repeat AVR looming after only 6 years!

[Simon Booker]

Hi Eddie - what type of tissue valve do you currently have?

The valve choice issue is notoriously complex and my experience is that no two people offer the same advice, although you do pick up common threads. I looked at the graphs and data that are summarised above in respect of my Dad's operation (he was 62 at implant) and we took a view based on the stats, but also some other factors . But the On-X also looks like a great valve, with possible applications in the future (3-5 yrs I believe) of superAspirin only - but nonetheless people here show how anti-coagulation can be made pretty easy.

S

 

[edjspi]

I have an Edwards bovine valve, Implanted in 2004
Happy to be getting my On-X valve tomorrow and getting this over with!!

 

[ottagal]

Wishing you all the best with your surgery tomorrow. Hopefully someone will be able to post to let us know how you are doing. Godspeed.

 

[edjspi]

thanks! I'm on the home stretch now. relaxing at home with family tonight, having pizza from my favorite local joint, and hopefully getting to bed early (not too sure I will be able to do that one)!

If my wife doesn't get on to post, I will post updates as soon as I get online...

Thanks to everyone at VR.com again for all the help and support!
-Eddie

 

[havasu ed]

Eddie This is Ed. Just picked up on the thread. STACK that pizza with the pepperoni man!! These tissue valves seem to be a curse for for the under 60 group. My mitrel was replaced in late 05( Medtronic Mosiac) and the cardio gives it 2 to 3 years at the max. I wish you the best man. Enjoy the family tonight.

 

[normofthenorth]

At the risk of continuing a thread hijack AND reviving a moribund thread, there's a new article out reporting results from 1100-odd patients who got the same model of Medtronic pig valve from the same institution from 1982 to 2004. Not many have made it past 25 years (or HAD 25 years post-op yet), but the data for 10 & 15 & 20 years seem encouraging -- though more so for us 60-somethings than for the young sprouts. It's entitled "Hancock II Bioprosthesis for Aortic Valve Replacement: The Gold Standard of Bioprosthetic Valves Durability?" by Tirone E. David, MD, Susan Armstrong, MS, Manjula Maganti, MS, in Ann Thorac Surg 2010;90:775-781, abstract at ats.ctsnetjournals.org/cgi/content/abstract/90/3/775? .

BTW, I distinctly remember seeing reference to a credible-sounding study that seemed to show that bovine (pericardial) valves were lasting 5 years longer than porcine (xenograft) valves. I thought it was in a "sticky" here, but now I can't find it anywhere. Sound familiar to anybody? (This study seems to show it the other way, at least with this valve and this team.)

 

[bdryer]

I was considering the Edwards Perimount over the On-X. I'm 55. edjspi, is it the Edwards perimount the valve that failed prematurely?

 

[edjspi]

My first valve was a Edwards Bovine tissue valve. Not sure if that is the same?
Doc said it wad so calcified he could barely see it. Had a 'cocoon' of calcium around it

 

[Lynlw]

At the risk of continuing a thread hijack AND reviving a moribund thread, there's a new article out reporting results from 1100-odd patients who got the same model of Medtronic pig valve from the same institution from 1982 to 2004. Not many have made it past 25 years (or HAD 25 years post-op yet), but the data for 10 & 15 & 20 years seem encouraging -- though more so for us 60-somethings than for the young sprouts. It's entitled "Hancock II Bioprosthesis for Aortic Valve Replacement: The Gold Standard of Bioprosthetic Valves Durability?" by Tirone E. David, MD, Susan Armstrong, MS, Manjula Maganti, MS, in Ann Thorac Surg 2010;90:775-781, abstract at ats.ctsnetjournals.org/cgi/content/abstract/90/3/775? .

BTW, I distinctly remember seeing reference to a credible-sounding study that seemed to show that bovine (pericardial) valves were lasting 5 years longer than porcine (xenograft) valves. I thought it was in a "sticky" here, but now I can't find it anywhere. Sound familiar to anybody? (This study seems to show it the other way, at least with this valve and this team.)

