NEWBIE: Needs advice

[pellicle]

The On-X opens a full 90 degrees.

claims to, but in practice doesn't.

See my above post

Best Wishes

 

[carolinemc]

I

Your rationale is very valid. That’s why, I prefer mechanical as well. There are only following elements that are making me hesitant:

1. Recovery time/process but pellicle has informed me that it is the same regardless.
2. Dependence on warfarin/Coumadin. My advising cardiologist discouraged me.
3. Any annoyance from valve noise, if any.

Must admit that freedom from any future surgeries is a very big incentive for me to head in the way of mechanical valve preferably St. Jude.

I was 36 when I got my St. Jude's Aortic leaflet valve in 2001. It is now 2023, still ticking and alive. And on warfarin and living alone. Very active. After one year, never heard the ticking, for you get so used to it, you won't hear it. So do not hesitate if you do not want another surgery 10 years later. Mechanical is a great way for a young person to go. Good luck with your decision.

 

[user 15848]

Although it's fair to think about the mechanical valves as not wearing out, scar tissue does get in the way and they may have to replaced and from everything I have looked at, it's sensible to imagine getting 25 years out of one, and hoping for the home run of living very long and not needing another heart surgery. As I said earlier, one could have bad luck, like having it last 30 years and needing another surgery then. If I could do it over again, starting at 58 instead of 40, it would be a toss up for me between mechanical or Bio, knowing that making the bio choice created a path to bio, bio, tavr. Or possibly, bio, tavr, tavr. My own experience with tavr at age 60 was it was basically like nothing though I was pretty anemic for a few weeks. I was back at work the next week. But I ended up on warfarin anyway as clots developed.

There just nothing easy about the decision but starting warfarin at age 58 instead of say 38, is useful.

In a ideal situation, you get a bio valve at 75 and tavr at 88 and never end up on any blood thinners. We just can't plan these things in the real world

Well, i know one lady with a Ball Cage Mechanical Valve, that she got 45 years ago at 22;
has 3 children and that was a way back then Mechanical Valve, so today's St Jude and Onx should last at least 70....., But, some other collateral issues may show up, aortic related.

 

[W84Me]

pellicle:

Your points are very well taken. A proven track record over the years is a powerful evidence of a product. And St. Jude thrives from that. One of the things I was made aware of was that On-X tends to be not prone to coagulation due to a specific coating. Hence they advertise lower INR requirement, at least in theory.

Will discuss both the valves with the surgeon and think about the benefits. I will definitely bounce the surgeon’s perspective here.

Meanwhile I came across this paper that relates to 20-year follow-up of On-X.

 

[Timmay]

So presently this where I stand:

1. Mechanical valve.
2. Preferably On-X due its being second generation and somewhat lenient on INR.
3. If available, keyhole surgical procedure.

1. Good Choice
2. In my opinion, your reasons aren’t valid. People like to throw around On-X being a “next generation” valve. Compared to what?! Lol. If so, then the SJM is a “next generation” valve too. The On-X is not lenient on INR (IMHO). It’s just marketed that way to get people to use it.
3. As long as the keyhole surgeon agrees that he/she can do just as good of a job as SAVR. I know that we’ve seen mini-sternotomies be extremely successful here (Chuck C).

 

[LondonAndy]

Two random thoughts from me:

1. I have never really noticed the ticking with my 29mm St Jude (now in its 10th year). It is very quiet, and I have to actively listen for it to notice. I am not sure of the factors that affect the sound level: valve alignment? Valve size (with larger valves quieter)? Our build (I'm on the large side)? So all are things that are largely out of our control. Also, as we get older we hear some frequencies less of course.
2. I was delighted to see that a new technique for appendix removal via the mouth is known as "cakehole surgery"

 

[pellicle]

Meanwhile I came across this paper that relates to 20-year follow-up of On-X.

first thing I noted

The mean clinical followup duration was 10.5±5.3 (median 10.9) years.​

10 years, hardly anything really, even for a bioprosthesis

Sorry if that seems hard, but I always have a hard look at data.

