Newbie: Replacing with oversized bioprosthetic

[mwkentner]

Hello everyone,
Like many who post for the first time, I want to thank everyone for having/making such a valuable place for research. It is definitely a overwhelming task when you get diagnosed with any type of valve/heart disease, All you want to do is reach out and do as much homework as possible. This forum has been a big help. so my story is.......
I am looking at having my second AVR. My 1st was done at Cleveland Clinic in July 1999, Dr Griffin as my Cardiologist, and McCarthy for my surgeon. I had a Homograft, with miniroot. All went well and never had any side effects. I'm 48 now and feel as if I did well the 1st AVR. I was hoping for 15-18 years before replacement, but it came a little sooner than expected. I work as a Full time Firefighter and have been on active fire companies all those years. So considering I have led a very active life /work style, maybe I strained it a little harder than the norm.
I returned again this past month to the Cleveland clinic after experiencing SOB along with chest pain during heavy activity. I did this after being check and diagnosed with prolapsed mitral valve as well as stenosis of the aortic valve at a local Hosp. they recommended surgery soon.
So once again I sought out a 2nd opinion with Dr Griffin and McCarthy. Dr Griffin has given two options for me to consider for my aortic valve. He doesn’t believe the mitral to be a problem. One AV is a mechanical, Not sure what make yet. The second is a Bioprosthetic. He recommends not going the first route because the side effects on blood thinners down the road when I get older. But it is an option. The second would be to put in an oversized Bioprosthetic, which might extend it life of the valve by not working as hard because of it size. Of course with the absence of having to use a blood thinner. It will need to be replaced again in 12 years or so.
With McCarthy gone I have been referred to Dr Sabik for surgery. I have yet to meet him but will in the next few weeks.
My question is, has anybody else picked the use of a oversized bioprosthetic ? How have you felt? Any problems with placing a large valve into smaller plumbing? Does this cause your heart to overwork to compensate for the nonrestrictive blood flow that you now have? Or are you feeling like superman who could run a marathon? Of course any input or help would be appreciated.
I’ll need to decide soon. They gave the warning of Sudan death syndrome if I don’t get a replacement soon. We all know we don’t want that. Thanks in advance to all.
Mk from Columbus

 

[karen14]

Hi MK from Columbus, welcome to the forum!
While I don't know about the question you have with the use of an over-sized bioprosthetic, I'd strongly recommend having the mechanical valve. Simply because it lasts longer and you won't be facing another surgery.

Plus, the statements about Coumadin (blood thinners) are all MYTH. There are no problems with coumadin, nor side effects. As has been stated on this site several times, you can eat and do whatever you like, and adjust the Coumadin to that. Is much simpler than is hyped up to be.

Also, there are many very active people on this forum who are running marathons, etc., that have gotten a permanent solution such as a mechanical valve, etc. Check those out before you make your decision. I'd rather NOT have another surgery later if it's not necessary.
Best wishes,
~Karen

 

[Ross]

McCarthy is at North Western in Chicago. You might just ask his opinion, though I doubt that it will be much different. I'm kind of partial to the man. He saved my life!

The idea of oversized is supposed to help keep your heart from working harder, but I'm not sure of the effects it would have on the rest of the system. I suppose the body would self regulate itself.

I was given a 25mm mechanical, which was supposedly oversized for me. Latest echo is stating that the area is small and may be a mismatched valve. How does one take that?

 

[skeptic49]

I'm surprised at your cardiologist's recommendation against going mechanical. I'd much rather be on anti-coagulants then risk having to endure yet another surgery.

Jim

 

[kfay]

Mk, Welcome to the site. I can't help with your specific question, but just wanted to say that valve choice is a very personal decision and don't let yourself be swayed by others opinions which are based on what THEIR personal preference is. That doesn't mean it has to be your preference. If you feel uneasy about anti-coags, then go tissue. If you feel uneasy about repeat surgeries, then go mechanical. That's really what it boils down to.

Good luck in making the choice that best fits your lifestyle. Just don't wait too long to make it!


