/perioperative-management-of-inr.html
Lastly there is no cure for valvular heart disease. All we can do is exchange valvular heart disease for prosthetic valve disease. There are two types: bioprosthetic or mechanical.

One is managed surgically when it fails (assuming you don't die first) the other is managed with drug therapy and generally is a life long solution.

I believe that its important to get the actual facts not just some impressions.

Best Wishes

 

[Lucker]

The risk of stroke with properly maintained INR is about the equaivalent of the age related general population.

For ischemic or hemorrhagic stroke, or both?
Yes, I've read some of your blog and know the risks of reoperations (infections, arrhytmias). Tissue is even less desirable to me, than mechanical, but may be in 5 more years we'll have good data for Inspiris Resilia.
Thank you, talking this generally known things over and over again helps to make up my mind.

 

[pellicle]

Hi Daniel

here's the thing, I normally have you on my ignore list because you are not a person who appears to be interested in any other view than your own. You know it all and are apparently here to tell us why we're wrong. You don't engage in genuine discussion. Further I don't believe you are genuinely interested in listening or prepared change you mind.

However for the sake of testing if I'm wrong lets have a look at the points you raise.

Firstly I'd like to say it would be nice if instead of throwing down a gauntlet you could speak (write) in a civil and polite manner. That in itself makes me disinclined to discuss things with you.

Two things:

or did you mean 4?

#1 You have claimed in the past that getting 15 years from a tissue valve makes one a statistical outlier.

If this is the case, is 60% of an outlier a relevant argument?

it strongly depends on the age at operation. I have not seen any evidence to show that a person operated on at (say) 38 will get 15 years from a tissue valve.

For instance:
https://jamanetwork.com/journals/jama/fullarticle/1910112

The 15-year cumulative incidence of reoperation was higher in the bioprosthesis group (12.1% [95% CI, 8.8%-15.4%] vs 6.9% [95% CI, 4.2%-9.6%]; hazard ratio, 0.52 [95% CI, 0.36-0.75]).​

and from this study
https://academic.oup.com/ejcts/article/25/3/364/380558?login=false

Fifteen-year actual freedom from all-cause reoperation was 94.1% for aortic mechanical valves, 61.4% for aortic bioprosthetic valves, 94.8% for mitral mechanical valves, and 63.3% for mitral bioprosthetic valves.​

So "all causes" did not specify how many aortica mech valves were replaced due to failures of anticoagulation (causing obstructive thrombosis and if those properly followed treatment options with tPA) or aneurysm development. Further this graph suggests its just getting worse if you to past 15 years, and the younger you are the more you'll be anticipating a lifespan exceeding 15 years ...

So its pretty clear.

#2 Do you have any statistics on how many mechanical valvers:

provided above.

A. Will still have the cognitive ability they have today to self manage anticoagulants (using your spreadsheets, etc.) 15 years into having their valve? How about after 20? Or 30?

why wouldn't they? And why wouldn't they have a carer who can (actually some of the people I help are carers for people who don't have the ability to manage themselves

B. Will still have the ability to get themselves to an anti-coagulant clinic on a regular basis in 15 years or more if self management fails? What happens when they can no longer self manage or regularly get to a clinic?

seems like a very outlying case ... can you explain who you may mean? Such as a specific example case?

C. Will NOT develop another condition (arthritis, cancer, strokes, ulcers, etc, etc, etc.) whose treatment will be negatively affected by or impossible to implement due to anticoagulants used for their mechanical valve in 15 years? 20? 30?

well the vast majority of common or anticipable conditions are indeed manageable with ACT ... can you suggest which ones can not?

What about Cancer? As far as I know its a high probability that your tissue prosthetic valve will be badly damaged by chemo (shredded was the word a patient I know was told) which is not the case for a mechanical valve.

So, I've diligently and conscientiously answered you demands for answers. I hope you find worthwhile avenues for investigation with the data presented here. Remember: these are in large NOT my opinion. They are research data.

Best Wishes

 

[pellicle]

For ischemic or hemorrhagic stroke, or both?

for both as far as I've read. Of course prompt treatment will be critical for any IC bleed.

Thank you, talking this generally known things over and over again helps to make up my mind.

you're welcome.

I have nothing invested in your decision, I really only participate here to assist. This can be in a practical way and in a facilitative discursive way ... I generally say that on the path to decision one will likely change ones mind at least once.

Best Wishes

 

[Superman]

hang brutha ...

Thanks. One of those totally random coming up on 50 years old things. Walking normally in my house. Not even lifting anything. Back said, “Hey, screw you, you’ve got it too easy!” As soon as I felt something move I said, “That’s not good.” Said it out loud too. . Fortunately got on it with meds right away so it didn’t last.

