Ross vs On-X

[jumpy]

I've been upgraded now to first class on this website and after 44 years with my trusty bicuspid aortic valve it's time for a replacement. It's seen me through a marathon, several half marathons and a couple of triathlons. I'm now looking at September or October surgery before I can get my endeavours back on track. I still have to meet the surgeon but I have been interested in the Ross Procedure for a while. It seems however that this is falling out of favour and I'm wondering why? If you have an experienced surgeon doing a modified Ross, should that not limit the risk of re-operation? It has the best hemodynamic characteristics being a native valve....

Barring that for me it's only the On-X valve as a backup. Tissue valve would put me in the same position of waiting and wondering that I've been in for a while. I know that I need something that will allow me to get past the waiting game.

Anyone know the re-op rates for Ross vs Tissue valves? Especially in active middle aged patients?

 

[epstns]

I can't help with regard to the Ross procedure's statistics, but maybe I can help a bit regarding tissue valves. There it depends upon where in middle age you might be. At the moment, in the US, hospitals seem to be recommending tissue valves for patients even just past their mid-50's. (To me, that is young middle age. I'm 67.) I was 63 at time of valve replacement, and there was no push-back when I told my surgeon that I was leaning toward a tissue valve. The surgeons feel that the newest (3rd) generation of tissue valves are projected to have service life spans in excess of 20 years, so they feel that for most patients in their 50's and older, the valve (on the average) will last the remainder of their natural lives. This is all built upon projections, averages, and statistical models. There are NO guarantees (and I suppose that also holds true for the Ross) in this game. All you can do is evaluate the information, make your own informed decision, and then go on with your life.

Also, from the little I (think I) know about the Ross procedure, they move your native pulmonary valve into the aortic position, then implant a prosthetic valve in the pulmonary position. I do not know how the various artificial valves perform as pulmonary valves. Someone else will have to help us with that.

Maybe pellicle has some info. . .

P.S. Being active will keep you and your heart healthy, but it will have no impact on the longevity of your valves. As long as you allow proper time for healing, normal activity (with the possible exception of heavy weight lifting) won't hurt your valves. They won't wear out before the rest of your body does. The calcification that may affect tissue valves is the result of your immune system. The valve leaflets will not suffer "fatigue" failures.

 

[jumpy]

I am 44 so I think even with the newer generation tissue valves I wouldn't be close to the high end estimates for tissue longevity. The Ross interests me because the normal risk to re-op is the potential for aneurysm which is somewhat mitigated by the modified reinforcement of the aorta. The variable is the valve put into the pulmonary position which can also break down. It does offer a more natural flow and a return to an active life.

Mechanical is my fall back and my only reluctance is the noise and management of INR. I know that I can manage it myself but I still worry about whether it would fit into my active life. I am fairly thin and hear my heart when trying to sleep now and fear having the noise be a constant companion.

 

[Lawdog]

Jumpy: I would be surprised if they performed a Ross on you. I am 40 and due for surgery in August to repair an ascending aortic aneurysm and to replace my aortic valve. I inquired about a Ross and I was told that these days a Ross is a good procedure for a child or a teenager who requires a valve that will grow them, but is heavily discouraged in adults in their 40s. Besides the transferred pulmonary value does not last long in the aortic position, requiring another replacement any way. A guy in his 40s is better off keeping his pulmonary value where it is and choose an artificial valve to replace the aortic valve.

 

[honeybunny]

Jumpy, I cannot speak to the Ross procedure, but like you I don't like to hear my heart beat and am concerned that a ticking mechanical valve would freak me out. I found samples of ticking mechanical valves on YouTube if you want to listen.

I also was not keen on taking Warfarin for the rest of my life even though I am rather sedentary. I am 60 and would rather face a second surgery if needed.

Those are my thoughts for what they are worth.

 

[jumpy]

Interesting article from 2011 from a doctor that specializes in the Ross Procedure. It sounds like the successful outcome (probably more so than other valve replacements) is the experience with the surgeon doing this procedure.

http://www.researchgate.net/profile/...&inViewer=true

It seems anecdotally there are many online having had successful outcomes from the Ross in their 40's. To me it's the age where we are too young for a tissue valve and also having to face blood thinners for a longer duration.

No closer to deciding....but thanks for the discussions.

