Review of Valve Choices

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I just thank God every day that we live in a world where all these choices are possible.

I know if I had been born just 25 (or even less) years earlier, I would probably not be alive today.

There were not a lot of choices in valves when I had my first surgery and, since the surgeon was so sure he could repair, it was not even discussed. I woke up clicking and am still doing so almost 25 years later (with a few hitches).

There are no wrong choices if the research is done and you have made your choice. Be happy you have the options and so many wonderful people to share their stories.

None of us made the wrong choice because we are still here.
 
No matter what your situation, there is always someone that you would not want to trade places with. When my wife was 32 she developed a brain tumor and there was no second chance. She was dead by 34 and I was left with two small children.

But I wouldn't have traded places with the woman who was 22 with a baby and her husband's truck slid on ice and got hit by a train. The doctor told me that he was the most seriously injured person that he ever seen live through the hospitalization. Went to a nursing home and died a year later.
 
Clearly, which type of valve to choose is vitally important to anyone faced with the need to replace a native valve. As someone has already stated, it is important to feel confident in one's choice when making it and recognize after the fact that whatever choice was made was indeed the best choice given the available information and the individual circumstance at the time.

I have been told by my surgeon, "people will tell you mechanical valves last forever. They do not." I have been told by my cardiologist, "I see mechanical valves last, on average, 20 years." My surgeon has recommended a tissue valve for me, recognizing it will need to be replaced in 10 to 15 years. He is confident that by then replacements will be done percutaneously (through an artery in the groin--as in the recently posted article about the procedure performed Mid-March in Michigan).

Assuming both types of valves continue to evolve, how long has any one specific brand, type, model of currently available valve been studied? I'm 42. It seems like, with either type valve, I've got at least 2 replacements in my future (I hope :) ) It would seem that removal of a mechanical valve would be difficult (impossible?) percutaneously. I mean, I can envision tissue being "mulched-up" and sucked out, but could that be done with teflon or whatever a mechanical valve is made of, particularly if it's not designed for percutaneous removal? If percutaneous is the way of the future, does having a mechanical valve implanted now mean I won't be able to take advantage of a percutaneous procedure in the future? (I will ask my surgeon this)

If I get a tissue valve now, I get however many years it lasts without the anticoagulation therapy. Those of you who live with Coumadin generally say it's no big deal, and I believe you, but I do think that is very life-style dependent. Both my parents are on Coumadin for A-fib and it does present its problems. For instance, when they come to visit me (1000 miles away) they prefer to drive and they like to stay for a few weeks. They have to make sure they have enough meds for length of the stay (sure, that's true with any meds, but I have high and reasonable hopes of not being on any prescription meds), they have to have their levels tested here (or somewhere near the Grand Canyon, if that's where their travels take them), and that's a pain. They are active and physical people who do things like bowl and garden and home and lawn maintenance. Their bumps and bruises are never little on Coumadin. Mom recently hurt her neck/arm bowling. Turns out she has a ruptured disc in her neck. I wonder if thinner blood makes it easier to rupture a disc? When that veggie dicing and chopping knife slips now, Mom spends ten minutes getting the bleeding to stop and the bandaid on. I recently bumped my knee getting into a helicopter for a scenic tour and drew a bit of blood. Would that mean an aborted helicopter ride in the future or would I spend the 10 minute tour dealing with a bandaid? A lung doctor friend recently saw a patient in the ER who was "coughing up blood." He suspected the patient was actually spewing blood from his stomach because he was on Coumadin and had earlier had a nose bleed. The patient lived 2000 miles away and my friend had to decide whether to take this guy off his Coumadin to further explore, which would cause the guy to have to stick around until his levels were right again. I'm not saying this isn't all deal-with-able, but realities should be weighed.

For me, I am deciding when to have surgery. I have an aneurysm that, by itself does not require immediate surgery and a leaky aortic valve that also does not require immediate surgery, but while I wait and watch, I can't lift, push, pull, run (which I have always done) or do anything that makes me go "unh!" or gets my heartrate up. I feel like as long as I don't do anything fun I can wait and see. Is this living? Yeah, but is it enough? I know, only I can make that determination...

Any thoughts?

P. J.
 
Your mom's ruptured disc was not caused by warfarin. You have fallen for the popular misconception that warfarin thins the blood. It does not. It slows the ability to form a clot. There is no difference in the viscosity regardless of what the recent article in the New York Times said.

