tissue (bovine) in younger than 60

[Lynlw]

I know that the stats always say a valve will last so long in someone over sixty,but "less" in people less than 60. I've been looking and looking for what is "less'
NOw this is just one thing from the Cleveland Clinic and it is about 40 years old, not younger but I was pretty surprised by the results. They aren't as good as a 60 year old, but better than i always thought. especially for the aortic position ( knew they lasted longer in the pulm position since the pressure is lower)
this is from their Aortic valve choice in younger people article
http://www.clevelandclinic.org/heartcenter/pub/guide/disease/valve/youngvalve.htm

under tissue valves it says
"Drawbacks: Studies on the PERIMOUNT pericardial valve show that in a 40 year old patient, these valves have a 50 percent chance of lasting 15 years or longer, without decline in function. In younger patients, these valves will not last as long, but still last longer than previous generations of bioprostheses. In older patients they will last longer. Durability of present generation pericardial valves and homografts are very similar Click here to learn more."

I followed the link in the click here to this study (which isn't very detailed)

http://www.clevelandclinic.org/heartcenter/pub/guide/disease/valve/pericardialvalvestory.htm

Heart valves are marvels of natural engineering. Most people's last a lifetime. But when valves go bad, they may need to be repaired or replaced. Almost 90,0001 Americans a year need surgery for valve disease. Many of these people will get new, replacement valves made of mechanical or biologic (animal) materials. Which type of valve they get is an important decision and is often not decided until the time of surgery.

Up until now, the biologic valve had one big disadvantage: it didn't last very long. Recently, however, Cleveland Clinic Heart Center researchers have turned that belief on its head. The biologic valve turns out to be a lot tougher than many people thought.

Mechanical valves are known to be very sturdy. They are made of carbon covered with polyester mesh, and are practically indestructible. The big drawback is that patients who get this type of valve also need to take special blood thinners for the rest of their lives. Biological valves, by contrast, are made of specially processed and shaped animal tissue. They don't require the patient to take the blood thinners forever (unless they have other conditions which warrant it). On the other hand, surgeons were hesitant to implant them in patients who were much younger than 60. It was thought that they would wear out long before the patient did.

That belief has now been challenged. Heart Center researchers Michael Banbury, M.D., Delos Cosgrove, M.D., James Thomas, M.D., and others2, discovered that patients who had received biologic heart valves, did very well. Even 17 years later.

The Heart Center researchers studied 267 patients who had received a Carpentier-Edwards aortic pericardial valve replacement between 1981 and 1983. The researchers followed up on these patients every year thereafter. Many patients not only got echocardiograms, they filled out questionnaires. Outcome measurements included improvements or declines in the New York Heart Association classification of clinical symptoms and echo measurements to determine performance of the valve and size of the valve opening.

How did they do? According to Dr. Banbury, after 17 years they were doing very well. The majority of patients, even with an increasing age enjoyed good functional status.

The hemodynamic durability of this valve is excellent and resilient over time," says Dr. Banbury. "The findings from this study support its use in patients and may be considered for individuals younger than 65 years."

References:

American Heart Association, 2001 Heart and Stroke Statistical Update, http://www.americanheart.org/statistics/medical.html ( a new browser window will open with this link. The inclusion of links to other web sites does not imply any endorsement of the material on the web sites or any association with their operators)
Banbury MK, Cosgrove DM 3rd, Thomas JD, Blackstone EH, Rajeswaran J, Okies JE, Frater RM. Hemodynamic stability during 17 years of the Carpentier-Edwards aortic pericardial bioprosthesis. Ann Thorac Surg. 2002 May;73(5):1460-5

 

[katie1234]

My mom (age 55) went for two opinions for her sugery for mitral and aortic valve replacement, and both surgeons said that the information on tissue valves in younger patients is generally outdated, and that the valves actully last longer than was ever expected. I am definitely hoping so, since my mom just got two bovine tissue valves on July 30th. She went in thinking they would be mechanical valves, but the surgeon said when he got in there that the bovine valves provided the best possible fit for her. She goes to a post-op meeting with him next week, so I am hoping to tag along and ask what specifically he saw that made him choose the bovine. Both surgeons we consulted said that we could expect the carpentier-edwards bovine tissue valves to last about 30+ years for my mom, even though she is very active, etc.

