New here - Getting ready for surgery 10/21

[Ross]

FIRST I agree with what you said about the need/or lack for blood these days. BUT I don't know why they told you that about your own blood, IF you give a auto donation that blood should have tags with your name on it and goes to you first. THEN IF you don't need it and all the tests are fine, it would be released to the general blood bank, so it doesn't get thrown out. It should also work that way for any direct donors you might have, (friends family ect, but honestly the banked blood is probably better than some direct donors, since sometime family friends, shouldn't donate, but are too embarrased to admit, their blood might have something worng so just keep their mouths shut and donate)

They USED to always need 1 unit of blood to just prime the bypass pump, but they don't anymore, so most people don't need any blood.

Don't know, that's what they told me though when I asked about having my own blood back. They said most likely, it would be needed for someone else and would be used if the need arose. At least I'm an easy type match, so there is usually plenty to top off my tanks.

 

[Lynlw]

Don't know, that's what they told me though when I asked about having my own blood back. They said most likely, it would be needed for someone else and would be used if the need arose. At least I'm an easy type match, so there is usually plenty to top off my tanks.

They were probably too lazy to do the paperwork. Justin is Aneg and believe it or not both my husband and I are too, but when he had his first 2 surgeries, the surgeon wanted 6 units of 1 day old whole blood, because all the clotting factors, platelets were still fresh. It was tough to find 6 Aneg people that could take off work in the middle of the week to donate, I almost had a break down when the day before surgery he had a bad rxn to the Cath dye and surgery was almost postponed. I remember saying WTH will I find 6 more people with Aneg to donate if suregery isn't tomorrow.
I'm glad things are much easier as far as needing blood for OHS go.

 

[Bill B]

While I suppose there is nothing wrong with doing what your doing, most people simply have their blood cleaned and returned to their system via bypass machine. Of course, there are always a few people that do need blood after surgery, so it doesn't hurt. They must be doing things differently today. When I asked about it, I was told that I could bank my blood, but that there were no guarantees that I would be getting my own blood back. Doesn't much matter now. I've had about 6 pints since then.

Hi Ross:

Ah, I gather you are talking about blood being reclaimed from the operative field, "cleaned" and reinfused. I'd heard of that before, but it wasn't mentioned to me in this case. I'll have to ask about that. Since this was a designated autologous program, I'd be disappointed if I got someone else's blood. I signed a bunch of consent forms. Maybe I missed that disclaimer. Anyway, the donation was so innocuous that as long as SOMEBODY gets my blood, I won't mind. Thanks.

Bill

 

[Bill B]

Bio valve freedom from reop in "younger" patients

Bio valve freedom from reop in "younger" patients

Ah, now I understand!

I just looked at the two large studies published in the last year cited by St. Jude.

1. 20 years experience in 1712 patients
http://www.sjmprofessional.com/Reso...ts-with-the-Biocor-Porcine-Bioprosthesis.aspx

An abstract of the study with some critical numbers is available here, and you can buy a pdf of the full study:
http://jtcs.ctsnetjournals.org/cgi/content/abstract/137/1/76

2. 20 years experience in 455 patients
http://www.sjmprofessional.com/Reso...cor-Bioprosthesis-in-the-Aortic-Position.aspx

The full text of the latter article is available here:
http://ats.ctsnetjournals.org/cgi/reprint/86/4/1204

I now understand that Dr. Miller, my surgeon, is right in saying the new 3rd generation valves are not significantly better than earlier generations in terms of freedom from reoperation. It isn't that he doesn't believe the data. If you look at the subset of patients less than 65 years old, the reop rates at 15 years in these two studies are about 50%. These are no 20 year+ valves in "younger" patients, like me. Yes, in patients older than 65 the freedom from reop might well be over 90% at 15 years and close to 90 at 20 years, but the data is sparse. In the scheme of things, these are very small trials.

That still doesn't mean I might not choose to get one of these valves. I just now understand that Dr. Miller is not particularly biased in his view. He just was referring to my age subgroup. There are many reviews with the earlier generation bio valves that show similar reop rates in younger patients.

I see in reading some other posts that you guys seem to be aware of this, but I see a lot of indiscriminate mention of new "20 year" bio valves too. I didn't pick up the age dependence until today. And even that can be subject to some serious question, as the average follow-up in the studies was only 6 and 8 years, so there is a lot of statistical extrapolation (life table analysis) going on here and the number of patients out over 10 years is quite small due to many deaths. For the vast majority of patients who entered these trials the re-op interval was irrelevant as they died relatively early before they could reach a projected 15 or 20 year re-op. Maybe that's something for all of us to consider. I did note that there was a high rate of coronary disease in the patients in these trials, so that may be an important factor. Dr. Miller, when he strongly recomended the mechancial valve, noted my coronaries are clean and I am going to live a long time. It's commonly held that 90% of the medical literature is seriously flawed in terms of study design or results analysis and interpretation, and I don't think these studies are in the exempt group.

