Thought I had My Mind Made Up...Confused

[harleygirl528]

Hi there, many of you already know my story...i am a 41 year old recently diagnosed with aortic aneurysm at about 5 cm and looking and imminent surgery, most likely in January or February of next year. Oh yeah, I have the classic precursor to most aneurysms which is the dreaded bicuspid valve. I just had another consult today with a surgeon here locally. Although I am not considering him for my surgery (he admittedly only does about 5 surgeries like mine a year) my cardio wanted me to meet with him to possibly to my post surgery case, especially since I may be travelling out of area for the surgery. Anyway, great guy and answered a lot of my questions but also brought up some new issues. At my age, the initial recommendation of most seems to be mechanical valve but my objections to mechanical are mainly lifestyle. Specifically, dietary changes and not being able to drink alcohol. I know, you can eat and drink what you want in moderation and as long as you are consistent, but honestly I am not a very consistent person and I like being spontaneous. I like, also, to drink in excess and really enjoy myself....particularly when I am travelling, on a cruise, etc. I am definitely not an alcoholic and honestly haven't drank more than a few glasses of wine in the last couple of months. But, I have been know to "tie one on" and I enjoy that from time to time. That being said, my primary dilemna now is this. One surgeon told me bovine valves are the way to go...the one today said pig valves are the way to go in terms of how long they last. Since I am assured a replacement, God willing, I want to chose the one that has the best track record, pig or cow. Also, the surgeon today said that the complications from Coumadin accumulate 1% a year so if I lived another 40 years I would have a 40% chance of complications from Coumadin, so perhaps tissue would be the way to go regardless. Not sure if I understand this. Also, I have a history of kidney stones and they bleed like heck....and they are very likely to recur...wouldn't this be a contraindication to mechanical anyway? I was really hoping to be able to salveage my native valve but the general consensus now is that the valve has to go so a decision is in order. I guess the surgeon I eventually choose is going to have a preference anyway, right? Thanks in advance for any advice you can give me...perhaps there is a website or study that compare bovine and porcine tissue valves?

 

[briansmom]

The only downside to the tissue valve is the need for re-op. I think that in the future straightforward valve replacements will be done via catheter so MAYBE re-ops will not be as bad as we think. I personally would not be concerned about an occasional night of partying with the coumadin, but I'm not sure about the kidney stones. As you said, maybe that is a no brainer and means you should go tissue. As for what kind of tissue valve, I have no opinion. I did not do research on tissue for my son. Please rest assured that whatever decision you make will be fine and you will be able to live a fun-filled life.

 

[KenBeirne]

Always a close decision

Always a close decision

This decision is always close, no matter who has to make it. it is all a matter of odds, and your own comfort level with multiple operations vs. the coumadin. If you look around the web site, you will find many people younger than you who have gone with tissue and many older who have gone with mechanical (e.g., me ), so it is not like there is any uniformity around here. As Briansmom said, your kidney situation is a different wrinkle, but your doctors will have to give you a better idea on what the odds are on getting stones again. Having gone through the operation once, I am not sure I would want to do it again, but if there is a chance of large scale bleeding with the stones, tissue might make more sense. However, you need to keep in mind that a fair percentage of tissue valve recipients also end up on coumadin.
I am not sure what your target INR level would be, but it if it is anything like mine (around 2.5) you might not have that much to worry about with the bleeding, unless the stones cause really severe bleeding -- i.e. if you end up needing blood after an attack, then you should probably try to avoid anti-coagulants, but if the bleeding is not that abundant now, I haven't noticed that bleeding is much more at 2.5 than it was before.
Ultimately, though, it is more a question of your own comfort level--I haven't noticed a whole lot of regrets by people regardless of which direction they went, with the exception of cases in which their choice did not live up to its expectations (e.g. they went mechanical, but then needed an operation again within a few years, or they went with tissue and it didn't meet its usual life-span or required coumadin anyway). Not much you can do about that either way.
So unless there is a clear medical reason which mandates one direction or the other, just go with your gut, so to speak.

