Valve Decision - Mechanical or Tissue

[Bridgette]

Good luck with your decision Johnny. Whatever choice you make will be the right one for you because it's the one that YOU feel comfortable with.

FYI - I have an On-x mitral valve, am on Warfarin, home test my INR and am doing fine.
There are no guarantees as others have said but for me, MY choice was based on the fact that I was 43 at the time of my operation and did not want to have to go through OHS more than once.
For many other people the thought of being on Warfarin for life (which at present is guaranteed if you go mechanical) does not appeal, and they go tissue. Good luck to them.

All the best
Bridgette

 

[plexxer]

You had your BAV repair about 14 years ago, and if I did the math correctly, you were only 27 at the time. I'm glad the repair lasted as long as it has.

I know this thread is about the valve, but I want to emphasize that the valve is just one part - a very important part - of the picture for those with BAVD.

BAV regurgitation in someone young - where the tissue is not strong enough to hold its form and close properly - is and indicator that the tissue is failing after not that many years of life and there may be an associated progression of failure of the tissue of the aorta also.

No matter where you go, and who you speak with, if they do not address your aorta along with your valve, get another opinion from someone who will. In many ways, although it can have its complications also, valve surgery is done routinely by many. The aorta is another story. There are centers that have established aortic surgery practices handling both the valve and the aorta. Searching them out - and getting opinions from more than one if you are able to do it - will give you the best odds of receiving state-of-the-art treatment.

Both the valve and the aorta should be part of your decision making process. If you can find a surgeon/center that is current and knowledgeable about BAV disease, you are giving yourself all possible advantages for both the valve and the aorta. You need the best possible solution for them both!

You are still a very young man and I wish you all the best!

Arlyss

This is what my surgeon told me about the bicuspid valve and the aorta. Since the defect is congenital, the aortic artery near the valve does not grow like that of a person with normal aortic valve. This is because the walls of the artery do not get subjected to the same pressures as they should, so they grow thinner, increasing your chances for an aneurysm later in life, especially when the valve gets repaired and the artery starts getting the larger pressures.

 

[ALCapshaw2]

When it comes to mechanical valves, I have focused on 2 providers.

On-X because of the technical improvements outlined on their website www.onxvalves.com and www.heartvalvechoice.com These valves have been in use in the World Market since 1996 and in the USA since 2001. I have just learned that On-X has been approved for use at the Cleveland Clinic.

St. Jude because of it's proven record of reliability for 30 years. See www.sjm.com

'AL Capshaw'

 

[BDMc]

I'm With BMac

I'm With BMac

Each of us has our own criteria for valve choice, and one can research most of them through this wonderful site. I have friends on both sides of the aisle in this debate, and while I'm happy with what I got in terms of quality of life, I didn't actually have any choice! So whenever someone makes it "over the mountain", I celebrate, and if they had a choice, even better! The only prejudice we harbor here is against ignorance, and we do our best to help with that. Stay open to the pros and cons of each, listen to your heart, and you will make the right decision. Looking forward to welcoming you back once you are over! Brian

 

[geebee]

You know, I was going to comment again and have just decided to scrap all this. I have had it with being policed.

 

[Bina]

Gina......smart girl.
Let's eat some chocolate.....

 

[Karlynn]

You know, I was going to comment again and have just decided to scrap all this. I have had it with being policed.

You're right, it's not worth the effort. How about some Bailey's???????? I'll buy!

 

[Natanni]

I will bring a bottle of chardonnay...wait a minute....according to todays news, if we have more than one SMALL glass of wine a day, we won't even need to be worried if Nathan's valve will make for 20 years My Mom can't figure how she is still around after all her martnini's and prime rib in the 70s....

Sorry....I was going to respond initially to but joined the party instead

 

[johnnycake23]

No, no,no. Please respond with any thoughts. Knowledge is power, after all. Don't censor yourselves. I have read every last word and it will be great knowing this stuff when I go in to meet my surgeon tomorrow. Will keep you all posted.

Please don't stop posting.

 

[Karlynn]

Johnny - I'm sure you are probably already leaning one way or the other, just trying to cover all bases to see if you see anything totally startling that might shift. I always worry about people who come on and are dead-set against or terrified of, any option, because BMac is right, we have enough members who go in expecting one thing and wound up with another. But you probably went in to your repair knowing there was a possibility that they might end up replacing it. The surgeon you see will probably have their own biases as well, as well as the hospital just make sure they are ready to do what you need once they get in there and see what they are dealing with. There may be scar tissue growth that tells them a 3rd surgery will be more difficult, or they may see something that causes them to think a mechanical wouldn't be the best.

 

[johnnycake23]

When looking at the stats, tissue & mechanical valves have the same rates for re-op up to about 12 years - then the rates for re-op with tissue valves starts to rise. T

BMac, you say that the re-op rates are the same for both. This is the first I am hearing that. If that's the case I wonder why more folks wouldn't opt for tissue valves, since the prospect of taking Coumadin can't be too inviting.

