Should I choose a mechanical valve or a tissue valve?

[user 11863]

I'm 46 and have a congenital bicuspid aortic valve. It's now time to replace it and my surgeon have given me the choice of either a Medtronic Freestyle tissue valve or an ATS mechanical valve.

The issues are quite well known:
The ATS mechanical valve will require warfarin but (hopefully) no further operations.
The Freestyle tissue valve won't require any medication but will require about 3 further operations (if I live that long!)

The surgeon told me that the re-operations with the Freestyle valve will be done using a TAVI procedure. This has about a 2% fatality rate and a quicker recovery than Open Heart Surgery.

Are there any other issues here that I've missed?

The re-operations don't bother me, and given the choice between warfarin and re-operation I'd have a preference for the operations. I realise this wouldn't be everyone's choice, but on this basis I would have a preference for the tissue valve.

What does everyone else think?

 

[ski girl]

I think you're overly and unnecessarily scared of warfarin ! There is a recent thread on the daily effects of Warfarin on your life, read that. Warfarin has zero impact on my life, I recently got into mountain biking and as I'm not very good I fall off quite a bit - still haven't managed to bleed to death.

My opinion? Go mechanical.

 

[Agian]

Is it just the valve he's changing? What about your aorta?
I doubt the mortality rate will be 2% for TAVI, in a younger person. Your surgeon can't predict what TAVI will 'look like', when it becomes more common.

 

[big_L]

I'd ask more about the TAVI. Here in the States, currently this is only done on those patients that are deemed to high of a risk for OHS. It may be different in the UK. Personally, I'm not comfortable with a 'maybe' for an option. I'm going mechanical as I find re-operation to be a huge hurdle for me mentally, but obviously you have to make up your own mind.

 

[Heart Of The Sunrise]

I am glad I went with the ON-X Aortic Valve. I too had a fear of warfarin...although I have chosen to go with the brand specific Coumadin.
I am having no issues with the Coumadin and I am extremely happy with my valve choice. In fact the On-X valve is so good that my cardio feels it is perfectly safe to establish my INR between 2.0 and 2.5. I am 17 weeks post op this coming Monday. I am doing just fine.
My recommendation...go mechanical. As for noise...only occassionally do I hear it. In Europe many ON-X valve patients only take asprin.....no Warfarin!
The idea of multiple reoperations in my lifetime was totally unacceptable.Much easier to take Coumadin everyday!!!! Anyone have any knowledge of the ON-X/Asprin rumour?

 

[ElectLive]

Here in the States, currently this is only done on those patients that are deemed to high of a risk for OHS.

That's not quite true anymore. The original FDA approval was for otherwise inoperable only, but that has now been extended to all high risk patients (there is a difference - specific to surgical risk score). There is also a trial ongoing in the US for intermediate risk patients to have TAVI performed, and by the numbers, risk for that group could be as low as 4%.

All that being said, it is not "mainstream" by any stretch of the imagination here in the US, nor will it be anytime soon. The "catch" with TAVI is that it will inevitably be compared to open heart surgery. No one may like having a full (or even partial) sternotomy or going on bypass, but standard OHS is extremely safe and successful, even for repeat surgeries, so some of the inherent problems of current TAVI technology (paravalvular leak, operative stroke) will really need to improve in order to approach the gold standard (OHS) from a safety standpoint. Quicker recovery sounds great from a patient perspective, but unless the safety is there too, even the availability of TAVI in the future may not mean it will be the best option.

Now, in Europe, use is farther along, so from that standpoint, nigelp, you may be in better position to ask questions, although I don't personally know how pervasive it is one country versus the next. The 2% mortality rate for Europe is a number I've seen, but I'd certainly ask about the risk of other complications (stroke most importantly) too. I know one of the TAVI valves in Europe caused an incredibly high amount of patients to need a pacemaker for instance.

