Tissue Valve vs. Mechanical Valve?

[DanaH]

Hello all. I am trying to do some research for my 50 year old dad who is about to have his aortic valve replaced in a couple weeks. He has a bicuspid aortic valve with stenosis but didnt find out about it until his 30's. He does not have a spleen and has to be careful of infection or illness but is very healthy otherwise. Per the cardiologist that did his heart cath, his arteries are "crystal clear". He has the choice of a tissue or mechanical valve. His hobbies include riding the motorcycle, volunteer firefighting, mechanical work, hunting, fishing, etc, which are pretty important to him. I think he is leaning more towards a tissue valve since there would be less doctor visits, no Coumadin, not having to be careful of what he eats, etc. He has mentioned to me in the past that he doesnt like the thought of having to take medicine everyday (being dependent on the Coumadin- with mechanical valve). I personally feel that tissue valve is the way to go because of his age and health, but the decision is ultimately his. Also at the most recent visit with the surgeon, he was told it is very common to have to have a pacemaker put in after the replacement. I am hoping to find people on here that have both done and what do you feel are the pros and cons of having either done. Also if any of you had to have a pacemaker. Any help/info is greatly appreciated.

Dana

 

[Cooker]

I was just about to turn 50 when I had my AVR. I went mechanical to avoid a second surgery if at all possible. It is a very personal choice and you will get opinions running from one extreme to the other. Your dad and his cardiologist and surgeon will arrive at the right choice for him.

And I would like to say that warfarin (Coumadin) has been no issue. My lifestyle has not changed one bit. I am sure your dad will do well.:thumbup:

 

[Jkm7]

Hi and Welcome. Happy you found us. This is a wonderful community with loads of experience.

Choosing which type valve is one of the hardest decisions we have to make when it comes to our heart health.
There are good arguments for both and you seem to have done enough research and reading to know the pros and cons.

For many of us, avoiding coumadin is important and desireable. We realize there is a strong possibility of a second or even third valve replacement if we opt for tissue valve. Many of our very fine surgeons in top heart centers feel very strongly less invasive, less traumatic replacements will become the norm in the foreseeable future. They are already being done by cath on patients too ill to have traditional surgery.

It should be noted there is always a chance of coumadin being prescribed if patient develops a fib. It is a small percentage and sometimes temporary but the chance exists.

Mechanical valvers and coumadin users have varying experiences with the drug and its management.
Simply taking the pill daily is not a big deal to most. It is the rest of it. The requirement of testing for the rest of their lives. The sometimes not so good management of coumadin therapy by professionals. The need to sometimes stop use of the drug if requiring dental or medical procedures which might involve bleeding. The need to bridge with lovenox. For some, these are not major issues. For others, it is harder to cope and handle.

There are some mechanical valvers who are very active in all sorts of sports but certain restrictions are necessary. Bumps to the head are never good but certainly not for a coumadin user. You say your Dad is a volunteer firefighter. (Many thanks to him for that work). Some Departments refuse active duty to coumadin valvers....... it varies but might be something for him to research as pertains to his department.

My second OHS was valve replacement. I was using the same surgeon, at the same hospital, same cardio, even some same nurses and techs still on the cardiac floor of Mass General from when I had my first OHS. I certainly knew what the surgery was like, what I would experience having had my first surgery just four years prior. Despite the chance of needing another surgery, I opted for tissue valve and for me it was the absolute right choice. It is four years later and I am grateful I made that choice. Most surgeons leave that decision to their patients absent any compelling reason for one style or the other.

There is no wrong choice.
The issues you raise as reasons your Dad may wish to avoid coumadin are legitimate and reasonable to consider.
The only wrong choice of valve is to not go forward with the surgery.
You are wonderful to be doing this research and learning to assist your Dad.
Sending all best wishes.
Let us know how he is doing.

 

[Lynlw]

Welcome, as Cooker and jk mentiond both choices are good choices and people who chose either usually are quite happy with their choice. For someone in their 50s either choice can be the "right" choice for them, depending which "cons" they rather live with, the chance of needing this valve replaced if it is tissue or since mechanical valves can clot the need to take coumadin and everything that goes along with that- for mech valves, and for some the possibility they might have a valve that "ticks" louder than others is a concern. other people dont worry about the sound or end up liking it, or at least finding comfort in it.. .