Kim

 

[Lynlw]

Mk, Welcome to the site. I can't help with your specific question, but just wanted to say that valve choice is a very personal decision and don't let yourself be swayed by others opinions which are based on what THEIR personal preference is. That doesn't mean it has to be your preference. If you feel uneasy about anti-coags, then go tissue. If you feel uneasy about repeat surgeries, then go mechanical. That's really what it boils down to.

Good luck in making the choice that best fits your lifestyle. Just don't wait too long to make it!


Kim

I agree with what kim said.
Not to start problems, but that isn't true that there are NO problems with coumadin, there ARE problems, especially as you get older, get other medical problems, have weaker bones ect. IF there weren't any problems with long term coumadin, valve choice wouldn't be an issue, everyone would just get mechanical to hopefully be done surgery. But more and more centers are going to tissue valves in younger and younger people because of the issues with coumadin. Even if they are rare people have problems because of coumadin, which is why for the most part, even tho it is also rare for poeple to die during surgery, your odds for a long happy life are about the same no matter which valve you choose.

 

[Ross]

Just a word on anticoagulation. If you are compliant, test frequently and maintain your range, the likelihood of adverse events it's practically nil. We have older people on this board that have been around since heart valve replacement began and other then doing something wrong at one time or another, they are doing just fine. You have to respect the drug. If you don't, it will bite you.

The largest drawback to being on anticoagulation is that, for as long as the drug has been around, the healthcare professionals have not stayed up to date on current trends and proper management of INR. We work very hard around here to dispell many of the myths that are still rampant amongst the medical community.

The lions share of Warfarin patients are elderly, with some having dementia and other problems. It seems all studies about adverse events with anticoagulation involves those over 65 years of age. Not all, but I'm positive it represents the largest percentage.

http://www.medscape.com/viewarticle/584462

Conclusion: In this cohort of elderly men, current warfarin use was not associated with lower BMD, accelerated bone loss, or higher nonspine fracture risk.

 

[Jkm7]

Hello and Welcome, MK. Happy you found us.

While you are doing your reserach and considering all options, please think about checking with your Fire Department re: working as a firefighter if on anti-coagulants. While it does not happen in all Fire Departments, we have read here that some police officers and firefighers were not permitted to do their active work when they went on Coumadin/Warfarin. It probably will not be an issue for you but better you have that info to put into your considerations.

Best Wishes.

 

[Lynlw]

I'm surprised at your cardiologist's recommendation against going mechanical. I'd much rather be on anti-coagulants then risk having to endure yet another surgery.

Jim

CCF gives ALOT more tissue than mechanical valves, usually in patients 40 and up, but even younger. There are a few reasons they feel it is the best choice, part of is slimmer chances of needing coumadin, but alot has to do with how good their stats are for REDO surgeries, tissues lasting longer ect.
From their 2008 annual report (page 29)
"Bioprostheses (biological tissue valves) are the prostheses of choice for most aortic
and mitral valve replacement procedures. Bioprostheses are durable and allow
most patients to avoid lifetime use of anticoagulants after surgery. In 2008, 1,234
bioprosthetic valves, 190 mechanical valves and 66 allograft valves were used."

And that is even tho 1/3 of their valve replacements were REDOs. (page 27)

 

[Mentu]

Welcome to VR, MW

Welcome to VR, MW

Welcome to VR, MW. Considering that you have done this before, I feel hesitant to offer much advice as my own experience is limited to this past year or so. I can say that when I asked, my surgeon discouraged the idea of oversizing. I suspect that the possibility of using a larger valve may only be a consideration for certain individuals. I hope you will let us know what you learn as you read more and, especially, after you discuss this with your own surgeon.

Larry

 

[tobagotwo]

Ten years on a homograft (or any biological valve) for someone below forty is actually very good. Age and chemical activity go hand-in-hand, and the more chemically reactive you are, the quicker the body gets around to calcifying the valve.

I would think that in order to put in an oversized tissue valve, you would be talking about a Medtronic Freestyle or similar, where the valve and the portion of the aorta it's contained in are put into place as one piece. An oversized valve put into the normal-sized aorta would cause regurgitation (leakage), due to the walls of the aorta interfering with the valve's required movement. The equivalent in mechanical would be a St. Jude ready-built into a conduit or a combination of a mechanical valve and a fabric sleeve.