And, yes, I am leaning more one way than another before I meet the surgeon (Karlynn) but I don't want to tip my hand with him or with you nice folks here. I'd rather wait to see if what surgeon says is consistent with my hopes. I'm just trying to gather as much info as possible, and it is being provided here.

J

 

[ALCapshaw2]

BMac, you say that the re-op rates are the same for both. This is the first I am hearing that. If that's the case I wonder why more folks wouldn't opt for tissue valves, since the prospect of taking Coumadin can't be too inviting.

And, yes, I am leaning more one way than another before I meet the surgeon (Karlynn) but I don't want to tip my hand with him or with you nice folks here. I'd rather wait to see if what surgeon says is consistent with my hopes. I'm just trying to gather as much info as possible, and it is being provided here.

J

Johnny -

My first choice for AVR was a Bovine Pericardial Tissue Valve but that was not deemed a good choice once my surgeon saw how much Radiation Damage I had after 'getting in there'. He implanted a St. Jude Mechanical Valve in hopes that I would never need another replacement.

Living on / with Coumadin / Warfarin on a day to day basis has NOT been the hassle I feared. Having to go OFF Coumadin for invasive procedures (esp. surgery) is a bit of a hassle but is doable with proper Bridging using Lovenox injections which can be self administered or using a Heparin Drip which requires admission to a hospital.

Did you read the "sticky" posts at the top of the Valve Selection Forum? If not, click on the Valve Selction Forum and you will find them listed as the first two threads. Those provide a good background for valve choice and living with Coumadin. Also see www.warfarinfo.com

I am surprised by the comment that early re-ops are equally common with mechanical and tissue valves. I would want to verify that statement. Single events don't prove anything so it is best to look at the Large Study results to get the "Big Picture". OTOH, statics don't mean much IF you are the exception. EVERY valve has positive and negative aspects. In the end, most of us who choose, choose based on our 'gut' reaction and choose a valve whose negative aspects we believe we can best live with.

It is a known fact that tissue valves WILL wear out at some point in time. The early Bovine Pericardial valves that were implanted in patients over age 60 are approaching 90% durability at 20 years. Recent addition of anti-calcification treatment to these valves is "hoped" to lengthen that to 25 years or more.

It is important to know that tissue valves wear out more rapidly in younger patients.

I recently saw some interesting information on GRADIENTS for various valves (pressure drop across the valve). Bovine valves were around 20-25 mmHg (mm of Mercury) which is a bit higher than a non-diseased native valve and will diminish maximum exertion capacity somewhat. This is of more concern to athletic types. I believe that most mechanical valves have a gradient under 10 mmHg. (this data is from www.heartvalvechoice.com)

The Stentless Porcine Tissue Valve has a much lower gradient (around 12 mmHg if I remember correctly) which is closer to an undiseased native valve. It is too early to tell how long those valves will last.

Ask your surgeon about his experience with Early Failures for all types of valves.

'AL Capshaw'

 

[Karlynn]

Johnny -


I am surprised by the comment that early re-ops are equally common with mechanical and tissue valves. I would want to verify that statement. Single events don't prove anything so it is best to look at the Large Study results to get the "Big Picture".

It's new to me too and I'd also like to see where that came from. But then I stopped to think about it. Remember that there are probably few tissue valve replacements in that 12 year time because of the age of the majority of the tissue recipients. Most tissue valves are implanted in older patients (and the statistics we see of tissue valve longevity also has to do with older patients as well.) So a 30 yr. old shouldn't look at this and think "I'm being told a tissue valve will only last 10 years in me, what's the point if a mechanical will only last that long." Johnny, you're right - there wouldn't be a point to use mechanical then, if this type of statistic applied. But it wouldn't.

A 30 or 40 year old shouldn't look at that statement and think that they are the mean age in any longevity or re-op study.

Yes, there are a few mechanical valve recipients that will have their valve replaced w/in 12 years either due to unpredictable tissue growth or poor installation. But the majority will not.

So this just brings us back to this point.
Going with a mechanical doesn't guarantee no more OHS, but gives you a very high probability that you won't need another - and at 41 years old, given the science of mechanical valves now, I don't have a problem with someone telling you that a well-seated mechanical valve will last you the rest of your (hopefully long) life.

Going with a tissue valve doesn't guarantee you won't have to take warfarin, but there's a high probability that you won't have to. (Although I will say, with mitral valve surgeries, each additional surgery increases the risk of arrhythmia - I don't know about aortic valve surgery) At 41, a tissue valve will not last you your lifetime. With new valves, it's probable you may get 20 years out of it. (or maybe more). If it were me and I was leaning to a tissue at 41, I'd go in thinking I'll get less than 20 because there just aren't the studies out for younger ages and newer valves to make me secure about projecting 20 years or more.