The goal is to have the bleeding time about 2 to 4 times longer than normal. A cut finger that bleeds for 10 minutes would be one that bled for 3 or 4 minutes before. A bumped knee might have swollen the next day but it would not have aborted any immediate desire. You can bleed about a quart before you get into big trouble. Throw a quart of milk on the floor and wipe it up with Kleenex. Nobody is going to watch that amount run out before getting help.

Right now you are being scared by all sorts of urban legends, fables and nonsense. Please look at my website www.warfarinfo.com and especially the page http://www.warfarinfo.com/outrageous.htm

Have your mom get a self-tester from www.hometestmed.com then she can check it at the bottom of the Grand Canyon if need be.

You will find that there is no one right answer. RCB will probably be on here soon. He has had artifical valves since 1960, so he can tell you how long they will last.
 
What allodwick said. I'm on Coumadin/Warfarin and consider it to be little more than an annoyance. At the same time, you do need to be a bit more careful about stuff - e.g. if you didn't buckle up in a car, you need to start now if you're on Coumadin/Warfarin since head versus windshield encounters can be unusually messy now.
 
Rarely do I criticize a someone's cardiologists.........

Rarely do I criticize a someone's cardiologists.........

PJmomrunner said:
I have been told by my surgeon, "people will tell you mechanical valves last forever. They do not." I have been told by my cardiologist, "I see mechanical valves last, on average, 20 years."

Any thoughts?

P. J.

But in this case I will make an exception because he has grossly misled you or you did not correctly quote him:

1. When people state mech. valve last forever- that is a statement of fact
for the purposes of the human life span. It is EXTREMELY RARE for a mech. valve to ware out. Mech. valves are replaced for various of reason, but not wearing out.
2. If your cardiologist say mech. valves lasting only 20 years- did you ask him how long HIS PATIENTS LAST ON AVERAGE? Mech. Valve have a better
record than the pts. they are implanted in, meaning most mech. valves are in good shape when they are buried with their host, who died of something else besides a bad valve.

You might show him this study of valves that last over thirty years and keep in mind this valve are a first generation valve that are not anywhere as durable as the ones being implanted now(Since the newer generation of valves are only at the most 10 to 15 year old, anyone who gives a medical
statement about a statistical fact that is on its face, untrue["on average, 20 years"] not only doesn't understand statistics, but shouldn't be practicing medicine) :

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9066373&dopt=Abstract

Then ask for the his study that backs his statements! If he can't- time to get a new cardiologist and report him to the medical board of your state.

PS If this guy is so hot on his statistic, ask him what the mean, median, and mode is of the average tissue valve is? It has to be a lot less than 15 to 20
years that get tossed out here.
 
P.J.:

I agree with Al; I doubt that being on warfarin had anything to do with your mom's ruptured disc. BTW, my sister -- who is NOT on warfarin -- ruptured one & had to have it replaced last fall.
If your parents have to test with great frequency, they should check into getting their own PT/INR testing machine, as Al suggests.

You don't have to be on warfarin to get bruises, particularly if you're older. My mom (78) has a huge bruise on her arm she got from pruning shrubs -- and she's not on warfarin, Plavix or any similar Rx that would cause such.

Right before Christmas, I sliced off part of a fingertip. Went to the ER. Bled that night, some on and off for a couple of days. I believe it would have bled that night regardless -- the slice was an "avulsion," which doesn't lend itself to suturing. I had just gotten my knives professionally sharpened and just was not looking when I sliced into an onion. :eek:

Recently, I judged a show at which a cat scratched me. No big deal -- I had my clerk get the first aid kit, cleaned the scratches, put on antibiotic and bandage my hand -- not because it was bleeding, but because I didn't want to get a drop of blood on any white cat I might handle after that.

From what I've read, mechanical valves DO and COULD last 20+ years. Some of our mechanical valvers here are going on 20+ years with one valve. However, sometimes leakage develops around the ring that holds the valve.
 
Joe's aortic mechanical was implanted 28 years ago and still in there and working well.

Plus he's been on Coumadin for 28 years.
 
allodwick said:
Your mom's ruptured disc was not caused by warfarin. You have fallen for the popular misconception that warfarin thins the blood. It does not. It slows the ability to form a clot. There is no difference in the viscosity regardless of what the recent article in the New York Times said.