I don't know of any comparing the perimount to the pig, but you might be thinking of this one comparing bovine to human in younger patients http://jtcs.ctsnetjournals.org/cgi/reprint/131/3/558.pdf

 

[bdryer]

Darn kind of got excited about a tissue valve but having strong second thoughts

Darn kind of got excited about a tissue valve but having strong second thoughts

Wow, it seems that if we are prone to calcification of the AV, the disease destroys the tissue replacement AV. I have read that as we age, calcification of the tissue AV lessens. Is calcification alone what destroys the AV, or is it a combination of an active life style and calcification which prematurely destroys the tissue AV?

What got me thinking about a tissue valve, was a link sent to me by a future surgeon. It indicates that the future of valve replacement surgeries will be by catheterization after initial replacement of AV with a ValveXchange AV. As the valve leaflets wear out, the doctor does the surgery via catheterization and only replaces the leaflets. The frame or stint stays in situ. I do not know how far out approval is. It sucks as we are going through the same old process on the cusp of breakout technology.

Some here know that I have a very athletic lifestyle. Even though I'm 55, I do enough sports for 3 people. Several of you have been put down again WAAAAY to early after replacement of a tissue AV. Are their any tissue AV recipients out their who are incredibly athletic, who have had a tissue valve last 10-15 years? Far to many of you fine folks tell me the tissue AV is a bloody failure!

I'm close to drinking the On-X Koolaid!

Thanks

 

[Lynlw]

Valve choice is a really personal decision and what is important for one person may not be the most important thing for another, I personally think the 50s are one of the toughest ages to decide which way to go Both choices come with their own set of risks, it just depends which risks you rather live with.
How active you are has NOTHING to do with how long a valve will last. It has to do with your body's chemistry. Nothing is guarenteed, but for the most part someone in their 50s would most likely have their tissue valve last longer than someone in their 30s. Since it seems to be related with your body's ability to grow/heal bones
But of course some people with both tissue or mechanical valves will need surgery much sooner than they had hoped.
Valves need replaced for a few reasons, calcification, endocarditis, a stitch popped ect. Of course just like some people with Mechanical valves may need a REDO, having a tissue valve doesn't mean you won't need to take coumadin, it just gives you beetter odds.
Most of the people who have had their tissue valve 10 or more years and are doing fine most likely wouldn't be members/posting here since this is a place people tend to join when they are having problems and need surgery. (or have mech valve and have a coumadin question) Since the site is only about 10 years old, people who had their surgery who joined before surgery and stayed around to give back all have had their valves less than 10 years.
As for how will a valve that someone gets to day be replaced when it needs to be, I've heard some things about the replacing the leaflests only type valve replacement, but MOST of the doctors believe the entire valve will be replaced percutaneously (by cath with the new valves being on stents. that are placed inside the old valve (tissue only not mechanical) Right now there are trials in the US and Canada for the Sapien valve on patients too high risk for surgery that are going well (the PARTNER trials if you want to google them) and Metronic Corevalve will most likely start trials in the US (I don't know if they already are in Canadian Trials) soon too. Percutaneous pulmonary valves (Melody) are already FDA approved for anyone who needs them.

ps Canada is part of the current corevalve trials http://clinicaltrials.gov/ct2/show/NCT01051518

 

[bdryer]

Lyn

I really appreciate your words of experience!

Thanks for spelling out the reality! Stay with me and keep up the support!

 

[Shobu]

@bdryer: I drank the On-X koolaid and have been pretty happy with the results. It has gotten pretty quiet, I'm happy with the way it handles fluctuations in my INR (no strokes yet, so I'm happy Being on wafarin is no big deal, I'm back in the pool and the gym and doing better than ever. Good luck.

--Dan

 

[ottagal]

I don't know of any comparing the perimount to the pig, but you might be thinking of this one comparing bovine to human in younger patients http://jtcs.ctsnetjournals.org/cgi/reprint/131/3/558.pdf

Lyn and NormofNorth,

Here's an abstract (2010) from the University of Ottawa Heart Institute discussing the Long-Term Clinical and Hemodynamic Performance of the Hancock II Versus the Perimount Aortic Bioprostheses

Thought you might be interested.
http://circ.ahajournals.org/cgi/content/abstract/122/11_suppl_1/S10

Conclusions—For the same manufacturer valve size, the Perimount is larger, which may warrant enlarging the aortic root more often, and it is associated with better hemodynamics than the Hancock II. These differences do not impact survival or left ventricular mass regression, and the long-term clinical performances of the Hancock II and Perimount bioprostheses are equivalent.

