Tissue valves in young patients??

[Guyswell]

Alex,

I've been in your shoes. I had my aortic valve replaced and my ascending aorta repaired with a conduit eight years ago when I was 41 years old. I quizzed two surgeons and several cardiologists. The surgeons were consistent in saying they personally would rather have another operation and avoid warfarin (tissue valve) if they were the patient. The cardiologists preferred warfarin and only one operation (mechanical valve). I chose the Edwards bovine pericardial valve, planned on having another AVR operation, hoped for 15 good years or more before reoperation and went right on leading an active lifestyle - riding my bike, climbing ladders, drinking beer, eating whatever I wanted and not thinking about my valve (took a baby aspirin every day). After only eight years, my tissue valve became severely calcified and narrowed and I had it replaced 7 weeks ago with a mechanical valve at the age of 49. I now take warfarin and have had no problems yet. I am making some concessions. I'm not riding my bike in traffic and I don't go off-trail anymore. I took my bike to the park tonight and rode ten miles on the paved trails. I don't think I'll be climbing tall ladders anymore and I rarely drink alcohol.

For the re-operation, I had the same surgeon again and we discussed valve choice. Since we still don't know why my first valve failed quicker than average (even considering my relatively young age), we have to assume there's something different about my metabolism or immune system. My very wise surgeon advised me that we could continue to do tissue valves but they would probably calcify again and I would have at least several more operations after this one. I chose the mechanical valve this time. I don't regret my first valve choice or this one.

Do your homework, decide what's important to you and make your choice. If you choose the tissue valve, you can go on with all the same activities without concession, plan for another operation down the road, and hope the valve lasts a long time (it might). If you choose the mechanical valve and take warfarin, you would be wise to make some common sense concessions with your activities. Personally, now that I'm on warfarin, I would not want to overturn a kayak in a boulder-strewn stream or crash my bike into a tree stump. A heavy blow to the head in the back country while on blood thinners, would be extremely serious and could put me in the grave or a nursing home for life.

Like the others who have responded to your question, I'm not advocating either valve for you. I've had both and been happy either way. This time, I've been willing to make the lifestyle adjustments. Although my second AVR operation was easier than my first, and the recovery has been very smooth, I wouldn't want to do this two or three more times (at 59, 69 and 79). The older the patient, the higher the mortality and morbidity risk of open heart surgery.

Good luck!

Edwards pericardial tissue aortic valve and ascending aorta conduit in 2004 by Dr. Bruce Lytle at the Cleveland Clinic. Pacemaker in 2006 for bradycardia. Re-do aortic valve replacement with On-x mechanical valve on July 3, 2012 by Dr. Lytle at Cleveland.

 

[normofthenorth]

Two quick responses:
1) Re Guyswell's

The older the patient, the higher the mortality and morbidity risk of open heart surgery.

I don't think that's strictly true, at least within the age range we're talking about (59, 69 and even 79). What is true is that "co-morbidities" -- other health conditions like diabetes or high blood pressure or arrhythmias or CHD etc. -- many of which are more common among geezers than young sprouts, increase the risk of mortality and morbidity. But I THINK that the effect of age per se is small or tiny, after correcting for those others. Put another way, I don't think an otherwise healthy 70-something is at much higher HVR risk than a similarly otherwise healthy young 'un.

2) H.E. Pumper wrote:

Good point, BUT, someone PLEASE correct me if I'm wrong, from what I understand after much research 'lifestyle' has absolutely nothing to do with the survival rate of an artificial heart valve. Only the progression of time has a deleterious effect on a tissue valve.

First, we were discussing the impact of valve selection on lifestyle, not vice versa. Second, my research (like yours) suggests that our activity level does not impact the life-span of a tissue valve -- e.g., it's not as if they have only a fixed number of beats in them, and running and jumping and cycling will use them up sooner. (I also wonder whether active people's hearts beat more often or less often in total, since fitness lowers our resting heart rate, and we spend more time sleeping and resting than running and jumping.)
But lifestyle also includes smoking and cocaine use and other "heart-abuse" choices that most likely DO affect all parts of our hearts, including our new tissue valves. I haven't seen studies on that, but I wouldn't give any guarantees that those lifestyles are harmless.

