New study finds mechanical valves offer superior long-term survival for AVR

[eftdan]

Just wanted to share this new study:
https://www.eurekalert.org/news-releases/1071025

 

[Chuck C]

Thanks for posting:

From the publication:

• "Decline in mechanical valve use: Despite superior outcomes in younger populations, mechanical valve use decreased from 20% to 10% over the study's 12-year period."
• "The findings are particularly relevant considering the increasing adoption of bioprosthetic surgical valves in many patients and the recent trend of bioprosthetic transcatheter aortic valve replacement (TAVR) in younger populations without clear evidence. "

This speaks to the effectiveness of marketing. There is very little profit in mechanical valves. So, except for Cryolife doing some marketing of the On-x, not much marketing of mechanical valves. On the other hand, sales figures are much higher for tissue valves, and a TAVR valve sells for many times more than a standard tissue valve. So marketing of tissue and TAVR (which is also tissue) is where we will continue to see very big $$ spent. Marketing works.

Selling TAVR is easy. No OHS needed. It is like selling ice cream at the beach on a hot day. But, that so many young patients (under 60) are getting TAVR done, without evidence to support the justification for this shift, is concerning. I expect that the trend will continue due to how easy it is to exploit the fear of OHS.

It also should be noted that this study found that age 60 was the inflection point, after which the data supports a tissue valve.

 

[pellicle]

Hi

Just wanted to share this new study:
https://www.eurekalert.org/news-releases/1071025

its interesting, from that:

• Decline in mechanical valve use: Despite superior outcomes in younger populations, mechanical valve use decreased from 20% to 10% over the study's 12-year period.

and to me the only reason for the decline in mechanical is the following

• massive increase in TAVR (pushing mechanical down lower in the percantage of AVR)
• lengthy (and I suspect copy cat) tendency to preface every study on Bio with wording like "the burden of INR testing" and other such stuff
• a significant increase in the hysteria surrounding warfarin (despite it being safer than ever if you combine Patient Self Testing and Weekly testing and Patient Self Management)
• push from valve makers to push for BioProsthetic for all ages (rather than previous sub-65yo guidelines)

In your study they are very optimistic in the ability of patients to actually pay attention to this fact (witnessed here just this week):

“The decision between a bioprosthetic and mechanical valve is one of the most consequential for patients requiring aortic valve replacement,” said Dr. Michael Bowdish, lead author of the study and a cardiothoracic surgeon at Cedars-Sinai Medical Center in Los Angeles. “Our research underscores that for patients with an age threshold of 60 years, mechanical valves confer a significant survival advantage. This data will help patients and providers make more informed choices about their care.”​

I would say that this supports every study I've read starting with "The Edinburgh" Study which dated from 2003 and focused on a cohort of patients from 1975 ~ 1979. This has also been repeatedly found in studies but ignored by the front line and (in America at least) TV advertising (of products which cost more and last half as long) and will still have you statistically see you needing warfarin at the end of a 5 or so year honeymoon period (that is unless you die from a valve related thrombo event).

An amusing (*note black humor) study in this context
https://www.sts.org/press-releases/...60-years-choose-tavr-over-savr-worse-outcomes

I noted this sort of thing in a recent Australian study ... clearly "patient outcomes" are more about pandering to anxiety and hysteria than they are to health and long term "all cause mortality"

An Australian study was brief but telling in the conclusion

https://pubmed.ncbi.nlm.nih.gov/34780091/
(underline mine)

Conclusion: Rates of AVR have increased significantly over the past 16 years, particularly in the elderly. Despite international guideline recommendations, fewer mechanical AVR are being used in younger cohorts. The uptake in TAVI rates might reflect evidence that suggests it is a safe alternative, at least in the medium term. BAV has also seen a resurgence during this time period. ​

NFI ... let me just say that people get what they choose, but as my wife would say "you should be careful what you ask for".