 

[Bryan B]

This decision is always close, no matter who has to make it. it is all a matter of odds, and your own comfort level with multiple operations vs. the coumadin. If you look around the web site, you will find many people younger than you who have gone with tissue and many older who have gone with mechanical (e.g., me ), so it is not like there is any uniformity around here. As Briansmom said, your kidney situation is a different wrinkle, but your doctors will have to give you a better idea on what the odds are on getting stones again. Having gone through the operation once, I am not sure I would want to do it again, but if there is a chance of large scale bleeding with the stones, tissue might make more sense. However, you need to keep in mind that a fair percentage of tissue valve recipients also end up on coumadin.
I am not sure what your target INR level would be, but it if it is anything like mine (around 2.5) you might not have that much to worry about with the bleeding, unless the stones cause really severe bleeding -- i.e. if you end up needing blood after an attack, then you should probably try to avoid anti-coagulants, but if the bleeding is not that abundant now, I haven't noticed that bleeding is much more at 2.5 than it was before.
Ultimately, though, it is more a question of your own comfort level--I haven't noticed a whole lot of regrets by people regardless of which direction they went, with the exception of cases in which their choice did not live up to its expectations (e.g. they went mechanical, but then needed an operation again within a few years, or they went with tissue and it didn't meet its usual life-span or required coumadin anyway). Not much you can do about that either way.
So unless there is a clear medical reason which mandates one direction or the other, just go with your gut, so to speak.

OK...as someone who had a Ross Procedure I think I can play the neutral party here, but I have a couple of issues.

The first is with what harleygirl said. I might be wrong, but I don't believe complications from Coumadin "accumulate" over time. But let's say they do just for kicks. That means that by the time you are 81 there would be a 40% chance that you had an adverse reaction from Coumadin. That means there is a 60% chance that you wouldn't. And who is to say that an adverse reaction would be serious?

Now the flip side. KenBeirne said that "a fair percentage of tissue valve recipients also end up on coumadin". And to preface this Ken I'm not trying to be mean here but to make sure that "the facts are the facts". First...what is a "fair amount"? Second...what age range would this "fair amount" be applicable to? IMO unless a 41 year old has a history of A-Fib then the likelyhood of ending up on Coumadin after a tissue valve replacement would be less than "a fair amount". Also...if a patient has a history of A-Fib I think that patient would be smart to go with a mechanical valve anyway given their history.

Again...I'm not trying to call anyone out, but when making a decision on which valve to choose you need concrete facts. HG...if you read the threads "stickied" at the top of this forum I think Bob (Tobagotwo) may have covered both of these issues in his discussions of mechanical and tissue valves. I had a Ross Procedure so I'm not in a position to tout a tissue or mechanical valve. Like I've said before...both have pros and cons. You have to decide which pros and cons you are most comfortable living with. And obviously this is difficult because at this point you can only assume which type of valve you could best live with. It's the hardest decision I've ever made in my life. But the bottom line is that when you wake up from surgery you will have made the right choice because you made a choice and will have a new valve (and in your case aorta and/or root) that will allow you to lead a normal life again.

 

[Karlynn]

The surgeon's comment on Coumadin being cumulative would make me run the other way and not have him do a surgery on me. It is NOT cumulative and his believing it is would make me wonder what else he doesn't know. If it were cumulative, there would be no reason for it to be used and thought of as a "lifetime" valve. I had mine installed at the age of 32 and have had it for 16 years. My risk of clot and stroke is the same now, as it was 16 years ago.

The drinking is an issue. You can have alcoholic beverages while taking Coumadin. You can have a glass or two of red wine a day (or a cocktail), but 7 in one day is not good. Although depending on the regularity of partying once you get your valve fixed, I'm not so sure alcohol over use is something you want to put your newly remodeled heart through, regardless of valve type. Alcohol over-indulgence isn't good for a lot of things in the body, including kidneys. This isn't a judgment, (I love a good party too) but a suggestion that you might want to consider the stress it will put on your body if done too often.

Yes, if you have a big history of kidney stones causing bleeding, it probably is wise to avoid having to take Coumadin.

As far as eating and Coumadin. I don't give a thought about what I eat and how it affects my Coumadin. Most people's diets really don't vary all that much, and if they do occasionally it's not a big issue.

I'll let others comment on the ups and downs of mooing or oinking, I don't do either.

 

[ALCapshaw2]

The ON-X website www.heartvalvechoice.com has an interesting chart comparing Porcine, Bovine, and Mechanical Valves.

It was interesting to note that the Stentless Porcine Valve has a Gradient about HALF that of the Bovine Pericardial Tissue Valve but still about 50% higher than for the On-X mechanical valve. Clearly the Stentless Porcine Tissue Valve would be the best Tissue Valve choice for EXERTION tolerance.

