Review of Valve Choices

[Guest]

Am Heart Hosp J. 2004 Summer;2(3):149-52.

Transitions: selecting the best heart valve for your patient: mechanical or tissue.

Phillips SJ.

the National Library of Medicine of the National Institutes of Health, Bethesda, MD. [email protected].

This review provides general guidance for heart valve selection. Mechanical heart valves exhibit excellent durability and hemodynamic performance but require anticoagulation to reduce thromboembolism, and therefore risk of anticoagulation-related hemorrhage is increased. Tissue valves were introduced to avoid anticoagulation, but in fact often do not, and lack durability. A literature review was performed to compare the complications of thromboembolism, anticoagulation-related hemorrhage, reoperation structural valve deterioration, and reoperative mortality associated with mechanical and tissue valves. The thromboembolism rates for mechanical and tissue valves are equivalent. During their lives, many recipients of tissue valves receive anticoagulation therapy due to comorbid conditions. The anticoagulation-related blood loss rates associated with mitral mechanical valves and mitral tissue valves are equivalent, whereas the blood loss rates associated with aortic tissue valves are less than those associated with aortic mechanical valves.

 

[Barry]

Am Heart Hosp J...Tissue valves were introduced to avoid anticoagulation, but in fact often do not...

Wasn't expecting that finding at all! If I'm reading this right, there doesn't appear to be much advantage to going for a tissue valve, and there's the downside of it wearing out over time. And if, like me, you have Atrial Fibrillation, you're going to get stuck on Coumadin/Warfarin anyway (although probably at a lower dose than what would be required for the mechanical mitral that I've got).

 

[Guest]

The dose difference is insignificant. The ranges overlap for half of the graph. I haven't written much about this because I see only the people who need to take warfarin, so my position is biased.

 

[ALCapshaw2]

AL Lodwick -

What are your thoughts about the On-X Mechanical Valve for reduced clot formation risk compared with the St. Jude Mechanical valve, especially in the Mitral Valve position?

Can On-X valve recipients use a lower INR target range than St. Jude valve recipients, especially in the Mitral Valve position?

'AL Capshaw'

 

[Guest]

There are no convincing studies proving this.

I exchanged correspondence with this company shortly before the valves were introduced and this is what they were hoping for. I think that it worked in animal studies. I'm sure that the FDA will want long-term data on a lot of people before they will agree to this. It may be so expensive to run these studies that they will never be done.

Bottom line: Don't count on On-X people not needing warfarin any time soon. If it happens before 2010 I'll be surprised.

 

[RCB]

Al- Care to comment on.......

Al- Care to comment on.......

The dosing difference between ACT for mech. valves vs. A-fib. Some have implied that warfarin dosing for a pt. with a tissue valve who has a-fib is less of a practical problem than those pts. who are on warfarin for valves.
As someone who deals with the diverse pt. population all the time, what does your expertise tell you?

 

[Guest]

I never noticed that there was any difference.

 

[RCB]

I never noticed that there was any difference.

You will be quoted.

 

[Nancy]

Said it before and I'm going to say it again. Going into valve replacement for the first time, it appears that there might be many choices. As you go down the road and get older, having reoperations becomes a MAJOR factor. It's definitely not like your first time. You are older, you could have comorbidities, you will have scar tissue and adhesions.

The body's ability to recover after repeat major traumas requires longer and longer periods of time. And in some cases, you will not ever return to full recovery and might even lose additional small pieces of your former health.

As a young person it's hard to project into the future. But this site gives all a glimpse of people with varying degrees of difficulties, some brand new, and some who have trudged the long road many times.

The effect on the body of repeat trauma has to be weighed very carefully and should be a part of every decision you make.

I'm speaking as the spouse of Joe who has had three valve surgeries and also two lung surgeries, for a total of 5 MAJOR thoracic surgeries. And he is not the only one here who has had many surgeries.

I hope they will come along and relate their experience with repeat surgery.

 

[Wise]

Thanks

Thanks

for this thread...it provides a snapshot of choices for us who will probably someday face valve replacement surgery. At age 45, and not knowing when (or maybe if) I may have surgery, it really brings things into perspective thinking about the ramifications of subsequent surgeries at an older age. I had thought that it would be best to not have a mechanical valve, but I'm beginning to understand that the older I get that mechanical may be the way to go. May change my mind. I've read a lot here about valve options and coumadin and have come to realize that for me I probabaly need not be too concerned about the lifestyle limitations of a mechanical valve. Gosh, some people are participating in rigorous and challenging physical activities and eating who knows what. If I have surgery I believe that, although I'll certainly have anxiety about it, I will be much better able to handle it because of what I've learned at vr.com. Just wanted you to know Al that this thread has really helped me. You just never know when something clicks with a new vr.com member like me. Thanks again.

 

[Barry]

I never noticed that there was any difference.

Wouldn't someone with a mechanical mitral valve, like myself, require a higher dose to attain a higher INR than someone with a tissue valve and/or a-Fib? And with a higher INR, increased hemmorage risk?