 

[Tell-Tale Heart]

A quick comment from someone who's had both types of valves. I opted for a tissue valve (human aortic) when I was 37. After a successful recovery (about 6 weeks) I felt great and like my old-self. No physical restriction, no medication, no dietary adjustments. I could drink alcohol a little or a lot - the choices were mine to make.
When it was time to replace the tissue valve (after 20 years), I chose mechanical (On-X). I felt it wasn't fair to make my family keep going through surgeries & recoveries (and it really does affect everyone in your life). Now I have a valve that will probably last a lifetime, but I also am tied to a lifestyle that isn't me. My INR is stable now, but I have one I viable vein left for blood-draws. Yes, I can eat and drink what I want, but now I have to think about it - frankly, I have better things to do. Scared to even go to he dentist (can you give yourself shots in your stomach?). It's not the popular viewpoint of this forum to whine or "spell it out". A bunch of people will probably comment that I'm wrong about ACT. Yes, I'm certainly happier to be alive and I am making the adjustments I will live with the rest of my life. I just wish someone would have told me the real story when I was making my choice.

 

[dick0236]

Now I have a valve that will probably last a lifetime, but I also am tied to a lifestyle that isn't me. My INR is stable now, but I have one I viable vein left for blood-draws. Yes, I can eat and drink what I want, but now I have to think about it - frankly, I have better things to do. Scared to even go to he dentist (can you give yourself shots in your stomach?). It's not the popular viewpoint of this forum to whine or "spell it out". A bunch of people will probably comment that I'm wrong about ACT. Yes, I'm certainly happier to be alive and I am making the adjustments I will live with the rest of my life. I just wish someone would have told me the real story when I was making my choice.

Unless you are very much atypical, ACT will little interfere with your lifestyle.....unless you let it. My diet includes whatever I choose to eat. I do think about not eating salads EVERY day, but beyond that I pay little attention to my diet. Drinking in moderation is OK, while overdoing it will cause problems, regardless of valve type. I have never needed Lovenox shots for anything in the years I have been on warfarin, and that includes a couple months ago when I had two molars pulled. I didn't even reduce my INR for the procedure. The vein INR draws you are getting is "old school" ACT therapy. Most of us get a finger stick, either by home monitoring or at our docs office. Vein draws are only necessary is special instances. It appears your surgery was pretty recent, and I understand your frustration in having to change whatever protocall you had with the tissue valve.

 

[dtread]

After having almost died from OHS, and then the long recovery, I think subjecting oneself to repeat OHS for Coumadin avoidance is short sighted. With home monitoring its pretty simple to check INR and not the monster that many folks envision. I'm an avid bicyclist and exercise enthusiast and have made few changes to my lifestyle since the surgery. The recovery from the surgery was long (at 58 years old, about a year to get back to 100% of pre-op conditioning). Haven't seen this mentioned much, but five days after my surgery I had heart block, necessitating that my heart be shocked, return to ICU, and then the implantation of a pacemaker (which I still have; probably for life). These types of complications do happen. The surgery is certainly no cake walk. They do ask you to update your will and get your affairs in order before the surgery, and with good reason.

 

[Guyswell]

Tom,

I've also heard there's not much you can do to prolong or shorten the life of a tissue replacement heart valve. With that said, the first question my surgeon asked when we met to discuss my re-do operation was "so did you take a lot of calcium supplements?". I had not. We don't know why my tissue valve calcified in only eight years. I even asked if I had over-exercised. Both my cardiologist and surgeon said exercise wouldn't have caused it. As I'm sure you've read, there is definitely a positive correlation between tissue valve longevity and the age of the patient as younger patients have more active metabolisms and immune systems and tend to calcify valves quicker. I was 41 when I received my tissue valve.

 

[chris.c]

Tell-Tale Heart

How did you get a human tissue valve? Is that even an option?

 

[dtread]

Cryolife is only company I know of that makes heart valves from cadavers: http://www.cryolife.com/products/cardiac-reconstructive-surgery

Don't know how they compare to tissue valves in terms of longevity and hemodynamics

 

[DanaH]

I must say, Im so glad I found this post. Everyone's opinions have been very informative. Not trying to take over Alex's post but I am new to this forum and its comforting to know that others are out there with similar situations. I am trying to do some research for my 50 y.o dad. He has BAV and has the choice of a tissue or mechanical valve. He is scheduled for surgery in a couple weeks. He is pretty active, riding motorcycles, mechanical work, volunteer firefighting, hunting, fishing, etc. These are pretty important to him as well. Also, at his most recent visit with the surgeon he was told that it is very common to have a pacemaker after the AVR. Have any of you had to have a pacemaker?

 

[H.E.pumper]

I must say, Im so glad I found this post. Everyone's opinions have been very informative. Not trying to take over Alex's post but I am new to this forum and its comforting to know that others are out there with similar situations. I am trying to do some research for my 50 y.o dad. He has BAV and has the choice of a tissue or mechanical valve. He is scheduled for surgery in a couple weeks. He is pretty active, riding motorcycles, mechanical work, volunteer firefighting, hunting, fishing, etc. These are pretty important to him as well. Also, at his most recent visit with the surgeon he was told that it is very common to have a pacemaker after the AVR. Have any of you had to have a pacemaker?