I see claims for Extended Lifetimes for the Stentless Porcine Valve but NO ONE has provided the BASIS for these claims (and I have asked). It is my 'understanding' that this valve was introduced in the mid 1990's so there is only about 12 years of history for it (same as On-X).

Standard Unmodified Porcine Tissue Valves (straight from the Pig, NO treatments) typically last 8 to 12 years in ELDERLY patients, LESS in younger patients.

The Bovine Pericardial Tissue Valves that were installed in (mostly elderly) patients in the 1980's are approaching 20 years durability (at 90%?). The latest versions with anti-calcification treatments are "HOPED" to last for 25 years or so. The Cleveland Clinic is a Big Proponent of Bovine Pericardial Tissue Valves.

It is also a KNOWN FACT that Tissue Valves *Wear Out* Faster the younger you are when the valve is replaced. Unfortunately, there is NO PERFECT Artificial Valve to date, Mechanical or Tissue.

It's always a Tough Choice that usually comes down to which set of negative attributes do you think you can best live with.

Good Luck making that choice!

'AL Capshaw'

 

[Kate]

I'll agree with those posting above - mechanical vs. biological (or Ross, but that isn't really an option for you) is a decision that each individual must make with consideration to medical history and personal preferences. However, in my opinion, that is the primary choice that needs to be made. Especially if you are planning to go to a premier facility like Cedar Sinai or the Cleveland Clinic (as I know you are), I'd leave it in the Drs. hands regarding the specific type of mechanical or biological valve you receive (with the possible exception being the new mechanical valve that may require less anticoagulation - On-X? I can see the wisdom of advocating for that.) Based on my research, the performance differences within each category are not significant and decisions are generally made based on surgeon familiarity and patient characteristics (ie heart size, need for aorta repair, etc.) If someone else has information showing significant differences, I'd be interested to see it. Kate

 

[ALCapshaw2]

Coumadin Risk is NOT Cumulative

Coumadin Risk is NOT Cumulative

It is a popular MYTH and Mathematical IMPOSSIBILITY for the Coumadin Risk to be cumulative.

One of our members teaches Statistics at a Major University (including to Pre-Med Students). He is appalled by the misunderstanding of his students when it comes to interpreting statistics. He wrote a definitive Post detailing the Risk of a SINGLE Bleeding Event over time based on a Constant Yearly Risk (of 1, 2, 3 %). Naturally, that risk increases the longer you are on Coumadin.

To PROVE that a Cumulative Risk is Mathematically Impossible, consider a 3% risk for year 1. If it was cumulative, that would mean there is a 99% Risk of a Bleeding event EVERY YEAR after 33 years. (and a 102% risk at 34 years... whatever 102% risk means)

Bottom Line: There are NO Case Histories that support this ridiculous claim (i.e. Everyone who has been on Coumadin for over 30 years does NOT have a Bleeding Event Every Year). Several of our members are living PROOF. Ask RB, or Gina (GeeBee), or Nancy, etc.

'AL Capshaw'

 

[Kate]

It was interesting to note that the Stentless Porcine Valve has a Gradient about HALF that of the Bovine Pericardial Tissue Valve but still about 50% higher than for the On-X mechanical valve. Clearly the Stentless Porcine Tissue Valve would be the best Tissue Valve choice for EXERTION tolerance.

Hi Al,
I'm curious about this issue of exertion tolerance. Basically, this information suggests that someone with a bovine valve has significantly less ability to exert themselves than people with the other two types of valves. Yet, I have a bovine valve and can run a 5k race with 12 minute miles - not super fast, granted, but good physical endurance by most people's standards.

What level of exertion would cause one to run into the physical wall caused by my valve's higher gradient? It seems to me that no one besides a very serious athelete or hard physical laborer is likely to ever approach it. What do you think? Kate

 

[Superbob]

I don't see anything in the responses you've received that I disagree with. I agree with the others that the "cumulative" stats that were quoted to you are bunk.

As for your main question, porcine or bovine, I don't know of any definitive research that "proves" one or the other is best per se. I think it depends on the how advanced the technology is with any particular device -- for example, in the anti-calcification treatment. Tobagotwo is the resident expert on this; hopefully, he will come along with some guidance.

I needed a combined root and valve replacement, and learned of the stentless device I wound up choosing, and I understand it has a good track record so far, even though it hasn't been around a real long time. I sort of rolled the dice and went with my gut on it. So far, so good.