 

[sonavogel]

Really--30+ years for your mom's bovine valves? Did they stress that this included (in their opinion, at this point) no discernible loss of functionality or level of productivity toward the latter third of the term? If they didn't specify, could you check that with them? I'd be very interested in learning not only what their opinion is on this part, but why they hold this opinion--that is, what is it about the latest generation of bovine valves that makes them feel this way.


Thanks, Katie. And I hope your mom is feeling really good today!

Best, sona

 

[Susan BAV]

This is interesting and got me to wondering again...

This is interesting and got me to wondering again...

There are some medications that are known to possibly cause damage to heart valves. Fen Phen, if I'm spelling that correctly, was one. Some other meds for various disorders over the years have been pulled because of resulting damage to heart valves. This is one reason that I don't want to take any med or homeopathic thing, etc., that I don't absolutely have to, in hopes of keeping my porcine valve in as healthy a state as long as possible.

What possible inbalances can cause the tissue valves to wear out sooner rather than later?
Metabolism? Hormones? Body chemistry? Rogue medications?

 

[starfish11040]

She went in thinking they would be mechanical valves, but the surgeon said when he got in there that the bovine valves provided the best possible fit for her. She goes to a post-op meeting with him next week, so I am hoping to tag along and ask what specifically he saw that made him choose the bovine. Both surgeons we consulted said that we could expect the carpentier-edwards bovine tissue valves to last about 30+ years for my mom, even though she is very active, etc.

katie,

The surgeons told your mother to expect 30+ years from the bovine valve. Yet the surgeon went in thinking he would use mechanical valves. Why would he even have considered using a mech valve if he has a tissue valve that will last over 30 years? It doesn't make total sense. I must be missing something.

 

[katie1234]

i am really confused also

i am really confused also

I agree that it doesn't make sense. Before the surgery, both surgeons we consulted said that the information out there on tissue valves is generally outdated, and that the newer tissue valves are outperforming their projected longevity. When my mom decided to go with Dr. Krieger as her surgeon, she said that she was pretty sure that she would prefer mechanical valves just to be more sure that they wouldn't wear out (since we have definite proof that they will last 30+ years). Her decision was that she would prefer mechanical valves, but that she understood her case was a complex one with the radiation damage and all, and that it would ultimately be up to Dr. Krieger to determine the best possible valves for her once he got in there. So last Monday, she went in pretty much expecting mechanicals, and woke up with two bovine valves. The surgeon and his team have assured us that these valves were the best fit for her, and his nurses and assistants keep telling us that she should get about 30 years from them. I am skeptical about this, but honestly, just trying to focus on the extremely positive result that she is doing well right now and just got home today. When I think about 'what if the surgeon made the wrong decision?' i first feel confused, then angry, then ungrateful (then more confused). So in answer to your comment, I agree that 30 years doesn't sound right. At the same time, it better be.

 

[tobagotwo]

Some thoughts...

I'm not convinced that tissue valves will yet last thirty years reliably. I feel that was an irresponsible statement, if it was made in the way described. There is currently no data to support it. I would strongly urge people to avoid making a decision solely based on that comment.

By the numbers, there is a very good chance that a pericardial valve placed in a 55-year-old woman would last until she's 76 or 78 - an average lifespan. In that sense, I suppose they could feel it would last longer than she needs it. However, it seems that most people who last that long tend to last beyond that. It's entirely a crapshoot to feel it will last her to 80, much less 85. It may happen for her, and I certainly hope it does. But there is no one who can positively say anything more concrete than "may."