 

[pellicle]

delighted to see that a new technique for appendix removal via the mouth is known as "cakehole surgery"

 

[pellicle]

@W84Me
its fascinating how much almost nothing has changed since 1979

I recommend a hard eyed read of this (with a highlighter pen) attachment.

Note, the mech valve being studied was the ball and cage, not the newer improved models of today like we all will get. Remember, Dick still has his from back then.

 

[pellicle]

Hi

this paper that relates to 20-year follow-up of On-X.

so I thought I'd walk you through how I read that sort of thing

First I take their data and put it in a meaningful presentation order

This sort of slab isn't easy to read and process (for at least me)

Between 1999 and 2015, 861 patients (mean age=51.6±10.9 years) who underwent prosthetic valve replacement using the On-X valve in the aortic or mitral position were enrolled (aortic=344, mitral=325, double=192). The mean clinical followup duration was 10.5±5.3 (median 10.9) years. Operative mortality occurred in 26 patients (3.0%), and linearized late cardiac mortality was 0.9%/patient-year without an intergroup difference. Linearized thromboembolism, bleeding, prosthetic valve endocarditis, non-structural valve deterioration (NSVD), and reoperation rates were 0.8%/patient-year, 0.6%/patient-year, 0.2%/patient-year, 0.5%/patient-year, and 0.5%/patient-year, respectively. Prosthetic valve endocarditis was more frequent after double valve replacement than after aortic or mitral valve replacement (P=0.008 and 0.005, respectively). NSVD and reoperation rates were significantly lower aortic valve replacement than after mitral or double valve replacement (P=0.001 and 0.002, P=0.001 and <0.001, respectively). Valve replacement in the mitral position was the only risk factor for NSVD (hazard ratio [95% confidence interval]=5.247 [1.608–17.116], P=0.006).​

So I pull out what's significant in a text editor so I can reformat it

The mean clinical follow up duration was 10.5±5.3 (median 10.9) years.

not terribly long for a mech (already mentioned this)

Operative mortality occurred in 26 patients (3.0%), and linearized late cardiac mortality was 0.9%/patient-year without an intergroup difference. ​

ok, is that good or bad?

https://pubmed.ncbi.nlm.nih.gov/34795909/A total of 11,190 index cardiac operations were performed during the study period and operative mortality occurred in 246 (2.2%) of patients.

so looks like their results are a little worse

Linearized ​

(why did they linearize?)

to me its not suitable nor good for anything other than hiding data Its like a flash flood that kills everyone in the township vanishes in linearised 20 year data.

thromboembolism: 0.8%/patient-year,​

bleeding; 0.6%/patient-year,​

prosthetic valve endocarditis: 0.2%/patient-year,​

non-structural valve deterioration (NSVD): 0.5%/patient-year, and​

reoperation rates: 0.5%/patient- year,​

ok .. but why is NSVD even a thing in mech valves, I've literally never heard of it outside of bioprosthesis and why is it that high?

Valve replacement in the mitral position was the only risk factor for NSVD (hazard ratio [95% confidence interval]= 5.247 [1.608–17.116], P=0.006).​

right ... now we see where the NSVD occurred ... even if we don't know why. I'm reminded of an old engineering quote

Theory is when we know why something should work, but it doesn’t.
Practice is when something works, but we don’t know why.
Here Practice and Theory meet: It doesn't work and we don’t know why."

I hope this shows you the sort of due dilligence which is required when reading a journal article. If you don't do that then you're just accepting what they say without question.

This car was one owner.

HTH

 

[nobog]

3) The On-X opens a full 90 degrees. However, there’s some studies going around that show this makes one part of the flow better while making the other side worse. It’s a give and take.

I can tell you that is absolutely not true. "On paper" the valve will, in practice it does not. Marketing hype. Hint: that tells you something about the flow through the valve.