I am not trying to sway you one way or the other. I am just saying, in my understanding, porcine or bovine is not the main consideration.

 

[lance]

Tissue or mechanical? The ongoing debate.

Tissue or mechanical? The ongoing debate.

Good morning HarleyGirl,

Congratulations for knowing enough to check out for yourself the differences between tissue and mechanical valves. You are lucky to have found this site with so many helpful people.

Mechanicals usually last longer and warfarin can be dealt with. It absolutely requires an experienced person to monitor your INR's and keep you in range. Most of the problems with anti-coagulation occur because of the ignorance surrounding the use of warfarin and remember this therapy is a life-long commitment. Learn all you can about this drug--it can be dangerous. The use of a home monitor is essential--I don't know how I would get along without mine. Most medical practitioners fear bleeding, I fear stroking. Kidney stones sound painful and they reoccur so thats a complication in itself.

My surgery was in 1999 so I have eight years of experience with ACT. My INR levels are managed by an expert and I have been successfully bridged for surgery. Do I like warfarin? No I do not. ACT requires constant vigilence. Strokes, thrombus do occur in persons even when their ACT is always in range. Some feel I have no reason to feel the way I do about ACT but there it is. It also requires a certain amount of discipline. Had I known in 1999 what I know now, I would have a tissue valve with the possibility of not requiring ACT for life.

So the choice is tissue with another surgery, or mechanical with ACT for life.
Either way you will enjoy a long, happy and active life. Being an informed consumer is being your own best friend.

 

[Susan BAV]

Hi Harleygirl -

I am not championing one valve choice over another. I think many people can make the best of whatever they may end up with. One nice thing now as opposed to several years ago, however, is that more people have more valve choices now. Best wishes to you as you make your choice, particularly in regard to your other health issues.

Regarding Cumulative Coumadin Risk, though, I found the following information from a Johns Hopkins website and the bolding is mine:

"Prescription Drugs Special Report - How To Stay Safe on Coumadin (warfarin)

Michael Streiff, M.D., Medical Director of the Anticoagulation Management Service and Outpatient Clinic at Johns Hopkins, talks about the benefits of self testing for warfarin patients.

Millions of people take Coumadin (warfarin) to help prevent stroke and to treat deep venous thrombosis and pulmonary embolism. But warfarin is notorious for not playing well with others -- its effectiveness can be altered by anything from vitamin-K-rich foods to other common medications. A 2006 study published in the Journal of the American Medical Association found that one out of every seven drug-related emergency room visits was caused by either insulin or warfarin.

In October 2006, the FDA required drug manufacturers to include a "black-box? warning on Coumadin and warfarin labels. Black-box warnings are included when a drug carries major risks of serious side effects or death. The warfarin warning emphasizes the risk of potentially fatal hemorrhage.

Warfarin works by inhibiting the production of blood-clotting proteins. In the right amounts, it is a very effective anticoagulant. However, excessive doses of warfarin can reduce the levels of blood-clotting proteins to dangerously low levels, resulting in an increased risk of hemorrhage. Factors that increase your risk of warfarin-caused bleeding include being over 65, high blood pressure, cerebrovascular disease, severe heart disease, renal insufficiency, and cancer. Major bleeding is also more likely to occur soon after starting warfarin, but the cumulative risk also rises with continued use of warfarin. Not surprisingly, patients on more intensive warfarin therapy are also at higher risk for major bleeding.

To make sure that they are taking the correct dosage of warfarin, people who take warfarin must undergo frequent blood tests to measure their prothrombin time, or how long it takes for blood to clot. Prothrombin time results are expressed as International Normalized Ratio (INR) numbers. For most patients, the safe range is 2.0 - 3.0 -- higher INRs are associated with an increased risk of bleeding, while INRs below 2 provide less effective protection against clot formation. "Published studies clearly indicate that warfarin patients who undergo frequent INR testing spend a greater proportion of time within the therapeutic range than patients who have less frequent INR assessments,? says Michael Streiff, M.D., Assistant Professor of Medicine and Medical Director of the Anticoagulation Management Service and Outpatient Clinic at Johns Hopkins.

Typically, patients on a stable dose of warfarin have their INR measured at least once a month in an anticoagulation clinic at a hospital. If patients want to monitor their INR more closely, however, self-monitoring is an option that?s shown promising results over the past few years.

