Second AVR Concerns and Questions

[pellicle]

Hi there ... hope you're well

Cathy, I'm in your predicament but I'm older at 65. I have a tissue valve and it's 12 years old. I will need a replacement some time in the future but don't know when. Currently, the valve has moderate to severe calcification.

Calcification of the valve is a significant problem in TAV ... the problem is that inserting the valve tends to knock off the calcium depsosits and they need to be trapped so as to not circulate in your blood and block things (meaning cause strokes)

I recommend you read this article (not a journal, but still)
https://www.tctmd.com/news/bicuspid-patients-calcification-fare-worse-after-tavr-device-type-matters

Device type is listed as a major issue:

Among patients treated with CoreValve, Sapien XT, and Sapien 3—the three devices most commonly used—30-day mortality rates were highest among those with calcified raphe, ranging from 9.3% with CoreValve

nearly 10% died ... not good

On the subject of durability I strongly recommend this 2017 article
https://www.tctmd.com/news/tavr-durability-some-reassurances-corevalve-trials-out-9-years

some key observations to my eye:

Session co-chair Raj Makkar, MD (Cedars-Sinai Medical Center, Los Angeles, CA), told TCTMD the “great news” now is that 30-day mortality and stroke rates are around 2% across a wide range of TAVR devices, with 1-year survival of around 90%. “I think it tells us the devices have matured and our technique has matured,” he commented.

30 day and 1 year out ... these are "long term" for them, but not me ... when I had my 3rd valve I hoped to live another year with greater certainty.

“What we can say is that the current data sets are limited in terms of making any definitive conclusions about durability because of the competing mortality risk in this patient population,” Makkar said.
...
The number of patients was so few at 9 years that investigators truncated their analysis at 7 years, when the mortality rate was 68.1%.

But comparing Standard AVR and TAVR:

Signs of bioprosthetic valve dysfunction - including issues that were structural and nonstructural and endocarditis, but no cases of thrombosis - occurred at comparable rates after TAVR and SAVR at 55.4% and 65.2%, respectively, through 5 years (P = 0.10). Bioprosthetic valve failure—including valve-related death, aortic valve reintervention, and severe hemodynamic structural valve dysfunction—was seen in 8.5% and 9.5% of the patients in the TAVR and SAVR groups (P = 0.89).

I'm unclear what their wording means "but no cases of thrombosis" ... does mean there were none or that they were excluded? None is unusual.

“It’s so challenging to look at long-term morbidity of valves, and probably it will take something like 3, 4, [or] 5 years until low-risk and some of the intermediate-risk patients survive enough and we’ll have a large pool of patients that will give us the magnitude to really do statistical analyses,” said Dvir, who was summoned from the audience following Søndergaard’s presentation. “But it’s a moving target,” he added, “because the valves change.”

by Danny Divr, MD (UW Medicine, Seattle, WA)

meaning patients die before they get a long term look, which explains why they are quickly fishing around for youger takers. It may well be that they get 90% of the life of the current tissue valves. We just don't know ... myself I can't in good conscience recommend that path to anyone.


you write:

I think the jury is still out on how long they last. It's certainly worth asking the question anyway. I've been shocked by the interest there is in TAVRs in my case which I should say hasn't been looked at carefully yet.

I would say the Jury is still out, but that early evidence does not suggest its a good choice for an otherwise healthy person under 50 ... as to why there is interest in you, I'd say its clear - they are looking for healther subjects who can become part of their experimental data.

Changing the subject a bit, there are a lot of things that worry me about warfarin. I've known a lot of people on it including my Dad. Some people seem to do so well. Their diet and exercise hardly seems to be affected at all and others have had a hell of a time.

I'm curious about your fathers situation. The things you say here pique my curiosity because as far as I know everyone here whos a long term warfarin person has little or no impact on diet.

Why was he required to keep his diet consistent? Was this because of the ineptitude of the management team? None of us here try to keep their diet consistent, indeed the overwhelming message searching through all the threads going back over 10 years is to just "dose the diet" ...
How frequently were they measuing his INR? Weekly? Daily?
What measures were in place to allow double checks that he had not missed a dose or taken two (Eg pillbox and monitoring schedule, daily reminders on phones ... that sort of thing)
Was your father cofident in his ability to think and do these tasks?