 

[vprnet]

Good move Bill to have it done ASAP.Take it real easy up to the date, walking i would think at this point is better than pushing it on the dance floor.


I'm 55 on warfarin and still play with my machine tools. no problem, hand cuts, nail puntures, you name it. Home test and eat a consistent portion of veggies so my rat posion doseage is also.

Love my ON-X valve and conduit. Only hear it when I want to. The docs have lost interest in me. What more can i ask for!

Good luck, you'll be back on the dance floor in no time with plently of wind to spare.

 

[vprnet]

Good move Bill to have it done ASAP.Take it real easy up to the date, walking i would think at this point is better than pushing it on the dance floor.


I'm 55 on warfarin and still play with my machine tools. no problem, hand cuts, nail puntures, you name it. Home test and eat a consistent portion of veggies so my rat posion doseage is also.

Love my ON-X valve and conduit. Only hear it when I want to. The docs have lost interest in me. What more can i ask for!

Good luck, you'll be back on the dance floor in no time with plently of wind to spare.

 

[skeptic49]

Ah, now I understand!

These are no 20 year+ valves in "younger" patients, like me... Dr. Miller, when he strongly recomended the mechancial valve, noted my coronaries are clean and I am going to live a long time. It's commonly held that 90% of the medical literature is seriously flawed in terms of study design or results analysis and interpretation, and I don't think these studies are in the exempt group.

Interesting analysis, Bill.

Best wishes,

Jim

 

[Bill B]

Another factor to consider is that I am getting a conduit. I didn't see any mention of conduits in these trials. My wife remembers Dr. Miller saying something about reop on conduits being problematic. Anyone know anything about that?

I've looked a bit more at the way SJM slices and dices the data to create a subgroup of 60-70 year olds that seem to have very high 15 year non-reop rates (notice it's not 20 year). This is composite data that is not published, and they do not give the raw numbers. Even with 1712 patients in the latest trial, which sounds impressive, you can end up with so few patients at some points in these age subgroups that a few patients can greatly influence the results. I'm just making some casual comments here based on many years of being involved in clinical trials, but something like this either needs specific age-group trials with more control for underlying disease or much, much larger numbers to create realiable results.

 

[Danny]

I thought i did my research..lol.. Bill, can you Ross, and a few others come with me in a week and ask all these questions to my surgeon?

 

[Bill B]

I thought i did my research..lol.. Bill, can you Ross, and a few others come with me in a week and ask all these questions to my surgeon?

Danny: I think my recommendation is going to be more listening than asking. Dr. Miller was trying to tell me what he strongly recommended and I kept wanting it to go in another direction.

 

[tobagotwo]

The point about conduits is well taken. That could very reasonably be a dealmaker.

I can appreciate your use of these two studies to make your point about tissue valves. I was able to view the PDF for the larger study, but don't have print or send rights. Elsevier usually doesn't slip enough to allow the PDF to be brought up at all.

There is no question that tissue valves don't usually last as long in younger patients. That has been a longstanding understanding on the VR site.

However, the breakdown groups used of "all patients less than 65 years of age" is not representative at all of 50+ year-olds. The makeup of these groups include teenagers, who are extremely chemically active, and have been known to calcify tissue valves in as little as two to three years. That knocks the statistics awry quite a bit.

As an example, a table of actuarial freedom from aortic valve replacement (for the Biocor tissue valve) due to structural valve failure over a twenty-year period shows over 60% in people between 51-60, but less than 38% in those less than 50 years old. That's a telling leap in statistics.

Your general conclusion is correct: these are not generally 20-year valves for younger patients. However, the studies may not be detailed enough to provide such exact statistics as 50%/50% at 15 years for a reasonably representative age group for your or me. The 51-60 year-old age group is left out of most results in favor of the more simplistic (and functionally useless) <65 age group.

I also agree with your other conclusion that some statistics may be glossed over or emphasized through careful choosing of the display.

The usual guesstimate I have given for people at age 50 is that they will definitely have one, likely two more AVRs in their future, if they choose tissue. The reasoning I posted for my own, original AVR follows very closely to that, and the situation hasn't altered significantly since then. Interestingly, I had chosen 15 years as being a likely valve life at my (then) age of 52.

Statistically, neither has a significant advantage in overall survival. The difference is in daily life with ACT for a mechanical or when dealing with a tissue valve's decline before replacement, and in how you like to take your risks: in small, daily doses with some rises when bridging or abstention of ACT is practiced, or in bigger doses farther apart, when it's time for a tissue reop.

