Pretty well decided....I Think.

[70sdiver]

According to my surgeon (take it for what it's worth) my 27 mm will allow a valve in valve. My Inspiris Resilia card warns against using I believe a compression type valve. So lets hope Erricojj that we won't ever need to find out .

 

[Superman]

There seems to be a misconception that there is but one perfect solution for each unique case. If that were true, then every second or third opinion would be a spot on match with the first recommendation. The reality is that there are several good enough options that are all better than sticking with your native valve.

So from there it’s just a matter, as others have indicated, of how involved your want to be with the final choice. Some folks just want to defer to their medical team, which is fine. They will give you something better than you have. Others want to be engaged in the process and have some influence on how the rest of their life goes.

The biggest decision that has a real impact on how things are managed going forward is tissue vs mechanical. From there it’s deciding on your favorite running shoes or camera. All cameras are capable of capturing amazing images these days. But there remain Canon, Fuji, Nikon, Sony, etc people that swear by their favorite brand. Same for shoes. New Balance, Brooks, Saucony, Nike, Mizuno, etc.

Reality is ATS, St Jude, and On-X will sign you up for a lifetime of anti-coagulation. Which ever medical sales rep gives your surgeon the best support (devices available when and where I need them, timely follow up, etc) is the device your surgeon is likely to go with. Unless they are strictly track record people (St Jude) or like new stuff (On-X).

Same as above for tissue except if you’re younger, you’re signing up for subsequent intervention. Wether it be another surgery when the valve wears out, or TAVR if that progresses to standard of care (not there yet). And Resilia is the new and cool in that arena.

 

[pellicle]

Maybe I should ask again to be sure that's what was said?

an excellent idea, also maybe go one step more send an email and ask.

I would hope he would know better than me on what valve would be the best for me? Right?

well I doubt that your surgeon considers what things will be like for your and your valve more than 10 years from now (I realise you're 60). Why not ask that specific question. There simply are NO STUDIES for tissue valves out beyond 15 years and I notice that even newer tissue valves are only pushing their testing to 5 years. Doesn't bode well for being 80 (a reasonable life expectancy).

My view is that I don't want to be having heart operations and interventions when I'm in my 70's

I may (for other reasons) end up needing ACT (blood thinners) in my later years anyway, I personally see no reason to not get used to managing them now.

I've offered my assistance to the local nursing home (who actually know me pretty well) in advising on managing the INR of their elderly patients who are on warfarin; interestingly they've said that the older ones are more likely to be stable than the younger ones (dementia) and they are testing weekly with Coaguchek finger stick tests (as I do).

Learning how to manage INR yourself is about as important as learning to cook for yourself IMO.

 

[Dana]

It is the patient's choice of valve type, tissue or mechanical. Sometimes other options are available to choose from, such as TAVR, a Ross Procedure or a Homograft.
In my situation, I also had the choice of which mechanical valve, St. Jude or On-x. In fact, I scheduled my second consultation with my surgeon specifically to discuss the St. Jude vs the On-x and that consultation lasted almost an hour, for which I was very grateful for his time. He clearly preferred the St Jude, based on their long proven success record. He also made it clear to me that if I preferred to go with the On-x, then that is what he would go with.

Having the 2nd consult was my idea, as I had already met with him before. I'm sure that most people just leave it to the surgeon, even for the decision on tissue vs mechanical, and you will get what he prefers both in valve type and manufacturer. There is an argument to not be involved at all and let the surgeon decide based on his expertise. But, as the patient is the one who will have to live with the trade offs, I believe that the patient should be very involved in this discussion.

Once the valve type has been decided on, probably the vast majority don't get involved in the discussion beyond there. But, I think that there is a good reason to be involved at that point as well. For example, if one chooses tissue, does the patient want to go with the more proven track record of the Magna Ease, or do they want to go with the relatively new Resilia valve, with 5 years of data, but the hope that it might last longer due to its treatment meant to delay calcification? Similarly, if one chooses mechanical, do they go with the long track record of the St. Jude or the newer On-x valve?

