NEWBIE: Needs advice

[Gkeraney]

in which case I'd be very interested to know what your Lp(a) levels are.

https://academic.oup.com/eurheartj/article-abstract/43/39/3968/6670979?redirectedFrom=fulltextEuropean Heart Journal, Volume 43, Issue 39, 14 October 2022,
View attachment 889303

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6494952/

Lipoprotein(a) [Lp(a)], a major carrier of oxidized phospholipids (OxPL), is associated with an increased incidence of aortic stenosis (AS). However, it remains unclear whether elevated Lp(a) and OxPL drive disease progression and are therefore targets for therapeutic intervention.​

https://heart.bmj.com/content/107/17/1422

Conclusions Lp(a) is robustly associated with presence of AVC in a wide age range of individuals. These results provide further rationale to assess the effect of Lp(a) lowering interventions in individuals with early AVC to prevent end-stage aortic valve stenosis.​

You should also be, as if they are elevated then this would bode badly for a bioprosthetic too as its emerging that's a player in that area too.

Thanks for these great articles. My LPb was 67 and LPa 192 l when I took it about 3 weeks ago for the first time. Not on statins. HDL 84. These are good numbers except the little a. Yet my second valve wore out in just under 9 years. I was certain it was blood clots which they said wasn't likely and they wouldn't order the ct scan...until after it became completely obvious.

Ive now gone on statins and will closely monitor liver function and blood glucose as I have seen people have issues there. I have to say I tried the red yeast rice the past year prior to these blood test results so that may have helped. The statin is atorvastatin and I'll take 10 mg. I want that apo little b number under 50 and the little a down to the low normal range. And I am on warfarin with inr goal of 2.5 to 3.5.

The point is I guess that these are things that can be done to potentially extend the durability of a tissue valve, even a tavr...perhaps especially so.

 

[pellicle]

Hi

glad you found the articles helpful.

Ive now gone on statins and will closely monitor liver function and blood glucose as I have seen people have issues there. I have to say I tried the red yeast rice the past year prior to these blood test results so that may have helped. The statin is atorvastatin and I'll take 10 mg. I want that apo little b number under 50 and the little a down to the low normal range. And I am on warfarin with inr goal of 2.5 to 3.5.

So Lp(a) and its effects is not one of my areas of reading or study, mainly because I don't think it applies to me (and I've not been tested for Lp(a) levels). A couple of other members here are far more knowledgeable than me in this area. I understood from conversations with them that some statins perform much better in individuals with high Lp(a) than other statins. So given that background you may find this interesting.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7098730/

Subsequent studies, however, produced mixed results ranging from no effect to significant increases in Lp(a) levels with statins [5–7], raising concerns about the robustness of findings. Further, a relatively large study in subjects with heterozygous familial hypercholesterolemia reported a reduction in Lp(a) levels using either atorvastatin or simvastatin [8].​

Some additional reading here:
https://www.valvereplacement.org/threads/new-confused-scared-anxious-help.888762/page-3#post-923821
https://www.valvereplacement.org/threads/lp-a-is-causal-for-avs.887347/#post-901411
HTH

 

[Gkeraney]

Hi

glad you found the articles helpful.



So Lp(a) and its effects is not one of my areas of reading or study, mainly because I don't think it applies to me (and I've not been tested for Lp(a) levels). A couple of other members here are far more knowledgeable than me in this area. I understood from conversations with them that some statins perform much better in individuals with high Lp(a) than other statins. So given that background you may find this interesting.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7098730/

Subsequent studies, however, produced mixed results ranging from no effect to significant increases in Lp(a) levels with statins [5–7], raising concerns about the robustness of findings. Further, a relatively large study in subjects with heterozygous familial hypercholesterolemia reported a reduction in Lp(a) levels using either atorvastatin or simvastatin [8].​

Some additional reading here:
https://www.valvereplacement.org/threads/new-confused-scared-anxious-help.888762/page-3#post-923821
https://www.valvereplacement.org/threads/lp-a-is-causal-for-avs.887347/#post-901411
HTH

I have a ton of studying to do. the fact that it appears that high lpa is associated with high hdl's but also aortic stenosis is brutal. Some experts worry most about getting lpb way down. And yeah some statins will, actually raise lpa because they raise hdl's. It's clear very high hdl like I have had isn't ideal. It would be easy if high good cholesterol correlated with decrease aortic calcification, but no go. It's easy to see that it may be true that taking statins can backfire and raise the dreaded lpa number. I will continue to experiment carefully. And go with the flow with my doctors.

