Risk of reoperation with tissue valve vs. warfarin

[Guest]

This was just published in the journal Heart Surgery Forum
Background: Many patients are advised to have mechanical aortic valve replacement (AVR) because their expected longevity exceeds that of tissue prostheses. This strategy may avoid the risks of reoperation but exposes patients to the risks of long-term anticoagulation therapy. Which risk is greater? Methods: We reviewed the records of 1213 consecutive, unselected AVR patients, 60% of whom had concomitant procedures, who were treated from 1994 through 2002. Of these patients, 887 were first-time AVR patients, and 326 underwent reoperation. Of the reoperation patients, 134 had previously undergone AVR (redo). We constructed a risk model from these 1213 cases to assess the factors that predicted mortality and to examine the extent to which reoperation affected outcome. Results: Multiple logistic regression analysis indicated that factors of reoperation and redo operation did not predict mortality. In fact, the mortality rate was 4.1% for all first AVR operations and 3.1% for all reoperation AVR ( P =.891). Significant predicting factors (with odds ratios) were reoperative dialysis (6.03), preoperative shock (3.68), New York Heart Association class IV (2.20), female sex (1.76), age (1.61), and cardiopulmonary bypass time (1.26). Conclusions: In this series, the risk of reoperation AVR is comparable with the published risks of long-term warfarin sodium (Coumadin) administration after mechanical AVR. Any adult who requires AVR may be well advised to consider tissue prostheses.

 

[ShezaGirlie]

Why am I always a day late and dollar short..

Thanks Al -- just another reason for a tissue valve vs mechanical and Coumadin for life. Wish you could see my foot where a guy stepped on it at a formal dance the other evening -- entire outside half is black and blue.. And it usually takes at least a month for a bruise to heal...sometimes longer.

Have I mentioned that I hate Coumadin and dance floor hogs??

 

[Birky]

risk

risk

Do you think this applies for the mitral valve also? I know what you are talking about since I look like that I have been beat up all the time. Bruise so easy. My INR was 2.7 this Mon. so maybe this is the reason.

 

[Guest]

It does not seem like it would have been that hard to study both types of valves, does it?

It causes you to wonder if what they found did not fit their preconceived hypothesis so they did not publish it. Sort of like the news media. If it doesn't fit our agenda, you won't hear about it. It quickly becomes news that is not fit to print.

 

[Marty]

About 6 months post op our heart surgery department asked me to give a talk on warfarin at their weekly staff conference. I told them what I had learned from personal experience, vr.com, warfarinfo.com, and a pretty serious search of the literature. I mentioned the problems going home 4th post op day, the uncertain "handoff" to the PCP, and then the trials and tribulations of dealing with the central lab and getting "managed" from the PCP's office.In the discussion period one of the heart surgeons age 50 said if he needed a valve he would definitely go tissue to avoid coumadin. The prospect of having a second operation in 10 some years wouldn't bother him. I thought he was nuts at the time but it looks like this is a more and more prevalent view.

 

[Johnny Stephens]

As the tissue prostheses continue to improve, I suspect this tide may turn more convincingly. My first operation almost did me in - I'm for whatever keeps me out of the operating room in the future. At the time, it appeared that mechanicals were the clear winner. As Marty says, this may now be a wash.

But is this the only study of its kind out there?

 

[xtremlee]

IM with Johnny on this one.

 

[tobagotwo]

I think this just levels the playing field. I think most of us tissue touting types have suspected that the odds were equal for a long time.

However, especially with the new types of mechanical valves, I don't think this really changes the main issues. The new mechanicals are better, smoother, less apt to damage their mountings, have better flow characteristics, do less blood damage, and require less stringent anticoagulant therapy. Aspirin ACT may be an eventual option. Or less Coumadin. And, of course, most of the "old" mechanicals will keep ticking until the owner quits them for some other reason.

And the tissue valves keep improving, too. New treatments to reduce calcification and extend useful life.

Oy! What a mixed message: you celebrate your 1-year anniversary of valve replacement, but it also means that you now own "last year's model." Give us a break!

The tissue valves still require reoperations, barring auto accidents. The mechanicals should still outlast the recipients, but require semihazardous warfarin treatments. That doesn't change. Surgery:Yin. Coumadin:Yang. The serpent biting its own tail.

 

[Peachy]

This is good news for people like me who chose to have a pig valve rather than have to take coumadin. Second time round however I'll probably have to go mechanical unless as I'm hoping there will be tissue valves which "last a lifetime".

 

[Gail in Ca]

Crap!!!! I sure liked that porcine valve I had for 11 yrs and would've liked to have another, but nooooo, I had to have mechanical to avoid a 3rd surgery, which I will probably need anyway. We are often told the scar tissue around the valve is the issue, but is it really??
Gail

 

[LUVMyBirman]

Depending upon your age....either valve choice opens one to the possibility of a redo. When I went mechanical.....they told me lifelong. It did not take me long to figure out that they were basing that information on data that included 65+ somethings. Not 30 year olds.

I was recently advised that I should get 15-20 years more on my mechanical. Just over that 5 year marker. This was based on a average from my cardios patient base. Generalized statement sure. Can only hope at that point there is a valve that will last the rest of my life making #3 a non issue. If I took the tissue valve at 30, another at 40, 50 (the questionable #3)? If that works....60 #4.

Would rather role the dice with the Coumadin. Recovery from surgery was not a high point in my life.........would prefer to stay away from the OR

PS. Hey Gail....how are you girl? Don't worry about scar tissue..if you have a magic pair of hands they will pull you through

 

[Les]

You know...being that we are all members of VR.COM means we already have a valve of whatever type implanted and many of us in life threatening situations had no choice in the matter. Thus, we can't do anything about it so why worry? We could be stricken with a fatal disease or hit by a truck before another replacement is necessary. I've been through 2 surgeries,(mechanicals can come loose...) others have been through three or four...Just live life the best we can and play the hand that was dealt us.

