New here - Getting ready for surgery 10/21

[Lynlw]

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.

I believe the "water hammer" complaint had more to do with all the patients had a dacron conduit and not were one brand or type of mech valve. I'd have to check again but last I remember some had SJM all in one, some ON_X and conduit and 1 I believe had a tissue valve w/ a dacron conduit. Seth would have all the break down tho

 

[Bill B]

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.

Wow, that's quite a series of operations. I hope Justin is stable and healthy for a long, long time. Dr. Miller will do whatever I want and didn't put strong empahsis on using a combo valve and conduit. In fact, I don't think he mentioned it. I've been talking to a lot of his staff and they have been telling me a lot of things. My final decision will be made with Dr. Miller.

 

[Bill B]

I believe the "water hammer" complaint had more to do with all the patients had a dacron conduit and not were one brand or type of mech valve. I'd have to check again but last I remember some had SJM all in one, some ON_X and conduit and 1 I believe had a tissue valve w/ a dacron conduit. Seth would have all the break down tho

Thanks. I wonder, then, if it's the conduit more than the valve. I see there are other sources for aortic conduits other than the valve makers, which introduces another variable.

 

[Bill B]

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.

Sage advice. I have learned after confronting many choices in my life between two or more unclear or closely matched choices that I have been happy with my choice even if I just went with my "gut" when reason failed to provide an answer. I will fuss over this for a while longer, hoping to identify some more solid decision-making issue, then make the choice and let it go.

 

[Lynlw]

Thanks. I wonder, then, if it's the conduit more than the valve. I see there are other sources for aortic conduits other than the valve makers, which introduces another variable.

I'm not sure what it is, Hopefully Seth will chime in, (I'll pm him) I don't know if they know what kind/brand of conduits they all have or if maybe their conduits are closer to their sternums than others. It IS interesting and I noticed everyone that mentioned it has aortic conduits, and not Pulm, I've wonderring it it has to do with the fact the pressure is higher going thru the aortic one or that most pulm valved conduits are tissue valves that don't close as hard as mechanical (I don't know if I'm phrasing that right) Justin's conduit is VERY forward, it actually was fused to his sternum he last 2 surgeries and I know alot of the pulm ones are forward in the chest, anyway that is just my rambley thoughts about it.
the good thing is it seems to be vERY VERY rare, but if you are that rare person it really stinks.

 

[Bill B]

A week to go. Waffling back and forth on the valve choice. Will talk to the surgeon in the next few days with a few last questions then make the choice. My rational side says mechanical.

 

[ottagal]

Hi Bill,

I feel for you. It is not an easy decision for some of us to make. I personally agonized over this (even with the surgeon's input and numerous discussions). Hopefully, after your discussion with the surgeon you will be able to put you valve choice to rest. One quote that provided me with some consolation was: 'any' valve we choose (whether biological or mechanical) is going to be better than the current one we are living with. I wish you all the very best.

 

[kfay]

A week to go. Waffling back and forth on the valve choice. Will talk to the surgeon in the next few days with a few last questions then make the choice. My rational side says mechanical.

I'm glad that I didn't have to make this decision. I would have driven myself crazy with the pros and cons of each. I probably never would have gotten into the operating room!

Whatever choice you make, it will be the right choice for you. Go with your gut.

Kim

 

[Bill B]

Where I am at today - long hemming and hawing post

Where I am at today - long hemming and hawing post

Dr. Miller is out of town until the night before my surgery, so I talked with a surgical colleague today. He was quite open. My reading of our discussion is that he agreed that despite the strong preference Dr. Miller expressed for a mechanical valve based on the likelihood of reoperation with bio at my "young" age, it is a close call when you consider all other variables. Anticoagulation is not inoccuous or completely effective. He expressed hope for better alternatives to Coumadin, but noted he was saying that 10 years ago. Reoperation could be handled, perhaps with newer approaches that wouldn't require OHS, and he didn't paint reoperation as a big problem for them, at least. We talked about the valves they use routinely. They are happy to put in whatever I want, but they have most experience with and routinely stock the SJM Regent mechanical and the Edward's Piermount Magna bio valve. If I wanted the SJM Biocor, for example, they would have to order it (no problem with a few day's notice) but he was very upfront that they have little experience with it and his view is that the Edwards valve has some features that are better, but it's not worth going into, as I see this all as largely an issue of personal preference.

