Natural or Mechanial

[bucks1972]

This is my first post and up to three weeks ago had no medical issues. I am now scheduled for surgery on March 25th to replace an aortic valve at Riverside Hospital in Columbus Ohio . I still have not decided the type of valve. I am 65 and in good health. I am leaning to a natural valve. believing in 10 year I would still be healthy enough to survive replacement surgery or improvement of non-invasive procedures will have been made. I have learned alot on this forum which has eased my anxiety. Thank you for any commetns.

 

[pellicle]

Hey there and welcome aboard

Just wanted to be clear on a point: the only natural valve available is either the valve you have or a cryopreserved homograft. The most common tissue prosthetics are as "natural" as your leather shoes or wallet. They are a manufactured product and (just like tanning leather) chemically treated.

So as long as you are aware of that then the choice comes down to tissue prosthetic or mechanical.

At this point in my life I say if you have no other medical problems (chronic kidney disease, diabetes, cieliac disease...) then there is perhaps a slight advantage in having a mechanical. However at your age group you sit within the group most likely to get 18 years out of your tissue prosthetic.

I'm not a gambling man and even more so I do not like the odds when betting on the TAVI future. There are SOOOO many variables to take into acount, such thing as "is my tissue valve amenable to TAVI replacement."

Check the facts CAREFULLY, write it down and make your call.

Its up to you

 

[bucks1972]

Pellicle, thank you for your advice and clarifying that by natural I meant tissue. If I understand your thought is if there are no other major health issues than go mechanical. I am worried how the coumadin my effect my health as I age.

 

[pellicle]

Hi Bucks

If I understand your thought is if there are no other major health issues than go mechanical.

yes, that's more or less what I was saying and at my present point in development I feel is the best path ...

I am worried how the coumadin my effect my health as I age.

that's an understandable worry, however you should be aware that there is very little evidence to support that worry and most of the evidence that does exist (which is not reproduced in other studies) can easily be criticised with the point that monitoring INR and adjusting dose as needed has undergone a revolution created by electronics. Just as one can't really compare cars pre-electronic ignitions to cars today we can't really compare the past lack of monitoring to the present. Ask any diabetic about how much they monitor and how its improved their outcomes on insulin dose.

Lastly you may find that as you age you are prescribed warfarin anyway or it may even be that as a result of the surgery you come out with atrial fib and need warfarin anyway. So you'd get the worst of both your negative list of points: near certainty of a reop + being on warfarin.

Of course I am not attempting to push you one way or another, I'm just encouraging you to see more of the picture.

Its your decision entirely and no matter what you decide the outcomes will be much better than not having the surgery. In the main both choices are very very close in outcomes, so I can't say you can pick a loser either way you flip the coin.

 

[dick0236]

Hi Bucks1972 and welcome. From what I understand, you are in the "damned if I do and damned if I don't" age group regarding valve choice. At your age a tissue valve should last longer than 10 years.....maybe 15/20 years and a mechanical valve would, almost certainly, last your lifetime. Warfarin will be required with the mechanical and not normally required with a tissue valve unless you develop A-fib. . IMO either way you go seems like a good decision. Ask your surgeon what he would do if he where the patient.

 

[haggis basher]

Hi Bucks1972
I was 71 when I had my AVR. I had been a long distance runner most of my life, but by the time to operate, I could hardly get up a small incline without stopping!
I had a 'tissue valve' (pig)(I knew what you meant!) I only take half an aspirin a day, and a 'cholesterol' tablet. I am now 3.5 years on, and back into
the running again, but not to the extent of my past.
Being honest, I never had a choice about my valve, for being on the National Health in Australia, I had to take what I was given! I still would have took tissue, as I never have to worry about what I eat.
Good luck on your decision.
Brian

 

[cldlhd]

Hi Bucks1972
I was 71 when I had my AVR. I had been a long distance runner most of my life, but by the time to operate, I could hardly get up a small incline without stopping!
I had a 'tissue valve' (pig)(I knew what you meant!) I only take half an aspirin a day, and a 'cholesterol' tablet. I am now 3.5 years on, and back into
the running again, but not to the extent of my past.
Being honest, I never had a choice about my valve, for being on the National Health in Australia, I had to take what I was given! I still would have took tissue, as I never have to worry about what I eat.
Good luck on your decision.
Brian

Just curious if the lack of choice is based on age, at a certain age do they decide it's tissue only? I would imagine that a healthy 50 yr old would have some say in what kind of valve they would get.

 

[epstns]

I'm not sure how it goes in Australia, but here in the US, we almost always are involved in the choice of valve. I was 63 at the time of my surgery (now past 67 and doing fine), and could have gone either way. My surgeon recommended tissue, with his valve of choice being the Edwards bovine pericardial -- because he had been on the design team for that valve and had implanted many, many of them. We agreed that as long as he still felt that was the right choice once he "got in there" I would go with his recommendation.