 

[Gkeraney]

Hi

glad you found the articles helpful.



So Lp(a) and its effects is not one of my areas of reading or study, mainly because I don't think it applies to me (and I've not been tested for Lp(a) levels). A couple of other members here are far more knowledgeable than me in this area. I understood from conversations with them that some statins perform much better in individuals with high Lp(a) than other statins. So given that background you may find this interesting.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7098730/

Subsequent studies, however, produced mixed results ranging from no effect to significant increases in Lp(a) levels with statins [5–7], raising concerns about the robustness of findings. Further, a relatively large study in subjects with heterozygous familial hypercholesterolemia reported a reduction in Lp(a) levels using either atorvastatin or simvastatin [8].​

Some additional reading here:
https://www.valvereplacement.org/threads/new-confused-scared-anxious-help.888762/page-3#post-923821
https://www.valvereplacement.org/threads/lp-a-is-causal-for-avs.887347/#post-901411
HTH

this is very good and provides a decent path to lower the lpa. Its the PCSK9 meds. I'll start with some natural ones and see if I can lower the little a that way. I will probably put this on another thread when I have time. But its nice to know someone has an answer on how to reliable lower both hdl and ldl.

https://peterattiamd.com/benoitarsenault/

 

[BionicBuddy]

Ok, now if you do mechanical now, it's quite possible you have another surgery at age 78-88...sort of worst case scenario. Open heart.

This question is for anyone. Can pannus formation/ scar tissue be prevented with mechanical valves?

Thanks.

 

[W84Me]

there are a few people here who know a lot more about this area than me. But whatever is the theory first one needs that data.

Got my blood drawn today for Lp(a) test. Should have the result earliest by tomorrow.

Considering my aortic valve velocity is almost twice of 4 (the cutoff for severe), I am sure the numbers will be very damaging. So the AVR surgery is foregone conclusion. The important thing at this point is to find out what caused it. If that culprit could somehow be contained, it will be of benefit in the long-run. The Lp(a) test today and the cardiac catheter test on July 10 are the steps in that direction.

Thank you, Pellicle and everyone who have given their helping hands in this unchartered territory.

 

[pellicle]

The Lp(a) test today and the cardiac catheter test on July 10 are the steps in that direction.

All steps in the right direction and there is no real urgency*.

Allow your learning to progress organically. I suggest writing it up (what you know and what you've learned) in a document. Something like Google Docs. Put in links and URL's that you find handy and informative. This way you won't lose what you've learned.

Structure can be added later in "re-writes" as you change and add to it.

Best Wishes

PS: real urgency* is defined by waking up in a hospital bed with several medical professionals gathered around you, looking at you.

 

[user 15848]

Thank you so much for all your insights. So after my today’s initial appointment with a cardiologist, I have been referred to the actual surgeon who will be doing the surgery. My appointment with the surgeon is scheduled on July 20. In the meantime, I have to have my cardiac catheter exam done.

The cardiologist whom I saw today practically discouraged me from mechanical valve because he believes the dependence on blood thinner is a pain in the ***. I was told that you can have minimally invasive surgeries when tissue valves wear out.

His recommendation directly contradicts the recommendation of preferring mechanical valves in this forum. I am so confused. I will have to settle on a decision by the surgery date.

Hi,

You must choose what you feel more comfortable with, IF having 2 or 3 open heart surgery or otherwise 1x years from now, then tissue could be good for you, but, there is no warranty that u will never ever have to use warfarin;

The Warfarin is not a problem if you self test with a Coagucheck machiine or similar, or live in a country where is eassy to go to a lab and it is free for you, but i personally use both methods.

As per infections, anything foreign tissue or carbon base inside your heart will require you to take antibiotic pills 1 hour before you go to see your dentist, or bacteria from the teeth could end up in the wrong place and produce endocarditis, so there is no diff there.

I myself, like many here, had the same dilemma and spent 6 months thinking about it
choose mech during interview with the surgeon, and after i made the choice, he told me, the good thing about it, is that you dont have to see me again, and that is something you dont want to do.

Good luck with your choice and your process, here u will always find people with support ideas and words

 

[Gkeraney]

Got my blood drawn today for Lp(a) test. Should have the result earliest by tomorrow.