Since your dad is leaning tissue, it might help to know MANY surgeons are now reccomending tissue valves for people in their 50s for a couple reasons, the tissue valves today "should" last pretty long 10-20 years in someone in their 50s, of course it can always be shorter if you arent lucky, also IF you need a REDO surgery the stats right now are as good for 1st time redo as they are the first surgery, but there also is a chance, some believe pretty good, that if/when this valve needs replaced they can do it by cath and avoid OHS. This is being done today in the higher risk patients and so isnt just a far off, hopefull dream and to hopefully avoid Coumadin. Just like the advancements in tissue valves, they are working on other kinds of anticoagulants, that wouldnt require the weekly, or monthly, blood testing and don't block vitamen K from doing all its important functions, but you would still need to be on some kind of anticoagulant which increases chances of bleeds

JK also brought up an important point about being a fire fighter, some depts it isnt a probem to be on Coumadin but others, like some police dept and the Military, wont let you be an active member if you take coumadin. It would be something to ask the dept before surgery.

No matter how "safe" OHS is now there are still risks and bumps along the way, one of the complications is you might end up with a pacemaker, but I think the odds are relatively low, even with the thousands of members who have passed thru here over the years a small percentage needed pacemakers. FWIW my son needed on when he was 10 but he needed his after a intverventional cath, so things happen you dont expect.

You Dad is lucky to have you

 

[AgilityDog]

What they all said. They said it well.
Yes, I have a pacemaker, but it is because of the maze procedure I had to have to stop the a-fib, plus I also need the defibrillator function due to my tendancy to go into v-tach (just 'cause that's so fun).
It's not because of my valve replacement. Lots of people get pacemakers without needing valve replacement. Lots of valvers don't have pacemakers.
If your dad has an arrhythmia issue now, then the pacemaker is more likely in the future, as is lifelong coumadin no matter which valve he chooses.

 

[dick0236]

Valve choice is a personal choice, but to choose tissue "just to avoid warfarin" may be short sighted. I have several "golfing buddies" with pacemakers for a-fib, that, like me must take daily warfarin. A lot is being written about the new meds to replace warfin for non-valve patients, but it seems they have a whole set of side affects worse than warfarin. Warfarin is not difficult to deal with so long as you "take the med as prescribed and test routinely". I actually find the monthly doc visits for INR test helps me stay on top of my medical needs. Had my INR test yesterday and he reminded me I needed a phneumonia(sp?) booster and flu shot for the upcoming flu season.....got 'em both and am good to go for awhile.

 

[Bina]

The previous responses have pretty much said it all.
Going tissue doesn't guarantee no daily pills, doesn't guarantee no rhythm issues, etc.
My surgery at age 46 gave me a mech valve which scared me less than a "guaranteed" repeat surgery.
I bought my own home tester for INR and take care of everything myself.

Who knows what the future brings; if I need to do this again when I am older, I may consider a bovine valve. Moo.
Best wishes.

 

[DanaH]

A BIG thanks to all who have posted so far! I have showed these responses to him and he was so glad that I have done this for him. Please keep them coming! I think this is really comforting to him to see other stories that are similar to his.

 

[Lynlw]

I'm not sure I would call it short sited to choose a tissue valve to avoid coumadin , since that is pretty much the main reason people choose and doctors reccomend tissue valves. Sure anyone can end up with end up on Coumadin anyway, with or with out a valve replacement, but it still comes with risks that -increase in the elderly. Many people do choose Tissue valves and don't end up taking Coumadin and these days when mech valves will guaruntee Coumadin or maybe another anticoag in the future choosing a tissue valve in your 50s does NOt guar needing another OHS, even IF you outlive your first valve. Which is one of the reasons the use of tissue valves has gone WAY up while mech valves have really decreased since the mid 90s.

 

[tom in MO]

I chose a mechanical valve in February and I am the same age as your father. I knew people on warfarin/coumadin before the operation, thus I knew it was no big deal. For some reason people fear this drug, maybe because it is mistakenly called "rat poison"...although the same people don't call morphine "smack".

As far as it being tiresome to take pills every day, taking a pill every day is a fact of life for just about everyone as they get older. If your Dad takes no pills now, he probably will in 5 years. To me the pain with warfarin is the testing, however this was solved by a home testing unit. The cost of warfarin therapy and testing is covered by insurance. I have not restricted my diet in anyway. However, being on warfarin helps me not drink too much, which is good for legal reasons

I wanted a tissue valve since it is "natural", has better fluid dynamics, less initial complications and no warfarin. Even though I knew warfarin was no big deal, why take it if you can choose not to.

