Second Opinion

[Jimmyk]

i was just diagnosed with Aortic Stenosis, and would be needing a Aortic valve replacement
After the shock started to wear off , my wife and I had been talking about the surgery.
As a relatively healthy 52 year old male, who has heart disease running on my fathers side, I've decide to have the surgery,but would really like to get a second opinion . The dr. we spoke to the other day, says it would be a minimally invasive surgery ,through the left side of the rib cage.
Without putting hospital names out there, we decided to look up the best hospitals in Florida to have this surgery done.
We reside in the Orlando area, and noticed the hospital that we've be going to, is nowhere on the list.
We then looked up reviews of this hospital , and found neumerous 1 star reviews, with many complaints.
There is another hospital in the area, that was towards the top of the list. I sent them an email this morning,and was given a conformation of my mail with a promise to get a return call in one or 2 business days.

A question, for anyone who has had this procedure.
ive been kind of leaning towards the mechanical valve, due to its longevity . Then again, there is risk of stroke with these valves & id be on blood thinners the rest of my life.

It would be great to hear of benifits of both types of valves, biological & mechanical, success stories, the down side of the surgery.
The shock has passed, and I'm ready for this if I really need it. Hopefully everyone has a happy Memorial Day , especially those who have served.

Thanks. Jimmy

 

[pellicle]

A question, for anyone who has had this procedure.
ive been kind of leaning towards the mechanical valve, due to its longevity . Then again, there is risk of stroke with these valves & id be on blood thinners the rest of my life.

If you manage your INR properly and stay in range (myself I am in range over 95% of the time), then with out other factors being involved (orher medical conditions not mentioned by you here) then your risk of stroke or bleed complications is about equal to the general population of your age group.


​​​It really is just that simple.

There are the horror story tellers, who aren't usually on warfarin, or are out of date doctors dealing with data from 20 years back VS those of us on it & many researchers. There isn't big bucks to be made out of warfarin as it's about the cheapest drug out there (and redo surgery generates good revenue).


A post from my blog on management of my INR

http://cjeastwd.blogspot.com/2014/09...ng-my-inr.html

Also you may end up on warfarin after a tissue valve surgery anyway if you get afib or your valve decides to throw clots. I'd feel pretty stupid if I talked myself into a redo surgery choice based on a misinformed opinion of avoiding warfarin, to find myself on it anyway & facing a redo in between 10 and 20 years.

I strongly recommend writing it all out on two big sheets of paper, then looking at that as you develop more input.

Keep asking questions here and read old posts ... you will learn a lot and your decision will become clear to you

 

[Jimmyk]

Thank you very much Pellicle.
Appriciate your input.

 

[pellicle]

Thank you very much Pellicle.
Appriciate your input.

You are totally welcome.

Read posts here , heck read my blog to see what my post surgical lifestyle is, and then come to what ever decision you feel comfortable with.


Best wishes

 

[mikeccolella]

My surgeon told me that With the improvements in transcatheter implants the tissue valve not a totally bad choice. He speculated that they will continue to improve that option where it will be a first choice option, but that is speculation. At 64 years of age for my recent operation in February 2017 I did choose a tissue valve. At my age the surgeon said it was pretty much a coin toss. At your age he would have pushed for the metal valve. I guess that makes sense, however before my surgery I resd the following article and it kind of pushed me toward a tissue valve. You might want to check it out.
http://www.acc.org/latest-in-cardio...c-valves-are-better-even-in-the-young-patient

 

[dick0236]

Looking back, a mechanical valve was certainly the best choice for me........and I have no regrets. The pro of a "one and done" surgery has far outweighed the con of 'living with warfarin". Study what you can and make the decision that makes sense for you.

 

[neil]

hiya and welcome, firstly there is no bad choice, which ever you choose is gonna save your life, theres stats to back whichever way you go and in general its a hard choice, some choose mech others tissue, its whats best for you,As I say don't measure your needs using somebody elses ruler lol,, For me it was I didn't want to be on anti coags and the problems that may occur, for others its not wanting another op down the line, although that's no given, good luck whichever path you take

 

[QuincyRunner]

Hi Jimmy,
I had my valve replacement six years ago when I was your age. No regrets about going with a mechanical valve so far. Daily Coumadin has been a non-issue and INR testing at home has been very convenient. My diet is rarely inconvenienced and I am in range 88% of the time. Also, take into consideration that if you are very active, as I am, a tissue valve would probably deteriorate faster that if you were sedentary.