 

[W84Me]

While I wait for my cardiac catheter test on July 10, I came across a good read relating to quality of life after AVR. Although the papers are from 1992 they are good read, IMO.

 

[LondonAndy]

While I wait for my cardiac catheter test on July 10, I came across a good read relating to quality of life after AVR. Although the papers are from 1992 they are good read, IMO.

I disagree that they are a good read. The document is more than 30 years old, and much has changed since then. Not least the introduction of POC devices like the CoaguChek meter to monitor INR and enabling the patient to manage it effectively, and valve design.

The author of the first report, Donald Ross, considers a mechanical valve to be a "sword of Damocles" hanging over the patient, with the threat of "embolism, thrombosis and anticoagulant haemorrhages" and the need to attend regularly at haematology departments. As the "owner" of a mechanical valve I feel exactly the opposite, with the sword of Damocles being if I had a tissue valve wondering how long it would be before my quality of life started to decline and another operation become necessary.

He then goes on to state that a biological valve does not require anticoagulation, which may be true for the risks he has already set out for mechanical, but ignores the increased risk of atrial fibrillation all valve replacement patients face.

At least the authors of the second report, Dieter Horstkotte et al, acknowledge the benefits of home prothrombin estimation, describing it as a "major advantage, not only in the reduction of morbidity and mortality after valve replacement surgery, but also in the improvement of the quality of life".

They also make some interesting remarks about the issue of valve noise, stating that those with "high tone sound sensitivity ... (exceeding 8kHz) may find the high tone clicks of a mechanical valve especially unpleasant ...". As we get older we naturally find our high tone hearing reduces, so I wonder if it is worth a prospective patient undergoing a hearing test to see how good their high tone hearing is, and therefore whether that might be an issue for them. In my case the clicking has never been an issue, and mine was done when I was 48 years old, so I am not sure how much the sound level varies due to other factors.

I am only half way through the 33 pages, so may add to this once I return and read on.

Edited to add: I do not wish to dismiss tissue valves as an option; we each have our own set of issues that are important to us, placing different values on different factors, and whatever valve we choose will be a better outcome than ignoring the problem, or putting off a decision until our heart is in a worse shape. There is no doubt that being a "highly compliant" patient, taking medication regularly and not missing doses, is important for mechanical valvers, but earlier in this thread you have already said that you are good in this regard..

 

[W84Me]

I always admire a good and thoughtful analysis. Just for the record, a good read meant “entertaining“ not necessarily factually up-to-date.

 

[carolinemc]

I can tell you that is absolutely not true. "On paper" the valve will, in practice it does not. Marketing hype. Hint: that tells you something about the flow through the valve.

That is why I go by expert information, not marketing.

 

[W84Me]

So I did the STS risk score calculation based on what I so far know including blood levels etc. (including first cardio surgery) and left the items blank that I did not know. Attached is the result. The thing that comes out me at is the morbidity and mortality at almost 15%. Should I be worried? Of course, it is only one parameter in the whole scheme of things.

 

[pellicle]

Should I be worried?

no you should be vigilant.

The accident rate is not what happens to everyone, its what happens to the group who behave like a group
Do you eat like this?

or like this?

that isn't taken into account when dealing with the average who eat like the above one

What you do makes a difference to those scores.

Just Saying

 

[LondonAndy]

Did you do the test on the basis of NOT having the valve replaced? That score is 100%

 

[Superman]

no you should be vigilant.

The accident rate is not what happens to everyone, its what happens to the group who behave like a group
Do you eat like this?
View attachment 889360

or like this?
View attachment 889361

that isn't taken into account when dealing with the average who eat like the above one

What you do makes a difference to those scores.

Just Saying

I eat like the first picture. Did a 20 mile bike ride today though. I’m all about balance.

 

[LondonAndy]

@W84Me are you on Facebook? There is a Heart Valve Surgery Support Group, where I saw this post today:

Life is what you make of it