I did consider both. I had been "in The Waiting Room" for almost 10 years by then. Had I been ready for surgery while in my 50's, my cardio and I had agreed that I would choose a mechanical valve to minimize the likelihood of a re-operation. Since I was able to wait until 63, we both felt that the data supported the notion that I would have good odds of a tissue valve lasting 15 years or more. Some patients who have tissue valves implanted while in their 60's actually are still doing well into their 80's, so there is no hard rule of how long these things last. The current tissue valves are "third generation" valves. The second generation valves have proven to last up to 20 years or more (notice that I said "up to" as not all of them get that far), and the third generation are "expected" to last even longer. Yes, there is still an element of uncertainty, but I felt it was a good bet as opposed to using warfarin/Coumadin for the remainder of my life. I was not afraid of warfarin, as my mother and my mother-in-law had both used it for years, but I wanted to avoid the complication of having to take a medication that needed monitoring to be safe. I just didn't want to deal with it, and felt that the odds of a tissue valve lasting the remainder of my life were decent.

You have to make your own decision, but as the others have said, in your mid-60's, the only bad decision would be not to have the surgery. I would not, however, base any decision on the potential availability of catheter-implanted replacement valves. It is still too early in their development to know if they will prove to become mainstream. If they do - great. If not, you need to be comfortable with your choice now and in the future.

 

[bucks1972]

I would like to thank all of you for your comments. I had not thought about an AFib problem requiring coumadin anyway. I remain puzzled but see my surgeon for further discussion on this matter on Monday. For whatever reason my gut is telling me to go with a tissue valve.

 

[Paleowoman]

Hi Bucks - I live in the UK and I had aortic vavler replacement last year when I was 60 years old. I chose tissue valve. My cardiologist and cardiac surgeon were completely behind me about that and no one tried to dissuade me. My personal reasons for choosing tissue were a) I have ultra senstive hearing and I would not like the ticking noise, even if it were only slight, and b) I didn't want to be on warfarin as I have other health issues and taking another med would complicate things. I'm happy with my choice even though I know I will need a re-do before the end of my natural life (hey I plan to live until at least 85)…..sometimes people with mechanical valves need a re-do too so it's no guarantee.

 

[tom in MO]

I have a mechanical valve for 3 years now w/o any physical problems related to warfarin. However the one thing I did not realize when I made my choice, is that warfarin usage precludes the extended use of any drug that may cause internal bleeding. There are many arthritis medications that carry the risk of internal bleeding. If you are an arthritis sufferer or are expected to suffer from it, make sure you factor this into your choice.

 

[pellicle]

Hey Bucks

For whatever reason my gut is telling me to go with a tissue valve.

when in doubt go with your gut I say ... as we've all said its very nearly a 50 50 split at your agegroup and they're your dice to roll

you'll do well ... find peace with it and be comfortable no matter what your choice is

best wishes

 

[pellicle]

Hi Eps

I'm not sure how it goes in Australia,

I'm also a bit confused by HaggisBashers comment as well ... Health issues are actually state by state, and its only funding that is "national" with medicare, which is actually a safetey net for people with nothing in the way of private health care. Actually Private Health Care is slowly morphing into something which resembles the US system, but that's a different grief. I certainly had choices offered to me, even before I told anyone that I had private health care. Indeed the surgeon never asked me if I was restricted in any way. That's Queensland (my state) so it my be different in other states ... I'm not sure where Haggis lives

 

[haggis basher]

Hi pellicle
I had NO health insurance,(live Sydney) but as you say, I obviously had medicare. I found out later, that for the 'Private Surgeons' to operate in a "Public Hospital', they have to operate on so many public patients a year... When I saw him, I was filled with anxiety and worry, and living on my own, I wasn't thinking too straight! All I remember, him saying was that I needed a new AORTA valve, and it would be done within 2 months! I never knew about tissue or mechanical.
6 months later...Still waiting! I eventually had to see my cardiologist, and said to him "I am dying on my feet" - 2 DAYS later, I was operated on.
See Ya

 

[pellicle]

Hi HaggisBasher

I had NO health insurance,(live Sydney) but as you say, I obviously had medicare. I found out later, that for the 'Private Surgeons' to operate

the situation is quite different in Queensland (god, don't you love the state by state approach). As it turns out, up here if you have a life threatening issue you'll get attended to asap.

I went from operator sus about ultra sound to on the table in under 3 months. I was told (by friends in the business) that I actually would have done better in the hospital had I not mentioned my private health care (first time anyone asked about it was on admission).

Same goes for my 1992 operation where I had a homograft (a transplant from another human, as living tissue {or what I call a natural valve}) also done under the public health.

in a "Public Hospital', they have to operate on so many public patients a year... When I saw him, I was filled with anxiety and worry, and living on my own, I wasn't thinking too straight! All I remember, him saying was that I needed a new AORTA valve, and it would be done within 2 months! I never knew about tissue or mechanical.

that's a common story and results in many mis-understandings between the rushed communications that surgeons (busy fellas) are prone to and people who are suddenly swimming in everything new.

I was born into this and so I have totally no idea how you felt, except perhaps in talking with my wife who was shocked.