I'm not advocating either type of valve for you. And of course, it's a very personal decision that I wouldn't have to live with (only you will). Fortunately, you have a good grip on your personal nature, and that understanding of yourself will (I feel) be your best guide.

Whatever you choose, embrace it and don't look back once you have the surgery.

May it go well for you,

 

[Lynlw]

Another factor to consider is that I am getting a conduit. I didn't see any mention of conduits in these trials. My wife remembers Dr. Miller saying something about reop on conduits being problematic. Anyone know anything about that?

I've looked a bit more at the way SJM slices and dices the data to create a subgroup of 60-70 year olds that seem to have very high 15 year non-reop rates (notice it's not 20 year). This is composite data that is not published, and they do not give the raw numbers. Even with 1712 patients in the latest trial, which sounds impressive, you can end up with so few patients at some points in these age subgroups that a few patients can greatly influence the results. I'm just making some casual comments here based on many years of being involved in clinical trials, but something like this either needs specific age-group trials with more control for underlying disease or much, much larger numbers to create realiable results.

I'm not sure what you are asking about the conduits. My son has had several replaced and cut and patched over the years, but I'm not sure what you are asking. I know some surgerons don't like the extra time to sew the conduit to the valve, but it seems to me you are asking about needing re eops on the conduit.

Also I'm not argueing with you and would never tell anyone not to listen to their surgeons recs, I just find these discussion interesting and since I have trouble sleeping and try to keep ontop of what is going on for the past 20 years, since Justin's heart is so complex. (and I have to say that is MUCH easier with the internet, before I had to go to the medical library and read the actual books and journels) As for Tissue valves, most of the centers, like Cleveland, that are using tissue valves in younger (and I belive younger usually refers to 40 and up and NOT in your 60s ) are using the CE Bovine valves, not the porcine ones. http://jtcs.ctsnetjournals.org/cgi/reprint/131/3/558.pdf Heres a few more things to read if you are interested, http://my.clevelandclinic.org/heart/disorders/valve/pericardialvalvestory.aspx

Also what they take into consideration is the benefits risk of re ops vs coumadin, especially as you get older. The old recs of tissue over 60 and mech under, took into account multiple redos vs coumadin. but since the newer (2nd genration with anticalcium) lasted longer and the mortality rates for first time redos improved, especially in the bigger centers, many surgeons started to recomend the CE perimount for younger patients (40,50s) as the benefits/risks ratios changed.
Here is an interesting article from 2007 http://www.circ.ahajournals.org/cgi/content/full/116/11_suppl/I-294 Very Long-Term Survival Implications of Heart Valve Replacement With Tissue Versus Mechanical Prostheses in Adults <60 Years of Age

 

[ottagal]

RE: "Long Term Survival Implications of Heart Valve Replacement With Tissue Versus Mechanical Prostheses in Adults <60 Years of Age "

Lynn,

I had to comment on your most recent post. This particular study you referred to was done at the Heart Centre where I will be having my aortic valve replaced (and a possible pulmonary valve repair). The surgeon (who is one of the co-uthors of this study) and I spoke extensively about this study. After all was said and done, I asked the surgeon what his valve recommendation would be for me (based on my personal heart and health situation, lifestyle etc.). He recommended the CE bovine perimount (newer generation) and I am in my forties. He has performed over 1000 valve replacements/repairs in the course of his career. Of course, we all know that the patient has the final say. Just thought I would share.

Bill ....sorry....didn't mean to hijack your thread.

 

[Bill B]

I'm not sure what you are asking about the conduits. My son has had several replaced and cut and patched over the years, but I'm not sure what you are asking. I know some surgerons don't like the extra time to sew the conduit to the valve, but it seems to me you are asking about needing re eops on the conduit.

This is something my wife says she heard while I was probably not paying attention. She thinks there is some issue with reattaching the coronaries in older people, and may not apply to your son. I'm guessing it's not a problem with patching the conduit itself, but if they have to replace the bad valve, they must have to do something with the conduit and coronaries. I honestly don't know, so I'm going to ask for clarification.

Thanks for the additional information, as well.

 

[Bill B]

Bob H:

Thanks for your comments. If the conduit re-op is a dealmaker, then things will be simpler. I will sort that out with the surgical staff. My next challenge might end up being On-X versus SJM Master. Miller is pro SJM. I do like the Valsalva conduit of the Master HP. I wonder if the "water hammer" patients got that or the Master Hemashield conduit. I see Seth got the straight Hemashield. The HP Valsalva conduit description empasizes its compliance.

