Surgery delay after pre-op testing?

[ALLBETTERNOW!]

30 years is a long time unless it's your 30 years. I think edwards had a 20 year study or close to that and depending on age at implantation, freedom from valve failure approaches 90%. I could be remembering that wrong and if you are 1 of that 10%, your stat is 100%. Clearly mechanical will last much longer and almost as likely, less than 10% will require explanant of the mech valve. It's a choice, cancer patients wish they had such a dilemma, we are lucky to be splitting such hairs

 

[ALLBETTERNOW!]

Pell, I get it but at 50 what about the guy who dies from cancer in the next 15 years, then I thinking he would have been better off with a tissue, life is a series of what ifs and in my experience, it is what is will be and our attempts to,game or control it are futile! Not that we shouldn't try.........

 

[pellicle]

Hi

Pell, I get it but at 50 what about the guy who dies from cancer in the next 15 years, then I thinking he would have been better off with a tissue, life is a series of what ifs and in my experience, it is what is will be and our attempts to,game or control it are futile! Not that we shouldn't try.........

well I agree, but all things being equal I don't set my planning on "being dead in 15 years". Certainly not when I was 28 nor 48.

I could be hit by a car and killed tomorrow ... I've certainly attended (provided first aid) at a number of fatalities ... my wife died of cancer at 33 ... who knows.

I perfer to plan for me not being dead ... because if that happes (I'm alive) then I'll have to deal with those consequences then.

PS: I am NOT trying to sway you on your choice, simply provide input. I personally have zero invested in what others choice is. I simply try to be a sounding board for what I believe. Indeed if anything I perhaps tend towards suggesting to people "get a tissue" if I feel they are not going to be competent with managment of their INR.

 

[Ske1973]

Just curious for folks going to Cleveland Clinic. Are they doing minimally invasive procedures for most valve replacement surgeries?

Not sure if the CC is doing minimally invasive procedures for "most". I can however share with you that I had the minimally invasive procedure and will have it again in November.

 

[ALLBETTERNOW!]

Hi



well I agree, but all things being equal I don't set my planning on "being dead in 15 years". Certainly not when I was 28 nor 48.

I could be hit by a car and killed tomorrow ... I've certainly attended (provided first aid) at a number of fatalities ... my wife died of cancer at 33 ... who knows.

I perfer to plan for me not being dead ... because if that happes (I'm alive) then I'll have to deal with those consequences then.

PS: I am NOT trying to sway you on your choice, simply provide input. I personally have zero invested in what others choice is. I simply try to be a sounding board for what I believe. Indeed if anything I perhaps tend towards suggesting to people "get a tissue" if I feel they are not going to be competent with managment of their INR.

No worries it's an honest debate and you rely on facts. My parents died at 55 & 65 from cancer so to be honest I always thought I'd die young from cancer which I guess could still happen. it is a hard choice and I'm still convinced there is no right choice, maybe in a few years there will be a new less complicated Coumadin. All I know about it that when I was on it after the surgery all I could ever think about eating was kale ;-). It wasn't terrible though it did take me 4-5 weeks to get into range. Truth is my per aneurysm surgery catherization, the day before surgery revealed my valve was shot so I literally had 12 hours to decide. I don't know if that is better or worse than having months to think it over.

Sorry about your wife, you have sure had you obstacles but seem not as bitter as others might be about bad luck health bs

 

[MethodAir]

maybe in a few years there will be a new less complicated Coumadin. All I know about it that when I was on it after the surgery all I could ever think about eating was kale ;-). It wasn't terrible though it did take me 4-5 weeks to get into range.

My warfarin management equates to about 5 minutes per week. No diet restrictions. If one can increase the odds of their long term survival, with minor (if any) lifestyle modifications, I think that's a good thing.

 

[pellicle]

Hi

My parents died at 55 & 65 from cancer so to be honest I always thought I'd die young from cancer which I guess could still happen

it may, I hope it doesn't. Cancer is a dreadful way to go.

I view it from this slant: if preparing for one thing that never happens makes outcomes for what may happen worse then that's not a good plan.

I think its likely that Cancer treatments are improving and you may not die at the same time. When I was young I expected to be dead by my 20's... blew that one didn't I...

. it is a hard choice and I'm still convinced there is no right choice

agreed ... there are no wrong choices. I have said before "flip a coin (heads tissue, tails mechanical), and see ... if you don't feel you like that outcome then chances are that it means you personally like the other more.

, maybe in a few years there will be a new less complicated Coumadin.

entirely ... however warfarin is NOT complicated to manage (although some complicate it) and its reversable ... something nothing else is.

You can manage your warfarin, you can not manage what "oh, well my Tissue prosthesis is calcifying"

People say they got 10 years out of it , clearly it seldom goes from perfectly fine to "oh reop needed" over a weekend. So what I would like to see more of is open and honest input of what the last few years were like.

All I know about it that when I was on it after the surgery all I could ever think about eating was kale ;-)

this food thing is overblown, it makes such a minor difference (although some have reported otherwise I wonder about the rigor of their evaluations) and even if it DID cause you to go up or down if you simply aim for 2.5 then even if your INR dropped to 1.8 for a week it would do nothing.

