Should I choose a mechanical valve or a tissue valve?

[Luana]

I think the BIG THREE for me are: endocarditis, stroke and bleeding.

I meant that for me these are the three most concerning complications. I wasn't responding to anyone in particular.

I don't know why you're including endocarditis in this. I had endocarditis years before I ever had VR. One does not need a tissue or mechanical valve to get endocarditis. It should not come into the decision of a tissue vs. mechanical valve; you can have it with either.

Still not sure what you mean by complications. Are you concerned about these three being more likely with a tissue or mechanical valve?

 

[Agian]

You don't need an artificial valve to get endocarditis. If you have a bicuspid valve (like me), you're already at risk. However, anyone with a valve replacement is at much greater risk than the general population. My surgeon said that endocarditis happens less in tissue than mechanical valves. I don't know what to make of such a comment. It may be baloney.

The complications of stroke and bleeding are obviously more of an issue with mechanical + warfarin.

I don't know a lot about endocarditis. When I've read about it, they make it sound so terrible. Is there a way to identify it early and treat it, before one needs heart surgery?

 

[VegasBAV]

How do you know that the operations to replace the tissue valve will be TAVI procedures? I got a tissue valve in November and don't regret it, but my surgeon told me that he thought my next replacement (in about 15 years) would probably still be surgical.

 

[user 11863]

How do you know that the operations to replace the tissue valve will be TAVI procedures?

My surgeon recommended the Medtronic Freestyle tissue valve. It's a stentless valve and I believe he said that it was designed to be replaced using a TAVI procedure (does anyone know if this is the case?).

He definitely said the replacements would all be done using TAVI procedures. I won't go with a tissue valve if I have to have OHS another three times after this next operation.

 

[Agian]

They can't make up their mind, can they? We need a crystal ball.

I'm no expert, but for some reason I reckon TAVI will be the way to go before the 15 years is up. The reason I say this is because everyone is excited about it, researchers are vying to get there first AND most importantly 15 years is a long-long time. Fifteen years ago was 1998 and things have come a long way since then. They're using robots now.

 

[pellicle]

My surgeon recommended the Medtronic Freestyle tissue valve. It's a stentless valve and I believe he said that it was designed to be replaced using a TAVI procedure (does anyone know if this is the case?).

Hard to see the future is....
This seems to be 2008

http://m.icvts.oxfordjournals.org/content/7/6/1129.full

We will find out for sure when the time comes ;-)

 

[ElectLive]

My surgeon said that endocarditis happens less in tissue than mechanical valves. I don't know what to make of such a comment. It may be baloney.

This thought seems to appear more often, but at one time, it was even thought that mechanical valves were less prone to endocarditis. Nothing is ever truly equal in life, but in the valve world, this is as close as it gets...there just is no noticeable difference either way. When the FDA reviews new heart valves, they have maximum allowed complication rates that must be met for approval based on the historical rates of all previously approved valves. For mechanical valves, the value is 1.2%. For tissue valves, the value is...guess what...1.2%.

 

[ElectLive]

My surgeon recommended the Medtronic Freestyle tissue valve. It's a stentless valve and I believe he said that it was designed to be replaced using a TAVI procedure (does anyone know if this is the case?).

He definitely said the replacements would all be done using TAVI procedures. I won't go with a tissue valve if I have to have OHS another three times after this next operation.

If planning for TAVI, one of the most important factors in the choice of valve is the opening area, and I think the Freestyle has a good reputation in that regard among stentless valves. The Edwards valves are much more common here, though, so not as much exposure to the Freestyle. Edwards advertises their Magna as a stented valve with stentless performance, and it seems like it is forecast more for TAVI potential here. Not only the size of the opening is important, but the shape is too, and stentless valves might potentially be more prone to paravalvular leak. It might be worth inquiring further about that with your surgeon...that would be an interesting consideration of how they weigh that in their decisions, opening size versus shape. As an example, native biscuspid valves are probably considered to be the least suitable for TAVI.

Your surgeon's confidence is not completely inappropriate because the CoreValve has already received CE Mark approval (but not FDA) for valve in (bioprosthetic) valve use. So, without question, they will be doing this. The more important question, though, will it be as safe as OHS in lower risk patients, and if not, what is the tradeoff for easier recovery. That for sure remains to be seen. In my opinion, it is a reach to say all replacements will be done with TAVI. For instance, even ignoring complications, procedurally speaking, suitable transcatheter access may not be possible in all patients. Of course, no matter what surgeons are stating...be it TAVI, or how long a valve will last, etc...there are only reasonable forecasts, never guarantees. The biggest question then is to try and determine just how reasonable (or unreasonable) it really is. You won't be able to ever know for sure, but the more questions you ask, at least the better idea you'll have.

 

[Duffey]

You don't need an artificial valve to get endocarditis. If you have a bicuspid valve (like me), you're already at risk. However, anyone with a valve replacement is at much greater risk than the general population. My surgeon said that endocarditis happens less in tissue than mechanical valves. I don't know what to make of such a comment. It may be baloney.