Personally, I like to know the trade offs and be very involved in the decision process. I understand that some don't feel the same way. I'm glad that I have medical professionals that welcome this involvement and are willing to get into deep discussions with me about trade offs, as well as discuss the medical literature. I had input from my cardiologist and surgeon on valve type, but ultimately going mechanical or tissue was very much a personal choice. I'm the one that has to live with reoperation or a life on warfarin. As to valve manufacturer, it was also my decision. Ultimately, I went with the St. Jude, as recommended by my surgeon. At that point, it probably would have taken a lot for me to choose a valve manufacturer different than that preferred by my surgeon. But, I was glad to have had the discussion with him as to why he preferred the St. Jude over the On-x.

Bore me, I am unsure of what you are saying. Like I said the nurse said th Dr would pick the "Best" valve for me. Evidently after he sees' what the conditions are? Maybe I should ask again to be sure that's what was said? I don't know one valve from another, How would I pick? From a manufacturer's advertisement? I would hope after the thousands of valve jobs that the surgeon has done, he would be much better at picking the right valve than me. I'm all about doing research but can I expect to better pick a valve than he? I'm rooting for Dr Badhwar on this I think.

One more topic to discuss with your doctor is the potential for hemolysis with a mechanical valve. I have two mechanical valves, a St Jude and a SORIN not to mention one tissue valve. One or both mechanicals is slicing and dicing red blood cells causing hemolytic anemia. I won't go into it but I'll just say that I'm symptomatic. There may be some metric on each valve's likelihood of shearing RBCs that should be considered when choosing values. When I had my discussion with surgeon this was not mentioned and I only found out the hard way. Tissue, being soft doesn't damage cells but that hard surface of a mechanical valve can cause damage particularly under high contractility and higher heart rates and probably higher BP.

 

[AZATADINE]

Is that common to all mechanical valves/people or are some people more prone to it than others? Haven't really come across this before if I recall correctly.

 

[nobog]

One more topic to discuss with your doctor is the potential for hemolysis with a mechanical valve. I have two mechanical valves, a St Jude and a SORIN not to mention one tissue valve. One or both mechanicals is slicing and dicing red blood cells causing hemolytic anemia. I won't go into it but I'll just say that I'm symptomatic. There may be some metric on each valve's likelihood of shearing RBCs that should be considered when choosing values. When I had my discussion with surgeon this was not mentioned and I only found out the hard way. Tissue, being soft doesn't damage cells but that hard surface of a mechanical valve can cause damage particularly under high contractility and higher heart rates and probably higher BP.

It's not the surface of the valve but the leakage jets (in the closed position) and valve clearances that cause the blood damage. Never heard of "contractility" but heart rate would have little to do with the damage but higher BP as you mentioned is a major concern.

 

[dornole]

I remember reading here before that hemolysis is a particular issue when someone has two valve replacements, in particular someone else with 2 mechanicals.

When I had anemia, though, turbulence caused by my rheumatic mitral valve (I still have my native one) was one of the causes they investigated, they said the disturbed flow through the valve can rupture the red blood cells. It turned out that something else was the cause of the anemia, but it doesn’t sound like the issue is exclusive to mechanical valves.

Not sure what great options one has if you need 2 valves replaced - lots of potential for re-ops if either tissue valve fails, hemolysis risk if mechanical - very tricky. Definitely trading native valve disease for prosthetic valve disease on that one. I’m sure you would have liked to know about the hemolysis risk beforehand though. They can’t do anything for you?

 

[pellicle]

I remember reading here before that hemolysis is a particular issue when someone has two valve replacements, in particular someone else with 2 mechanicals.

it is and can be, but its usually more strongly associated with higher heart rates over a longer duration (eg athletes) and isn't actually a significant problem unless its combined with anaemia. But platelet activation is actually the more significant factor (which is why we're on ACT).