Another issue to discuss with your surgeon is you native valve size. TAVI may be able to be done valve-in-valve (very limited so far) more in the future, but if your own valve size is low, then it won't be an option for you since it would shrink the opening beyond a functional level. So, in other words, assuming everything should go all to the plan of the surgeon, surgery #3 could potentially mean OHS again when you are much older and possibly higher risk, IF you don't have a large enough valve. Agian also brings up a good question about the status of your aorta...since some folks actually need a second surgery for the aorta irrespective of the valve.

So, those are just a few other things to consider. Most importantly, the best information you will find here is just how normal your life can be with either valve choice, there really is no bad answer. Two good options...just with different sets of "conditions."

Welcome to the community and please keep us posted on your situation. Best wishes to you.

 

[Agian]

TAVI has been used for those deemed inoperable, on humanitarian grounds. The valve itself does not appear to be the most robust of things. The mortality rate for open valve replacement is less than 1% for a healthy youngish person. If someone was to tell me that I'd need three more operations, each with a mortality rate of 2%, I would find the risk unacceptable, IF I believed it. When TAVI becomes routine, it will be just that. It may even be done in a cath lab. There's a guy in the UK who is working on valves that can be withdrawn and repositioned; so eventually it may be like changing a tyre... Eventually.

I'm still undecided. But I trust what people here say about warfarin not being that big a deal.

 

[ElectLive]

In Europe many ON-X valve patients only take asprin.....no Warfarin!

You know, someone posted something like this about a month ago, based on what a surgeon said, but it is not true.

Aspirin only is not an option even being trialed by On-X right now. It was about a decade ago and was pretty quickly halted. The protocol that is being studied/trialed is Aspirin + Plavix...more specifically Aspirin 325 and Plavix 75. But even the Aspirin-Plavix regimen has not been approved anywhere, not even submitted for approval in fact. Enrollment in that PROACT study group was only completed two months ago, so it is well behind the reduced INR portion of the study. For reference, the reduced INR protocol with the On-X is not approved in Europe yet either...although On-X did submit for that back in the fall, at the same time they submitted to the FDA. So, in other words, the official indication for the On-X in Europe right now is the same as it is here: standard Warfarin therapy.

Also, the distinction of the actual protocol (aspirin vs aspirin/plavix) is important...a pretty significant portion of patients will not have a clinically acceptable response to one or both of those medicines, in fact anywhere from 1/3 to 3/4 of potential patients, the trail results are now showing. So for patients for whom that is true, they would be ineligible and need to say on Warfarin.

 

[dick0236]

I'm 46.......
The issues are quite well known:
..........The ATS mechanical valve will require warfarin but (hopefully) no further operations.
The Freestyle tissue valve won't require any medication but will require about 3 further operations (if I live that long!)

What does everyone else think?

You have been on this forum for a year or so and probably have read many responses regarding the "mechanical vs tissue" arguments. My biggesr concern would be "will require about 3 further operations"......not "will require warfarin".

 

[Heart Of The Sunrise]

One operation was more than enough for me. I hope that with my valve choice it is a one and done situation.

 

[pellicle]

I
The re-operations don't bother me, and given the choice between warfarin and re-operation I'd have a preference for the operations. I realise this wouldn't be everyone's choice, but on this basis I would have a preference for the tissue valve.

What does everyone else think?

I think you are foolhardy and unwise in the extreme.

The operations don't bother you? Well its one thing to face up to it with courage, but its entirely another to disregard the very real issues that come with multiple surgeries.

If there is some sound mitigating reason to avoid a mechanical valve, then for sure. But because you are afraid of warfarin? Well that's misguided and perhaps even slightly mad.

Don't be deceived by stats. There are more negative outcomes that come along with surgery than death. I suggest you have a good long think about it, and discuss it candidly with your surgeon.

I get sick of the hysterical anti warfarin reactions by those who know nothing about it.

• atrial fibrulation
• post surgical infections
• nerve damage
• complications of reoperation from scar tissue
• reactions to the anasthesia
• ... the list is long

Don't kid yourself that reoperation is like a bad flu

That's what I think.

Spend the time to glance through my experiences here

http://www.valvereplacement.org/for...nd-feelings-(some-may-find-images-disturbing)

Keep in mind that I am still on antibiotics and will be for the next year. There is no certainty that after that that more cutting won't be needed.