The goal is to have the bleeding time about 2 to 4 times longer than normal. A cut finger that bleeds for 10 minutes would be one that bled for 3 or 4 minutes before. A bumped knee might have swollen the next day but it would not have aborted any immediate desire. You can bleed about a quart before you get into big trouble. Throw a quart of milk on the floor and wipe it up with Kleenex. Nobody is going to watch that amount run out before getting help.

Right now you are being scared by all sorts of urban legends, fables and nonsense. Please look at my website www.warfarinfo.com and especially the page http://www.warfarinfo.com/outrageous.htm

Have your mom get a self-tester from www.hometestmed.com then she can check it at the bottom of the Grand Canyon if need be.

You will find that there is no one right answer. RCB will probably be on here soon. He has had artifical valves since 1960, so he can tell you how long they will last.


The New York Times is not alone in referring to warfarin as a blood thinner.
So does the American Heart Association and any number of other reputable sources on the web. (http://www.americanheart.org/presenter.jhtml?identifier=3013398) I don't argue your point that warfarin does not effect viscosity. Point taken. MY point is NOT--and never was--that warfarin's effects are catastrophic...They obviously are not. That's what I meant by "deal-with-able." Sorry if that was unclear. Nothing I related in my post was based on "urban legends", "fables" or "nonsense." I trust those who know you better will recognize whether you typically respond to others' concerns by characterizing them as such.
 
Hi Runner,
Sorry to hear your folks are having a bit of a problem with Coumadin. It can be a harder concept of care for older people to grasp.

Al Lodwick is the best expert I know of on warfarin management. He is a pharmacist, a registered anticoagulation specialist and runs his own clinic. He travels the world speaking to medical groups and professionals about the use of warfarin. I have learned so very much from him. I home test and do my own dosing, thanks to his expert knowledge and guidance. His site www.warfarinfo.com is a goldmine of information and you may want to encourage your parents to give it a look. He also has some publications that I would recommend and believe that any warfarin user should have.

You are correct blood "thinner" is a popular term for Coumadin, although it is incorrect and misleading. Unfortunately it gives people erroneous ideas about what it does and what it can cause. I wish news agencies who report on it would not refer to it as such. We spend a lot of time on VR having to debunk a lot of what people have learned through media, as well as their own doctors. It's still a highly misunderstood medication. We just like to make sure that people have the correct information when making a valve choice.

Best wishes and welcome to our site here. You were "lucky" enough to jump in on an issue that is hotly debated from time to time.
 
A few things (some of which PJmomrunner asked about)...

You are right that a current mechanical valve, such as a St. Jude, is unlikely to be removable percutaneously. Current percutaneous technology is that the native valve is actually just flattened against the wall of the passage with a stent (the new valve is incorporated into the stent). There isn't really time for removal, as everything is still flowing and the heart is still pumping. Must feel incredibly weird for a few beats. Pass the versed!

At this time, they are functionally inferior to all types of valves that are implanted in the more usual way. Of a certainty, they will improve. It will be interesting to see later if they can be removed for a new one, when the time comes...

There are quite a few posters on this site who are between 25 and 30 years on their mechanical valves, Joe (of course) included. There are also a number here who have had resurgeries before their 30th year, but they are likely quite overrepresented. They might never have had cause to look for this site, if they hadn't required the reoperation in the first place.

When mechanical valves "don't last," it really means there were other issues in the heart or in the tissue the valve was seated in. As RCB pointed out, they rarely fail in and of themselves.

Here are ten- and twenty- year St. Jude mechanical results from a study that broke them down by length-of-service, as I understand them:

St. Jude Aortic Valve Events
............................at 10 years?..at 20 years?
Required Reoperation............7%........10%
Thromboembolic Event.........18%.......32%
Bleeding Event....................23%......34%
Endocarditis in Valve..............6%.......6%
Valve-Related Mortality..........6%......14%
Valve-Related Morbidity........36%......54%

Source: J Thorac Cardiovasc Surg. 2001 Aug;122(2):257-69; Twenty-year experience with the St Jude Medical mechanical valve prosthesis. Ikonomidis JS, Kratz JM, Crumbley AJ 3rd, Stroud MR, Bradley SM, Sade RM, Crawford FA Jr.
from:
http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=14688722

After 20 years, 90% have not required reoperation. The issues that cause "failures" of mechanical valves are almost always in our own, all-too-human flesh. Sometimes it's myxomatous tissue problems, sometimes keloid structures, sometimes other valves, cardiovascular disease, complications from lung issues, or accumulated damage from waiting too long to have the first valve done. To clarify for those who might not have seen it in this context, morbidity means disease, not death.

