Tissue valve or Mechanical Valve for your adults

[ashadds]

I have gone through this journal which goes to contrary to my belief that a mechanical valve improves survival in young adults over a tissue valve followed by re operations:
Can anybody comment on this paper

http://circ.ahajournals.org/content/116/11_suppl/I-294#T5

 

[Agian]

I think it implies that re-operation does not imply a shorter lifespan, when compared to mechanical and Warfarin.

 

[pellicle]

Hi

I didn't see where decisive life spans were discussed.

However as per the arguments I usually discuss (arguments which I re-presented by Dr Harztell Schaff that I enumerate in more detail than his talk) it would seem clear that the risks of reoperation are not equally well presented. That is to say that there seems to be a data selection bias by those who wish to promote reoperation and tissue valves. I think my blog post on this makes that point well (and explores why).

The primary argument for a tissue valve is to avoid AC therapy (which is not certain, as something between 10 ~ 30% will need AC therapy anyway). This makes sense especially in those over 55, where it just may be that you die of something else before needing a reoperation anyway.

The data used to compare risks (risk analysis) between reoperation and AC therapy is based on the premise of ALL AC THERAPY users, not a specific cohort of Aortic Valve or Mitral Valve replacement patients only. Worse it is based on the analysis of horrible outdated INR management practices which are last century (which is to say far more than 17 years out of date).

As I repeatedly say, data on who survives and how long is usually limited to 10 years ... seldom is it 20 and 30 is unheard of. Yet for those of us who are (or were) in their 30's at operation time 20 years does not seem like a sufficient long term examination.

Show of hands here who has had a tissue prosthesis for longer than 30 years here without reoperation?

... going once

.... going twice

.......

 

[Agian]

The article talks about survival (i.e., longevity) only.

 

[FredW]

After reading this study, I conclude two points:
1. Don't get a valve implanted that is no longer on the market, for they sucked.and don't get one that was developed 20 years age, for today's technology is better.
2. Get on living your life because we are all going to die - heart valve replacement or not,

Seriously, read the section on "Limitations" carefully. I quote: "Furthermore, prosthesis type selection was not randomized and depended for each patient on one or several factors, as outlined in the methods section; consequently, selection bias may have affected results," I would not put too much trust in a study that admitted a possible bias, and was written nine years ago.

So, get a valve, any valve, manage it well, and get on living.

 

[pellicle]

So, get a valve, any valve, manage it well, and get on living.

I suspect his issue is that for a younger patient (less than 40) you can not manage it if you get a tissue valve ... its managed purely and simply by replacement when it fails. This is contrary to a mechanical where you can manage outcomes. With a mechanical valve (either well or poorly) and outcomes are related to YOU and your management.

Myself I don't think fully randomised data is of as sufficient meaningfulness as propensity matched scores. In a randomised trial it would be ignored that patient A is healthy and athletic (except for the valve) and that patient B was ill, obese, had diabetes and other morbidities ... it would therefore be no surprise that patient B dies earlier than patient A

 

[Paleowoman]

I have gone through this journal which goes to contrary to my belief that a mechanical valve improves survival in young adults over a tissue valve followed by re operations:

Hi Ashadds - aren't you jumping the gun a bit ? Did you pick up the private message I wrote to you in reply to your private message a couple of days ago ?

 

[ashadds]

Hi Ashadds - aren't you jumping the gun a bit ? Did you pick up the private message I wrote to you in reply to your private message a couple of days ago ?

your absolutely right ! It seems that I should live my moment and when the future comes address this and be happy ! Thank you so much paleowoman ,and your absolutely right ....

 

[Agian]

The standard way Warfarin is managed may contribute to mortality higher than it should be.
There are people out there getting their INR tested every three months, especially older folks. Dangerous.
I think the standard is monthly now.

Let's not kid ourselves. Valve replacement comes with a set of risks, some of which are preventable. Others aren't.

Like I've said before, people with asthma have a higher chance of dying of an asthma attack than people without asthma. That's just bloody obvious.

 

[Agian]

your absolutely right ! It seems that I should live my moment and when the future comes address this and be happy ! Thank you so much paleowoman ,and your absolutely right ....

The waiting room sucks.

 

[Paleowoman]

The waiting room sucks.