... but it can't happen to you, right?

 

[AZ Don]

Cleveland Clinic seems to have a preference for tissue valves, but I haven't seen evidence support this position for those under 60-65. The Mayo Clinic has an excellent presentation that makes a strong case for the mechanical valves over tissue valves. See the link in this thread: http://www.valvereplacement.org/for...linic-Presentation-on-Artificial-Heart-Valves. There are a number of issues that you have missed that are raised in this presentation, namely the complications that can be associated with valve replacement. The presentation shows that negative outcomes are generally more common with tissue valves.

I was given a choice between mechanical, tissue, or sparing my valve. Given my valve is functioning well and may never have to be replaced I chose to keep it, but mechanical was my 2nd choice. I'm no fan of warfarin but the discussions on this forum convinced me it was something I could live with, and I would choose it over the certainty of repeat operations.

In any case, it's your life and your choice. You are the one that will have to face the prospect of repeat operations or life on warfarin. There are no good choices. You have to pick what for you is the lesser evil.

 

[Duffey]

It seems that you are peering into the too distant future.:wink2: First off, I'd question whether you'll need 3 re-ops if you go tissue.
Second, it's one thing to believe before you have a replacement that you won't mind having more. Perhaps you won't, perhaps you will, but you won't know that until after your have the surgery.

Regarding ACT management, I see comments made by mechanical valve recipients, some with only a year or two under their belts with INR management, that discount the difficulty that coumadin MAY pose. If you're going to weigh the possibility of future difficulty with coumadin, you should probably consider what member's like Dick0236 report. I believe, and I'm sure **** will correct me if I'm wrong, that he's done very well over the years with only one serious incident. And it's possible that my memory is wrong and he's experienced no serious problems.

All in all, it's your decision to make. I've had a tissue valve since I was 53, 8 years ago, and there is nothing to indicate that it will need to be replaced in the near future (5 years). I do intend to go tissue when this valve needs to be replaced.

Choosing to go tissue now does not mean you are locked into a tissue valve if it turns out that it needs replacing. You can cross that bridge when you come to it.
Best wishes making a decision. You'll feel much better once you do.:smile2:

 

[ElectLive]

Ok, so Pellicle, let me get this straight, from his single short post, you've established that Nigelp is "foolhardy", "unwise in the extreme", "afraid of warfarin", "misguided", and "slightly mad"...and that he is "hysterically anti warfarin" while "knowing nothing about it"...and that he's "deceived by stats" and "kidding himself" thinking that "reoperation is like a bad flu"? Do you know Nigelp from somewhere else? I guess I'm just going to assume you may have been speaking more generally...this is supposed to be a support community, after all!

In any case, fortunately the content behind all the excited language was more appropriate to include, since complications aren't often given much attention by surgeons, as my earlier post alluded too. Certainly not something that should ever be ignored. But I tell you what, despite anyone's particular choice of valve, I've always found it a little hard to believe that anyone could be presumed to be taking valve replacement surgery and inherent complications lightly. I mean really...who isn't ever petrified knowing their heart will be stopped?

Fortunately, there are generally only fairly low probability risks on either side of the decision. The problem is...no one ever knows for sure which type of risk they will be most susceptible to, it might even be one that sneaks up, not the more likely one. My own medical profile makes me more at risk for infection and stroke, and yet I got the pacemaker instead...1% odds my surgeon told me beforehand. So thanks to my actual 100% odds, I guess he was then able to promise his next 99 patients zero percent risk... :wink2:

Back to the discussion, though... No, re-operation is not like having the flu nor are anticoagulants like taking vitamins. Risk and benefit go hand in hand. Meanwhile, world class surgeon "A" will recommend mechanical valve while world class surgeon "B" recommends tissue valve. So not too hard at all to understand all the uncertainly then.