... I don't know if that is better or worse than having months to think it over.

hard call, but when its in, then just move on ... I'm totally comfortable with my situation. Even if a new valve came out tomorrow which was the holy grail. It wasn't there when I needed it.


With respect to my handling of my grief I try my hardest to get better, not to get bitter. I wish to regain being the person I was. The one she loved. Its not always easy but I just keep the bow pointed thattaway

anyway, from your perspective you already have a new valve, so discussion with respect to yourself is unfruitful. You should be at peace with your decision and nobody should attempt to make you otherwise. I discuss these things from the abstract perspective which I hope is helpful to anyone reading (unregistered but reading) who is trying to make their own decision

 

[pellicle]

for anyone reading:

... All I know about it that when I was on it after the surgery all I could ever think about eating was kale

on the subject of food I recommend this thread here:
http://www.valvereplacement.org/forums/forum/home-anticoagulation-monitoring/43179-novembinr

there are few if any daily measurement studies of INR ever published ... this one shows what we who home test know. Food makes little predictable significant difference

 

[QuincyRunner]

My surgeon strongly recommended a mechanical valve for me precisely because I was an active distance runner, which he believed would shorten the life of a tissue valve, even more so in the mitral position. My age (53 at the time) did not play much of a role in the decision making process. I too find it ironic that many doctors recommend a tissue valve for those with an active lifestyle, although I think they are more concerned about the warfarin and bleeding than they are with the actual longevity of the valve. Fortunately as a runner I have yet to sustain any cuts or knocks to the head.

 

[pellicle]

has anyone else ever noticed that on many of these "discursive threads", the OP asks a question and somehow never posts again?

 

[Paleowoman]

that "increased mechanical stress" to me implies athletic style exersize.

[FONT=Arial, Helvetica, Verdana, sans-serif]Oh well, just better sit on my backside doing nothing then LOL Honestly, most young people aren't that active. I certainly wasn't and I can't remember any of my friends being very active. Of course there are athletes in the world - how many ? And how many of those athletes need AVR when they are young ? I think,as in the other thread where we were talking about the immune system being supposedly stronger in the young and that being the cause of faster tissue failure, that there really are too many unknowns in this. My immune system is better now I'm older....go figure. [/FONT]I'll continue to be active and keep my immune system in order regardless !

Not sure if the CC is doing minimally invasive procedures for "most". I can however share with you that I had the minimally invasive procedure and will have it again in November.

I was scheduled to have the minimally invasive procedure but the surgeon had to abandon it - I was always puzzled by the length of my incision scar (not that I minded it) and surgeon wrote to me earlier this year that due to the position of my aortic valve she was unable to do mini-sternotomy and had to do standard procedure. So that's something for people to bear in mind - it may be planned but can't always be done.

 

[McCbon]

All I know is that I looked at the old link Pellicle provided and the first and second post led me to conclude that greens and alcohol have opposite effects on INR. Therefore I need to drink lots of red wine whenever I eat greens! : ) Yeah.
McCbon

 

[McCbon]

Once I get my new valve, that is.
McCbon

 

[Paleowoman]

PS to my post above - my surgeon said my tissue valve would last me "12 to 15" years - not 20. So I'm actually prepared for a re-op when I'm 72 to 75. Not that I'm that looking forward to it but it's something I knew, and the surgeon didn't try to dissuade me from tissue. I don't think valve in valve would be too good for someone with a small valve like me so I'm certainly not counting on it, and by today's records I would not want valve in valve - it would have to improve a lot - far too high mortality from stroke and no long term studies.

Going back to the post where someone mentioned cancer. My previous cardiologist who I sacked because he'd only refer me to his surgeon friend and not any others, said to me once, about three years before I had AVR "you may die of concer before you ever need your valve replacing" ! Not a very appropriate thing for a doctor to say was it ! But what he meant was to live life to the full as you never know what is goig to happen.

And the other issue: what does elderly mean anyway ? In a sceptic doctor's blog I follow (Dr Malcom Kendrick) who mentioned studies which showed that higher levels of cholesterol are protective in the "elderly" and that a high choleterol level doesn't lead to athersclerosis in the "elderly", I asked at what age do doctors consider a patient elderly. It appears to be 55 !

 

[pellicle]

[FONT=Arial, Helvetica, Verdana, sans-serif]Oh well, just better sit on my backside doing nothing then LOL Honestly, most young people aren't that active. I done.

By athletic I mean regular jogging for instance, certainly half marathons.

Sure many people are couch potatoes but I see a many posts here from people who du running and active lifestyles who are talking about a valve. I am considering them when I write replies.

 

[pellicle]

All I know is that I looked at the old link Pellicle provided and the first and second post led me to conclude that greens and alcohol have opposite effects on INR. Therefore I need to drink lots of red wine whenever I eat greens! : ) Yeah.
McCbon

There was an old thread here that discussed a SHTF scenario with no warfarin. My plan is tomato, red wine and aspirin. Red and tomato in the evenings aspirin in the mornings.