I've been going over and over this in my head. My conlussion is the data needed to make these choices unequivocally are simply not there. For example, the SJM Biocor valve seems to have the most published data on durability, but after looking it over I think it is rather disappointingly meager and fraught with patient population issues such that it really does not apply well to me. There is no magic about that valve that should make it any more durable than the alternative newish biologics. I read a discussion by the author of one of the SJM studies in which he basically says all the different new generation valves are just variations on the same theme and probably not significantly different in terms of durability, whether there is published data or not (my interpretation).
http://www.theheart.org/article/915155.do.

Conversely, although the On-X valve appears based on company claims to have superior features that should lead to superior results compared to the older SJM valve dsigns, there is no substantial data. It may be great, but it's all supposition at this pont.

So, the underlying problem with making a sound decision is that not only is this a complicated subject, but the information you would need to make a concretely rational call is just not there. The bio valves appeal to me based on "lifestyle" and to some extent, safety issues around anticoagulation (granted this does not appear to be a problem for most patients). Yes, there is the known issue of reoperation, be it 5-10 or 15-20 years. Should I live as long as I expect to, I will certainly require reoperation. So, in a general way, it boils down to which do you WANT.

So, my leaning at this point is to not quivel much over getting a particular mechancial valve or particular bio valve but to use what they favor, as I don't see good reasons to overule that. Granted, at the Cleveland Clinic, that would mean I would get a different valve. So, be it. That doesn't concern me. One is not right and the other wrong. These are preferences, and maybe biases. Maybe if I took 15 years to become an accomplished thoracic surgeon I would have different ones.

If I were 70+, the choice should be clearer. At my age, I'm now seeing it as a toss-up in terms of risks. It's not even worth it to make up a pro and con table, although I probably will as a large part of me still wants to believe there is a right and wrong answer and I just need to find it. Yes, perhaps we will see 15 years from now that there was a right answer. I don't think that can be sorted through right now.

To be continued...

 

[Lynlw]

SOOO does this long post mean you this still holds true from yesterday "My rational side says mechanical." or have you changed your thought?

 

[mainframe]

Good luck with your choice Bill. My first AVR I choose a tissue valve and would have been thrilled with the 12 years the surgeon suggested, rather than the 7 years it seemed to last. This time, at 52 I'm definetely going mechanical and will accept the surgeons preference and since we are sharing the same surgeon, it would seem to be the SJM mechanical with graft. I'm o.k with that.

Maybe I'll bump into you in the hall. I'm flying down on the 21st for a CT and echo on the 22nd with my surgery with Dr. Miller on the 4th of Novermber.

 

[Bill B]

SOOO does this long post mean you this still holds true from yesterday "My rational side says mechanical." or have you changed your thought?

Actually, I have moved away from that. The rational argument for mechanical is certainty of reop with bio, if you are otherwise healthy. Note in the SJM studies, only a small fraction of patients made it long enough to get to reoperation anyway (they died for other reasons). Sure, on the surface the reop issue would still seem an overriding factor. But then that needs to be balanced against lifetime anticoagulation, which is not innocuous. Some have said here you really shouldn't use that as a consideration, but I don't accept that. I actually think I would be more likely than most to get into trouble with that based on my personality and personal habits. Even well-managed, there is risk of bleeding or clotting that is not negligible, and the risk is cumulative based on my reading, although I've seen some say here that it isn't. Then there are the rare but potentially disturbing anomalies with mechanical valves, like Seth's "water hammer", not something I believe is getting much sympathy.