 

[normofthenorth]

Nice catch, OttawaGal! I think these findings are consistent with an answer I got from my heart surgeon a few months ago. I'd read that a study found that "cow valves had better blood-flow performance than pig", maybe from a ScienceToday report on this study. Dr. Feindel said that the results weren't quite what they seemed, because the cow valve was actually LARGER than the "same size" pig valve. Among other things, that means that one patient (say, ME!) would not have the choice between the same two valves, but between a cow valve of one "nameplate" size and a pig valve of a LARGER "nameplate" size. Those two valves, the real choice facing me and my surgeon, would be of comparable size, and would probably have comparable hemodynamic performance.

I haven't read "your" study, but I wouldn't be shocked if the whole fully-nuanced truth turns out to be in-between what I understood from my reading and what I understood from my surgeon.

If it turns out that there's a tradeoff between hemodynamic performance and valve durability, that will just add more fascinating complexity to this damned decision, especially for us athletic types!

 

[Lily]

Normofthenorth, Ottawagal, and Lyn - I enjoyed that discussion; thanks for sharing

 

[Lynlw]

Nice catch, OttawaGal! I think these findings are consistent with an answer I got from my heart surgeon a few months ago. I'd read that a study found that "cow valves had better blood-flow performance than pig", maybe from a ScienceToday report on this study. Dr. Feindel said that the results weren't quite what they seemed, because the cow valve was actually LARGER than the "same size" pig valve. Among other things, that means that one patient (say, ME!) would not have the choice between the same two valves, but between a cow valve of one "nameplate" size and a pig valve of a LARGER "nameplate" size. Those two valves, the real choice facing me and my surgeon, would be of comparable size, and would probably have comparable hemodynamic performance.

I haven't read "your" study, but I wouldn't be shocked if the whole fully-nuanced truth turns out to be in-between what I understood from my reading and what I understood from my surgeon.

If it turns out that there's a tradeoff between hemodynamic performance and valve durability, that will just add more fascinating complexity to this damned decision, especially for us athletic types!

This is just the abstract,(and I'm too cheap to pay for the full text) and of course you can't read the charts breakdowns ect, but it says the the hemodynamics are better for the Perimount and in this small group of people for this time frame at least, the durability is about the same.

I don't think I'm reading the explanation for the different sizes the same as you are, when you say that you would just get a larger nameplate Hancock than you would Perimount, so it would pretty much be the same hemodynamic (paraphrasing you) because of the statement "the Perimount is larger, which may warrant enlarging the aortic root more and it is associated with better hemodynamics than the Hancock II" in the conclusion Ottawagal posted. Altho the fulltext probably explains things better,

here is the
Methods and Results—Between 1990 and 2007, 1659 patients (mean age, 73.1±9.3 years) underwent aortic valve replacement with either the Hancock II (N=1021) or the Perimount (N=638). Patients were prospectively followed-up with serial clinic visits and echocardiograms for up to 16 years (mean, 5.0±3.3 years). There was no significant difference in aortic root size preoperatively (P=0.7). Aortic root enlargement was more commonly performed with the Perimount (P<0.001), and the manufacturer valve size of the implanted prosthesis was larger with the Hancock II (P<0.001). Postoperatively, peak and mean transprosthesis gradients were higher for the Hancock II (32.7±0.7 and 16.0±0.3 mm Hg, respectively) than for the Perimount (24.9±0.7 and 13.4±0.4 mm Hg, respectively; P<0.001). However, no difference in left ventricular mass regression was observed at late follow-up (P=0.9). Unadjusted 10-year survival was 59.4%±2.4% for the Hancock II and 70.2%±3.8% for the Perimount (P=0.07). Multivariable predictors of survival did not include prosthesis type (P=0.2)."