 

[pellicle]

PS

in 2014 (two years after I got my mech, which was my 3rd OHS and I was 48) I wrote this

https://cjeastwd.blogspot.com/2014/01/heart-valve-information-for-choices.html

which references this chart from a cited study:

you'll note that mechanical is better than any bio, has more data than anything other than porcine (which wsan't doing as well , Pericardial (like the Resilia) has wide uncertainty bars and only allograft (aka homograft) was showing better than mechanical almost anywhere. Mechanical and Porcine had the longest data follow up.

be careful what you ask for

 

[dick0236]

Selling TAVR is easy. No OHS needed. It is like selling ice cream at the beach on a hot day. But, that so many young patients (under 60) are getting TAVR done, without evidence to support the justification for this shift, is concerning. But, the trend will continue due to how easy it is to exploit the fear of OHS.

Sadly I have to agree with this. Who wouldn't pick a valve that is implanted thru a vein vs the opening of the chest......only a fool would do that.....right???. Most patients, even if they are told, don't hear the doctor say "the TAVR valve wears out quickly so we are just kicking the can down the road a little".

I have "lost" two neighbors and a personal friend within 5 years of TAVR placement. Would traditional OHS been better......who knows?

 

[pellicle]

I have "lost" two neighbors and a personal friend within 5 years of TAVR placement. Would traditional OHS been better......who knows?

know, not sure; but I have a strong suspicion based on the data

 

[Beach77]

I was 64 when I was told my aorta was ready to be replaced. I insisted, I wanted a TAVR, Mick Jagger had one and was back to touring in a few weeks. (If I remember correctly). My doctor and heart team had to approve, because I was young. haha! They approved but wanted me to talk to a heart surgeon about a mechanical first. The TAVR surgeon highly recommended the surgeon, and he said "the OnX would be a good choice for me too, either one".

My thought was "who in their right mind would go for OHS"! Crazy! FYI....I didn't find this forum until after my surgery.

Next, I started doing my own research on the OnX and then I had my visit with the surgeon. My choice was to choose OHS, with blood thinners or a TAVR. Choosing was the hardest part of my aorta valve repair!!!! A couple of weeks later, I decided on the OnX with Warfarin. Crazy me! My surgery was Dec. 2020. Surgery wasn't nearly as hard as I thought it would be! I was discharged on my 65th birthday. That was 4 years and almost 2 months ago! Warfarin is manageable without much thought now. I'm very happy with my choice! Hoping for "one" surgery!

 

[pellicle]

A couple of weeks later, I decided on the OnX with Warfarin

I'm curious as to what tipped you over

 

[Chuck C]

I was 64 when I was told my aorta was ready to be replaced. I insisted, I wanted a TAVR, Mick Jagger had one and was back to touring in a few weeks. (If I remember correctly). My doctor and heart team had to approve, because I was young. haha! They approved but wanted me to talk to a heart surgeon about a mechanical first. The TAVR surgeon highly recommended the surgeon, and he said "the OnX would be a good choice for me too, either one".

My thought was "who in their right mind would go for OHS"! Crazy! FYI....I didn't find this forum until after my surgery.

Next, I started doing my own research on the OnX and then I had my visit with the surgeon. My choice was to choose OHS, with blood thinners or a TAVR. Choosing was the hardest part of my aorta valve repair!!!! A couple of weeks later, I decided on the OnX with Warfarin. Crazy me! My surgery was Dec. 2020. Surgery wasn't nearly as hard as I thought it would be! I was discharged on my 65th birthday. That was 4 years and almost 2 months ago! Warfarin is manageable without much thought now. I'm very happy with my choice! Hoping for "one" surgery!

Thanks for sharing.

I insisted, I wanted a TAVR, Mick Jagger had one and was back to touring in a few weeks.

Good point. Mick was 75 years old at the time. Choosing TAVR at 75 makes a lot more sense than for a person who is only 65. However, in my view, 75 is still too young to consider TAVR for most people, but it is certainly approaching the age at which TAVR is the more reasonable choice. If a person is 75 and in poor health, with a high risk of not surviving OHS, then by all means choose TAVR. But, for a healthy 75 year old, with a life expectancy of 10 to 15 more years, in my view, OHS is still the way to go. For 80+ it is probably a no brainer to go TAVR. For you, at the young age of 65, I think you absolutely made the right choice in going OHS. Significant money will continue to flow into TAVR, given the sales it generates and the hope of expanding the age range, so it should improve with time. But right now I just don't see the data to support this choice for young patients, in fact, much the opposite.