Then there's the subcutaneous valve replacement option we've heard about. Go tissue now - and by the time you need a replacement, they'll be able to do it subcutaneously. This may or may not be an option for you for a 3rd "valve job". They're starting to do them now on people who are receiving their 1st valve, I believe. I'd need to see more info on how it applies to redo's before I'd hang my hat on that.

So this is what I would be thinking right now, if at 48, I found out my mechanical valve needed replacing (and thank God that at 16 years ticking it's looking very pretty and unobstructed.) Right now, I'd still go with a mechanical - most likely the On-X (given that the surgeon felt my heart was looking good for a successful mech replacement). If I were 10 years older, given the advancement in tissue valves, I'd probably lean towards a tissue valve hoping it would last my life (both my parents died before they were 80), if the surgeon felt my heart was looking good for that. If it got me to 78, I'd be praying there would be good techniques for valve redo's on spry old ladies!!!

PS- I'd probably go with the On-X because of the newer hemodynamics, not because it may need no, or lowered, Coumadin. Coumadin has been a non-issue for me.
Best wishes!

 

[geebee]

Another thing that I feel is important to emphasize is that with a tissue valve, it will probably (please note the word probably) deteriorate in a manner similar to your original valve. If you were very symptomatic before your replacement, you might not want to deal with that again. Despite being one of those who did not get a lifetime out of a mechanical, I would choose another mechanical simply because the failures I had were rapid and did not subject me to the years of decline I had before my first surgery. I would not want to go through that again and I would should I choose a tissue.

In addition, each surgery is harder on your body. I haven't not been given good odds should I need another surgery so I would sure choose the best path for avoiding future surgeries. Please also keep in mind that I am not a member of the "norm" team - no smart comments, please.

Just my opinion tho.

 

[dick0236]

To: Johnnycake23. From your initial post you have been thru this type of surgery before. Repair several years ago ? OHS, while it is far less dangerous than in the past, AIN'T no fun. If I were 41 years old, and all else being equal, I would get a mechanical valve since it might very well last a lifetime. I was told 2 months ago by my cardio that my valve shows little deteriation and unless "something goes haywire" this valve should last my lifetime.
I have never understood the Coumadin(warfarin) controversy. I take a pill daily, get checked regularly and make small adjustments as needed due to exercise, diet etc. Since I have the benefit of a lot of hindsight, the inconveniance of warfarin has far outweighed the potential problems and risk associated with hospitalization and multiple surgeries.
I fully expect that my comments will draw severe challenge from many on this site. That's what makes the world go 'round. I had my ONLY surgery 40+ years ago.......I rest my case !

 

[Dustin]

I just changed my post, because it occurs to me that choosing a valve should not be some contest. Just read as much material on the topic you can. Only you can make the decision.

 

[johnnycake23]

OK, here's the news. Met with surgeon today and after he ran down to me the ups and downs of each (much of which I already knew from info from this site) we are leaning towards a tissue valve. The cat sure seems like he knows what he's doing. He is well experienced in this which made me very comfortable. We've got to move on this soon and my options are few.

I will go in on Monday for bloodwork and for CAT scan of the chest, which is like a card cath I received 14 years ago except it goes through the right arm instead of the groin. They will know more for sure after the tests but the guess here is surgery will be scheduled by late next week. I got a bunch of pamphlets to read from his assistant, and some do's and don'ts for before the Monday testing.

That's really all there is to report. Of course I will keep you all posted. Thank you so much for your input. I know it takes effort and is time consuming to write in this forum all just to help a stranger, but truly it is appreciated. God bless you all.

Johnny

 

[Perry]

Johnny,

A little background:
I had what turned out to be a leaky bicuspid aortic valve that slowly deteriorated in funtion over 5+ years. This site was very helpful. My informed choices became 1) Ross Procedeure 2)On-x valve 3) tissue (can't recall which). That's kinda how I broke it down, and each of the options was at the top of the list for a period of time before surgery. Had the surgery been delayed 10 minutes I may have changed.

Once I was opened up the surgeon felt that the Ross procedure was not a good option - so much for my choice. I became the first On-x recipient at Johns Hopkins. I have taken 5mg of coumadin daily since being at the hospital and figure I am in the 'easy to manage' group. Things went well and are fine now.

When my wife nagged me awake after surgery (lovingly of course) the surgeon soon popped by and told me I received an On-x valve. The thoughts and doubts hit me over the next couple of days and lingered for some time after. Was that the right choice? Darn right - for me it was. Just like everyone here who made a similar choice - regardless of what that choice was. Why look back?

I think it seems pretty logical that an elderly patient (70s ??) receive a tissue valve - but at 60 and on back it is a gray area for each of us to navigate with our family and doctors. Be well.