The complications of stroke and bleeding are obviously more of an issue with mechanical + warfarin.

I don't know a lot about endocarditis. When I've read about it, they make it sound so terrible. Is there a way to identify it early and treat it, before one needs heart surgery?

I thought that I had read that tissue valves were less prone to endocarditis than mechanical valves, and posted such in a thread a little while back, but I couldn't find mention of it when I looked at old forum posts. If your surgeon stated it was so, I would ask him if he can point you to specific studies that confirm the assertion. Please let us know if he does.

 

[tom in MO]

Surgeons fix things by cutting, thus they would not really know much about warfarin. Cardiologists, GPs, internal medicine doctors, etc. prescribe a lot of warfarin, they are the doctors to trust about anticoagulation.

The article below was very helpful to me.

Prosthetic Heart Valves : Selection of the Optimal Prosthesis and Long-Term Management Philippe Pibarot and Jean G. Dumesnil Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 2009 American Heart Association, Inc. All rights reserved. Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 doi: 10.1161/CIRCULATIONAHA.108.778886 Circulation. 2009;119:1034-1048

Personally, I am more than a little cynical, most likely due to the profit motivated US healt care system. WARNING, here comes a bad joke, that I hope is not true, but speaks to the surgeon's bias "Tissue valves are a full employment program for cardiac surgeons...guarenteed at least two operations per patient."

I had 3 operations before my valve replacement. None of them went as planned, each left me with lifetime problems that I was not warned about before hand. At 54, my surgeon told me there was no gurantee that any of the new procedures would (a) work and be approved, (b) work for me in my case and (c) be approved in time for my next replacement (5-15years). I chose mechanical due to fear of reoperation.

Both choices are a choice for life. Only you can judge what you can live with.

 

[SuzanneSLO]

Surgeons fix things by cutting, thus they would not really know much about warfarin. Cardiologists, GPs, internal medicine doctors, etc. prescribe a lot of warfarin, they are the doctors to trust about anticoagulation.

The article below was very helpful to me.

Prosthetic Heart Valves : Selection of the Optimal Prosthesis and Long-Term Management Philippe Pibarot and Jean G. Dumesnil Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 2009 American Heart Association, Inc. All rights reserved. Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 doi: 10.1161/CIRCULATIONAHA.108.778886 Circulation. 2009;119:1034-1048

Personally, I am more than a little cynical, most likely due to the profit motivated US healt care system. WARNING, here comes a bad joke, that I hope is not true, but speaks to the surgeon's bias "Tissue valves are a full employment program for cardiac surgeons...guarenteed at least two operations per patient."

I had 3 operations before my valve replacement. None of them went as planned, each left me with lifetime problems that I was not warned about before hand. At 54, my surgeon told me there was no gurantee that any of the new procedures would (a) work and be approved, (b) work for me in my case and (c) be approved in time for my next replacement (5-15years). I chose mechanical due to fear of reoperation.

Both choices are a choice for life. Only you can judge what you can live with.

I agree that the division of work between cardiac surgeons and cardiologists you outlined makes sense.

It is worth noting as well that there is another trend which is reducing the workload of cardiac surgeons as more patients are receiving stents implanted via transcatheter by cardiologists and fewer are thus needing CABG surgeries.

In this context, it is hard to completely discount the "full employment" that comes when a cardiac surgeon recommends a tissue valve. Yet, as Gail in Ca and others have reported, there is evidence that cardiac surgeons are not recommending an unlimited number of OHS.

It is almost impossible to ever receive a completely unbiased opinion; the best you can usually do is to try to recognize the bias and adjust for its existence. -- Suzanne

 

[ElectLive]

It is worth noting as well that there is another trend which is reducing the workload of cardiac surgeons as more patients are receiving stents implanted via transcatheter by cardiologists and fewer are thus needing CABG surgeries.

In this context, it is hard to completely discount the "full employment" that comes when a cardiac surgeon recommends a tissue valve. Yet, as Gail in Ca and others have reported, there is evidence that cardiac surgeons are not recommending an unlimited number of OHS.

Interesting point, and to take it a step further, it seems like surgeons may have learned a lesson. Beyond just the particulars of the procedure, surgeons appear to be embracing and leading the TAVI push much more so than was true for stents/CABG, and at least for the time being, the surgeon's presence in the TAVI OR will be no less important than it is for standard OHS. This is not at all a procedure just being handed off to interventional cardiologists. It remains to be seen if that changes over time, though.