With proper warfarin use, and avoidance of cretins who would have patients go off Coumadin for a hangnail, I am certain (as certain as I am allowed to be as a nonprofessional on this site) that the thromboembolic event percentage would be cut deeply, perhaps in half or better. Warfarin-educated health professionals could change this statistic immensely. Those who listen to Al Lodwick and their fellows here, refuse to go off warfarin for hedging dentists, and demand bridging for other procedures are a big step ahead of the percentages, in my mind. They are not playing into this unnecessary statistic.

As with other statistics, don't read more into these than is there. Some events may be multiple events for the same (unlucky) person, who may not have been knowledgeable about their warfarin, or may have had complementary problems that heightened their valve issues.

Interesting note: endocarditis seems to be relegated to the beginning of new valves' lifecycles, hinting that once the epithelium is healed, the incidence drops dramatically (perhaps to "normal" levels). This goes toward validating a longstanding suspicion of mine that our long-term risk for endocarditis is often misrepresented because of the much higher risk just after surgery.

I favor tissue valves whenever appropriate. However, there are times when a mechanical valve is probably the wisest choice. And a heckuva lot of gray area in between. I would not want to gloss over the value of mechanical valves for those who benefit most from them, or who make them their choice.

Best wishes,
 
Second Look

Second Look

PJ,
You might choose a tissue and this is okay, but has your cardiologist and surgeon informed you that your choice may be dictated by bi-cuspid and aorta tissue problems? There has been much discussion on it here and if you do a search, it should bring of lots of threads. Sometimes, because of these special tissue problems, a mech. valve may be in your future. Good luck.
 
RCB said:
PJ,
You might choose a tissue and this is okay, but has your cardiologist and surgeon informed you that your choice may be dictated by bi-cuspid and aorta tissue problems? There has been much discussion on it here and if you do a search, it should bring of lots of threads. Sometimes, because of these special tissue problems, a mech. valve may be in your future. Good luck.
You bring up an interesting issue. My entire aortic root and ascending aorta through the left common carotid artery will be replaced. I am told that during embryonic development the aortic valve and all aortic tissue up to and including (at least, not sure if it continues up the innominate or LCC arteries--not sure I want to know :confused: ) the origination of the LCC forms from the same cells. Consequently, all this tissue, I am told, is abnormal. I have not explored the possibility that the adjacent heart tissue may also be abnormal.

Your speculation that a mech valve may be in my future seems to intimate that the remaining heart tissue may be abnormal and not able to withstand multiple operations. Or maybe you were assuming only replacement of the valve and not the root, which would mean leaving "known" abnormal root tissue in place? Either way, I will look into this. I am having genetic testing next Thursday (to identify whether I might have Marfan's, rheumatoid arthritis, other lovely familial goodies). The geneticist is probably just the person to ask about this.

Thanks for your insight.

P. J.
 
I wasn't given a choice, the surgeon just told me when and where to report for surgery. we did not discuss valves....pros or cons.....we (he) just did it......
 
PJ,
There are other on this forum that have your condition and if you PM them I'm sure they would be glad to help you. My valve just wore out and was not anywhere as complicated as what you have. Some of the members here know the best surgeons for these special cases. I'm sure you will do fine :)

PJmomrunner said:
You bring up an interesting issue. My entire aortic root and ascending aorta through the left common carotid artery will be replaced. I am told that during embryonic development the aortic valve and all aortic tissue up to and including (at least, not sure if it continues up the innominate or LCC arteries--not sure I want to know :confused: ) the origination of the LCC forms from the same cells. Consequently, all this tissue, I am told, is abnormal. I have not explored the possibility that the adjacent heart tissue may also be abnormal.

Your speculation that a mech valve may be in my future seems to intimate that the remaining heart tissue may be abnormal and not able to withstand multiple operations. Or maybe you were assuming only replacement of the valve and not the root, which would mean leaving "known" abnormal root tissue in place? Either way, I will look into this. I am having genetic testing next Thursday (to identify whether I might have Marfan's, rheumatoid arthritis, other lovely familial goodies). The geneticist is probably just the person to ask about this.

Thanks for your insight.

P. J.
 

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