 

[mikeccolella]

Hi Jimmy,
I had my valve replacement six years ago when I was your age. No regrets about going with a mechanical valve so far. Daily Coumadin has been a non-issue and INR testing at home has been very convenient. My diet is rarely inconvenienced and I am in range 88% of the time. Also, take into consideration that if you are very active, as I am, a tissue valve would probably deteriorate faster that if you were sedentary.

Yes your right that while exercising your heart beats faster than when sedentary so it would seem to make a tissue valve wear out sooner. But consider two people with tissue valves one is sedentary and the other exercises a reasonable amount. The liklihood of the exerciser having a lower resting heart rate is much higher and therefore all that time not exercising means less beats and a longer lasting tissue valve. 23 hours a day at say 60 bpm vs say 80 bpm sure makes a HUGE difference in how many beats per day. I got over 27,000 beats more a day for the non exerciser in my example.

 

[QuincyRunner]

Mike - It is my understanding that it is not necessarily the increased number of beats that wears out a tissue valve faster, but rather the increased pressures and turbulences that the valve is subjected to while exercising that causes the damage and accelerated wear. BTW, it is "you're right" not "your right".

 

[pellicle]

Mike - It is my understanding that it is not necessarily the increased number of beats that wears out a tissue valve faster, but rather the increased pressures and turbulences that the valve is subjected to while exercising that causes the damage and accelerated wear.

this is also my understanding, and its added to by the calcification actions and other chemical attacks on the valve created by more active people. There is special treatment of these tissue valves to attempt ward this off. So its not just simple mechanical wear that is tested in a lab by actuations in a tube with an air pump causing operations to simulate heart beats.

Additionally some people have metabolisms which provide a mixture of chemistry in the blood that degrades the "leather" leaflets (I say leather because that's what they are ... bits of leather

I suspect such is at work with say, Paleowoman who has just had a new generation tissue prosthetic valve calcify to the point of replacement in a few short years. It can not be just mechanical wear.

 

[Paleowoman]

I suspect such is at work with say, Paleowoman who has just had a new generation tissue prosthetic valve calcify to the point of replacement in a few short years. It can not be just mechanical wear.

No calcification has shown on up on either of the recent echos, nor on the CT angiogram. Next is the TEE (TOE) in just over two weeks' time to get a better look at the valve.

 

[pellicle]

No calcification has shown on up on either of the recent echos, nor on the CT angiogram. Next is the TEE (TOE) in just over two weeks' time to get a better look at the valve.

that's good to hear, and I'm glad I got that wrong. So there is no stenosis of the valve then?

 

[Paleowoman]

that's good to hear, and I'm glad I got that wrong. So there is no stenosis of the valve then?

There is stenosis going by the pressure gradient and the valve area size but it's not clear if this is due to degeneration of the leaflets (non-calcific degeneration ?), or something else (?pannus was suggested to me by someone), or the fact that the valve is simply too small, patient prosthesis mismatch. The initial mean and peak pressure gardients 4 days post op were quite high (17 mean, 33 peak) but that didn't attact attention, and then I developed mild left ventricular hypertrophy which showed up on echo six weeks post op. No LVH prior to surgery or 4 days post op. Pressure gradients steadily increasing, and suddenly sharp rise at echo just under four weeks ago with the valve area dropping to 1 sq cm. The echo which was done two weeks ago was the same pressure gradient result as six months ago, though the valve area was around 1 sq cm again, but it was done immediatley after having had big doses of betablockers for the CT angio !

 

[pellicle]

There is stenosis going by the pressure gradient and the valve area size but it's not clear if this is due to degeneration of the leaflets (non-calcific degeneration ?), or something else ...

sounds very frustrating ... I hope its cleared up and rectified soon.

 

[epstns]

Jimmy - Let me back up a few steps to ask some questions for clarification. You say that you were recently diagnosed with aortic stenosis and told that you need valve replacement surgery. Did they tell you the "stage" of your stenosis? (e.g. Mild, moderate or severe.) It may be that they meant that you will some day need surgery but that day may not be now.