My surgeon said it was very unlikely that I would need a pacemaker after my AVR surgery. But they did place pacemaker wires in my heart just in case. A nurse practitioner removed the wires the day I left (One of the most excruciating, painful eight seconds in my lifetime!!!). From what I have seen on this forum pacemakers are not all that common.

Tom

 

[Guyswell]

DanaH

Your father's surgeon is correct. Your father may need a pacemaker as a result of the surgery. When an aortic valve is replaced, the work of replacing the valve (cutting out the old valve and stitching in the new valve) is very close to the AV node. If the AV node is damaged by the surgery or by calcium buildup prior to surgery (happened to me), it could affect the heart's electrical system and a pacemaker might be needed. In my experience, a pacemaker is not something to worry about. Two years after my first valve replacement surgery, I developed bradycardia (slow heart beat that can cause fainting). I received a pacemaker and rarely think about it. My pacemaker kicks in when my heart rate gets too slow (about 10% of the time). I don't even know when it's happening. Having a pacemaker has not changed my lifestyle at all. Of course other patients may be more dependent on their pacemakers than I am. Every three months, we check the battery life on may pacemaker. So far so good after 6 years. When this battery starts to wear down, I'll go in and have a new one installed.

 

[Guyswell]

Tom
My experience was different than yours. Removing the temporary pacemaker wires was fairly painless in my case. However, having the chest tubes pulled out and the sutures tightened for those incisions was quite painful since there was no local anesthesia at that point.

 

[Jkm7]

My surgeon said it was very unlikely that I would need a pacemaker after my AVR surgery. But they did place pacemaker wires in my heart just in case. A nurse practitioner removed the wires the day I left (One of the most excruciating, painful eight seconds in my lifetime!!!). From what I have seen on this forum pacemakers are not all that common.

Tom

We all get temporary pacer wires at our surgeries. Most of us have the wires pulled and the pacer was only temporary but in an emergency, it is necessary they be available.

I was fortunate that both of my OHS, it was painless but a sort of fluttery feeling for a brief moment when they pulled those temporary pacer wires.

I had horrible pain when they pulled my three chest tubes the first surgery. My second surgery was very much less painful as I had spoken with the PA about my experience the first time. Bless him, he promised it would better the second time and it was.

 

[Jimjam]

I'm day 7 post porcine freestyle valve ( Medtronic ) OHS and feeling like a got hit by a bus. im 37 and lead a very active lifestyle - ride bikes and ocean swim. I know I will need a replacent in the future I also work in the medical field and know that they are already doing transcatheter ( through the groin ) replacements - monash university in Melbourne Australia were the first with an 85 year old lady. This is happening now. As robotic procedures become the norm over the coming years, i believe we're going see changes in surgical approach - whilst the products themselves may not change but who knows - pick up a copy of new scientist!

Remember any healthcare professional wants evidence!

Everyone's case is different but I know that when mine needs replacing I'm going to be researching and tabling every option available to me with a surgeon I trust. If that means taking a plethora of tablets to deliver what I want - so be it.

Good topic.
Jim

 

[hannahsmom]

Hello,

My daughter had her valve replaced at 10 years old. The original plan was the ross procedure. Have any of your dr's metioned this to you? It is a great option for good candiates? Hannah ended up not being a good canidate. She ended up receiving an adult sized mechanical valve, which should last her decades, if not her whole life.

She takes warfarin and is involved in cheerleading, dance, and gymnastics and swims constantly. With a consistant routine the warfarin has not altered her life very much at all! She has had the normal bumps, bruises, and cuts. We have not noticed a significant difference in bleeding. She takes antibiotics prior to her dental appointments/cleanings but she has always had to do that for her BAV.

Her cardiologist, surgeon (from 2 different hospitals) both recommended this for her due to her age. She had already been through 1 OHS prior to the replacement and we are hoping that this will be her last.

Good luck to you.

Kelly

 

[chaconne]

Kelly,

Sounds like a mechanical valve was a good choice for your daughter. Like her, I'm very active and notice very few symptoms from Warfarin. The Ross Procedure seems to be out of favor these days because of the need to deal with two valves in a complicated surgery. These days, it seems that tissue valves are getting better and surgeries are less risky, for those that go that route.

