Tissue Valve and on Warfarin

[alan_delac]

Hi

In another tread CRB (our member) stated:
"Ten years after a tissue AVR, 25% have to be on warfarin. Ten years after a tissue MVR 66% have to be on warfarin."
I spoke to my surgeon on probability of needing warfarin with a tissue valve and he stated that it was very small. 25% in not a small probability.
Could someone please provide more info (or links) on this topic.
 Are there particular risk groups?
 Any connection to valve types or new/old generation of valves?
 Age of patients?

I tried to find something on Internet but without much success.

Here is an interesting link on a new mechanical valve development. Animal study showed excellent blood compatibility (much better than On-X bovine model). Could not find more info about that valve or manufacturer (Triflo Medical Inc).

http://www.ncbi.nlm.nih.gov/entrez/...ist_uids=12558318&dopt=Abstract&holding=f1000


Regards

Alan

 

[Kevin M]

Where did these stats come from?

I've never heard stats anywhere near being these high.
Having had a tissue valve for a total of 14 years, I've had
the opportunity to talk to a lot of doctors. None have ever
said there was this high a probability. In fact, they have all
said it would be only in rare cases that a tissue valve requires
coumadin. It's usually in cases where there are other complications
in addition to a standard VR-related problem.
Kev

 

[Ross]

It was in the Round table discussions part 2 I believe and can be found in the reference section in the new sticky thread.

 

[RCB]

Several places

Several places

I think you could be talking about my post. It is a stat.
I had seen a couple of places, recently posted by our member Betty. What surprised me about this, was in all the tissue vs mech debates, it was not talked about.
This round table discussion that Ross is talking about
happened in 2001 and was represented by most of the great
heart centers in the U.S. When this stat. was stated, no one objected to it, rather they all seem to agree on it. You can read it for yourself , but that was my take on it.

Here is a link to a graph:

http://www.onevalveforlife.com/ovflcontenttmp.aspx?section=2&page=3

Also, I not sure how much you can draw from the Triflo
animal study. For one, it was very short time period and two, I was off
warfarin for 4 1/2 years with an old ball and cage valve that was in me for 17 years that had a hugh crack in it(see Al Lodwick's website)- before I had my stroke.

 

[Marge]

I read the Roundtable discussion in which that statistic was given. (Don't know how to get back to that thread, but I think I remember correctly what was said.)

One thing I noticed -- it did not say WHY such a large percentage of tissue valve patients might need to go on warfarin later down the road -- which was the first question in my mind when I read that. I reread the whole thing to see if I had missed anything, but couldn't find anything that said whether any later need for warfarin would be due to problems associated with the valve itself, or with other problems and conditions.

A fairly large proportion of the people who get valve replacements are elderly, and this group tends to get tissue valves. My understanding is that the incidence of atrial fibrillation is quite high among older patients whether or not they have had valve surgery. I wondered if the high incidence of going on warfarin after tissue valve replacements might be due to a-fib among this older population that is not necessarily related to their valve surgery. Or possibly to other medical problems that might be entirely unrelated to valves

 

[Susan BAV]

Could the high percentage number include ones who only took Coumadin/Warfarin for a limited time? I had to take it for three months because of post-op A-fib but that's gone and I don't have to take Coumadin anymore. ~Susan

 

[johnbelloh]

The only reason a tissue valve recipient would need coumadin is for a heart beat problem unrelated to the valve. The only other reason would be if the tissue valve wore out and the individual had a mechanical valve implanted.

 

[Ross]

The only reason a tissue valve recipient would need coumadin is for a heart beat problem unrelated to the valve. The only other reason would be if the tissue valve wore out and the individual had a mechanical valve implanted.

The exception to this would be someone predisposed to clotting or history of previous stroke. Valves are not the only reason Coumadin is used.

 

[RCB]

Many reasons

Many reasons

The exception to this would be someone predisposed to clotting or history of previous stroke. Valves are not the only reason Coumadin is used.

There are many reason to be on warfarin therapy-
all to control clotting- some related to the heart like an enlarged heart, others related to operations like joint replacement and DVT etc. Maybe we should ask Al Lodwick
for an exhaustive list.

 

[alan_delac]

Thank you all for your responses.

Something is not quite right with these high percentages for warfarin use and tissue valves in particular for the Mitral position. You would be mad to go for a tissue valve if you had 64% chance to finish on Coumadin. It would be good to find more about background for the presented statistics.
Regarding the Bovine model and Triflow valve. It makes sense in context of On-X Bovine model. Check this link:
http://www.mcritx.com/pdf/vol4iss1.pdf

and compare to Triflo
http://www.ncbi.nlm.nih.gov/entrez/...ist_uids=12558318&dopt=Abstract&holding=f1000

With all other tested valves (On-X link) thrombosis occurs within 10 weeks, so 5 months (20 weeks) is very good result.

