New Information About Heart Valves

[Guest]

This is what we call evidence-based medicine. This is how the decisions are made about what are the proper dosages, which valve to use etc. For an article to be published in a journal it must be peer-reviewed. The reviewers check to see if what they did justifies the conclusions that they make. After it is published, readers have a chance to write and make comments either in support of disputing what was written. These thing are then considered by panels who make recommendations for people practicing in the field. Hopefully your doctor chose your valve on this basis and not on which sales rep made the last call!!

Annals of Thoracic Surgery February 2002 published this study from Japan about the CarboMedics valve. There were 468 patients aged 13 to 76 years included. 239 aortic valves, 167 mitral valves and 62 with both. The follow-up time mean was 4.4 years (rather short) and covered 2,016 patient years (again not real long but not too bad either). A patient year is one patient followed for 1 year

Here is the part of interest to me - the target level for their warfarin was 1.5 to 2.8.

The results 1.2% died before leaving the hospital. This is a 7-year actuarial analysis (maybe somebody else can explain that).
87% were alive
6% died from valve-related causes

Valve site % who had clotting events % who bled
Aortic 18 12
Mitral 5 9
Both 4 15

2% needed an additional valve operation.

The percentage of aortic people with problems seems high since we usually thing that they could get by with a lower INR, but that is the data.

Remember that this was done in Japan. There may be some slight difference in applying the results to other ethnic groups, but thi shas never been proven.

 

[Guest]

This is a similar study to the one above, but I wanted to put it in another box so there would be no confusion.

This was done on St. Jude valve patients by a surgical group in Minnesota. It was published in the Journal of Heart Valve Disease in January 2002.

This was a 20-year follow-up (Much better than 4 years) that covered 13,208 patient years (much more valid data). But they only did aortic valves. 1,500 males and 890 females.

3% had clotting events
6% had bleeding events
6% died
0% structural failure of the valve

The anticoagulation therapy was standard and not studied.

The obvious shortcoming, no data for those wondering about mitral valves.

Data from Minnesota is much more likely to apply to Americans, but still there will be some ethnic bias.

 

[Marty]

Interesting Data

Interesting Data

Al, I'm sorry they didn't do mitrals as that's what I have. Mitrals are ususally considered to be more trouble prone than aortics. I liked that
0% structural failure however since St. Jude is my brand! I hear they have a valve that's been beating away at 200 bpm for 20 years in the Minneapolis factory and its still going strong!

 

[LUVMyBirman]

"The percentage of aortic people with problems seems high since we usually think that they could get by with a lower INR, but that is the data".

Al, what are your feelings on this subject? Do you recommend a higher INR for your patients with an Aortic valve? Minimum of 3.0?
I am only asking because my cardio told me he keeps his Aortic patients on the higher end of the scale.

 

[Guest]

I keep all valve patients at 2.5 to 3.5 unless the physician specifically says another range.

It has proven safe with few complications.

 

[Zipper]

Aortic

Aortic

My Doc says 2.5-3.5 also...Mine is an aortic St Jude's..so far so good!

 

[Simon Gee]

consistency

consistency

It's good to hear that there is consistency in INR - here in England I am also advised to keep within the 2.5-3.5 range. I've also got a St Judes valve and I like the idea of one ticking away for 20 years at 200 bpm, that's reassuring!

Best regards to all, Simon

 

[Hank]

INR Ranges

INR Ranges

Thanks for the study results Al. Me personally, I like 3.0 - 4.0. I have been keping it in that range. I have still have not had anyone convince me (or even attempt it) that clotting danger is better than bleeding danger. Bleeding is reverseable, clotting is not. I believe that higher makes more sense. As long as a higher INR can be maintained without adverse effects (bloody nose, bruising, etc.). I have an aortic St. Jude mechanical valve.

 

[Guest]

There was a recent study of patient and physician attitudes toward warfarin in atrial fibrillation. The patients wanted to avoid strokes. The physicians wanted to avoid bleeding.

Dr. Cathy Hassel, a hematologist at the University of Colorado during her talks asks, "What can you do about bleeding? You can put pressure on it, ice it, cauterize it, suture it, give vitamin K, give fresh frozen plasma and you can even dump in more blood. What can you do for a stroke? (or ruined valve) ..........."

 

[Zipper]

High/Low INR

High/Low INR

Thanks Al for sharing those comments!!! It really gives us food for thought! I hadn't personally related to it in that context! Between you and Marty, we are really receiving very valuable expert opinions. Putting that together with all the experiences of others here makes this site better than any I have known! I have learned a great deal in my short time here. What a wonderful thing Hank has created for us all!!!