However, I've had 3 previous surgeries, none as severe as valve replacement, but I don't want to repeat any of them. In addition, a tissue valve brings the prospect of not only repeating the reoperation, but (a) having to constantly monitor valve performance and (b) then suffer the poor quality of life that comes with the inevitable valve deterioration. I was in the "waiting room" for an operation for 20 years and with a tissue valve you don't get to leave. For some people the valve deteoration is not noticable and they are asymptomatic, but not everyone. With my first bad valve, I thought I had no symptoms, but now with my new valve, I have more stamina and know I was kidding myself.

One thing to also consider, is that if your dad lives in a rural area or works in a proffession with poor health insurance, a reoperation can be much more difficult than for others that are wealthier, have better health coverage or live in urban areas. I have a friend with a bicuspid valve who works in the food service industry. Due to the poor health insurance in that industry, he feels limited in his choice of jobs, since so many restuarants don't have good insurance. My OHS with no complications came in at about 200K, of which all but 30K were "written off" as a discount to Blue Cross.

From what I've read and been told by my doctors is that if your dad has no other problem but a bicuspid valve, he should not need a pacemaker due to a valve replacement.

Both choices lead to life and thus there is no wrong choice.

 

[Roberta]

Hi Dana,

I agree that you have received some great replies. I had an edwards perimount bovine valve placed at 46 years of age a few years ago. I did not need a pacemaker and am currently on no medication other than a baby aspirin daily.
Good luck to your father with his decision.
As Tom in Mo said "both choices lead to life and thus there is no wrong choice".

 

[epstns]

I'll add a few comments from the tissue valve/pacemaker group. I was 63 when I had my stenotic bicuspid aortic valve replaced with an Edwards bovine valve. That choice was easy - my surgeon was a member of the team that developed the current generation valve and had implanted thousands of them. At 63 years old, they projected a long life span for the valve, so I agreed. Had they suggested a mechanical valve, I would have done that, too. My mother took coumadin for many years for afib, and it just wasn't a real issue to her, so I didn't think it would be for me, either.

As for the pacemaker, it isn't really a big issue either, once it is adjusted correctly for your lifesyle. We are not sure why I ended up needing the pacer, but immediately following surgery my heart rate was nearly impossible to regulate. It would soar up into the 160's while I was still in bed, then it would drop to the low 40's, skip beats and finally a couple of times it just stopped for 15 to 20 seconds at a time. Rather than risk a long time trying to regulate it, I agreed to have the pacemaker implanted. Again, from my mother's experience with hers, I didn't foresee any real life issues. At first I was 100% paced by the pacemaker, but over the last 18 months the percentage has dropped to 50% or less. We think that in my case, my valve was so calcified that when the surgeon cut the bad valve out, he may have injured some of the pacing nerves that run right next to the valve. This may have caused my irregular heart pacing and necessitated the pacemaker. With my pacemaker, I still go to the gym 5 days a week. I ride an exercise bike, jog, lift light weights and work 50-60 hours a week. I'm pretty much doing all that I could do a year or two before my surgery. The pacemaker was tricky to adjust, but it helped to have a really good electrophysiologist (pacer doc) to discuss my needs and experience with it. They can set your minimum and maximum paced heart rates to allow for most activities, and they can also set various compensating features to allow for pretty vigorous physical activities like my jogging. The only issue I've noted with it is that it isn't well adjusted to activities with rapid start-stop requirements (like lifting bags of rock and putting them down, one after another). Other than that, most days I don't even realize that I have it until I look in a mirror.

As the others have said, I think your dad's thinking is on the right track, and he definitely is lucky to have you to help in the process. Good luck, and keep up the good work.

 

[Madsometimes]

I had my valve and aortic root replaced nine months ago, and my choice was mechanical. I was 39, so a little younger than your dad, and I did need a pacemaker after my surgery. Only a small percentage of people end up needing a pacemaker, but it is good that your dad's surgeon has warned him of the risk beforehand. Needing one came as a bit of a shock to me, and it took a while to accept that I needed a device that I had previously associated with old people!