The body naturally destroys blood cells and replaces them, it has an excellent internal parts recycling process.

A good introduction read. More detail here.

those pressures and the pressure jets of the opening and closing of the valve (just like when you put your thumb over an open hose to shut of the water as you walk around the garden) are the cause.

Its part of what comes with "prosthetic valve disease" but its far more manageable than valvular disease (which is fatal if not exchanged for one of the prosthetic valve disseises which can be managed).

I've mentioned this here before:
Eg
https://www.valvereplacement.org/th...going-mechanical-this-time.850503/post-850522

Of course I'm only pretending that I know anything and naturally you should consult your doctor.

 

[dick0236]

I am trying to stay away from the "valve choice issues" since the industry has changed a great deal since my surgery. My one and only OHS surgery was in 1967 when I was 31 years old (1967).......and I have had no need to visit a hospital since. Now fast forward to today when I am 86+. My cardio tells me that my old "ball valve" shows no sign of wearing out.....and that is a very good thing. Unfortunately, other issues have cropped up since I entered my 80's. All of these issues are associated with heart disease. Two of the issues (afib, and pulmonary hypertension) are treated with warfarin which requires no new drugs since I was already on warfarin. The other issue is an upper aortic aneurysm. That would require the replacement of my working valve alone with the aneurysm repair. My surgeon and I agree that that kind of major surgery carries significant risk.......not necessarily death but disability and "quality of life" for seniors (old men). My choice is to take my chances since there is nothing good about surgery in the 80's.

If you make a poor choice in your younger years you can just go in and fix it the next time.......the older you get the harder surgeries can be. Make this an important issues as you consider your choices.

Warfarin use for valve issues is dwarfed by the use of that drug for other issues (afib pulmonary hypertension etc, etc.............so the odds are you will be on warfarin or similar drug. Maybe they will invent another anti-coagulant to replace warfarin. BTW, I have been on Warfarin for over 55 years with no issues since the INR system was introduced.

 

[pellicle]

Unfortunately, other issues have cropped up since I entered my 80's. All of these issues are associated with heart disease. Two of the issues (afib, and pulmonary hypertension) are treated with warfarin which requires no new drugs since I was already on warfarin.

I have a personal hypothesis that the primary reason for reactions against being put on Anticoagulants is that because the person otherwise feels fine there is a reaction against being put on a medication because it implies that one is getting old.

I suspect the shock of that offends people more than they care to admit. Now if they had some other disease (like say, hypertension) they may not mind being on blood pressure tablets because they can see the effects of high blood pressure.

The point is that after we're 40 the chances go up we'll need something no matter how fit we think we are. Here's an example of an athlete:

https://www.velonews.com/gear/tech-...rivetrain/#:~:text=For my 60th,all too obviou
So it always strikes me as curious when people make such an ado about their valve choice being "to avoid warfarin" and then find themselves in a few years needing just that ...

Indeed Dr Schaff of the Mayo mentions exactly this in his old presentation from 2012. A more current paper

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6306127/
BPVT is a major cause of either acute or indolent bioprosthetic valve degeneration, and often has an elusive presentation causing delayed recognition and treatment. The literature has extensively addressed the risks and benefits of anticoagulation following bioprosthetic valve replacement to prevent BPVT, without conclusive results or evidence-based recommendations. It seems that the exponential research and clinical use of catheter-based and to a lesser extent, surgical-based, valve therapies have not been paralleled with commensurate research in the required adjunctive antithrombotic and anticoagulant therapies to assure safe delivery and long-term outcomes of such therapies, especially with regards to BPVT


UltimateFacePalm if you ask me.

 

[Superman]

I have a personal hypothesis that the primary reason for reactions against being put on Anticoagulants is that because the person otherwise feels fine there is a reaction against being put on a medication because it implies that one is getting old.