 

[jordan]

I had similar worries about warfarin, but once I had stable INR values it became no issue. I had AVR surgery last December with a Carbomedics valve installed. After recovery, I got back into cycling. I race road and crits, not mountain. My wife's concerns have limited my crit racing, although I didn't crash at all this year (I only say that because my racing season is over!). I plan on still racing, group rides, and training. I wear a Road ID saying I have a mechanical aortic valve and am anticoagulated. If I do ever crash, I'll head to the ER because of the potential for internal bleeding.

I haven't had a winter yet, so I haven't gotten to ski. But it's not something I'm going to limit. I didn't really ever bruise before surgery and now I bruise more. However, it is no where near what I thought I'd bruise. My wife (not on warfarin) bruises more than me. I did fall playing basketball. My legs went out from under me while in the air. Landed squarely on my hip. I had a bruise but was what you'd expect anyone to have falling onto their hip.

It definitely takes longer to stop bleeding if I cut myself. It doesn't bleed more, just longer.

I'm 4 weeks between coag clinic appointments, so if you have stable INR values, I'm not sure why your physician would have an issue with you being in wilderness for 3 weeks. You just need to manage the risks, but you don't have to completely change your lifestyle. I didn't.

For me it wasn't much of a decision. A tissue valve had a high likelihood of re-surgery in 10 years or so. However, that was much less likely with the mechanical valve. It didn't take long to get used to warfarin and clinic visits.

 

[ski girl]

Hey Alex- I've had both! I had my first AVR in 2011 and got a tissue valve because I also whitewater kayak, MTB, ocean paddle, etc and to do these things I would be in areas where medical evacuation wouldn't be easy. My cardio and surgeon agreed tissue was the way to go (I was 39).

A year later I got endocarditis and had to have a re-do AVR, and this time it was going to be mechanical, no choice. I stay away from the kayaking now because unlike MTB I can't put on the brakes if I see a rock that worries me! I don't regret my choice the first time, and being young and fit it's much easier to get over OHS. It will take you a year to get back to where you were before things went downhill, and at 27 you're guaranteed to need a replacement if you get a tissue valve.

If I were you (and I kinda am!), I'd go tissue valve and get another 10-15 years of doing whatever you want out of your life!

 

[Fergus]

Hello Alex, im in kind of the same position as you were in!

Im 27, had a heart murmur picked up two years ago in a routine medical. I also had a BAV. I work at sea as a marine engineer, and when I was diagnosed it was a massive shock to me. I had absolutely no symptoms whatsoever (apart from the murmur) even right up until surgery. I was in a position of either having a mechanical valve or tissue valve. With a mechanical valve, i would no longer have been able to work away at sea due to the possibility of something happening to me whilst deep sea and not being able to be tended to quickly enough.

So i was put in a position of not being able to carry on doing what I really enjoy, or having to make big sacrifices at the age of 27. The way I looked at it was I really enjoy my job and lifestyle, and even if the tissue valve lasts maximum 20 years, I will still only be 47 when I am operated on again. If you are the kind of person that kayaks, skis, and generally enjoys a bit of thrill seeking then i think the tissue is for you. You will have a level of fitness greater than most people that go for heart surgery, and therefore the risks are reduced. Plus the activities you do involve a level of risk anyway.

I was operated on 6 months ago in April, and Im now going back to sea next week with my new medical passed. I know that next time i get operated on I will no doubt have to go for the mechanical, but my advice would be to live the life you want to as best you can.

Fergus

 

[H.E.pumper]

Hello Alex, im in kind of the same position as you were in!

Im 27, had a heart murmur picked up two years ago in a routine medical. I also had a BAV. I work at sea as a marine engineer, and when I was diagnosed it was a massive shock to me. I had absolutely no symptoms whatsoever (apart from the murmur) even right up until surgery. I was in a position of either having a mechanical valve or tissue valve. With a mechanical valve, i would no longer have been able to work away at sea due to the possibility of something happening to me whilst deep sea and not being able to be tended to quickly enough.

So i was put in a position of not being able to carry on doing what I really enjoy, or having to make big sacrifices at the age of 27. The way I looked at it was I really enjoy my job and lifestyle, and even if the tissue valve lasts maximum 20 years, I will still only be 47 when I am operated on again. If you are the kind of person that kayaks, skis, and generally enjoys a bit of thrill seeking then i think the tissue is for you. You will have a level of fitness greater than most people that go for heart surgery, and therefore the risks are reduced. Plus the activities you do involve a level of risk anyway.

I was operated on 6 months ago in April, and Im now going back to sea next week with my new medical passed. I know that next time i get operated on I will no doubt have to go for the mechanical, but my advice would be to live the life you want to as best you can.

Fergus

Very sound logic Fergus. Congratulations.


Tom