 

[OldManEmu]

Duffey

I thought that I had read that tissue valves were less prone to endocarditis than mechanical valves

Endocarditis is usually treated and cleared before a VR is done this is as I was treated. However the valve function in some patients is to poor and the patient is likely to die while the normal month of treatment needed to clear the endocarditis can be completed. In this instance the VR is done with an active infection even though there is a considerable risk of the new valve becoming infected.
Homograft valves are the preferred valve choice for patients with active endocarditis as they are the least likely to become reinfected.

http://www.ctsnet.org/doc/101

 

[Luana]

You don't need an artificial valve to get endocarditis. If you have a bicuspid valve (like me), you're already at risk. However, anyone with a valve replacement is at much greater risk than the general population. My surgeon said that endocarditis happens less in tissue than mechanical valves. I don't know what to make of such a comment. It may be baloney.

The complications of stroke and bleeding are obviously more of an issue with mechanical + warfarin.

I don't know a lot about endocarditis. When I've read about it, they make it sound so terrible. Is there a way to identify it early and treat it, before one needs heart surgery?

Yes, I know you don't need an artificial valve to get endocardidits, though I don't know why a tissue or mechanical would make a difference in getting it. I had it long before VR.

I doubt the risk is "much greater" after VR. I pretty much don't believe what your surgeon said about it happening less in tissue valves. Seemed to happen just fine with me with my own native valve, which was my own tissue.

Terrible? Well, it's not a romp in the park and it is a life-threatening infection, and before antibiotics, it was a death sentence, 100%. It's easily diagnosed, and treatment is very likely to be successful. As my infectious disease doc said to me, "Well, kiddo, it's antibiotics or death." And it doesn't always require surgery. I did not need it when I had it, though there are cases where it will require surgery.

My concern about getting endocarditis is about the same of getting killed in a car crash. The main thing to be aware of is if you have a fever, don't seem to be getting over a cold or flu, get yourself to a doc ASAP. I was misdiagnosed several times and ran a fever every day for 3 months before I got diagnosed. That was 20 years ago. It shouldn't have happened, but doctors are more hypervigilant about it now than they were back then, especially if you've had VR.

I don't see any logical reason to let the likelihood of getting endocarditis determine valve choice.

 

[Agian]

Great answer Luana. Was your native valve 'normal', or did you have bicuspid?
Have you gone mechanical?

 

[Agian]

The other thing to consider about all this is the anxiety associated with trying to predict the future.

1) Warfarin and INR management may be anxiety-provoking, but predictable. People who self-manage are better able to contain this and seem to have a sense of control.
2) Going tissue means no Warfarin and possibly less risk of endocarditis. However, fretting over when it will need replacing or when TAVI will be up and running may be an issue in itself.

I spoke to an 80 year-old fellow yesterday, who's aortic valve 'packed up' twenty years ago. Got a VR and has been on Warfarin since: 'Doesn't bother me.' Gets his INR checked 'every three months'.

Having said that, Kevin Rudd (PM) has recently had his tissue replaced and is still able hatch machievellian plots and run the country (he thinks he is anyway). He referred to his operation as 'an oil change'.

 

[Lily]

I joined this site ten years ago. I had already carefully researched my options. I inquired of my doctors. I weighed the facts, not relying on anonymous people for opinions, because only I knew what I thought I could live with. In fact, I have always been puzzled about the debates that occasionally ensue about this very personal valve choice. Live and let live.

There are many factors to consider. There are all kinds of possible post-op complications, no matter what valve you choose. And some of them might hang on a bit. Nearly ten years post-OHS, and I still have some occasional and painful twinges of Costochondritis. Nobody has the very same OHS as someone else. We all have individual issues that factor in, including the individual structure of our hearts. As it happens with my genetically flawed heart defect, the opening to my aorta is considered small. So no matter what valve I choose, it won't quite be adequate because the opening necessitates a smaller valve than my heart and my body needs. Also, my body did not respond well to my temporary post-op Coumadin regimen. On the flip side, I have a dear friend who is so allergic to aspirin that she could literally die from so much as licking one. And so far, I believe it is still true that every valve replacement option requires some type of heavier or lighter ACT-type post-op regimen. Another point is that many of us have or may develop more than one heart issue. And these too might necessitate further surgical procedures.

Anyway, weigh the pros and the cons with what sounds and feels Reasonable to you. And find doctors who are highly recommended and who have a high success rate and those whom you can believe in. And present your questions to these experienced medical professionals. Ask them why. Ask them what they would choose. And again ask them why.

My opinion, and it is only an opinion, is that you can probably make whatever choice you choose work for you. Forget the rest. Go forward. Best wishes

 

[Agian]

Old article

http://www.news.com.au/national-new...cess-says-doctor/story-e6frfkvr-1226106081850

 

[pellicle]

Hi

Having said that, Kevin Rudd (PM) has recently had his tissue replaced and is still able hatch machievellian plots and run the country (he thinks he is anyway). He referred to his operation as 'an oil change'.

Classic. Hard to avoid the dipstick joke that comes along with that

 

[pellicle]

.
2) Going tissue means no Warfarin and possibly less risk of endocarditis. However, fretting over when it will need replacing or when TAVI will be up and running may be an issue in itself.

OK, I thought it was the reverse. Did you have anything to support that or are you like me going on "something you picked up, but not sure where"?