Valve Selection Redux

[Lex Luther]

I have participated and lurked on this forum since I was advised I had a 4.7x4.7 ascending aortic aneurysm when I was 60. Because I had and have afib, my selection at that time, if surgery was necessary, was going with a mechanical, since I have been on warafin since 2008 with no real problem maintaining levels. My cardio initially instructed me to quite my distance bicycling, but fortunately, the surgeon who I consulted countermanded those instructions indicating the cycling would be beneficial, and I have continued it. His advise appears well founded, as I have no real symptoms, other than those associated with my advancing maturity at age 67 (out of breath only slightly which is alleviated by asthma inhaler prior to cycling). The aneurysm grew slightly to 4.8 and has remained stable for the last 4 or 5 years. I guess I am one of the few that draws comfort from being in the waiting room, as I am the sole caregiver for my wife who has dementia. But now I would like others input on potential valve for replacement, as the guideline the surgeon (Dr. Cosselli at St. Lukes Houston) gave me back when I was 60 was that the standard normally leans to tissue valve after age 65. My concerns are the usual for this tissue, the potential for need for follow up replacement. I still want to remain active with ability to have a high rev exercising heart rate, and also concerned that tissue will not hold up to my activities. Input for specific valves also appreciated.

 

[tom in MO]

My suggestion is to pick the type of valve, tissue or mechanical, but let your surgeon guide you in the actual valve that will be implanted. That's what I did and it's worked out fine.

If you have specific questions, ask them of the surgeon. When I had my mechanical valve implanted, I asked about the OnyX valve due to its lower INR. My surgeon doesn't use that valve but would put it in if I wanted it. He recommended a St. Jude due to its history of robust performance and of course, his experience with the valve. In fact, the INR range for the St. Jude was dropped from 2-3 to 2-2.5 right after my surgery which is pretty close to the OnyX valve range of 1.5-2. I've had one surgery w/o any need to bridge due to the robustness of the St. Jude valve.

When it comes to activity, if you have one doctor who says to limit activity and one doctor that says not too, just make sure you understand the reasons behind both decisions. Your cardiologist takes care of patients over a much longer time period than a surgeon. If someone dies of an aneurysm, they never made it to the surgeon, but they may have been seeing a cardiologist. The cardiologist may be basing their decision on their anecdotal experience, which is not always incorrect. Once my echo showed I needed surgery, my cardiologist would say "Get the operation done before you suffer the symptom known as 'sudden death.'" My surgeon was not as dramatic, I kind-of think that was because my cardiologist has suffered the pain of dead patients who waited too long.

 

[dick0236]

........... my advancing maturity at age 67.......

At the age of 67+ it is your call. A mechanical valve would, most likely, last your lifetime.....plus you are already on warfarin(Coumadin) for the Afib. A tissue valve might last your lifetime and in 10-15 years TAVR should have advanced enough to be a viable option if the tissue valve needed replacement.

PS: I like your definition of old age........"advancing maturity"

PPS: I reread your initial post and thought I would clarify. The aneurism repair would, as I understand, pose a problem for a TAVR redo and the tissue valve option might require another OHS when you were well into "advancing maturity" and that would not be a good thing......my opinion only.

 

[Paleowoman]

Hi @Lex Luther - the call is always with the individual with advice from their surgeon, but there is a new tissue valve being used now which came out just over two years ago which has been designed to last much longer than previous tissue valves and is even being given to much younger patients than 60 year olds. It’s the Edwards Inspiris Resilia valve. Of course there have been no long term studies in people because that would be impossible to do, they can only do comparative studies in animals and the lab. And of course there are no guarantees as is the case with any valve, tissue or mechanical. There are some here on forum who’ve been given this valve. The valve is also designed to take TAVR in it - valve in valve (I had my AVR five years ago when I was 60 and chose, and was advised, to go with tissue so I was three years too early to get this valve - sickening to know a more advanced tissue valve was just around the corner !). There’s another valve been mentioned on forum which is in development called Foldax which is an entirely new type of valve, neither mechanical nor tissue but made of a ‘biopolymer’ - apparently the FDA has approved a study for that valve. Things are always moving forward in the heart valve replacement field !

 

[pellicle]

Hi

welcome, somehow this feels like dejavu (even me saying something about @Superman)

...I have been on warafin since 2008 with no real problem maintaining levels. My cardio initially instructed me to quite my distance bicycling, but fortunately, the surgeon who I consulted countermanded those instructions indicating the cycling would be beneficial, and I have continued it.

I was about to say something disparaging about Cardio's but happily your Surgeon fixed that issue.

... I guess I am one of the few that draws comfort from being in the waiting room, as I am the sole caregiver for my wife who has dementia.

very sorry to hear that. I imagine that's hard. My heart goes out to you.

My concerns are the usual for this tissue, the potential for need for follow up replacement. I still want to remain active with ability to have a high rev exercising heart rate, and also concerned that tissue will not hold up to my activities. Input for specific valves also appreciated.

To me the need to follow up after surgery is increased by tissue prosthetic, especially as SVD begins to occur (in say 10 years from now).

There are many active mech valvers here, some who are no longer here (or part time) include power lifters, competitive surf ski riders (these are human paddle powered not motorized) and cyclists ... maybe even an ex Cross Country Skier who now has a torn ligament in his knee. Thus I don't see that there is any pressing need for a tissue valve. Indeed if you listen to Dr Schaff's talk you'll see he has the view (from evidence) that even elder patients do perhaps slightly better on mech



So take a moment to consider that, and factor in that you already know that you have no problems with warfarin managment and I ask why are you searching for a "kick the can down the road" option when you will also be fixing the primary cause of redos at the same time (meaning Aneurysm).