Either way Both valves seeem to be very good valves, and for most people I don't think the small hemodynamic differences would make any difference in their lives

FWIW IF you really want to drive your self nuts reading even more studies when I was searching to see if I could find a free copy of the full study OG posted, I found another study (from Canada too) comparing Hemodynamics between the Perimount Magna to the Hancock II in a small (a little more than 100) group of patients.The study just started in 2005, (the magna is from 03) so there is no data showing how long the Magna would last in a person compared to the Hancock II, it was to see which has better hemodynamics post op
This link goes to the fulltext of that study and one of the interesting things it says is because the sewing ring is thinner on the Magna than the Hancock II that is how the same size has a bigger valve area. It made me wonder if the perimount in OG's study had a thinner ring compared to the hancock or if there was a different reason for the lower gradient. http://ats.ctsnetjournals.org/cgi/content/full/annts;83/6/2054
this showed a better gradient with the magna than Hanncock II also, but it mentions a new Hancock (Ultra) coming soon, that will have a thinner ring, but as far as I can see the only trials being done right now on it so far are in Germany, Italy, UK http://clinicaltrials.gov/ct2/show/NCT01213615?term=Hancock+II+Ultra&rank=1

 

[drivetopless]

i can only conjecture, but i would guess this is most likely the reason, too. i'm 30 and my surgeon said that given my active lifestyle i would most likely go through a bio valve in 7 years at the top end, maybe even faster. i really didn't want to have a third surgery in just a few years, so i opted for mechanical. he joked around with me saying i was going for mechanical because i was sick of heart surgeons. no offense to him, of course. he seems like a nice guy and all.

Kinda makes you wonder doesn't it . . . . .A surgeon might like the chance to reop in a few years . . . .ok. I dont really think surgeons are that selfish, but it does make you wonder.

 

[normofthenorth]

Thanks for the link, Lynlw. I'd just found the abstract for that same study, but not the fulltext you linked. For me, one of the most interesting things about that study isn't that it's from Canada: the last listed co-author is "Christopher M. Feindel, MD", my surgeon -- the one I distinctly remember telling me a few months ago not to believe the studies that say that the cow valves have better hemodynamic performance than the pig valves. And it turns out he's co-authored one of them himself! Yikes!

Reading these studies -- maybe especially the new one showing the great "Gold Standard" durability of the Hancock II -- makes me aware of one MORE issue that could drive a person nuts while choosing a valve (if that's what I'm doing).

That's basically the question of "How close to the leading edge do you want to be?" Put another way, by the time ANY valve has solid 15-year and 20-year durability stats, there's ALWAYS an improved next-gen version out there, and maybe even the generation after THAT one! They can test the hemodynamic performance (etc.) on newly implanted valves, but the ones that score best on those tests won't necessarily last the longest without structural degradation, or the need for replacement -- and those results can't be rushed.

Maybe the newest ones will do better in the long run (and there are excellent reasons to suspect that they will), but the older generation have proved themselves in solid evidence-based scientific studies, and the newer ones haven't yet. I'm all for progress, and for taking advantage of it, but I'm not as keen about being "the first kid on the block" to try new technology as I was in my teens -- and maybe LESS so if the technology is a heart valve! (I'm trying to avoid the phrase "bleeding edge", but it's a struggle!)

This discussion is also making me wonder if Dr. Feindel et al are actually planning to give me a Hancock II, or if they've moved on to something newer (maybe the Medtronics Freestyle?). Their study population of patients that got the Hancock II ended back in 2004, and I doubt that it took them many years to analyze the data. . . Maybe somebody can tell me on Tuesday, when I go in for my pre-admission exam. . .

 

[Lynlw]

I'm sorry it really isn't funny, but I laughed when I read it was your surgeon, who said don't believe the cow is better, was one of the coauthors of that study, I knew it was from Toronto, but didn't think about the fact you are too.

You are right about one of the problems with studies for longevity on valves (or many medical things) is often by the time that valve has lasted 20 years, it isn't the newest most up to date and there are newer valves that may be better and often thats the valve that many surgeons are using now. I think it makes a difference, if the newer valve is a completely new valve, or is pretty much the same as one of the "proven" valves, just tweak a few things to improve it, like the perimount Magna is based on the older perimounts as far as anti-calcification ect and it looks like the Hancock Ultra is based on the older Hanncocks so hopefully they would last just as long, but no one will know for sure until they've been around 20 years or so.
I think IF I were choosing a tissue valve today, one of my questions would be, is this a valve that any of the percutaneous valves around today could be used if it needs replaced, or is there a reason other valves would work better to be replaced percutaneously