So, what am I doing here? Am I simply trying to force my argument toward a bio valve? I don't know. Am I being realistic, knowing myself, that bio would work out over all better for me, despite an almost guaranteed reop? I'm still looking over information and mulling, but I think this is going to boil down to a gut-level choice.

I've at least decided that what I am going with is just mechanical or bio and leaving what specific device I get to what my surgeon prefers to use as I don't think you can make a concrete argument for one vendor/model. Perhaps that should have been obvious.

You see people here going either way, bio and mechanical, at all kinds of ages, and rarely do I see a concrete reason. Even Bob H, one of the most obviously knowledgeable people here, who has chosen bio twice, has not, as far as I can see, exposed the inner workings of his decision. It's a tough one. At one point I said that things like this are often not really knowable. You can think at one point things are clear and then later understand that was just one view among many alternative ones.

Anyway, I wish it were an easier, clearer, unbiased, fact-based, unequivocal, unemotional descision.

 

[Bill B]

Good luck with your choice Bill. My first AVR I choose a tissue valve and would have been thrilled with the 12 years the surgeon suggested, rather than the 7 years it seemed to last. This time, at 52 I'm definetely going mechanical and will accept the surgeons preference and since we are sharing the same surgeon, it would seem to be the SJM mechanical with graft. I'm o.k with that.

Maybe I'll bump into you in the hall. I'm flying down on the 21st for a CT and echo on the 22nd with my surgery with Dr. Miller on the 4th of Novermber.

Chris: You're a young guy, much younger than me. Hard to argue with mechanical, but I suppose I might. (just kidding)

I probably won't see you in the hall - the CT scan is off-campus, although the echo is downstairs in the hospital. I'll look you up after your operation on the 4th and give you a call before you get discharged so we can share war stories.

Big Best Wishes for a good surgery and recovery!

 

[Lynlw]

Actually, I have moved away from that. The rational argument for mechanical is certainty of reop with bio, if you are otherwise healthy. Note in the SJM studies, only a small fraction of patients made it long enough to get to reoperation anyway (they died for other reasons). Sure, on the surface the reop issue would still seem an overriding factor. But then that needs to be balanced against lifetime anticoagulation, which is not innocuous. Some have said here you really shouldn't use that as a consideration, but I don't accept that. I actually think I would be more likely than most to get into trouble with that based on my personality and personal habits. Even well-managed, there is risk of bleeding or clotting that is not negligible, and the risk is cumulative based on my reading, although I've seen some say here that it isn't. Then there are the rare but potentially disturbing anomalies with mechanical valves, like Seth's "water hammer", not something I believe is getting much sympathy.

So, what am I doing here? Am I simply trying to force my argument toward a bio valve? I don't know. Am I being realistic, knowing myself, that bio would work out over all better for me, despite an almost guaranteed reop? I'm still looking over information and mulling, but I think this is going to boil down to a gut-level choice.

I've at least decided that what I am going with is just mechanical or bio and leaving what specific device I get to what my surgeon prefers to use as I don't think you can make a concrete argument for one vendor/model. Perhaps that should have been obvious.

You see people here going either way, bio and mechanical, at all kinds of ages, and rarely do I see a concrete reason. Even Bob H, one of the most obviously knowledgeable people here, who has chosen bio twice, has not, as far as I can see, exposed the inner workings of his decision. It's a tough one. At one point I said that things like this are often not really knowable. You can think at one point things are clear and then later understand that was just one view among many alternative ones.

Anyway, I wish it were an easier, clearer, unbiased, fact-based, unequivocal, unemotional descision.