But Warfarin interacts with those drugs, so I test and adjust accordingly. One of the negatives of mechanical. Certainly not the end of the world, but if one would find that too much to deal with, it may impact their choice of valves. My no big deal might drive someone else to an anxiety attack. For me, knowing another surgery was coming someday would trigger my anxiety.

 

[Chuck C]

Since you are Australian, why not tell us about your country instead of criticizing the US; a place you know little about outside of movies, TV and biased media. For example, are patients in Australia denied tissue valves if under your personal metric of 55yo?

Your post sure comes across as gratuitously abrasive and unkind.

Also, I find it ironic that you should scold someone that dares to comment on another county’s health care system. You have been very vocal about your criticisms of the British system, the NHS, here on the forum. I don’t ever recall anyone from Great Britain telling you to keep your clap shut, mind your own business, and just talk about the US health care system when you have made such criticisms.

For example, like you did here.

https://www.valvereplacement.org/threads/awaiting-replacement-for-too-long.888336/#post-913187
For the record, I believe that you make some good points and have valid criticisms of the NHS. But, also Pellicle makes valid criticisms of the US healthcare system. We have all heard plenty of stories by members of this forum of said systems to help shape our opinions, regardless of whether we are from a particular country.

Can we all try a little harder to be kind?

 

[pellicle]

But Warfarin interacts with those drugs, so I test and adjust accordingly. One of the negatives of mechanical. Certainly not the end of the world, but if one would find that too much to deal with, it may impact their choice of valves. My no big deal might drive someone else to an anxiety attack.

good points and of course why I always advocate weekly testing. Test and know thyself.

I'll take the time to mention out loud (what I know you already know) that the issue isn't an occasional "out of range" finding, its all about the majority of time spent in range.

One of the good aspects of this place is that for mech valvers we have so much knowledge about (and an entire pair of sub forums on) anticoagulation and self management that anyone who wants to can do a better job.

Personally I wish that the clinics and other INR managers would step up to the plate, but anyone interested can just browse all the good stuff here. I get a reachout now and then about my blog posts and I can see from the stats that its usually got some readership too, so that's great that the message is getting out.

 

[pellicle]

Can we all try a little harder to be kind?

thanks Chuck, I think that point is often missing here.

Some people just seem to consider debating is negative, when in fact it should be about two sides trying hard to not only uncover the issues of the other side, but to defend their side in rational an unemotive ways. This is the basis of scientific thought processes

The missing aspect (in perhaps mainly public perception of this) is that it should always end with both sides reflecting on what the other has said and rolling that into their thinking. This is because the purpose of debate should be to get another perspective, another angle on things. This is because perspective can change what we see. From where group A stands they see a Triangle, while group B sees a circle

but from where the perfect observer stands, they see its a cone.

This is where debating (presenting views in a formalised way called argument) brings value to discussion. However for discussion to produce value itself both parties in the discussion need to be willing to adjust their views on the presentation of facts they had not seen before, and to actually listen to the other side.

Anything else is just this:

Best Wishes

 

[Superman]

And back to 2.6 INR this morning. Normally a 6mg daily (with a couple 5’s mixed in). Took 3mg the morning after my 5.2 INR, then 5mg, then tested this AM. I’ll go back to my normal program now. Probably one more test in a couple days to be sure I’m not continuing a downhill trend.

 

[pellicle]

I’ll go back to my normal program now.

as the old show said: do not adjust your television set:

 

[grassfarmer]

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)

I am 82 years old and never had any doubts that TAVR was the only way to go and so far I am not wrong. I don't have any noises in my chest, my tinnitus ringing in my ears is the only noise I hear. I liked you carbr reference but really your getting your alternator replaced IMO. If you ever have had surgery and know the tough healing process you go through after that then TAVR is like having a splinter taken out of your finger. good luck!!

 

[pellicle]

I am 82 years old and never had any doubts that TAVR was the only way to go

nor would I.

at 48 having my 3rd OHS I would not have made that call (especially as I also had an aneurysm to fix)

if you were answering a 36YO would you say TAVR? (do you see my point?)

 

[dick0236]

I am 82 years old and never had any doubts that TAVR was the only way to go and so far I am not wrong. I don't have any noises in my chest, my tinnitus ringing in my ears is the only noise I hear.

At 82 TAVR would seem to make a lot of sense........at 48 not so much. Mechanical valves are designed and built to last 4 to 5+ decades and should get a young person well into "old age"........TAVR cannot do that.

 

[Unicusp]

I am 82 years old and never had any doubts that TAVR was the only way to go and so far I am not wrong. I don't have any noises in my chest, my tinnitus ringing in my ears is the only noise I hear. I liked you carbr reference but really your getting your alternator replaced IMO. If you ever have had surgery and know the tough healing process you go through after that then TAVR is like having a splinter taken out of your finger. good luck!!