 

[Ross]

.......but what if I don't want to play cards anymore? There is no doubt whatsoever in my mind that I would not make it through a third time around at this game.

 

[Nancy]

I believe that Joe is very high risk now for any future operations. I think he would have to have one eye closed and the other half shut before thay would open him up again.

I know doctors and surgeons have said that they would charge ahead with any redos they would need on their own body without hesitation. I suspect that this view is from those who have never experienced the actual operation.

The view is much different when you are looking at it from a a remote position.

Having helped my husband through his multiple valve surgeries and lung surgeries, I can tell you that it takes a toll on the body which increases each time the body has to recover from repeat major trauma.

I still feel that anything you can do to avoid repeat surgery is a very good thing.

I realize that there are NO guarantees on any surgery, even mechanicals. But with a tissue valve you are certainly going to have to have one or more redos in your lifetime.

At the time that Joe had his original aortic mechanical implanted, 1977, his other choice was a porcine valve which his body could not tolerate, so he got a mechanical. That is still in there, 26 and a half years later. Unfortunately over the years, he's had to have additional surgeries on his mitral valve.

I have said this before and I still feel that there needs to be studies done on the effects of repeat major trauma to the body and what permanent effects there are. That is the information that is needed to make this above study complete.

 

[McCln]

I have seen in the last three years, no matter which type of valve you have, you will eventually will have a redo. That is always a possiblity. I will keep my mechanical one till it does fail and check out the new advances when I need to. Medical science changes things all the time. I hope that one day we mechanical valvers will be able to be off coumadin. Till then, I will take all the advances in stride.

Caroline
09-13-01
Aortic valve replacement
St. Jude's valve

 

[KathyH]

Geez, just getting over having my surgery, I can't deal with this thread. At 50, I chose the mechanical hoping never to have to go thru this again. Nothing I have read here as made me this nervous since before my surgery. Did you have to spoil my positive recovery?
I know anything is possible, just hope I can keep my valve working forever. As far as being on coumadin, I honestly bruised more when I was on ASA and vitamin E. Like I read before, make your valve choice and don't look back.
Kathy H

 

[tobagotwo]

Rethinking your valve choice after surgery is like replanting cut flowers. It's physically possible, but nothing of any value will come of it, and the beauty that was to be had is lost.

Enjoy your new valves, and the freedom they have given you to live your life again. Every working valve is a blessing to its owner.

No matter which way you go, once it's done, it's all good...

 

[Guest]

There should be nothing here that makes you nervous or regret your choice. The point is that the choice should not be made solely on the basis of warfarin or not.

If you haven't read much of the Coumadin Forum please do so.

I have been monitoring warfarin full-time for 7 years. The risks are this:
You will average a bloody nose about every 18 months.
You (KathyH) will probably not have a bleed that requires a transfusion because they happen at the rate of one every 33 patient years. Neither will you have a major clotting episode since they happen at the rate of 1 every 100 patient years - maybe a little bit higher in valvers since my clinic is anyone on warfarin - but I'd still bet big money against a clot happening in any one person's lifetime.

Also please look at my website www.warfarinfo.com it has about 200 pages of information.

 

[ticktock]

What a great thread. In response to your comment Nancy;

"I still feel that anything you can do to avoid repeat surgery is a very good thing." You are on the money, girlfriend. No one will convince me that Coumadin is "worse" than a repeat surgery. I had to beg a Surgeon to go back in a fourth time, and that was done with a lick and a promise. Here I am 5 years later, and still tickin'.

I also agree with the repeat trauma question. There is no doubt that I lost "some" cognitive function with the last surgery, and looking back, I probably declined after the third. I am a high functioning individual, relatively speaking. Although they have retired me from work at 48, I live a wonderful life.

Coumadin is NOT the kiss of death!! Joe and I (and Nancy) know that long term use can be well tolerated. It just takes some discipline, monitoring and caution. Sheesh, I'll take this over a major stroke or diabetes ANYDAY!
mindy

 

[Brian]

Isn't it a fact that after a tissue valve that Warafin has to be used for at least 3 months and possibly forever depending on the situation? We all hope that which ever choice that we have made is the best choice for ourselves. I repeat, there is no right or wrong choice, only the best choice for ourselves. Bob is right, once it is in, make the best of the rest of your healthy life and don't worry about the what if's. If you are still deciding on what to do, take all the info and advice that you can get. If it helps, write them all down on a piece of paper and list the pros and cons..then make as much of an educated decision as you and your doctor can do. No matter what we do in life, we always second guess ourselves. Don't let this get any of you down. It is in fact just more information that we need to instill in our minds. Now 8 weeks post OP with a mechanical valve, I am still a new comer to this all. Yesterday I was told for the first time in eight years to go home and do what ever I want to do...NO LIMITATIONS...what a relief!! The worry about dropping to my feet from my old valve closing off and not allowing any emergency personel to be able to do anything for me was a by far much BIGGER worry to me than now when I am feeling like a new person with a new valve. What mother Nature gave me didn't last.....maybe what man gave me won't last....BUT...now I know it can be fixed and can be fixed very well.
I am just so happy to have a new lease on life that any second guessing is a long way out of my mind. I am repaired, I can do a lot more things and I know it will just get better and better and that is the only way I can look at things. I can't second guess, cause I don't know what it would have been like with any of the other procedures, all I know is right now...and how I am!!! ...and I am doing FANTASTIC!!!!!!

Have a good weekend everyone!!