My Dad couldn't wait to get off of it because he was bruising so easily

this strongly suggests an INR that was > 3 ... what sort of records of INR do you have?

I ask these things because its actually the critical point in management. Its actually what is the only important thing (diet isn't).

Anyway, for someone at your age and in your position I would not strongly advocate for a mechanical for you. Surgery to replace your existing valve is still some years away, by which time a tissue valve will more than likely give you a run to your 70's.

Best Wishes

 

[user 15848]

Hi Cathy

do you have any reasons that warfarin will cause you any difficulties (I mean apart from general fears)?

I am actually a convert to seeing that warfarin is actually a very well understood drug and is very easily controlled. I recommend you read my blog posts on that and also this post on making decisions.

http://cjeastwd.blogspot.com/2014/01/heart-valve-information-for-choices.html

on managing my INR
http://cjeastwd.blogspot.com/2014/09/managing-my-inr.html

and everything on my blog on managing INR (even around subsequent small surgeries)

http://cjeastwd.blogspot.com/search/label/INR

I've had 3 OHS, and on my third at 48 I chose mechanical.

The procedure to go through the groin is a TAV and to be honest is a temporary fix which will not last as long as you've already had from your tissue valve.

My view is that unless you have significant co-morbidities that weigh against warfarin that you should consider that you've kickked the can down the road, seen for yourself what happens with that and consider seriously a mechanical valve.

do you have any sign of aneurysm? (that's actually an IMPORTANT question.

Best Wishes

Pellicle's articles and messages were of extra ordinary importance to me while deciding what kind of valve to choose,

 

[Zoeey2011]

I am a returning member of this group. I was a member 12 years ago before I had my first OHS for a AVR. I was 44 and chose a tissue valve. I have had no problems whatsoever until now. I am now getting ready to turn 56 and am looking at a second AVR. I am having a difficult time deciding between another tissue valve or going mechanical. I am not a fan of warfarin and it worries me to be on this drug. I am a very active young 56 year old and don’t want my lifestyle to change. I am in perfect health other than the valve. I am afraid the warfarin will cause me to have other health problems. My questions to you all is this: 1. Who has had a second AVR and what type of valve did you choose? 2. Has anyone had the procedure where they go up through the groin area instead of opening you up?

I relied on this website the first go round and it really eased my worries so I am going to ask you all for help again. Thank you so much for making this easier.

Just like you I chose to have a tissue valve done in 2005 because of my fear of warfarin. In 2011 I had to have replacement surgery because the valve calcified after 5 1/2 years. My surgeon recommended a mechanical valve because the tissue valve calcified so fast. I have been on warfarin for almost 9 years now and have not had any problems. My INR range is 2.5 - 3.5 and I have no problem keeping it in that range. Hope this helps you.

 

[vitdoc]

I am 70 and have been on Warfarin since I was 34, 36 yrs. I have had three aortic valves. The first was an early tissue valve in 1977 which lasted 5 1/2 yrs. In those days I don't think they knew the expected longevity of the tissue valves and the mechanical valves were so so. The last valve was placed 12 years ago along with a new ascending aorta and a pacemaker. I was 58. The surgeon said you don't want to have another open heart so I had a St. Jude placed with the aorta. I had a previous St. Jude for over 20 years. Yes I would love not to take Warfarin. I bicycle a lot and I have fallen a few times. Once I lost about two units of blood in my leg and it took about 8 wks to recover. Once I had an unusual vasular process cause bleeding in my lower intestine that required stoppage of the anticoagulation and a surgical intervention. Otherwise no significant issues in 36 years. I also was not very careful with checking the INR probably for the first 25 years. Now I have a CoagCheck and check from time to time.
If I had a new valve today I might choose a tissue valve at age 70. I probably would get 10 years out of it. Then maybe a TAVR like technique might get me home. But if I was 50 then I don't think I would want to deal with multiple potential procedures. As far as I know TAVR can only be done once.
I also don't worry about NSAIDS unless I were to use them chronically. Even then with proton inhibitors such as Prilosec the irritation issues can be managed.
I also skied for 30 years on Warfarin without any issues. Not great to be on it but not that bad either.

 

[Chris]

The more I read, the more I appreciate everyone on this site. What a priceless resource.