Dr. Streiff notes, "While some warfarin patients like the reassurance of a visit to their doctor?s office, motivated patients who stick to their self-monitoring program will do just as well as they did when they went to an anticoagulation clinic.?

There are several potential benefits of self-monitoring. Says Dr. Streiff, "It?s especially useful if the patient starts seeing signs that their INR might be high, such as bruising. Self-testing offers the patient a convenient way to check his or her level of anticoagulation promptly.? (Other signs of excessive bleeding include nosebleeds, bloody gums, weakness, and blood in urine or feces.) Self-monitoring also has the advantage of being portable -- patients can check their INR while out of town.

Clinical trials tend to support self testing. In February 2006, The Lancet published a review of 14 studies of patients who self-monitored their warfarin use. Overall, people who went to a physician or anticoagulation clinic to measure their INR had more than twice as many thromboembolic events (such as stroke) as warfarin users who checked their own INR.

At-home INR monitors are similar to those used by people with diabetes. A patient pricks his or her finger with a tiny needle and places the blood on a test strip. The test strip is read by a tabletop monitor that displays the INR. The patient calls the doctor?s office with the INR, and, if necessary, the doctor adjusts the warfarin doses. The patient may be advised to cut warfarin tablets in half, or the doctor may call the pharmacy with a new prescription.

Self-monitoring for warfarin is not for everyone. Patients need to have enough motor control to properly use the needle and test strip. The machines and test strips are also expensive, and insurance may not cover the costs. Medicare covers self-monitoring equipment only for people with mechanical heart valves.

ON THE HORIZON -- Genetic testing may someday help further reduce the risk of warfarin-related bleeding. Researchers have found that genetic differences influence the way the body metabolizes both warfarin and vitamin K. Dr. Streiff says, "While genetic tests are still in their research phase, some day soon they may help physicians tailor initial warfarin dosages to each patient, which could make the initial phase of warfarin use safer.?

Medical Disclaimer: This information is not intended to substitute for the advice of a physician. Click here for additional information: Johns Hopkins Health Alerts Disclaimer"

http://www.johnshopkinshealthalerts.com/reports/prescription_drugs/819-1.html

---------------------------------------

I am no medical expert and I was only on Coumadin for three months post-op. But there are medical authorities who contradict some opinions that are occasionally expressed on this site. The report also speaks very positively in regard to home testing.

And please don't "flame" the messenger . My disclaimer is that I have nothing against Coumadin or mechanical valves. But Coumadin is a serious medication.

I hope this post and the ones following don't overshadow the personal experience post right before this.

 

[geebee]

HaryleyGirl,

I agree that you should probably let your surgeon decide which tissue to use. If you trust your surgeon and express all your concerns, I am sure he will choose the right valve for you. I do believe most excellent surgeons want to do what is best for their patients' lifestyles.

I cannot let this go without a comment on the coumadin information posted.

The important thing to consider is just what is meant by cumulative risks/complications. There is nothing in these posts that indicates the severity of of those risks. I have been on coumadin for 27 years and the only issue I have had is a cut finger that bled excessively. I do believe it bled more because I am on coumadin but I sure didn't lose enough blood to require a tranfusion. Does that fall into these risk/complications statistics? Without backup, the comments don't mean much and should be taken with a grain of salt no matter who said them.

To say that there is a 1% yearly risk that is cumulative means that I should expect 4 complications this year. I haven't even had one so.......... I guess I should be very careful for the next 3 weeks.

I realize all this information is provided to help and I think that is wonderful but I really worry about scaring people to excess. IMHO, Coumadin can be a dangerous drug if not well managed, however, well managed it is no different from any other drug.

 

[MikeHeim]

Also, I have a history of kidney stones and they bleed like heck....and they are very likely to recur...wouldn't this be a contraindication to mechanical anyway?

Based on my understanding, I think this might be the biggest issue you are facing. I would discuss this very seriously with my surgeon, cardiologist, and anyone else who will listen. If you are prone to internal bleeding, that is a MAJOR issue with warfarin.

 

[Ross]

Lorrie I suspect your somewhat of a partier. I would recommend mechanical because of your age, but tissue may be the better choice for you, though it will have to be replaced at some point in time. What you've described is what most of us on Coumadin do. We go overboard once in a while, but not all the time. Diet and Coumadin is pretty simple. Keep eating as you always have. If for some reason you start eating more Vit K then adjust the dose up to include it, no big deal.