Also, Anne, you seem to be sounding like anyone is questioning your choice. I certainly am not , I am only questioning the issue. To restate my position, you have said valve ticking is a primary decider. To me that is end or storey with respect to you.

That other people make different decisions should not reflect on your own decision. This is not a footy grand final with a winning and a losing team. It is a decision process which some people need facts and try to tease them out of the haystack of studies.

 

[Paleowoman]

Also, Anne, you seem to be sounding like anyone is questioning your choice.

Hi Pell - If I come across as sounding like people are questioning my choice I certainly don't mean that at all - sorry if I come across that way.

I am always of a very scientific set of mind so when someone says "x" I like to have references, not for myself particularly but just because of scientific interest. Heck, I get interested in scientific studies and references for conditions that I don't have just becasue I'm interested and need to know the reasosns and science behind things. One of my specialists says I should have been a doctor. I actually wanted to be a research scientist but was very ill during my teenage years so dropped out of school. By the time I was well (30's) I was on the way to having a family and not going to restart my education. I read science books for interest and enjoyment, and some history books, but never fiction (apart from Dune so I knew that fear quote you posted the other day and loved it as I think of it often too). With the advent of the internet I was in bliss with being able to find things out - love it. I don't believe the first thing I read, I always follow it up with references, …hence maybe me sounding like you say. I hope you understand.

 

[pellicle]

No apology need Anne, I was just making sure you weren't feeling embattled. I have been accused of being insensitive in the past (which surprised me) and so not understanding when I am and am not I try to err on the side of caution.

Seeking veracity to claims is proper, I hope you noted my post earlier where I backed away from certainty that it was exersise not just age as the factor.

The problem for us younger recipients (I include myself as I had one at 28) is that we are so few that there is little data gathered and collated which distinguishes "us" from > 60yo (which I arbitrarily classify as the entrance to elderly)

Best wishes

 

[cldlhd]

Hi



I would agree, it is so well known among surgeons that for years the guidelines were clear , less than 50 and you got a mechanical, greater than 50 it was choice. Now (perhaps in responce to patient complaints about ticking and compliance concerns with anticoagulation therapy) they (in some countries) give anyone who pushes for a tissue prosthesis what they want.

My wife used to always say to me "be careful what you ask for, you may just get it"

There is enough evidence however to my reading that at 50 with no other issues (co-morbidities) that you will be better off (statistically) with a mechanical valve. That Mayo Clinic link produces some clear points about that too.

Ask your sugreon this question : in a 30 year follow up of patients who were under 50 at time of surgery, what percentage remained free of reoperation.

If you find a single study I'll be surprised ... nobody studies against the obvious.

I can however point you to studies done on homografts where 29 year followups were done. There were zero free of reoperation who were under 50 at time of initial surgery.


In this journal http://www.hindawi.com/journals/iji/2011/263870/

I found the following interesting. It provides a clue to support why tissue prosthesis degrade faster in athletic people.



so essentially a tissue prosthesis can not undergo any renewal in response to mechanical loading stresses. Just like any "leather hinge" of old it will begin to fray, and be calcified. The mechanical valves avoid this.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2696738/table/T1/

Interesting point. My surgeon readily agreed with my backup choice of a mechanical valve ,even though he did say warfarin can be "a pain in the ***" ,because he felt as an active person in my mid 40's I'd probably go thru a tissue valve relatively quickly. He also pointed out that one of the advantages of my repaired valve is that it's still living native tissue that's capable of repair .

 

[cldlhd]

cldlhd; It reminds me of when I go shopping for shoes and the salesperson says "I have a pair of these, they are my favorite!" But I have become skeptical after 15 yrs in the waiting room and seeing lots of docs. CC does favor tissue, they are banking on TAVR eventually being the "new OHS" and standard re-op procedure. For my money, there are still many problems with the technology, not the least of which is that they haven't yet developed the prosthesis that would be used in the 10-20 year timeline for next ohs. Even if they did, those testing periods take 10 to 20 years to collect enough data to make predictions. Please, someone, feel free to correct me if I am wrong about that. I am truly interested in hearing as many broad ranging opinions as possible on these topics. That's what is good about this forum!
I decided not to go to CC because they were so ready to operate, even though my status did not warrant it. I found a team at Mayo and they surprised me by recommending mechanical for me, even at my age, one reason is my activity level and their feeling that the reason tissue lasts longer in elder pts is because they are less active. Because I am so active for my age, they thought I'd need the next OHS sooner that the averages. Anyway, that's just my situation. I have heard and read great things about your surgeon and as they say, any choice is a lifesaver. McCbon

Well I'm obviously biased but from everything I've heard from others, most of whom know a lot more than me, he is a great surgeon and he seems to be really passionate about his work. He's very busy and not hurting for work so maybe that played into the fact that he wasn't pushing me towards surgery. He basically said if I was willing to live with certain restrictions I could wait and come back in year or if I wanted to get it over with he was up for it. So i chose the latter because I didn't want the restrictions and I figured the younger I am the better my recovery would be . Also I have no other known health issues now so there's that.
Who knows what will be the standard in 20 yrs, it's tough to make a choice banking one way or the other on a possibility that even the experts don't fully agree on.