However, it should be pointed out that the long-term data that is used for current studies are from models of tissue valves that were made before nondamaging (noncrushing) preserving processes were developed and before anticalcification treatments were in use. So, even the most current data are out of date, before the information is even ready to be used.

I also want to point out that Dr. Cosgrove did a lot of development work with Carpentier-Edwards, and it is difficult for a man to critique his own work, all intentions aside, and just as difficult for his fellows to turn a hard eye on it, when they know it will reflect directly on him (a leading figure at CC). I am not casting aspersions at Dr. Cosgrove or his motives: I'm just commenting on a reasonable side-effect of being human.

I had my valve installed when I was 52. Although I have an "agressive heart," and my internal pressures (aortic gradients) are much higher than they should be, I'm hoping to get 15-17 years out of my tissue valve, which is still running flawlessly. The next one, sometime before I'm seventy, should last me for the rest of my life. I think that's a lot to expect right there, and a pretty good deal at that.

Best wishes,

 

[Lynlw]

Bob,I know you probably don't know, but was wonderring your thoughts, I'm curious, since Cosgrove has been at CC forever and Peterson (who wrote the one article) has been there quite a while, do you know why they made such a switch to tissue over mech? At first I thought maybe a doctor joined staff so pushed for his way, BUt if Cosgrove has worked on the CE, you would have thought they would have used more tissue all along instead of switching their "usual practice" just a few years ago. Or do you think it is a combination of factors like better success on redos?


"2002, there were 1,007 aortic valve replacements at The Cleveland Clinic Foundation, with bioprosthetic valves accounting for 74%, homografts 10%, mechanical valves 9%, and Ross Procedures 1%.

From 1990 to 2000, the choice of valve replacements indicated by the Society of Thoracic Surgery (STS) Registry for patients less than age 60 years with aortic valve disease was: mechanical valve in 77% of patients, bioprosthetic valves in 13%, homograft valves in 5%, and Ross procedure in 5%.

In 2002, despite the increased complexity of cases and rate of re-operations, the overall operative mortality (rate of death as a result of surgery) for valve procedures was 2.1%, far below the reported national average. Primary valve (excluding reoperations) mortality was 1.9%. The majority of young patients with aortic valve disease have a lower risk than the average risks cited here.

Mechanical Valve Replacement

 

[Karlynn]

Lyn, just guessing here, but in one of the round table discussions you posted a while back, it mentioned that reoperations were much more successful at hospitals and with doctors that do a lot of them. Maybe this is one of the reasons that CC tends to lean more to tissue replacements, because they know they have the teams that can do the reops and hope/assume that the people will come back to them when the time comes.

Does anyone know what Mayo's stats are and if it points to a "valve of choice" for Mayo?

 

[ALCapshaw2]

Lyn, just guessing here, but in one of the round table discussions you posted a while back, it mentioned that reoperations were much more successful at hospitals and with doctors that do a lot of them. Maybe this is one of the reasons that CC tends to lean more to tissue replacements, because they know they have the teams that can do the reops and hope/assume that the people will come back to them when the time comes.

Does anyone know what Mayo's stats are and if it points to a "valve of choice" for Mayo?

Karlynn, you almost took the words from my mouth.

A true CYNIC might ask if some Doctors aren't promoting Tissue Valves BECAUSE of the "REPEAT BUSINESS" down the road vs. a Valve That requires (almost) No Repair / Replacement in the future!

(Just for the record, a CE Bovine Pericardial Tissue Valve was my First Choice which my Surgeon had agreed to implant, 'until he got in there' and concluded I needed a valve that would last 'for the duration').

'Al Capshaw'

 

[Natanni]

We just got back from Nathan's cardio at the Mayo, and I sure don't have 'stats' for anyone, but in Nathan's case, it was re-confirmed that with lifestyle (mainly, his repetitive heavy lifing for work and at home-far more than the average person) he would not have seen 10 years with a tissue valve. His doc brought this up yesterday, we didn't even mention it. Back when he was still in the decision making process in 2005, they would have been happy to give him a bovine (Nathan's surgeon's prefer) if he wanted one, but they were very big on making us aware of his expected tissue life.