The reason I ask is that these things do not progress in any predictable manner (except maybe that they do not heal themselves). I was diagnosed with moderate-to-severe aortic stenosis at the same age as you (about 52), but I did not need my valve replacement until almost 11 years later. Your age at time of implant will have a bearing on which valves make sense for you, the patient. Had I needed surgery in my 50's, my cardio and I agreed that a mechanical valve made sense. When I rolled happily into my early 60's before surgery (surgery at 63), we decided that the tissue valve made good sense, both due to my advancing age and due to the improvements in valve technology built into the newest (then) generation of tissue valves.

I don't think I've heard of more than 1 or 2 cases of tissue valves failing due to leaflet wear or damage. I have heard of more that failed due to calcification of the leaflets - but so far, those I've heard of failing were "second generation" valves -- not the current "third-generation" valves. Not that they don't or won't fail, but we don't have the data yet to say when.

I never accepted the assertion that trans-catheter valve technology will make my "next" valve a simple procedure. I just accept that fact that some day I may need another valve, and at that time, I may be or may not be able to have it done via catheter.

Also, take a look at the Cleveland Clinic information pages. As early as 2010-2011 they were favoring tissue valves for patients in their 50's. If the #1 center in the country for valve surgery felt that tissue was appropriate, they may be onto something. I'll let you know in another 10-15 years.

 

[pellicle]

epstns

from 2013 ....

https://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/1749-8090-8-11

This report describes a case of early cuspal calcifications of a bioprosthetic valve in an elderly woman

they suspect alfacalcidol but actually have no evidence or proposed mechanism, and as they say "although serum calcium concentrations in the patient had been within normal limits"

so it happens ... rare, but it happens enough that there is at least on surgeon / group who published it.

 

[epstns]

pellicle - an interesting read. . . but I think I'll file it in the mental folder labeled "random factoids." What I mean is that since it appears to be rare (we haven't had any members here who have experienced this), I will accept the fact that it had happened but continue living as if it is not likely to affect me. I'm not at all trying to minimize the importance of the fact, I am just minimizing my own reaction to it.

Once again, I'll live my life based upon the averages until or unless something changes. Their hypothesis that Vitamin-D supplementation played a role in the calcification is interesting. Kind of makes me glad that I don't take a D supplement.

If there were other papers that presented more patients with this sort of failure, I would certainly be more concerned. So far, not so.

 

[pellicle]

What I mean is that since it appears to be rare (we haven't had any members here who have experienced this), I will accept the fact that it had happened but continue living as if it is not likely to .

Agreed. I don't recall suggesting you change your lifestyle or be worried, so im a little lost by your reply.

 

[Paleowoman]

I take vitamin D3, I've been taking it for a number of years. The study on the woman taking alfacalcidol whose bioprosthetic valve rapidly became calcified: Alfacalcidol is an analogue of vitamin D, it's given to people whose kidneys cannot convert the vitamin D that we get from sunlight or from regular vitamin D3 supplements into calcitriol which is the usable form of vitamin D. Our bodies convert the vitamin D3 from sunlight and from D3 supplements to calcitrol, this link explains it and how alfacalcidol works http://www.netdoctor.co.uk/medicines...-alfacalcidol/ So the woman in the link wasn't exactly taking vitamin D as such and she had a kidney problem.

I've been taking a prescribed highish dose of vitamin D3 for about ten years - 2,500 IUs D3 per day. My blood levels of vitamin D are checked six monthly and they are in the optimal range. I first read about vitamin D3 on Dr William Davies' (cardiologist) website when he wrote how useful it was for heart health. I had also been diagnosed with osteoporosis - vitamin D is recommended for that. So for two reasons I was/am prescribed vitamin D3. Vitamin D3 and the vitamin D3 from sun help the body keep calcium levels where they should be, If a person is taking too much D3 and they get too high a blood level of vitamin D then this can lead to a state of hypercalcaemia which is dangerous, but to get to that level people have to take massive doses of D3 for very many months, You'll see from that link about alfacalcidol that it enables the body to increase calcium, but it's not working like D3 supplementation nor D3 from the sun.