 

[Randy & Robyn]

Bottom line: Don't count on On-X people not needing warfarin any time soon. If it happens before 2010 I'll be surprised.

I believe Rich stated in one of his posts that his surgeon at Columbia told him they would be starting their own aspirin trial for the On-X after the German trial is concluded. That trial just passed the one year mark. So you are looking at four more years for the German trial. Then, if all goes well, probably a five-year trial at Columbia.

I would say an optimistic estimate would put a change in the requirement for anticoagulation in the US for On-X patients at around ten years. And that is assuming it passses those trials. I think it has a good chance but there are no guarantees.

On another note, has anyone seen the study that concluded a couple of years ago showing such dramatically low complicatin rates for St. Jude recipients under the age of 50? I thought it was amazing!

Here is the link:

http://ats.ctsnetjournals.org/cgi/content/abstract/75/6/1815

Randy

 

[BionicBob]

This thread is brimming with bias. Many tissue valves in fact DO NOT require anticoagulation. They have some other quality-of-life advantages. I make no pretense of being an expert, but I can do a Google and provide plenty of citations for that if we want to do dueling medical references.

Mechanical valves are best for some people; tissue values are the best choice for others. VR.com is at its best in presenting both sides, but sometimes the bias on this most personal of selections is a turn-off.

 

[starkone]

I agree

I agree

Thank you Bob for saying what I wanted to.
You expressed it very well.
Karen

 

[Barry]

My favorite color is plaid.

 

[Randy & Robyn]

This thread is brimming with bias.

No bias intended on my part. I still haven't made my final choice and may very well go with a tissue valve to avoid anticoagulation, at least for awhile. Cleveland Clinic, the world leader in heart care, recommended a tissue valve to me, even at my age of 36. That says alot. I can see both sides of the issue all too clearly.

Randy

 

[geebee]

I guess I must be dense because I don't feel biased opinions on this thread. I think it is merely expressing individual experiences and studies that have surfaced.

I, too, am one of those folks who lean on the side of avoiding re-operations. I almost died during my second surgery because the surgeon cut my pulmonary artery while clearing scar tissue to access the heart. HOWEVER, I am someone who "grows" a lot of scar tissue. I do not know how common that is but it does happen.

The surgeon who did my third surgery was very concerned about being able to get in without trouble. He even accessed a groin artery to use in case he needed an alternate path for the heart-lung machine. Turns out he didn't but the danger is there nonetheless.

I hope this is not considered biased but I think it is very important to point out nevertheless. I can assure you, it never gets easier to have additional surgeries just because you have had one. You know what to expect but, the older you are, the harder it is to bounce back. Just the facts.

I am not saying people who choose tissue valves are wrong. Everyone has their reasons for choices. I did not have a choice the first time as the surgeon was convinced he could repair the valve. If I had had a choice, I might have gone tissue because I was only 28 and had no children. However, I don't have a time machine so I can't alter the past. I can only try to learn from it and try to pass my experience on to others.

 

[gordy]

Tissue Valve

Tissue Valve

No bias intended on my part. I still haven't made my final choice and may very well go with a tissue valve to avoid anticoagulation, at least for awhile. Cleveland Clinic, the world leader in heart care, recommended a tissue valve to me, even at my age of 36. That says alot. I can see both sides of the issue all too clearly.

Randy

My surgeon (very highly respected heart surgeon) also recommended a tissue valve for me. At age 48 I know I will probably go through another surgery later on in life, but right now my anticoagulation therapy is one aspirin a day. More and more of the well-known surgeons are opting for tissue valves. I would listen closely to what they say.

 

[RCB]

Well of course there is BIAS

Well of course there is BIAS

This thread is brimming with bias....... VR.com is at its best in presenting both sides, but sometimes the bias on this most personal of selections is a turn-off.

However, I did not see you posting your objections when some pro-tissue valve types were in here shilling tissue valves with comments such as " I could do several OHS- it is no big deal" or " Warfarin is a nightmare drug." What ever did happen to Sheylathomas(the secret agent), Adoinas67(AKA pretty boy) or more recently-Goldfinger......All pro-tissue....all banned. They were not only bias, but their statement were just plain crude and fearmongering. There is no greater bias expressed on this forum than the people that have never been on warfarin, talk about warfarin. You think for a moment their thoughtless and misinformed statement are not a "turn-off"
to those of us who owe our life to this miracle drug?

I guess the bias here is on both sides and it is a matter of "whose ox is getting gored"

 

[Guest]

I only report what I find and I give references to peer-reviewed medical journals. They are the highest standard. Obviously everyone has some type of bias. I stated mine - I'm not a good judge because I run an anticoagulation clinic and only see tissue valvers for a little while after surgery or those who develop a-fib or have some other clotting disorder that requires anticoagulation.

If I found an article that said that there was a new valve that required no anticoagulation, I'd be happy to report it. I am pretty safe in saying that I will retire before there will be a replacement for warfarin, so I have no bias about keeping my daytime job.