Alan

 

[RCB]

I have too much time on my hands

I have too much time on my hands

It seems like everybody is doing a study- the more I read
the less I am certain of anything

http://64.233.167.104/search?q=cach....pdf+aortic+valve+reoperation+&hl=en&ie=UTF-8

 

[johnbelloh]

In all the years I have been doing research on valves I have never run across anyone with a tissue valve requiring warferin for just the valve. The only time warferin is given is if there is a stroke risk from a missed heart beat problem.

 

[Blanche]

Alan:
The quote you were interested in is, "Over a ten-year period, twenty to thirty percent of aortic tissue valve recipients are on Coumadin for other reasons , and up to two-thirds or more of mitral valve patients are on Coumadin..." Dr. Robert Emery

This quote can be found in the Reference Section of this board. It is included in one part of a three part report on a round table discussion. I have included a link below. The quote you mention is on page 7, in the right hand column, about one-third of the way down the page. The conversation about the quote of interest continues on page 8. The document is worth reading, IMHO, as well as the discussions on parts 1 and 3 of this round table discussion. I hope you find this helpful.

http://www.onevalveforlife.com/documents/2of3.pdf

If my link does not work, the one in the Reference Section does. You want Part 2 of the discussion.

Blanche

 

[Ross]

No offense meant here, but I think it is very unwise to base any decisions on statistics. There are far too many variables that come into play between individual humans. Numbers make things look a certain way, when in actuality, there are not.

 

[alan_delac]

It sounds to me that these patients had to take Coumadin sometimes during that 10 year period. It doesn't necessarily mean that all of them were on constant Coumadin 10 years after operation. Or maybe it is related to the period when older generation of tissue valves started to fail.

Confused

Alan

 

[Ross]

I know it's confusing. The best thing I can say is to think about all the factors involved and decide which holds the best set of the lesser evils for you. One way or another, your life is impacted, but you still have life. If you do nothing, you won't have a life to worry about much longer.

 

[Susan BAV]

Ross and Alan -

That is what I suggested (or tried to suggest) previously: could that statistic include those who took Coumadin for any length of time following valve replacement...

~Susan

 

[bvdr]

I have read that a person with a diseased mitral valve is more susceptible to atrial fib than patients that have aortic valve problems. It could explain the unexpected high figure quoted.

The valve most likely affected by rheumatic heart disease is the mitral valve and often times the first sign of rheumatic heart disease is arrythmias.

I have had quite a few episodes of atrial fib post-op and am sure I would have to be on coumadin even if I didn't have a mechanical valve. I'm very glad I've got my St. Jude valve.

 

[tobagotwo]

Coumadin is routinely given for stented tissue valves (3 months course at implant time) and also for stentless tissue valves by conservative cardiologists. This is an anti-clotting strategy for the healing process. This short-term anticoagulation therapy would also be used for many Ross Procedure recipients, for the same reason.

The only other surgery-related reason I have seen given for the use of warfarin sodium with tissue valves is for atrial fibrillation. The statements in the link are plain, inthat they indicated that 64% of mitral valve replacement recipients alone experience atrial fibrillation.

Again, it is generally a short-term therapy course, inthat the a-fib generally occurs in the hospital, or during the first few weeks of recovery, and the therapy is usually discontinued after three months if there is no recurrence (and there usually isn't).

If the statistics are for any tissue valve recipients who have had Coumadin therapy since implantation, then the numbers make sense. They're real, but don't actually mean what they seem to imply.

However, I get no sense that the numbers actually mean that these percentages ARE on Coumadin therapy after ten years.

Rather, the specific qualifier made by the doctor was, "over a ten-year span..." If you used Coumadin during the first three months due to post-surgical a-fib, then you qualify within that "ten-year span" qualifier.

There are also other, non-valve-related reasons for coumadin therapy, to relieve the possibility of strokes in folks who have had TIAs or previous strokes, and who have repetitive blockages. This is generally found in a more advanced age group. The popularity of this may be fading in favor of aspirin therapy, Plavix, and gout medications, which also reduce platelet stickiness, but are not as reactive as warfarin.

Benjamin Disraeli: "There are three kinds of lies: lies, damned lies, and statistics."

 

[RCB]

Please Reread the document!

Please Reread the document!

Dr. Emery ( on page 7) clearly states the statistic applies to pt. who "are on", not may have used at one time or another. Dr. Adams( on page 8) reacts to that statement using the term "end up on Coumadin". I don't see how those statements could interpreted any other way,
than to say you have a 25% chance with aortic tissue valve
and a 60% chance with a mitral valve replacement of being on warfarin after ten years.
I plan to have Dr. Gillinov(the dr. who represented CC
during the discussion) do my Maze when I have valve surgery. I will take the document to show him and see what he has to say. Maybe they were quoted incorrectly,
maybe they "misspoke" or maybe they were all drunk and didn't know someone was taking notes while they were joking around. It is pretty clear to me what is written about what was said there.
Perhaps, someone here knows Dr. Emory and could get
the source research. Same with the graph link I posted above- the data is footnoted, but am I too stretched now for time to go pick up the article. A little help anyone? It makes no difference to me - all my doctors voted mech.
valves for my next surgery. One less thing for me
to worry about.