BTW, I did a screen capture of that restricted pdf and saved the pages as JPEGs. I only read through that one quickly. There is a lot of data manipulation but not some of the raw data I was looking for on patient numbers in various subgroups that the earlier, smaller trial presented more directly.

 

[Bill B]

Ottawagal:

Best Wishes for your upcoming surgery! I'm only a few days ahead of you.

 

[cbdheartman]

Welcome and a dissent (a vote for tissue)

Welcome and a dissent (a vote for tissue)

Dear Bill,

Welcome to the forum. I am sorry you are dealing with this. I am glad you are dealing with your aneurysm now rather than later.

I had BAV and an aortic aneurysm. 7 weeks ago I had valve-sparing surgery to repair the aneurysm and keep my native valve. My leakage was very mild and my surgeon was able to keep the valve and actually the transesophageal echo showed no leakage.

I assume that Dr. Miller doesn't believe you are a candidate for valve-sparing surgery (David Reimplantation most likely) because of the condition of your valve? You may just ask.

I am only 31, but despite the good words so many here put in for mechanical valves, had my valve been unsalvagable I was going to go with a tissue valve. I didn't want to be on coumadin for the rest of my life. The other factors were these: 1) it does seem that the new tissue valves are lasting longer (and at your age the lifespan is probably longer than for a younger patient); and 2) while there is no guarantee it does seem as if we are on the cusp of having transcatheter valve replacements becoming standard within the next 10-15 years. If this is last point is true, then any future replacement might be done in a less invasive fashion. Now there are no guarantees, but that was my thinking going into it. I am glad that my valve was spared (though valve-sparing resurgery rates are very good there is still the chance that I will have to have surgery again in the future).

 

[Duffey]

Hi Bill.
I received the Edwards 3000 perimount in 2005, at the age of 53, and was told I could expect about 12 years before needing another replacement.
I've only got four years under my belt but still happy with my choice.
Having said that, you're the only one who can make the decision, so once you do, please don't spend your time trying to second guess yourself.

 

[Lynlw]

This is something my wife says she heard while I was probably not paying attention. She thinks there is some issue with reattaching the coronaries in older people, and may not apply to your son. I'm guessing it's not a problem with patching the conduit itself, but if they have to replace the bad valve, they must have to do something with the conduit and coronaries. I honestly don't know, so I'm going to ask for clarification.

Thanks for the additional information, as well.

That would be a good thing to have clarified before you make your final decision, FWIW Justin's 2nd surgery had a conduit made (of mainly his own tissue and some dacron when he was 18 months as a small part of the surgery where they basically rebuilt his heart), then the middle was replaced (with more of his own pericardial and heart tissue) at 10, (then was stented and re balloned a few times) then the whole thing was replaced when he was 17 with a section of conduit then a bovine valve (its his right side, pulm they odon't use mech) then another section of conduit. Then when he was 19 the section of conduit from his right ventricle to his valve was replaced (but they left the valve because it was "perfect" and 2nd conduit in place) My whole point of this is even tho surgeons probably prefer simpler surgeries, the best ones are quite the artists and usually can get around tricky problems, if they have to.

 

[Lynlw]

RE: "Long Term Survival Implications of Heart Valve Replacement With Tissue Versus Mechanical Prostheses in Adults <60 Years of Age "

Lynn,

I had to comment on your most recent post. This particular study you referred to was done at the Heart Centre where I will be having my aortic valve replaced (and a possible pulmonary valve repair). The surgeon (who is one of the co-uthors of this study) and I spoke extensively about this study. After all was said and done, I asked the surgeon what his valve recommendation would be for me (based on my personal heart and health situation, lifestyle etc.). He recommended the CE bovine perimount (newer generation) and I am in my forties. He has performed over 1000 valve replacements/repairs in the course of his career. Of course, we all know that the patient has the final say. Just thought I would share.

Bill ....sorry....didn't mean to hijack your thread.

Your lucky, I've heard very good things about that Center. One of the things that struck me in this study was
Stroke
Thirty-five patients in the cohort died from stroke. The 20-year freedom from death attributable to ischemic or hemorrhagic stroke was 97.9±1.2% in tissue AVR patients, 83.9±4.9% in mechanical AVR patients, 96.1±1.9% in tissue MVR patients, and 85.6±5.3% in mechanical MVR patients. After adjusting for coronary artery disease and atrial fibrillation, the use of a mechanical valve was a significant risk factor for dying from stroke in either implant position (for AVR, HR: 7.0; for MVR, HR: 4.5; both P<0.02).

That is a pretty big difference, Now this IS just the people who died from strokes, not everyone that had them, I wonder if they have the stats on all the people that had strokes broken down like this,