But I'm going to disagree a bit with AZ Don. In my view, there are two good choices. There are much riskier and annoying surgeries in the world than valve replacement, and there are much riskier and annoying drugs in the world than Warfarin. There's a tendency of course to analyze the worst case possibilities in order to help make the best decision, who wouldn't want to do so (I know I did) it makes perfect sense. But once the decision is made, Nigelp, it's important to always remember that good results happen overwhelmingly more often no matter what you choose.

 

[pellicle]

Hi

Ok, so Pellicle, let me get this straight, from his single short post, you've established that Nigelp is "foolhardy", "unwise in the extreme",

I have not established that, but given his statements that I quoted I think that his statement "reoperations don't bother me" is what I said it was.
I said:

But because you are afraid of warfarin? Well that's misguided and perhaps even slightly mad.

which does not mean to say he is mad, only that a decision process based on such is misguided and slightly mad.

Let me ask you ... has anyone ever said to you "what do you think about me doing X" and you have said something to the effect that "that'd be stupid"

I think you may well have done that ...

were you saying to your co-worker / friend / person on the street anything intended as insulting? I guess not ... I guess you were "expressing your opinions"

"afraid of warfarin", "misguided", and "slightly mad"...and that he is "hysterically anti warfarin" while "knowing nothing about it"...and that he's "deceived by stats" and "kidding himself" thinking that "reoperation is like a bad flu"?

well thanks for taking all that out of context, but none the less ... I think there is grounds to suppose from his post that he is afraid of warfain. I believe another picked that up too.

As you are perhaps aware, the use of the word IF in the English language means a contingency based on a set of possibilities. For example : "if I jump in the pool I will get wet". So those words mean that in the case where "I do not jump in the pool" that I may not get wet.

please note that my sentence was

If there is

I guess I'm just going to assume you may have been speaking more generally...this is supposed to be a support community, after all!

I was .. and I was making assumptions about the OP's intent and putting forward views which seemed to me to be relevant.

Also perhaps you missed the sentence he wrote:

and given the choice between warfarin and re-operation I'd have a preference for the operations

This implies some fear of warfarin and its risks, a greater fear than reoperation. Do you really think there is more risk associated with warfarin than reoperation?

Because this IS a support forum and because I strongly believe that (again as I said) unless there is a sound case for avoiding a mechanical valve or warfarin that it is the safest course of action - especially when you consider the risks associated with reoperation.

But I tell you what, despite anyone's particular choice of valve, I've always found it a little hard to believe that anyone could be presumed to be taking valve replacement surgery and inherent complications lightly.

I agree with you, and I am not contradicting you when I say that one needs to weigh all the factors carefully in the hard light of day. These must be facts and not fancies.

I have seen enough people reacting against warfarin as it it is a death sentence. This seems to be based on fear as there is little that comes from the literature to suggest that there is any real basis for that fear. If such a fear prejudices your decisions then that pushes it away from being a rational decision to being an emotional one.

People may be more comfortable with emotional decisions than rational ones. I will not deny anyone that privileged.

I mean really...who isn't ever petrified knowing their heart will be stopped?

and so why would you deliberately then set yourself up for a 2nd event?

Fortunately, there are generally only fairly low probability risks on either side of the decision.

exactly ... but knowing which is the lower probability is what I was addressing.

We all know here (or at least should) that any valve choice does not preclude a second operation. But some valve choices do essentially guarantee it.

So thanks to my actual 100% odds, I guess he was then able to promise his next 99 patients zero percent risk... :wink2:

Nigelp, it's important to always remember that good results happen overwhelmingly more often no matter what you choose.

which is a good point ... you should get 10 years clear on the tissue valve. But after that the bets are off.

Also, while everyone discusses improvements in medical science, few seem to discuss that gradually many bacteria are becoming resistant to the antibiotics we have. Since I did my degree in microbiology (around 20 years ago) I can say that the bugs are adapting faster than we are producing. Nosocomial infections are a serious problem.

To Nigelp I say this, there are many points to consider. which is why I said in my post to you:"I suggest you have a good long think about it, and discuss it candidly with your surgeon."

Discussions are best done with the analysis of all points and people speaking their mind (without being rude).