 

[MrsBray]

I love my On-X! It's not loud (to me), I hear it about half the time. It's like living next to the train tracks, pretty soon you don't even notice! Warfarin has been a non-issue for me. I'm more active and eat better, but have not changed my diet or lifestyle due to warfarin.
All that being said, it took me about a month to decide what kind of valve I wanted. My cardiologist suggested tissue, so I wouldn't have to limit my activities due to warfarin, and also in case I wanted to have a baby (NO WAY! ) My surgeon recommended the mechanical, due to my age - he showed me evidence that shows tissue valves don't last as long in younger patients. In the end, it was my decision. And when I made the choice, I simply stopped discussing with anyone. My heart, my choice. End of story.

Best of luck to ya!
-Meredith

 

[Fundy]

http://circ.ahajournals.org/content/122/12/1139.full

The above linked article may provide some data for you. It seems from the studies mentioned in that article that freedom from reop in one study was 56.7% at 13 years for those 16 years of age and up. While another study mentioned freedom from any cardiac reoperation of 85% at 15 years from operating date.

My feeling on this would be make sure you have a surgeon who has performed many ross surgeries and has very good results. But even if you go the Ross route you will still always be waiting and wondering, almost similar to the wait and wonder of the tissue valve which you mention wanting to avoid. The difference is it may just last forever whereas with the tissue your almost assured it will fail.

 

[Agian]

Honeybunny, I read somewher, the ATS valve is particularly quiet. I think Pellicle has one of these.
http://www.ncbi.nlm.nih.gov/pubmed/17592425
http://www.medtronic.com/for-health...s-surgical/open-pivot-mechanical-heart-valve/

 

[pellicle]

Hey ... just flicked over and saw my name

Honeybunny, I read somewher, the ATS valve is particularly quiet. I think Pellicle has one of these.

yes, I've got the ATS (now sold under "medtronic" label) people in the office (even when I'm trying to get them to hear it) can't. I can't really hear it either but I can sort of "feel" it. So far the main person who has heard it is my wife ...

as to a Ross ... my personal opinion is I would not do it unless there was some reason that I couldn't get a mechanical. It was never discussed with me at any stage in my medical history. I've read too many posts here of people who hoped to get more time but didn't. Further there will be more scar tissue from the surgery as you have to pull out two valves to fix one, this can only complicate redo operations. Sure redo operations are getting better but no professional surgeon will tell you a third op is a cakewalk. If you are younger and get a valve that lasts you 10years ... say 30YO, then its not looking good.

I have had 3 OH surgeries, one valve repair and then a homograft, then a mechanical. I would rather not have to face a 4th.

As mentioned above I understood "the Ross" is promoted for other reasons. The issue of being on warfarin for a longer duration is perhaps an issue or (likely) perhaps irrelevant in todays world of modern electronic self testing. The idea of a needle suck of blood from a vein is so twentieth century and can you imagine a diabetic (who tests many times daily) switching to that from self testing?

 

[epstns]

To those who complain that they can hear their mechanical valves, let me paraphrase a quote from the late Ross Young (former long-term member here), who had a mechanical valve:

"With my mechanical valve, the only time I worry about hearing it is if I were to hear it stop ticking."

Having a tissue valve myself, I can't speak from any experience, but I think hearing the valve would be low on my personal list of worries. Just wear a mechanical watch and tell people your watch is loud. (Just kidding. I know this is a major decision, but I'm just trying to inject some humor into the discussion. No offense intended or implied. . . )

 

[tom in MO]

I have a St. Jude mechanical and am overweight. I cannot remember the last time I heard my valve. No I am not going deaf The sound decreases with time and whether or not you hear it depends upon what you are wearing and the acoustics of the room you are in.

 

[jumpy]

Just found out my valve is down to 0.7cm...yikes. And I was about to participate in a triathlon...
Looks like I need to hurry with my decision.

 

[pellicle]

Hey jumpy

Just found out my valve is down to 0.7cm...yikes. And I was about to participate in a triathlon...
Looks like I need to hurry with my decision.

Well I'm known here for advocating mechanical valves for folks between 30 and late 50's

Warfarin is a boogy man (which scares kids) but the reality is when you turn the lights on (like information tends to do) there is nothing under the bed or in the closet.

Some food for thought.

http://cjeastwd.blogspot.com/2014/01...r-choices.html

And on the management of INR
http://cjeastwd.blogspot.com/2014/09...ng-my-inr.html

Both are lengthy posts with references and data to support my views.

Search for posts by SkiGirl. She is a smart and educated woman who has a mechanical valve and does surf ski and triathlon events. I just do XC skiing, hunting and hiking.

No matter what you decide the choices are all A class choices

 

[Nick17]

Hi Jumpy:

My story began in 02/2015 57yr old, originally diagnosed with BAV, w/regurgitation. Local Cardio advised to wait and monitor at 6mo interval ecos. I spent little time in the waiting room.