Considering my aortic valve velocity is almost twice of 4 (the cutoff for severe), I am sure the numbers will be very damaging. So the AVR surgery is foregone conclusion. The important thing at this point is to find out what caused it. If that culprit could somehow be contained, it will be of benefit in the long-run. The Lp(a) test today and the cardiac catheter test on July 10 are the steps in that direction.

Thank you, Pellicle and everyone who have given their helping hands in this unchartered territory.

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

 

[pellicle]

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

typically this is called pannus (link) and has risk factors like:

...occurred gradually over time with 10- and 20-year cumulative incidence of 0.3 and 5.0%, respectively. Young age, small prosthetic valve size, and concomitant MVR were risk factors for SAP formation. Therefore, we recommend efforts to select large prostheses for young patients requiring concomitant MVR

https://pubmed.ncbi.nlm.nih.gov/33940657/

 

[W84Me]

Hi,

You must choose what you feel more comfortable with, IF having 2 or 3 open heart surgery or otherwise 1x years from now, then tissue could be good for you, but, there is no warranty that u will never ever have to use warfarin;

The Warfarin is not a problem if you self test with a Coagucheck machiine or similar, or live in a country where is eassy to go to a lab and it is free for you, but i personally use both methods.

As per infections, anything foreign tissue or carbon base inside your heart will require you to take antibiotic pills 1 hour before you go to see your dentist, or bacteria from the teeth could end up in the wrong place and produce endocarditis, so there is no diff there.

I myself, like many here, had the same dilemma and spent 6 months thinking about it
choose mech during interview with the surgeon, and after i made the choice, he told me, the good thing about it, is that you dont have to see me again, and that is something you dont want to do.

Good luck with your choice and your process, here u will always find people with support ideas and words

Thank you for your insight. I am definitely leaning towards mechanical valve for the following reasons:

1. It is longer lasting if not forever.
2. The dependence on warfarin is manageable because I tend to be very strict when it comes to taking medicines regularly. Granted there are potential pitfalls going forward but it is much more preferable than undergoing a cycle of replacement surgeries .
3. As you mentioned as well, the likelihood of someone depending on blood thinners is there even if the AVR involves bio valve. In that event what would I have gained?

So pre-emptively speaking, at 58 mechanical makes more practical sense unless otherwise the operating surgeon convinces me with bio valve (during initial meeting on July 20).

 

[Mister_James]

Ok, now if you do mechanical now, it's quite possible you have another surgery at age 78-88...sort of worst case scenario. Open heart. You can't do a tavr. On average this would happen at 83, but I would defer to others. You CAN survive that surgery. This seems like a better option. If outlive that valve past 88 that's almost worse.

How did you get this...possible another surgery at 78-88? What would be the cause for that?
If it is mechanical valve related, explain. if it other than mechanical valve, then it should not be a factor.

 

[Mister_James]

typically this is called pannus (link) and has risk factors like:

...occurred gradually over time with 10- and 20-year cumulative incidence of 0.3 and 5.0%, respectively. Young age, small prosthetic valve size, and concomitant MVR were risk factors for SAP formation. Therefore, we recommend efforts to select large prostheses for young patients requiring concomitant MVR

https://pubmed.ncbi.nlm.nih.gov/33940657/

Scarring, pannus has nothing to do with the valve type but your body reaction. The sewing rings, the cutting...

 

[Mister_James]

Thank you for your insight. I am definitely leaning towards mechanical valve for the following reasons:

1. It is longer lasting if not forever.
2. The dependence on warfarin is manageable because I tend to be very strict when it comes to taking medicines regularly. Granted there are potential pitfalls going forward but it is much more preferable than undergoing a cycle of replacement surgeries .
3. As you mentioned as well, the likelihood of someone depending on blood thinners is there even if the AVR involves bio valve. In that event what would I have gained?

So pre-emptively speaking, at 58 mechanical makes more practical sense unless otherwise the operating surgeon convinces me with bio valve (during initial meeting on July 20).

Mechanical IS forever. Whatever re-op you will need are NOT because of the valve but surgery related. If someone says the valve could be defective...
Warfarin...well here is a stat to chew on. How many tissue valvers end up on warfarin anyway? Whatever anyone says, if you are under 60, there is a guaranteed re-op and TAVR may NOT be available for you. The beauty this discussion fails to mention is you will go through the same symptoms of heart failure, the heart will remodel to compensate, all that fun stuff before they re-do you. What other issues are you going to be dealing with at that time?
If there is a medical reason for a tissue valve, then by all means listen to the doctor. If it is choice, aim for a once in a lifetime surgery. If you must have a re do...oh well, God can be funny like that.