 

[Karlynn]

BMac, you say that the re-op rates are the same for both. This is the first I am hearing that. If that's the case I wonder why more folks wouldn't opt for tissue valves, since the prospect of taking Coumadin can't be too inviting.

Just to clarify the confusion in BMac's post that started the above concern. This is from one of the links that BMac provided.

http://cardiacsurgery.ctsnetbooks.or...ull/2/2003/825
Freedom from Reoperation

Freedom from reoperation for currently available mechanical valves is greater than 95% at 10 years and greater than 90% at 15 years.124,142–147 Bioprostheses have a significantly higher rate of reoperation due to structural valve dysfunction. In large series, freedom from reoperation is greater than 95% at 5 years, greater than 90% at 10 years, but less than 70% at 15 years.138,148–166 The long-term freedom from reoperation for several commonly available valves is presented in Table 32-7.

So, as I suspected, since bioprosthetic valves don't fail much in the first 10 years for adults (and the mean age was referred to as 65 in most of the links) - yes, they have close to the same re-op rates. And the re-op rates are low for both types of valves. Please be aware that, once again, these studies aim at older adults. There were a few tables in some of the links that dealt with adults younger than 60, and it is as we've always said here, longevity for tissue valves decreases with the age of the recipient.

So I don't want someone new coming on here and thinking that they have a good chance of re-op with ANY valve in the first 10 years. Regardless of valve choice, the stats are low. But, unfortunately, as we also caution - there are going to be people that draw the short straw that make up that low percentage.

Some of the linked studies of the mechanical valves included valves that aren't used now - Bjork-Shiley and Starr-Edwards. So this also can throw statistical analysis off. This is because many articles we see refer to studies that are decades old. This impacts the way we view the data of any type of valve. So I just caution anyone doing any online research to be very careful to check out the age of the studies referred to and when the data is collected. Unfortunately it can be hard to ferret out the newer studies and because of quickly changing technology there may not even be truly relevant studies available yet.

 

[Karlynn]

I wasn't referring to the date the actual articles were written but some of the dates of the studies that are referenced. I'm sorry if that wasn't clear. Some start back in the 70's and early 80's. And if you're like me, you still think it's the 1990's and have a hard time comprehending that a study done in 1996 is 11 years old because time flies! You have to go back that far to get long term studies, but when they are studies referring to valves (both mechanical and tissue) that are no longer in use it becomes a case of comparing apples and oranges.

Conclusions with no numbers can be too subjective to reader's interpretation and that was the problem with the original statment of re-ops. If you've read the article you understand it, but posting it can lead to confusion.

CONCLUSIONS: Tissue and mechanical valve recipients have similar survival over 20 years of follow-up. The primary tradeoff is an increased risk of hemorrhage in patients receiving mechanical aortic valve replacements and an increased risk of late reoperation in all patients receiving tissue valve replacements. The risk of tissue valve reoperation increases progressively with time.

This could mean a risk of hemorrhage of 3% or 30%, we have no way of drawing any solid conclusions from that statement. People see the word "hemorrhage" and get scared. And what is "late reoperation" - it's something different for a 65 year-old receiving a tissue valve, than it is for a 35 year-old receiving a tissue valve. We're left to come up with our own conclusions based on our own biases. One chart showed that people under 40 receiving a tissue valve had a 40% chance of re-op by 10 years. Not many people reading this statement right now from my post will take the time to look and see when that study was done and what tissue valves were being referred to in order to see if this statistic is still valid now. Some will argue it doesn't apply because of the newer tissue valves, and they may be correct.

Then this conclusion from one of the links has something different to say. But once again, is open to interpretation without reading the article. The word "survival" is kind of ominous sounding. And it talks about "valve failure". Makes it look pretty darned good for a mechanical valve, but in what context should it be interpreted? Johnnycake posted his confusion on one statement, most will not.

CONCLUSIONS
At 15 years, patients undergoing AVR had a better survival with a mechanical valve than with a bioprosthetic valve, largely because primary valve failure was virtually absent with mechanical valve. Primary valve failure was greater with bioprosthesis, both for AVR and MVR, and occurred at a much higher rate in those aged <65 years; in those aged ≥65 years, primary valve failure after AVR was not significantly different between bioprosthesis and mechanical valve. Reoperation was more common for AVR with bioprosthesis. Thromboembolism rates were similar in the two valve prostheses, but bleeding was more common with a mechanical valve.


I'm not being critical, truly. It's just that we seem to run into a lot of confusion from snippets and conclusions. I encourage everyone to do their own research and not take anything that any of us post here at face value. One of the reasons I rarely post links to articles is that I know I have a bias towards mechanical and could provide a passel of them that make mechanicals look like the best ultimate choice. But I think we do a good enough job here of providing balanced information by those who've had replacements, Ross's and repairs and can report the affects on their lives.