Sincerely,

Zipper *~*

 

[McCln]

Hey Zipper

Hey Zipper

Glad to see you. Been awhile. glad you are doing better. I have aortic St. Jude's valve. And you are right about getting informed and gratefu to anyone to give us the information. You keep hanging in there.


Caroline
09-13-01
Aortic valve replacement
St. Jude's valve

 

[Guest]

What hand of fate do you think sat Marty and I down at the same table for breakfast last May at the Anticoagulation Forum meeting in Washington DC? I don't even remember who was there first do you, Marty? Did you join me because you saw my name and had worked with Dr. Lodwick?

 

[Marty]

Just luck

Just luck

Al it was just chance, but when I saw Lodwick on your name plate
I immediately wanted to know if you were related to Gwilym,the radiologist, who was one of my teachers at the Armed Forces Institute of Pathology in 1955. Gwylym was one of the top bone tumor experts in the world and incidentally like you a hell of a nice guy.When I heard he was a cousin I knew why you are so sharp!
Its in the genes.

 

[Gail in Ca]

I guess I'm one of the few on this site with a carbomedics aortic valve.
My cardiologist also prefers an inr of closer to 3.5. Lately, my inr falls to 2.3 on the day I have been testing and so I take an additional 5mg and that bumps it up to 3.0.
Any food I could eat regularly that would raise my inr, so I wouldn't need to take more warfarin, which I have done for 2 weeks now? I don't take the baby aspirin because I have a low platelet level.
Why do mechanicals give more probs in the mitral position? Just curious as I might need one in the distant future.
Gail

 

[Zipper]

Good Questions!

Good Questions!

Hi Gail,

I have MVP which was not taken care of when I had my St Jude's Aortic valve 'installed' and my CABG x2 in 1998. It was not significant enough at that time and my surgery was risky enough with all the work they had to do!

I, too, wonder why it would be more troublesome... and what foods could be eaten as a 'quick fix' to raise INR. Thanks for asking these questions...with the expert help on this site, I bet we get excellent answers.

Salud,

Zipper *~*

 

[Guest]

There are no foods to eat to raise the INR but if you skip green, leafy vegetables it will go up. Actually you should not worry about your warfarin dose, it is only the INR that matters. I have people who take only 1 mg on 5 days per week and another who takes 110 mg per week. They both have the same protection and the same risk of bleeding.

Mitral valves are usually more troublesome because the blood flowing through them is at a lower pressure than at the aortic position. Thus there is more likelihood to clot.

Your doctor just has a feeling about the 3.5 level. There is no recommendation by any recognized panel of experts that 3.5 is better than 2.5. Actually I do not ordinarily adjust doses if the INR is between 2.3 and 3.7. People like to believe that the test has pinpoint accuracy when in reality, it does not. That is part of the reason that a range is acceptable.

 

[OldNick]

Since I have two St. Jude mechanical valves that have been clicking for 8.5 years, I am also glad to see that they are demonstrating good longevity. I was told by my Cardiologist and Surgeon to try to hold an INR range between 3 & 4. From what I have read, St. Jude recommends 3.5. I was told that the higher number was recommended for patients with mitral valves because there is a lower pressure drop across this valve, and, consequently a lower flow velocity, which makes the area more conducive to clotting. An annual echocardiogram has shown that my flow is still free and clear, so I'm a believer.

 

[Gail in Ca]

Al,
You don't think that someone taking 72mg weekly has it worse than someone on only, say, 28mg?
This would be reasuring to me since a few medical professionals have mentioned my high dose, like it was unusual, and it concerns me.
Over time, is taking more warfarin harder on the liver? Or does it not matter at all, only keeping the inr in range that matters?
Thanks for your opinion,
Gail

 

[Guest]

I haven't proven this with statistical analysis, but it seems to me that the people who tend to get grossly elevated INRs with warfarin are those who take small doses. I think that this is because they metabolize warfarin more slowly. So, if they get sick, don't eat, forget their other medications, the warfarin hangs around in their body for a long time and their INR gets elevated. People who take higher doses, seem to do so because they metabolize warfarin rapidly. It should therefore follow that they would tend to have low INRs more quickyl.

I'm not sure that it should be reassuring because if you are going to have a problem it is usually better to bleed than to clot.

I'm not even sure that this is true, but as I said, it seems to be.

 

[OldNick]

INR Spikes with Coumadin

INR Spikes with Coumadin

Hi Al,

I'm on 19mg per week to hold my INR around 3.5. Do you classify this as a small dose? Several times in the past eight years I have had unexplained spikes to INRs above 5.

Jim Nichols