That's great for you. Keep in mind that not everyone is a TAVR candidate (I wasn't). And TAVR was initially developed specifically for older people that would most likely not survive SAVR. It does not last as long which is not an issue for a 82 year old but definitely an issue for a 48 year old thus guaranteeing future surgeries.
SAVR is scary in theory, but much more precise and sustainable in reality. From an engineering perspective, SAVR is the fix and TAVR is the band-aid. Just my thoughts! Each can make their own decision.

 

[ThomasM]

There are things to consider when and if you can choose the type of avr you want. I have had my St Jude aortic valve for 35 years now, and it is still clinking away. I am a unique case in that the clinking doesn't bother me through the day at all, but at night time it seems to stir me up. I haven't been able to sleep well at all any night without some sort of help to get to sleep. Seroquel, in low doses, really have been a savior for me, and the occasional light dose of Ambien. Like I said, I am a unique case, and others are probably wondering why it's even an issue, but we are all wired differently. The St Jude mechanical valve has really been a battle ax for me for the 35 years it's been in there, but I don't enjoy the clinking at night time and can't seem to overcome it. As I type this post, I can hear it clinking away, and it doesn't bother me at all, but at night time, it stirs up my emotions somehow. I think I am rather an anomaly in this respect, but that's who I am. The thing with this particular aortic valve I have, if it ever needs replacing they have to do open heart surgery to dig it out, and then I would probably get a biological valve put in its place due to my age. I was just talking with a friend who says there are now mechanical valves that they can put in through the groin, similar to the cath procedure? I don't have any knowledge about them but that's what he was telling me.

 

[Chuck C]

I was just talking with a friend who says there are now mechanical valves that they can put in through the groin, similar to the cath procedure? I don't have any knowledge about them but that's what he was telling me.

Actually, the one that goes through the groin is called TAVR and they are tissue valves. There is not a TAVR available that is a mechanical valve that I am aware of. Also, in the very unlikely event that your St Jude needs replacing, TAVR will not be an option, as it can't be done with a mechanical valve, only with tissue valves. But, it should be a moot point, as you probably have another 35 years+ left on your St Jude.

 

[tom in MO]

There are things to consider when and if you can choose the type of avr you want. I have had my St Jude aortic valve for 35 years now, and it is still clinking away. I am a unique case in that the clinking doesn't bother me through the day at all, but at night time it seems to stir me up. I haven't been able to sleep well at all any night without some sort of help to get to sleep. Seroquel, in low doses, really have been a savior for me, and the occasional light dose of Ambien. Like I said, I am a unique case, and others are probably wondering why it's even an issue, but we are all wired differently. The St Jude mechanical valve has really been a battle ax for me for the 35 years it's been in there, but I don't enjoy the clinking at night time and can't seem to overcome it. As I type this post, I can hear it clinking away, and it doesn't bother me at all, but at night time, it stirs up my emotions somehow. I think I am rather an anomaly in this respect, but that's who I am. The thing with this particular aortic valve I have, if it ever needs replacing they have to do open heart surgery to dig it out, and then I would probably get a biological valve put in its place due to my age. I was just talking with a friend who says there are now mechanical valves that they can put in through the groin, similar to the cath procedure? I don't have any knowledge about them but that's what he was telling me.

Some people find a couple of vapes of THC before bed helpful as a sleep aid. I believe it is legal in MIichigan.

 

[Timmay]

… , but I don't enjoy the clinking at night time and can't seem to overcome it. As I type this post, I can hear it clinking away, and it doesn't bother me at all, but at night time, it stirs up my emotions somehow. I think I am rather an anomaly in this respect, but that's who I am.

Are you sleeping in a quiet room? If so, why? Why not run an air cleaner and/or use a white noise generator to play some soothing background noise? My wife and I enjoy the sounds of crickets coming from an app on her iPhone that sits on the dresser.

In a quiet room I sound like a loud watch. But I never really hear this because of the various white noise we have.

 

[ThomasM]

Are you sleeping in a quiet room? If so, why? Why not run an air cleaner and/or use a white noise generator to play some soothing background noise? My wife and I enjoy the sounds of crickets coming from an app on her iPhone that sits on the dresser.

In a quiet room I sound like a loud watch. But I never really hear this because of the various white noise we have.

Thanks for the responses. Interesting, I do have a gummy every now and then, but not sure the long term effects of thc? Of course, most sedatives have their side effects. Also I do have an air cleaner going at night, which acts like white noise. Very good suggestions, although I take advantage of them already.