 

[Susan BAV]

I don't have everything figured out but

I don't have everything figured out but

Regarding the earlier comment here about "surgeons promoting tissue valves for repeat business," perhaps it would be better to communicate with the facility and ask them, "Why?" rather than possibly maligning these physical engineering professionals and their motives and possibly insulting those who have sought their expert help?

Regarding further heart surgeries, frequently it's not just one valve that has issues. Other things and valves can and do go wrong, even much later. There are many members here who have had two (or even more) valves replaced and/or repaired, and sometimes not at the same time. And it's certainly not just tissue valves; mechanical valves don't frequently fail in themselves but other things can and do go wrong also.

Valve selection still comes down to a personal quality of life issue, as each of us decides on that personal definition with the recommendations of skilled surgeons and as much information as we have at the time but, unfortunately, without the possible benefit of hindsight.

And, in the end, we all of us want to live as long as we can with the best health possible, whether we choose a mechanical valve or a tissue valve. Right?

 

[catwoman]

And, in the end, we all of us want to live as long as we can with the best health possible, whether we choose a mechanical valve or a tissue valve. Right?

Right.
You can look at your family tree and use that as one of several factors in choosing which type of valve to request.

In 2003 at age 52, I thought of my 2 grandmothers. One died at 94 (Dec. 1993), the other at 99 years 5 months (June 2001). Both just "wore out," you might say.
At that time, all 3 of my mothers' siblings were alive (1 has since died), my dad's only sibling l alive (still is). My parents are 78 & 80.
This was one of the reasons I chose a mechanical.
Had my grandmothers died in their 50s, 60s or early 70s, I would probably have leaned toward a bovine valve.

 

[tobagotwo]

I have to say that there is a strong history of aortic tissue valves outlasting mitral tissue valves.

As far as the CC moving largely to tissue, I don't believe it's a repeat business deal. They have plenty of patients, and the repeat business should effectively lower their success rates (the patients are older, as well as having be operated on before). I don't know the entire motivation, but it's been a wave throughout the country for the last half-decade. Because of it, over time, we'll know for sure what the survival differences are between the two approaches.

I think that everyone is hoping to develop the crossover valve - the mechanical that requires no ACT, or the tissue valve that never wears out. More power to 'em. I hope they do.

Best wishes,

 

[felix8201]

Greetings.

I have lurked around the site for several months and learned a great deal. I am nearing my one year anniversery for AVR with the Carpentier Edwards Parachardial. I feel great. I am 45 years old. I wish I had found this site prior to surgery. The input of the folks here would have been invaluable going in.

When I was going through the selection process, I addressed the issue of tissue valve longevity with my surgeon. His reply was that there is no real difference in valve service life between younger and older patients. The different posted numbers are a result of the manor in which data are reported on the patients. Since younger patients are far more likely to outlive their original valve, the years to re-surgery are reported. Since older patients are likely to die of causes other than valve related, the life of the valve in those patients is ultimately reported as "infinity", as it is never replaced. Ultimately skewing the reported service life of the valve in older patients.

Degeneration of the valve is caused by calcification and pressure. Neither of which should be age dependent.

I have never seen the difference explained in that manor on this site, but I found it credible.

Felix.

 

[tobagotwo]

The notion that older people who "die with their valves on" have their valves' lives brazenly relegated to "infinity" within scientific studies is bizarre and incorrect. Fortunately, the physician who said that practices medicine, rather than statistics.

There are numerous studies that depict four- to six-year life spans in children and teenagers for early tissue valves that lasted reliably 12-15 years in adults. The "infinity factor" simply would not apply to those studies.