It might be very helpful to use an oversized valve, inthat it would reduce pressure and be easier on the heart as well as the valve. I've not heard of it before as a tactic, but it may be a good one. The more I think about it, the more I like it.

I'm not ready to agree that with proper INRs, the chances of a problem with warfarin are "practically nil." Warfarin was just given a new black box warning by the FDA, and is always one of the top two medication-caused reasons for hospital visits. That's not to say that it's unmanageable or to be avoided at all costs. It's simply that there are other physical issues that can gang up with warfarin to cause serious problems, especially digestive tract bleeding, a need for other surgeries, or fragile intracranial blood vessels (a larger consideration with advancing age). I would agree that the "2% Tax" often attributed to warfarin use can be significantly lowered by self-testing and better understanding of the product.

Let us know what the surgeon is thinking in terms of hardware. This is a very interesting line of thought.

Best wishes,

 

[Ross]

You know what we need? A replaceable heart lung unit. Just rip out the old, plug in the new. No muss, no fuss.

 

[Luana]

You know what we need? A replaceable heart lung unit. Just rip out the old, plug in the new. No muss, no fuss.

Plug and play.

 

[Luana]

"They gave the warning of Sudan death syndrome if I don’t get a replacement soon. We all know we don’t want that. Thanks in advance to all."
Mk from Columbus

Huh? Sudan death syndrome? Never heard of it and neither has Google.
Cleveland Clinic, from all I've read and seen in videos, really really favors tissue valves.
Luana

 

[Lynlw]

"They gave the warning of Sudan death syndrome if I don’t get a replacement soon. We all know we don’t want that. Thanks in advance to all."
Mk from Columbus

Huh? Sudan death syndrome? Never heard of it and neither has Google.
Cleveland Clinic, from all I've read and seen in videos, really really favors tissue valves.
Luana

I think he meant sudden

 

[mwkentner]

I did, just trying to type to fast

 

[mwkentner]

Well everyone thanks for the support.
Coumadin wouldn’t be a problem for me now. I’m sure they are thinking long term down the road. I may have to agree. I didn’t mention that I was diagnosed with cancer in 2002. I was treated (surgery) and radiated and have been cancer free since, but Cancer is one of the things that likes to pop its ugly head out when you think things are going great. So for me that could be an issue again down the road. Someone asked how Coumadin would affect my job. I’m sure it might become an issue, so yes I need to consider that problem as well, and I am. I believe that maybe its time to slow down though, but who can afford to let go of a great occupation in this economy. I also truly loved being a Firefighter and would miss it as well as my fellow firefighters. I know, mooshy, mooshy…..
I must agree with everyone else, I have no desire to have to go through this operation again. I didn’t enjoy the 1st time. I’m sure the 2nd will be tougher and knowing a 3rd is coming, Himmmmmmmm... I am fortunate that I am close to one of the leading heart hosp in the country. They have an outstanding Reop record so that is in my favor.
My big concern now is the idea of using an oversize Bio valve. In theory it sounds good, maybe to good. Just not interested in becoming an experiment. But in a way, we all are. Aren’t we? Of course I’ll have plenty of questions for Dr Sabik when we go to visit him.
Does anyone have any experience with Dr. Sabik ?
Until next time folks, take care, and Thanks
MK

 

[Luana]

I think he meant sudden

Oops, I saw Sudan and thought of the country.

 

[Bill B]

It's tough to decide just what is the best way to go because the information you would need is just not there. I don't know whether there is any validity to a larger valve being less subject to deterioration. People getting undersized valves is a recognized problem. They don't do well, but I'm not aware that the valve itself stenoses, as yours did, more quickly in that case. Also, your level of exertion should not have had anything to do with developing stenosis. Is your cardiologist suggesting that all people should get oversized biologic valves because they will last longer? Fascinating idea but I believe unfounded. My experience is that cardiologists do not have the best experience and knowledge in matters of valve replacement. I trusted my cardiac surgeon much more when it came to helping me decide which valve to get. If I had followed the advice of my now former cardiologist, I might not be here.

 

[neil]

hi,well you are doing your homework and whatever you pick is sure better than what you got now, its a tough call,but to say anti coag and side effects are a MYTH is very very misleading, hence docs are doing there best to do away with it, saying that most people on here seem to do well on it and long may that continue