From 02/15-05/15 regurgitation went from mild to severe, as my condition rapidly worsened. On 6/2/15 OHS w/MHV, 23mm Onx. Full sternotomy went textbook and immediately felt better.

At 4wks post op I returned to work and most activities incl driving. At 8wksfeels like full recovery is in sight and I feel good as new. Inr is stable, within range and looking forward to self-monitoring after 3 mos.

Almost immediately after my OHS, I no longer felt sick…that feeling my heart was drowning disappeared. Post op pain and discomfort for me became a good pain…the pain associated with recovery and absent of pre-op symptoms….the kind of pain only all of you folks could understand.

I just had an 8wk echo which showed a well seated annulus and no leaks. The valve has not been noticeable at all to me or others. I can feel the valve but I cannot hear it. The only way I have been able to hear the valve is with a stethoscope .

Don’t know much about Ross Procedure except that it’s much more complex from a surgical and outcome standpoint. I assume that if your surgeon is thinking Ross he must be top notch in his field.

The current generation pyrolytic carbon valves, (SJM/ATS/Onx) are all very similar in design and performance. It comes down to surgeon’s expertise and hospital stock. Not all medical facilities fully stock Onx and since size/fit is critical, you could go in thinking Onx and come out with another valve. Bottom line, if you are well informed and on the same page with your medical team, you can’t go wrong and will be most happy with the results.

You’re on your way to feeling better and better health. Best of luck and looking forward to hearing of your full recovery.

Nick

 

[Tank]

Hey Jumpy, I to gave up my ole trusty bi-cusp at the age of 44. For whatever reason at the time my Dr. and I discussed valves he recommended a bovine. Now almost 10 years to the month its time to give up to the knife again. This time with the surgeon is going with a mechanical and wondered why he didn't do this to begin with. The biggest concern at the time 10 years ago was that I did not want to be on thinners for the rest of my life, by todays standards they have improved the medicine and certainly the valves since then. I don't mean to confuse you but just to let you know, it sounds to me that you are plenty active and that may mean a shorter life expectancy for the valve, Talk to your doc and consider the best choice as everybody is different.

 

[rge177]

Jumpy, I'm 55 and getting ready to get a new aortic valve and my surgeon gave me the choice of the Ross, ON-X, or Bovine. I'm leaning toward the ONX now that a reduced amount of warfarin for this valve has gained FDA approval. I have a surgeon that specializes in the Ross procedure, but so far I haven't been able to justify the extra up front risks of the operation (and more complicated re-op risk if necessary), vs the long term risk with the blood thinner. I see it as really coming down to a gamble. You take a lot of the risk all at once, or kick that risk down the road over 30 or 40 years (if we're lucky.) I think the Ross procedure is a good option, IF, you have a surgeon that has a lot of experience with this procedure. Good luck to you in whatever direction you go. Let us know your decision when you figure it out.

 

[jumpy]

An update. Met the surgeon and he was quite clear about the risks of the Ross procedure. I'm no longer sure that the risks outweigh the reward. I really feel like I'm back to square one. Despite the risks though he indicated that if it were him it would be a toss up between the Ross and a Tissue. So far I have yet to meet ANY doctor that hasn't expressed reservations about the risks around long term blood thinner use. Is this a common response in the medical community? How does anyone end up with a mechanical valve if the established advice is the avoidance of Coumadin?

So confused and frustrated. Oh, and they wouldn't use the On-x either. His preference would be St. Jude as it has a more proven track record. So there is that too. I only have a few weeks to decide now....

 

[dick0236]

How does anyone end up with a mechanical valve if the established advice is the avoidance of Coumadin?

.

IMO the reason for OHS is to "fix" the problem and not just to "kick the can down the road" for a few years and then do it all over again....just to avoid a little pill a day. Mechanical valves are designed to last a lifetime....tissue valves are not.........so why would I, as a younger person, opt to repeat the experience a few more times. If I had to have the surgery at my current age(80) I would opt for a tissue valve since I probably would not outlive it. If I where young again(31), you can bet I would go mechanical.......again.

 

[almost_hectic]

Well there you have it. What better testimonial than from the guy who's had a mechanical valve and been on warfarin for almost 50 years with no issues, diet, or lifestyle changes! That just reinforces my choice in a mechanical valve at age 44. It sounds to me like your surgeons attitude toward warfarin is pretty outdated. There's so much more information about managing the drug now days and dosing and monitoring has become a far better science as well. When the drug is working properly it really has no almost no potential side effects. My surgeon never even considered a tissue valve for me. He's very big on advanced techniques and technology in all aspects of patient care.