Actually it sounded like you had new thoughts, but you didn't come out and say that so I wonderred. and yes the risk op reop vs long term anticoagulant is pretty much the biggy, I believe ONE of the reasons most recomend Tissue in people 60 and up is chances of reops ARE less, but equally important is the chances on having a problem because of coumadin is higher in older people, because of alot of reasons, falls, thinner skin and bone density, other medical issue ect. Alot as Bob says from time to time, also has to do with how people like their risks, smaller risks daily or bigger risks all at once for re ops. Its tough, but I honestly believe you will know when you made the right choice for YOU. Mech tissue was never one of the decidions I had to make for Justin (and believe me it is TOUGH to make these life decisions for your child and hope you don't screw up) BUT whenever I make a descision and feel peace with that choice in my gut, I know it is the right choice for us. One good thing IF you do choose tissue, REop stats are getting much better, especially first time, as more and more surgeons get experience in patients with multiple reops alot of it isbecause of what they've learned over the last 25 years as more of the complex Congential heart kids that NEED 2-3 surgeries just to make it to kindergardent and survived and reached adulthood ...

 

[ottagal]

Anyway, I wish it were an easier, clearer, unbiased, fact-based, unequivocal, unemotional descision.[/QUOTE]

Ditto, Bill. As I was angsting over valve choice, my cardiologist said "It really boils down to being a philosophical decision". For the longest time, I realized that I wanted 'choice C (biological with no re-op)" and not A or B. It actually took me a while to realize that choice C did not exist and I had to choose A or B.

All the very best with this.
I believe that when all is said and done, you have to 'listen to your gut' (as unscientific as that is).

Again best wishes with your decision. Believe me, I know it is not an easy one.

 

[Lynlw]

Can you read all the articles (do you belong) at that link you posted above? This article looks interesting in the footnotes but I can't read it "Low-volume hospitals continue to use mechanical valves for AV replacement despite recommendations for bioprosthetic devices "
[HeartWire > News; Apr 25, 2005]

 

[Bill B]

Lyn:

Yes, I just joined (it's free). Here is a link:
http://www.theheart.org/article/440015.do

If that doesn't work, see the original article from Circulation 2005, linked down at the bottom of this message.

The jist is (quote):

In 1998, writes Schelbert et al, the AHA and ACC issued guidelines for both mechanical and bioprosthetic valves. The guidelines recommend that bioprosthetic valves be used in the majority of patients 65 and older, although physicians and patients can still choose between the two, Schelbert clarified.

"One has to balance the risk profile of one valve against the other, and I think the guidelines make a pretty strong case that for most patients—not all patients—once your age goes beyond 65, the risks associated with mechanical valves and the exposure to anticoagulation exceed the risk of the tissue valve wearing out," Schelbert told heartwire. "As you get older, the risk of bleeding while on blood thinners increases, and conversely the risk of a bioprosthetic valve wearing out decreases."

---
They found hospitals with smaller volumes of surgery were not following the guideline as often. Actually the overall rate of use of bio valves in patietns >65 was not real high.

Here's a link to the original article.
http://circ.ahajournals.org/cgi/reprint/111/17/2178

 

[Lynlw]

Thanks I'll join

 

[ShezaGirlie]

"One has to balance the risk profile of one valve against the other, and I think the guidelines make a pretty strong case that for most patients—not all patients—once your age goes beyond 65, the risks associated with mechanical valves and the exposure to anticoagulation exceed the risk of the tissue valve wearing out," Schelbert told heartwire. "As you get older, the risk of bleeding while on blood thinners increases, and conversely the risk of a bioprosthetic valve wearing out decreases."

Exactly why I would choose a bio valve at age 65, but had I been given a choice 10 years ago I would have also chosen a bio valve then instead of the mechanical I have which has served me well so far. I can vouch for problems with warfarin after 65. I was on 10mg all these years and just this year am experimenting with my cardio on 8.5mg/7.5mg on different days of the week. Our tolerance changes, our bodies change as we age. My mother just celebrated her 94th birthday, longevity reigns..! We have no guarantees with either valve ~~ now if we just did..?!?!

I haven't seen it mentioned on this thread, but I do think there's a genetic test which can be done to assess one's tolerance for warfarin prior to OHS.

 

[marie]

I can only relate my own experience. I had an AVR with a tissue valve on 1/22/08 at the age of 66. That tissue valve is already giving me trouble.

I will need a replacement much sooner than five years much less 15 and I've been put on coumadin.

Good luck in whatever you decide.