Warfarin is a young man’s medication. My “blood thinners” were a bit of a running joke on bar nights in my early 20’s.

 

[pellicle]

My “blood thinners” were a bit of a running joke on bar nights in my early 20’s.

I'm sorta glad I dodged that and got to my mech valve days in the era of PoC machines to allow testing anywhere I wish.

(a mates workshop when I was staying there for a while)
(note rubber band)

 

[Dana]

I remember reading here before that hemolysis is a particular issue when someone has two valve replacements, in particular someone else with 2 mechanicals.

When I had anemia, though, turbulence caused by my rheumatic mitral valve (I still have my native one) was one of the causes they investigated, they said the disturbed flow through the valve can rupture the red blood cells. It turned out that something else was the cause of the anemia, but it doesn’t sound like the issue is exclusive to mechanical valves.

Not sure what great options one has if you need 2 valves replaced - lots of potential for re-ops if either tissue valve fails, hemolysis risk if mechanical - very tricky. Definitely trading native valve disease for prosthetic valve disease on that one. I’m sure you would have liked to know about the hemolysis risk beforehand though. They can’t do anything for you?

Doctor increased my dose of beta-blocker metoprolol arguing it would reduce contractility, which is the strength of force with which the heart muscle contracts, thereby reducing the slamming of the valves. Has it worked? I don't know yet. It's been about a month. My haptoglobin was unmeasurable which means the liver is trying so hard to clean up residual hemoglobin that is spilled when RBCs break apart, that the liver has exhausted it ability to produce any more. He mentioned another drug pentoxifylline but has not yet prescribed it. This one improves erythrocyte flexibility I guess making them less vulnerable to breakage.

IMHO opinion I think they have my PM pacing rate cranked up too high, to pellicle's point. They set it at a minimum of 80 bpm because I had a couple of episodes of atrial flutter and when the base rate was 60, the PM would default to that, which was not enough for me. (Normally the PM follows my intrinsic sinus rhythm but during periods of arrhythmia, it can't do that so it defaults to a base rate.) But since then I've stayed in sinus rhythm with no flutter. I tried to get them to reset the base rate but got the argument - if it anti broke, don't fix it, that is, if there's been no flutter, why change something. That argument does not compute but I was talking to the NP, not the doctor. Appointments with the EP are very hard to get.

 

[pellicle]

Doctor increased my dose of beta-blocker metoprolol arguing it would reduce contractility, which is the strength of force with which the heart muscle contracts, thereby reducing the slamming of the valves. Has it worked? I don't know yet. It's been about a month.

interesting approach ... please post back with the eventual findings

 

[dornole]

Re taking medications, I think for younger people it seems like such a big deal to take anything at all, but once you take one pill you’re like “eh it’s a pill big whoop”

 

[priley]

Well No need to second guess any longer. I went in on Thursday and got a RAVR with a medtronics tissue valve. I got home yesterday. Let me tell anyone who will listen that Less Invasive does not mean Less Painful. When I was rolled in to the OR and saw the Da Vinci Surgical System with her name tag that said ROSIE I had to smile. That's the last I remember seeing Rosie Thanks to Dr Vinay Badhwar and Dr Wei for their expert surgery services. Thanks to this forum for introducing mr to Dr Badhwar.

 

[Chuck C]

Welcome to the other side!

Hoping your recovery is a smooth one.

Please keep us posted.

 

[Beach77]

Did anyone feel much better after the surgery?

Welcome to the other side! I turned 65 on the day I was released from the hospital. This coming up Dec. 3rd will be 2 years post-op and I feel way better! The only symptoms I had were going up hills or a 2nd flight of stairs. I was walking 3 1/2 miles most days, along with yoga 3x a week. Now I fly up those same hills! When we're hiking, I don't have to look at the elevation gain anymore! to answer your question, I feel way better! It seems I had more symptoms than I thought.