Ultimately it is your decision and only you can make it. It is not an easy decision, but I again urge you to examine all the points and make a decision based on how you consider them. If you are leaning away from mechanical because of warfarin then I encourage you to outline your issues and discuss them here.

That's what we're here for ;-)

All the best

 

[Luana]

The Freestyle tissue valve won't require any medication but will require about 3 further operations (if I live that long!)

The surgeon told me that the re-operations with the Freestyle valve will be done using a TAVI procedure. This has about a 2% fatality rate and a quicker recovery than Open Heart Surgery.

Are there any other issues here that I've missed?

Four years ago, many here were saying, get a tissue valve because they'll be able to replace via catheter. Well, four years later that approach is only for those who cannot undergo OHS, in other words: the very sick. Recovery rate may be quicker, but stroke rate is higher. I would not make a decision now based on what may be later.

The decision for me between tissue and mechanical was additional surgeries. Surgeon told me I'd need two, possibly three, additional surgeries. Without even having had one OHS, somehow I knew this was not something I'd want to do again. And I was totally right about that.

Most will come through first surgery just fine. Some will do that with second, too, but there's been more than a few folks who've pretty much been at death's doorstep with the second surgery. It's a roll of the dice how well additional surgeries may go, and I don't want to play that game.

 

[ElectLive]

Let me ask you ... has anyone ever said to you "what do you think about me doing X" and you have said something to the effect that "that'd be stupid"

Yes, all the time, but only when I know them well enough to do so! :thumbup: I was giving you a hard time more than anything...it was his first post here for goodness sake! Anyway, you are easily the hardest member to "reply with quote" to, Pellicle, so I'm going to have to take another route here out of laziness more than anything!

As I said, you made good points, and what I didn't specifically mention, awareness of the stigma and fear of warfarin is perhaps the important issue to discuss. I think warfarin sentiment could easily take three or four forms. Some hear horror stories and run far far away (which fortunately folks here do their best to discourage). Some look at some of the logistics (like blood testing and possible interactions) and walk slowly away. Some analyze the ins and outs, including the false warnings and also the limited but real risks, take their time, and make conscious sound decisions either way. Finally, some are sold over time by how easy it really can be, and embrace it fully despite its limited flaws (that will be me one day).

I've been Type 1 diabetic for 30 years...8 blood tests and six injections a day in earlier years, and now 24/7 insulin pump and glucose sensor. Control is affected by every part of every food, every hour, every minute, the weather, stress, etc. So while I have not been on Warfarin personally, I'm obviously quite confident that when I am (I'm 38 on a second valve, chances are high, no matter what path is next) I will be able to handle it even with both eyes closed, and both hands tied behind my back. :smile2:

So based on a parallel experience, my personal hope is that valve patients facing surgery don't fear Warfarin because it will only be a struggle, a lifestyle problem. I hope they don't fear Warfarin because of the horror stories, or the heightened advertisements of its risks. One of the favorite warnings is that Warfarin is responsible for the most amount of ER visits. I think insulin actually is, but whatever the case, it's at least 2nd. Well, I've done wonderfully well on insulin the last 30 years, but yes, I've been to the ER too. It just happens, risk is low but risk is real.

What is more troubling to me is that everyone (doctors) is so excited offering promises of easier alternatives to both surgery and Warfarin. It seems overall safety is taking a backseat. Surgery and Warfarin are both proven, both effective, and both low risk. One more so for some than the other, depending always on the individual patient in the end. So I'd personally like to hear more from surgeons about making OHS even safer, and making ACT more patient driven, rather than just promising the future on quicker and easier alternatives.

 

[Agian]

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

 

[Agian]

By the way, for what it's worth, I think Pellicle's argument is a powerful one.

 

[Kimv]

I am pretty new to the world of valve replacement. My surgery is Monday and I chose a tissue valve after a long discussion with my surgeon. While I can't speak from any personal experience about OHS or Coumadin...I can tell you that once I made the decision it was a huge relief. Even after doing more research - and reading threads like this - I have really felt at peace with my decision and haven't changed my mind. I hope you feel that way as well when you choose.