As Steve has said, pacemakers have very little effect on lifestyle. I have AV-block, so signals cannot pass from the upper chamber of my heart to the lower chamber. My heart responds normally - it speeds up during exercise and stress and slows down when I'm calm. My pacemaker simply senses my physiological heart rate and then paces accordingly - it's a very clever device.

 

[DanaH]

Thanks again everyone. He has also asked how long is recovery and what should he expect immediately after surgery and what should we (the family) expect to see him like? The doc told us hospital stay is 3-5 days and recovery is 4-8 weeks. I know of course everyone will tolerate it differently. Will he be able to get up and walk the next day? A lot of people say it hurts to breathe etc.

 

[Lynlw]

You or him, should check out all the stickies at the top of the various forums I dont know if you saw this one it has a link to a helpful "what to expect" http://www.valvereplacement.org/forums/showthread.php?36996-PDF-from-STS-What-to-expect-after-OHS There are also some very good threads in the post op forums where many people describe their experience often while still in the hospital, or shortly after they come home
He should be up walking the next day, FWIW Justin never complained about it being painful to breath unless he had problems. I dont recall that many people saying breath hurts, now coughing and laughing ...yes but it helps to have a pillow to hug

 

[Jkm7]

My second OHS was four years after my first. I was walking, on the phone with DH and eating half a sandwich about 14 hours post op. Sure, I only walked maybe down the hall about three or four rooms (with my nurse and DH's help) and then back to bed but very soon, I was able to walk the floor as is usually encouraged as soon as patient is up to it.

The delay sometimes comes depending upon how many/how uncomfortable the chest tubes are. We all have chest tubes placed at surgery to drain fluids and it varies how many and how long they remain in place. I had three my first surgery and four the second. Many of us are relieved as they get pulled as we are more comfortable.

My nurses were very definite in advising they consider pain control as important as all other vital signs. I tolerated pain meds fine and they were given me at regular intervals keeping me comfortable. Most report the same.

As to recovery my second surgery, I was starting to do my usual activities about 6 weeks post op. Before that, I was given permission to drive local, non-highway roads and do my light errands. We all have a lifting limit which is very important. Whatever limitations his surgeon gives your father, should be carefully observed. He does not want his sternum to not heal well and fully first time through. Those who are careless about those limitations can do themselves serious injury. The limits are often in the 10 pound range for about 6 weeks but that varies by surgeon/patient.

 

[Guyswell]

Hi Dana,

The time frames given by your father's doctor sound about right. Recovery varies based on a lot of factors. I'm 49 years old I've had the surgery two times (at age 41 and 49). The recovery was easier the second time. Nine days after surgery, I was on a plane, flying home from Ohio to Kansas. I didn't have the energy to hike all the way through the airport so I rode around in a wheelchair. I was able to walk around the boarding gate area and walked on and off the plane unassisted. I started walking around the neighborhood in the second week after surgery and gradually increased my walking times and distances. About two weeks after surgery, I went to a wedding and reception and felt a little fatigued by the end of the night but fine otherwise. I returned to my desk job and started riding my bicycle again when I was allowed to drive (six weeks post surgery). I'm now nine weeks post surgery and two nights ago, I rode my bike 1.5 hours and mowed the grass for 45 minutes when I got home from my bike ride (no riding mower).

When you see your father in the recovery room, he may look pale and puffy. Patients get pumped full of fluids during surgery. You may be surprised to see his chest and incision exposed to the air. In the recovery room after my first surgery, my chest was bare and my incision (held closed by tape strips) was exposed for all to see. My wife remarked that it looked like a clean line down the center of my chest (not gross or disgusting to look at). After my second surgery, my chest incision was held closed by surgical super glue and covered by tape and gauze bandages.

When your father is in the hospital, he probably won't walk much until the urinary catheter is removed on day two or three. Your father probably won't get out of bed on the day of surgery. On the day after surgery, the hospital staff will help him sit on the edge of the bed, get out of bed, stand next to the bed, and sit upright in a recliner. That's probably all he'll feel like doing. He will feel pretty tired. By day three or four, he should feel strong enough to take short walks in the hallway. He should walk as much as possible. Lying in bed is not the best way to recover.

After surgery, it doesn't hurt to breathe but it does hurt to take a deep breath for 3-4 weeks. Even four weeks after surgery, a sneeze hurts a lot. When my kids heard me curse after sneezing they said "Daddy, I hope you don't sneeze in church". Your father's chest and ribcage will be sore for awhile. Even though it hurts to breathe deeply, your father should do it. It's very common for the lungs to be less than fully inflated after surgery. It's important for your father to do the breathing exercises as prescribed so his lungs become fully inflated again. He'll feel better sooner if he doesn't have atelectasis (partially deflated lungs).