As to selection, to my understanding each of each type (T or M) is more or less identical and so there is less to concern yourself with there.

Best Wishes with the decision

 

[Superman]

@Lex Luther

I can’t, in good conscience, give you any advise that would only prolong your ability to engage in nefarious activities while hunting down more Kryptonite.

You’re on your own.

But, if you’re already taking Warfarin, doesn’t that eliminate one of the primary draws of a tissue valve (the other being quiet operation).

 

[Duffey]

Another option: go tissue and later undergo ablation to deal with your afib. My husband is having ablation done in a few weeks so he can cease the Eliquist and heart meds (no valve problem for him) before undergoing major surgery this Fall.

 

[Superbob]

I can only tell you my experience and perhaps you will find common ground. Because of both an enlarged aortic root and a very leaky valve, I went at age 63 with a Medtronic Freestyle combined valve/root. The valve is a piggy; the root dacron. It has worked beautifully for nearly 15 years. In March, an echo and CT disclosed a growing aneurysm of the ascending aorta of approx 5.5 cm -- verified by two eminent surgeons I had look at it. My surgery to fix it is scheduled for September. Even though the valve continues to work fine, my surgeon at UNC/Chapel Hill will replace it in the process of dealing with the aneurysm because it just makes sense to have a valve job rather than having to go back in whenever this one might fail.

Soooo, you are 10 years younger than I am, so your considerations maybe are different than mine. My decision is to ask my surgeon the best tissue option for me, and do that. (I need to have that conversation with him.) I fully expect this will be the final OHS for me, any way you figure it, given I am 77. But at 67, you might figure it differently. Just lay out the pros and cons, and pick what option seems best for you.

 

[Lex Luther]

Hi @Lex Luther - the call is always with the individual with advice from their surgeon, but there is a new tissue valve being used now which came out just over two years ago which has been designed to last much longer than previous tissue valves and is even being given to much younger patients than 60 year olds. It’s the Edwards Inspiris Resilia valve. Of course there have been no long term studies in people because that would be impossible to do, they can only do comparative studies in animals and the lab. And of course there are no guarantees as is the case with any valve, tissue or mechanical. There are some here on forum who’ve been given this valve. The valve is also designed to take TAVR in it - valve in valve (I had my AVR five years ago when I was 60 and chose, and was advised, to go with tissue so I was three years too early to get this valve - sickening to know a more advanced tissue valve was just around the corner !). There’s another valve been mentioned on forum which is in development called Foldax which is an entirely new type of valve, neither mechanical nor tissue but made of a ‘biopolymer’ - apparently the FDA has approved a study for that valve. Things are always moving forward in the heart valve replacement field !

Thanks Paleowoman. I was not aware of the Edwards Inspiris Resilia valve and will investigate further. My leaning is still towards a mechanical, hopefully something that will not have to be replaced again in my life time. While it may be a small community of people with this problem, my sister and more recently my assistant had to have OHS. All reported cognitive issues with pump head, and I do not want to roll the dice a second time. Have my echo on Monday, and hope to hear no progression in aneurysm or aortic leak, last reported at mild/moderate.

 

[Lex Luther]

Another option: go tissue and later undergo ablation to deal with your afib. My husband is having ablation done in a few weeks so he can cease the Eliquist and heart meds (no valve problem for him) before undergoing major surgery this Fall.

My surgeon mentioned that as part of the surgery, there was a potential that he could address the area where the blood was known to pool to help the afib. My afib is not a regular occurrence, having had probably 4 to 5 moderate instances since 2008, which auto corrected within the next day or two. Have used magnesium which seems to correct without having to go to ER. Apple watch has also been helpful to monitor.

There was some mention that he may not need to replace the valve, assuming the repair of the aneurysm takes care of it. Valve last reported as mild to moderate leakage, and again I appear to be asymptomatic. Will learn more after MRA and echo in the next few weeks. Just want to be as prepared as possible, with the understanding that the surgeon will have to make the major calls when he gets in there.

 

[Lex Luther]

I can only tell you my experience and perhaps you will find common ground. Because of both an enlarged aortic root and a very leaky valve, I went at age 63 with a Medtronic Freestyle combined valve/root. The valve is a piggy; the root dacron. It has worked beautifully for nearly 15 years. In March, an echo and CT disclosed a growing aneurysm of the ascending aorta of approx 5.5 cm -- verified by two eminent surgeons I had look at it. My surgery to fix it is scheduled for September. Even though the valve continues to work fine, my surgeon at UNC/Chapel Hill will replace it in the process of dealing with the aneurysm because it just makes sense to have a valve job rather than having to go back in whenever this one might fail.

Soooo, you are 10 years younger than I am, so your considerations maybe are different than mine. My decision is to ask my surgeon the best tissue option for me, and do that. (I need to have that conversation with him.) I fully expect this will be the final OHS for me, any way you figure it, given I am 77. But at 67, you might figure it differently. Just lay out the pros and cons, and pick what option seems best for you.

Thanks Superbob. My mother just passed a few weeks ago from CHF at the age of 88 and was sharp as a tac. I am thinking that if I get the aneurysm/valve addressed when required and continue to stay active, I might have a few good years left. You hang in there! I am learning from this site that medical advances in relation to the heart just keep coming - wish I could say the same about neurology.