 

[MdaPA]

Mechanical IS forever.

This is not true.

Mechanical valves do have a reported life span, typically 20-30 years. Although rare, they also may need to be replaced sooner due to structural dysfunction, endocarditis, and various other reasons. In fact, I personally know someone who recently just had both their AV and MV St Jude valves replaced with tissue valves due to pannus in both valves (Dr. said pannus was due to under anti-coagulation).

 

[W84Me]

Mechanical IS forever. Whatever re-op you will need are NOT because of the valve but surgery related. If someone says the valve could be defective...
Warfarin...well here is a stat to chew on. How many tissue valvers end up on warfarin anyway? Whatever anyone says, if you are under 60, there is a guaranteed re-op and TAVR may NOT be available for you. The beauty this discussion fails to mention is you will go through the same symptoms of heart failure, the heart will remodel to compensate, all that fun stuff before they re-do you. What other issues are you going to be dealing with at that time?
If there is a medical reason for a tissue valve, then by all means listen to the doctor. If it is choice, aim for a once in a lifetime surgery. If you must have a re do...oh well, God can be funny like that.

I admire your objective and pointed advice. Thank you. Just wondering if mechanical valve can be placed using TAVR instead of open heart method?

I have a friend who actually had a heart attack reason being two of her main arteries were blocked over 94% (as they found). She realizes how lucky she is. So open heart surgery was done. She takes Aspirin everyday as blood thinner. I was told by her that it really is not anything to worry about -- the Aspirin part. Now I don't know if Aspirin is same as warfarin since they both are blood thinners.

 

[Superman]

This is not true.

Mechanical valves do have a reported life span, typically 20-30 years. Although rare, they also may need to be replaced sooner due to structural dysfunction, endocarditis, and various other reasons. In fact, I personally know someone who recently just had both their AV and MV St Jude valves replaced with tissue valves due to pannus in both valves (Dr. said pannus was due to under anti-coagulation).

I was told mine has a lifetime guarantee.

Your anecdotal example is not a case of a mechanical valve wearing out, but rather a second surgery being required for a different reason.

My second surgery was required due to an aneurysm, not due to the valve wearing out.

Can you find or cite an example of a mechanical valve being replaced due to wear and tear on the valve? I’m sure all would be interested. I believe there have been failures, but they are random and extremely rare isolated incidents. Not typical wear and tear.

 

[pellicle]

Thank you. Just wondering if mechanical valve can be placed using TAVR instead of open heart method?

ok, I suspect you haven't given this much thought. This is entirely understandable as you are still grappling with the abstracts and haven't considered the actuals yet.

To "valve in valve" replace a bioprosthetic the following happens

1. a catheter (think guide tube) is inserted down your artery (usually the femoral artery)
2. a smaller one is inserted and a complex and tiny mechanism is inserted down there
3. a net is deployed to prevent debris leaving the chamber and floating off with the blood to lodge in your brain (killing you)
4. a small set of scissors and pincers is deployed and the tissue valves are cut off (consider that they are coated in brittle calcium which will flake off)
5. these are then pulled back down the tube and disposed of
6. a new valve is then pushed through the tube to sit in place and is sprung loaded and "origami style" unfolds into place

In probably half the cases this complicated process can't be done (its called "not suitable for TAVR) and SAVR is needed

Worth watching is this "simulation" to upsell and assist one to visually explore the idea



Now a mechanical valve is a piece of pyrolytic carbon, so a ceramic of carbon originally made for missile nose cones

https://en.wikipedia.org/wiki/Pyrolytic_carbon
The first point in the applications:

Applications​

• It is used non-reinforced for missile nose cones and ablative (boiloff-cooled) rocket motors.

The valves made from that look like this

So somehow those hard pieces of dinner plate will need to be smashed up, no pieces left behind and dragged down that tube.

Perhaps in the universe of Star Trek but not in any world we know today.

So have a look at those valves, read that link about pyrolytic carbon and you'll see why they don't wear out.

Best Wishes

 

[pellicle]

I was told mine has a lifetime guarantee.

I still love this

 

[pellicle]

Scarring, pannus has nothing to do with the valve type but your body reaction. The sewing rings, the cutting...

true, where did I say it did? The reaction is a type of scar tissue.

Tissue valves also get pannus as far as I know, but its just less discussed. Perhaps because its accepted that those valves are in the main "disposable" and will need to be replaced eventually (its just when). It'll be sooner in younger people too.