Please let me know if you and your father have more questions.

 

[jklump]

I had my aortic valve and root replaced 4/2011 with a bovine valve. The operation was on a Friday morning , my wife saw me at 5:00 Friday evening. Saturday afternoon I took a short walk down the hall. The tubes and catheter were taken out Sunday afternoon and I went to a step down unit Sunday night. I went home Tuesday at noon. Saturday afternoon my wife drove me to the grocery. ( you can not drive for at least 4 weeks after surgery and will have to ride in the back seat when you do go anywhere) I saw my Cardio at the grocery store 7 days after surgery and he about fell over! My wish is that everyone could have as an uneventiful OHS experience as I had.

 

[Jkm7]

I had my aortic valve and root replaced 4/2011 with a bovine valve. The operation was on a Friday morning , my wife saw me at 5:00 Friday evening. Saturday afternoon I took a short walk down the hall. The tubes and catheter were taken out Sunday afternoon and I went to a step down unit Sunday night. I went home Tuesday at noon. Saturday afternoon my wife drove me to the grocery. ( you can not drive for at least 4 weeks after surgery and will have to ride in the back seat when you do go anywhere) I saw my Cardio at the grocery store 7 days after surgery and he about fell over! My wish is that everyone could have as an uneventiful OHS experience as I had.

Funny how you say you saw your cardio at the grocery store soon after surgery.
DH and I walk most nights after dinner and after my second OHS, we were walking around 6:30 and my cardio was driving by..... his office is nearby. He pulled right over when he saw us and was so delighted to see me up and out and walking. This was about two weeks post op.

 

[DanaH]

Hello again! A big thanks to everyone for all this information/support. I’ll be able to post more later but to make a long story short...

My dad was supposed to have surgery around the first or second week in September. Due to having a sinus infection/drainage he ended up not having surgery until Sept 28. So many emotions, just as I am about to type this. He went in to surgery around noon and we did not get to see him until close to 8pm. As the doctor came out to give us the report, he just drops his head. He said, "Frankly, I have no explanation as to how he is alive, much less, how he walked in here". He explained to us that normal valves are about the size of a water hose and said that my dad’s was literally the size of a PINHOLE! He said that he could not even see the hole with his naked eye and JUST ONE stitch would have completely closed it up!!! He is/was literally a walking miracle! (My dad had hardly any symptoms, except being tired and maybe a slight SOB when climbing a flight of stairs. But who wouldn't?!? He climbed approximately 130 steps every day at work for over 30 years!). The doctor also told us that he had a little complication with his BP and heart rate spiking through the roof (possibly due to in response to pain) and then was over-corrected which in turn dropped his BP too low. They were able to stabilize it though and that he remained stable and his new valve performed beautifully the entire time.

When we were able to see him, he looked very good. In fact, all the family (myself included) was surprised at how great he looked. He had a few bumps in the road during recovery but overall has done pretty good. Being sick and trying to get his lungs back in shape took a little while but he eventually got over that. Not sure that he would appreciate me telling this, but of course, he had issues with constipation while taking Percocet and overcame that obstacle too. His hospital stay was a little longer than anticipated due to getting his oxygen levels up and issues with paperwork etc. Also issues with work restrictions and paperwork (blah blah blah)

During all this time, my mom had an allergic reaction to her BP medicine that she had been taking over a year and was hospitalized at the same time....WHEW!

Now he is back to work with no restrictions. Overall, he seems to be doing ok. However, he has mentioned that when walking short distances or having to walk a long way when hunting, he just recently seems to be out of breath easier and feels like he has gained weight. I'm not sure exactly how much weight but I think he is going to start keeping track. He has quit smoking since the day before surgery. I know that weight gain is possible due to that. He is also taking Timolol because of the little tachycardic episode he had while in the hospital. I guess he gets frustrated because he has also mentioned that he felt better when smoking with a bad valve. Does anyone have any suggestions as to why this could be? I know worst case scenario it could be a bad valve and would need another surgery. Is it just too soon to be back to work with no restrictions?? Could the Timolol give him these symptoms??

Guess this wasn't so short after all...and thanks again in advanced.
Dana