Yes I know, but when the waiting room is going to be probably many years long it's best to concentrate on keeping fit and well and have regular check ups and echos. By the time ashadds may need surgery there will probably be new valves and new techniques to research and worry about ! Do stick around here though ashadds

 

[dick0236]

After reading this study, I conclude two points:
1. Don't get a valve implanted that is no longer on the market, for they sucked.and don't get one that was developed 20 years age, for today's technology is better.
2. Get on living your life because we are all going to die - heart valve replacement or not,

Uh, according to one of the charts in this study only one Starr-Edwards mechanical valve, like mine, was in the study. Seems odd since that valve was in production from the beginning, 1960 to 2007....almost 50 years........and I will enter my fifth decade with it in about seven months.

I really don't see any advantage in getting a tissue valve that will, almost certainly, require a re-op late in life........and certainly not just to, hopefully, avoid ACT.

BTW. my docs are pretty sure that "valve failure" will not be the cause of my demise.......things naturally start to go wrong beyond age 80. Fortunately I still have a very good quality of life.....and as we say in golf "I'm still looking DOWN at the grass".

Now I am off to go do my weekly hospital visits with OHS patients. If it's a typical day......90% will be CAB(bypass), 5% "other" and only 5% valve repalcement, mostly tissue (patients are normally in mid 60s to late 70s......with a TAVR every so often.

 

[pellicle]

Now I am off to go do my weekly hospital visits with OHS patients. If it's a typical day......90% will be CAB(bypass), 5% "other" and only 5% valve repalcement, mostly tissue (patients are normally in mid 60s to late 70s......with a TAVR every so often.

Interesting anecdotal stats, I wonder how close that reflects the whole of the USA

 

[Superman]

Now I am off to go do my weekly hospital visits with OHS patients. If it's a typical day......90% will be CAB(bypass), 5% "other" and only 5% valve repalcement, mostly tissue (patients are normally in mid 60s to late 70s......with a TAVR every so often.

That's really great that you do that. Hopefully someday the kids won't be so busy and I'll have an opportunity to give back. Whenever someone I know has open heart, I make myself available to them for questions, etc. and try to get down to visit. But within my circle, this is very seldom. I know of two people from work and one relative that have gone in for OHS. Considering it's been 26 years since my first - that kind of tells me just how exceptional we are as a group. Sure - almost everyone here has had open heart. But I'm always the only one with a scar at the resort pool in Disney.

 

[dick0236]

Now I am off to go do my weekly hospital visits with OHS patients. If it's a typical day......

Was a very atypical day. Saw no "cath" patients......no patients in surgery(I visit with families).....and only one post-op patient, a lady in mid 60s(?) who had 4 bypasses and tissue aortic valve. She had surgery monday 1/2/17 and should go home on weekend. I usually see 6 to 8 patients.......probably slow due to post holiday. It's amazing how many OHS are done nowadays.......total over 800,000/year in USA alone.

Got home with plenty of time to get my daily bag of microwave popcorn(movie theater butter) before dinner.

 

[pellicle]

Got home with plenty of time to get my daily bag of microwave popcorn(movie theater butter) before dinner.

So should we start a discussion about politics ?

 

[dick0236]

Interesting anecdotal stats, I wonder how close that reflects the whole of the USA

Pellicle, I see quite a few patients who have bypass and valve replacement at the same surgery and I tend to think of them as bypass. In hindsite my numbers at the one hospital I visit is more like 70% Bypass, 20% Bypass/Valve Replacement, 5% Valve Replacement only and 5% other(aneurism repair, etc).

I still think that Bypass surgery is a BIGGER deal than a typical valve replacement from a surgical point of view since more cutting, vein "harvesting" and stitching is necessary......and the post surgery recommended "life style" changes ain't no fun either.

 

[FredW]

...

Got home with plenty of time to get my daily bag of microwave popcorn(movie theater butter) before dinner.

Good for you Dick! I love popcorn and like your attitude. I have traded microwave popcorn for natural popped to be more healthy. That way I can have my scotch and butter with my popcorn. I call this dyslexic logic. The folks on the "staying the course" thread will like this.

On on a more serious note, I admire you doing your OHS visits.

 

[Agian]

So should we start a discussion about politics ?

Only if it's about American politics.
Obama is a bitch. Your turn.

 

[Zoltania]

I still think that Bypass surgery is a BIGGER deal than a typical valve replacement from a surgical point of view since more cutting, vein "harvesting" and stitching is necessary......and the post surgery recommended "life style" changes ain't no fun either.

I would have thought that valve replacement was a bigger deal because the heart itself is actually opened, while bypass surgery is more a matter of changing the plumbing outside the heart. Am I seeing this the wrong way?