It is also reasonable to accept that younger people are far more chemically active than aging ones. Drug manufacturers will attest to that, inthat older patients tend to respond to medications more slowly and less fully than younger ones, and often require more quantity to achieve the same effects. The buildup of minerals on heart valves is most certainly a chemical process.

A favored theory by the makers of statins was that the growth was associated with arterial plaque development and cholesterol. For a while, it was popular to give tissue valve patients Lipitor or similar statins off-label (as an unapproved use), to slow calcification of the new valve. However, large-scale studies have failed to find any link between them, or any evidence that statins slow calcification of new tissue valves at all. This makes real sense, as there is no correlation between valve calcification and arterial blockages, and there is even a negative correlation between them in bicuspid valve patients, who tend to have exceptionally clear arteries.

The process of calcifying a tissue valve is much more than the presence of calcium and pressure. Valve "calcification" is actually the buildup of a mineral called apatite. Apatite is made up of calcium; some fluorine, Chlorine or hydroxy ions; phosphorus; and varying amounts of other trace minerals. It's the same mineral that the body generates in different ratios to create teeth and bones. So we have a built-in knack for apatite generation.

One line of speculation is that this is exactly what the body is doing: growing amorphous and disorganized bone in the wrong place. One subnotion to that idea is that the immune system is attempting to isolate a perceived internal threat by sealing it within bone.

However, it seems most reasonable to me that damage to overworked leaflets causes certain chemicals to be manifest on the surface of the valve. These chemicals may be directly "sticky" to mineral-bearing molecules in the passing blood, or they may attract passing cells associated with bone building, or even "turn" indeterminate cells to that end. Independent research done by manufacturers hoping to prolong the useful life of tissue valves has led them down similar paths to eliminate the calcium-friendly molecules found on the surfaces of their products ("AntiCalcification Treatments").

Pressure doesn't really seem to be a part of the process. Apatite development on valves is not associated with high blood pressure. The pressures that do go along with it (such as aortic pressure gradients) are inherent in the fact that the mineral physically blocks the blood flow or the movements of the valve leaflets that allow bloodflow. They are effects, not causes.

Best wishes,

 

[dlangton]

25 years for tissue valve

25 years for tissue valve

My cardiologist expects that my third-generation (porcine) tissue valve will last me for at least 25 years. (I was 56 when it was implanted last year, so if he is right, that will take me into my eighties.) I am far from being an expert but I know that important new advances are being made every year and anyone who is trying to make a valve choice needs to be using information that is up-to-date. There are even many otherwise perfectly competent cardiologists who don't keep current on the latest data and advances. It can be especially confusing if you are researching on the internet because it is not periodically culled for currency and is full of old articles and information. Don't, for example, let ANYONE tell you that tissue valves only last 5 to 10 years, because that is no longer the case!

 

[Natanni]

That depends on a few factors; My husband was told by the Mayo in 2005 that he would probably get 7 years with a bovine, as I explained in my post above due to his physically demanding (on his heart, lots of lifting) lifestyle, at 34 years old. Tissue AND mechanical valve longevity will vary person to person. But yes, some tissue valves will only last 5 to 10 years.

 

[tobagotwo]

DL...

For an adult over 50, I agree, although to Natanni's point there are exceptions, even at our age. I was looking for about 18 years from mine (I was 52 then). Because I have a "very aggressive heart," I may get less than that (my gradients are high, although the valve is still running flawlessly). My personal estimation would be that I would expect about 18+ years for a top-o'-the-line tissue valve for 90% of folks over 50 these days, longer than that for older patients.

Best wishes,

 

[OldManEmu]

Looking for tobagotwo comments

Looking for tobagotwo comments

I have noticed that with valve life estimates, they don't appear to take into account valve area, yet this is one of the criteria for surgery along with pressure gradient. I have a 29mm AV, the same type as you tobagotwo and the cardiologist suggested because of the large valve size and being 41 at the time of surgery I could expect 12-15 years before a redo. This was her estimate before the valve area reduced to a size that would suggest a redo.