In an earlier post you mentioned:

as I never have to worry about what I eat.

99% of us on warfarin don't bother watching what we eat. Its a misinformation which perpetuates without much evidence. I have tried eating plates of spinnache for days on end and it makes no difference. I've even seen people who take vitamin K and even taking the tablets makes no observable difference to their INR. Indeed at hospitals when they reverse your AC therapy with Vitamin K they give heaps more than you could possibly eat in foods.

For instance(ref):

For most patients, 1.0–2.0 mg of oral vitamin K1 is sufficient. If the INR is particularly high, 5 mg orally may be required.

foods typically contain micrograms not milligrams


not that it matters for you, I only mention it here because many people read these forums and get impressions.

Best Wishes

 

[epstns]

When it came to Coumadin management (while I was taking it), I took Ross' advice -- "Dose the diet, don't diet to the dose." Simply put, he said to live your life, eat as you choose, then just adjust your dosage to accommodate your lifestyle.

My biggest concern, if I ever need to take Coumadin long-term, is the uncertainty and complication surrounding Coumadin management in case you need other surgery. It is, I know, entirely manageable, but is another complication to be dealt with.

 

[cldlhd]

I'm sure I'm oversimplifying this to a large degree because since I'm not on warfarin I haven't done nearly as much research on it but my only question would be about the differences between K1 and K2 and some of the things I've read relating to K2 and helping to prevent calcification of the arteries. I assume it's much too simple to say K1 is about clotting and K2 is about keeping the arteries clear. If so then I would imagine a K2 supplement would be ok for people on warfarin but I'm not a doctor so nobody should take that as any kind of advice.
I've heard of people on warfarin actually taking a daily K1 supplement to try to stay 'even' on their bodies stores and make dosing easier and their INR more steady. I would assume this means the warfarin dosage would likely have to be higher to counteract the K1? If you were taking K2 would a higher dose be needed and would that basically offset the advantages of the K2? I'm not on warfarin but just the curious type I guess.

 

[AZ Don]

There is a good comparison of valve choices here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1768482/. See especially figures 2 & 3. In figure 2 they basically compare life expectancy and event free life expectancy for those with tissue valve vs. those with mechanical. The lines cross at about 60 years of age so after this age tissue is often recommended. Figure 3 shows the risk with each. The article is just over 10 years old but I don't think much has changed, though there are many new possibilities on the horizon: TAVI, mechanical valves not requiring warfarin, stem cell grown valves. Still no way to know when these will be ready for prime time. One other factor that can effect mechanical is self management of the INR ratio. There is a Mayo study on this site that makes the case self management improves the outcome for those with mechanical. Still, you will find Dr's with a bias either way.

Good luck.

 

[Paleowoman]

I'm sure I'm oversimplifying this to a large degree because since I'm not on warfarin I haven't done nearly as much research on it but my only question would be about the differences between K1 and K2 and some of the things I've read relating to K2 and helping to prevent calcification of the arteries. I assume it's much too simple to say K1 is about clotting and K2 is about keeping the arteries clear. If so then I would imagine a K2 supplement would be ok for people on warfarin but I'm not a doctor so nobody should take that as any kind of advice.
I've heard of people on warfarin actually taking a daily K1 supplement to try to stay 'even' on their bodies stores and make dosing easier and their INR more steady. I would assume this means the warfarin dosage would likely have to be higher to counteract the K1? If you were taking K2 would a higher dose be needed and would that basically offset the advantages of the K2? I'm not on warfarin but just the curious type I guess.

I can't answer your question about K1 and K2 with respect to warfarin, but I do take K2 and I do know that it is very different to K1. They are described as almost different vitamins. K1 is to do with coagulation and K2 to do with putting caclium in the bones and keeping it out of the arteries. K1 is very easy to obtain from food and no one is deficient in it. K2 is not so eay to obtain from food, apart from Japanese natto (which apparently tastes awful) and other fermented foods such as sauerkraut and some cheeses. Bacteria in our gut make K2 but most of that is kept by the bacteria or pooped out. Rabbits eat their poo and so get good K2 levels. I wrote to Dr Claus Vermeer, one of the lead researchers into K2 and it's effects on coronary calcification, and asked him how people got K2 in the days before supplements - after all, the human body gets all it needs from foods otherwise we wouldn't be here as we are, i.e. most animals make their own vitamin C but humans can't so we (and guinea pigs) have to get our C from foods. Dr Vermeer's response about K2 was that prior to refrigeration most foods, like meats, were ever so slighlty going off/putrifying - this was normal and still safe - and the bacteria that caused this made the foods replete in vitamin K2 and so people did not suffer deficiences of it. It's all very interesting with a lot of research going on. I take vitamin K2 for both my osteoporisis and to help keep my arteries clear of calcification.

 

[cldlhd]

Thanks for the info. Well the multivitamin I take has 200 mcg of both k1 and K2 so that's good . I doubt I need the k1 though as I eat a lot leafy greens.