I'm only saying I think you could do it, but if tissue is the way you feel right, go tissue. Main thing is GET FIXED SOON.

 

[ALCapshaw2]

HaryleyGirl,

I agree that you should probably let your surgeon decide which tissue to use. If you trust your surgeon and express all your concerns, I am sure he will choose the right valve for you. I do believe most excellent surgeons want to do what is best for their patients' lifestyles.

I cannot let this go without a comment on the coumadin information posted.

The important thing to consider is just what is meant by cumulative risks/complications. There is nothing in these posts that indicates the severity of of those risks. I have been on coumadin for 27 years and the only issue I have had is a cut finger that bled excessively. I do believe it bled more because I am on coumadin but I sure didn't lose enough blood to require a tranfusion. Does that fall into these risk/complications statistics? Without backup, the comments don't mean much and should be taken with a grain of salt no matter who said them.

To say that there is a 1% yearly risk that is cumulative means that I should expect 4 complications this year. I haven't even had one so.......... I guess I should be very careful for the next 3 weeks.

I realize all this information is provided to help and I think that is wonderful but I really worry about scaring people to excess. IMHO, Coumadin can be a dangerous drug if not well managed, however, well managed it is no different from any other drug.

With regard to "letting the Surgeon Decide which valve to use" this statement needs a caveot. Note that MANY of the MAJOR Hospitals (including CC) have a LIMITED number of Tissue and Mechanical Valve Choices (usually 2 each) decided by COMPETITIVE BID. Until recently, CC Surgeons were NOT using the On-X Valve (and some others) for example.

Bottom Line: If you have a preference for ANY particular valve, you need to ask your surgeon if he is willing to agree to use your Preferred Valve as Option 1. It is also wise to have a Plan B in case that valve is not viable once he 'gets in there'.

If you have your 'heart' set on a particular valve and the surgeon you are interviewing is NOT willing to use that valve, you may want to consider finding another surgeon who is willing, preferably one with some experience with that valve if it has unique implantation requirements.

Regarding the CUMULATIVE RISK of Coumadin, I suspect there is a LOT of misuse of that word. YES, the Longer you are on Coumadin (or ANY drug), the higher the risk that you will suffered some side effect ONE TIME.

This is NOT the same as saying that you have an X% risk in year 1, 2X% in year 2, 33X% in year 33 etc. which is the more accurate definition of Cumulative Risk.

'AL Capshaw'

 

[geebee]

Regarding the CUMULATIVE RISK of Coumadin, I suspect there is a LOT of misuse of that word. YES, the Longer you are on Coumadin (or ANY drug), the higher the risk that you will suffered some side effect ONE TIME.

This is NOT the same as saying that you have an X% risk in year 1, 2X% in year 2, 33X% in year 33 etc. which is the more accurate definition of Cumulative Risk.

'AL Capshaw'

I agree with you but that is not what is often implied. The same can be said for anything we do, eat or drink over a lifetime (the chances of driving accidents, choking, allergic reactions, walking, etc. increase simply because we continue to live) but these things are merely understood, not beaten to death in posts.

 

[geebee]

But some here persist in posting what they want to believe and expressing those opinions as facts .

Susan,

I agree that it is important to keep us informed. I would like to point out, however, that me (or anyone else on coumadin) posting what I have experienced, IS fact. Not to say that anyone else will have the same experiences but personal experiences are facts and not opinions.

 

[geebee]

Why is it when some folks post of their experiences it is considered to be helpful anecdotal experiences and others are viewed as argumentative and mean? Just because someone disagrees with another does not make them mean or wrong - just different.

 

[Lynlw]

Lorie,
I'm sorry there are so many things to figure out where/what /who... anyway. I think it is a really good idea to ask your surgeons their thoughts about how your kidney stones that "bleed like heck" should play into any choices you have to make.
As for ..."perhaps there is a website or study that compare bovine and porcine tissue valves?" I don't know of any off the top of my head, but as far as "I" know the bovine with the chance of being the longest lasting is the CE magna, which the older model without the new anticalcification has a good track record (don't have the exact numbers but close to 90% at 20 years) The porcine valve I've heard the most promising things about is the stentless ones, but they only have been around 12 or so years.
IF you end up choosing CCF I believe the tissue valve they prefer is the CE http://www.clevelandclinic.org/heartcenter/pub/guide/disease/valve/pericardialvalvestory.htm
Lyn
ps how has the pain you've been having doing?