Valve Selection

[newarrior]

Hello Beautiful Cardiac Friends from Thailand my home since 2017,
I have some updates and questions after doing a follow up with a surgeon
1) My AVA is .87 cm 2 He recommends surgery in the next 0-3 months.
My LVEF is 73%. He said I have a 1% higher risk of stroke than the average
person due to my reduced AVA and has recommended I reduce intense exercise.
He said heart is still working/pumping normal.
2) He said my annulus in 20 mm and ideal annulus is 21 for a tissue valve.
He said I need to be at 23 for a TAVI though he thinks in the future they might lower the annulus size requirement to 21 for TAVI.

what this means in regards to valve selection is that if I get a tissue valve, when
it fails I will NOT be a candidate for TAVI and will need a 2nd surgical reopening
at a time when I may be too fragile-at which point I would expire.
I didn't know anything about annulus size until last week--do these facts and figures
and me not being a candidate for TAVI sound right ?
I have serious concerns around mechanical as well--ticking, managing INR (vegan, arthritis take a lot of herbs and supplements, high K diet, diet can change due to lots of travel).
Also concerned if I have an INR issue in a more remote area of Thailand/Asia/the World--not easy to reach doctors
easily here in Thailand between office visits.
So I am working on 3 things here:
1) Valve type
2) Where to do surgery--I am self pay so price is a consideration
3) Timing of surgery--I know sooner rather than later.
Thanks!

 

[pellicle]

2) He said my annulus in 20 mm and ideal annulus is 21 for a tissue valve.

larger is better for reducing SVD. Diameter is already established as a predictor for early onset SVD in bioprosthesis valves, however it seems its also the case for TAVR valves

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7657687/

SVD was more frequent in patents with a valve diameter of <26 mm (HR: 3.57, 1.47–8.69), oral anticoagulants (OAC), exposure at discharge (OR: 0.48, 0.38–0.61), or by a disease of renal dysfunction (OR 1.42, 1.03–1.96). ...​

SVD represents infrequent events after TAVR in the long term (>5 years), occurring more commonly in renal dysfunction patients, with small valve diameter and without OAC exposure. There may be an underestimation of the incidence if we assume death as a competing risk.​

Its interesting that OAC (Oral Anticoagulation Therapy otherwise known as blood thinners or warfarin) seems to factor against SVD. This is to me hilarious because the amount of people who seem to do anything (perhaps even cut their nose off) to avoid ACT by picking a tissue valve and then 1) end up on it and 2) may not have needed it if they'd started it as a prophylaxis (pure irony).

The article goes on to identify:

In this meta-analysis, we have discovered the following major outcomes:​

1. SVD is infrequent in 5 years after TAVR, and severe cases are rare.
2. Patients with small valve diameter, renal dysfunction, or without OAC exposure at discharge are at an increased risk of SVD.
3. There is an association of balloon-expandable valve and SVD, and further studies are needed.

 

[Chuck C]

larger is better for reducing SVD. Diameter is already established as a predictor for early onset SVD in bioprosthesis valves, however it seems its also the case for TAVR valves

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7657687/

SVD was more frequent in patents with a valve diameter of <26 mm (HR: 3.57, 1.47–8.69), oral anticoagulants (OAC), exposure at discharge (OR: 0.48, 0.38–0.61), or by a disease of renal dysfunction (OR 1.42, 1.03–1.96). ...​

SVD represents infrequent events after TAVR in the long term (>5 years), occurring more commonly in renal dysfunction patients, with small valve diameter and without OAC exposure. There may be an underestimation of the incidence if we assume death as a competing risk.​

Its interesting that OAC (Oral Anticoagulation Therapy otherwise known as blood thinners or warfarin) seems to factor against SVD. This is to me hilarious because the amount of people who seem to do anything (perhaps even cut their nose off) to avoid ACT by picking a tissue valve and then 1) end up on it and 2) may not have needed it if they'd started it as a prophylaxis (pure irony).

The article goes on to identify:

In this meta-analysis, we have discovered the following major outcomes:​

1. SVD is infrequent in 5 years after TAVR, and severe cases are rare.
2. Patients with small valve diameter, renal dysfunction, or without OAC exposure at discharge are at an increased risk of SVD.
3. There is an association of balloon-expandable valve and SVD, and further studies are needed.

That is a remarkable finding:

"SVD was less frequently observed in patients treated with OAC at discharge and more frequent in patients with renal dysfunction or in those using a small valve size (<26 mm). Reduction of the incidence of leaflet thrombosis (LT) with OAC, which also decreases the mean transvalvular gradient, was reported in a meta-analysis [24]. It may suggest that OAC can prevent SVD by reducing LT. "

So, the evidence at this point suggests that anti-coagulation may help prevent SVD. This is TAVR, and I hope that they study this for normal tissue prosthetics as well.

Wouldn't that be an interesting turn if OAC becomes recommended for those with tissue valves to help prevent SVD? I'm sure that would be a dilemna for a lot of people, given the reason many, if not most, people choose a tissue valve to avoid anti-coagulation.

 

[tom in MO]

Hello Beautiful Cardiac Friends from Thailand my home since 2017,
I have some updates and questions after doing a follow up with a surgeon
1) My AVA is .87 cm 2 He recommends surgery in the next 0-3 months.
My LVEF is 73%. He said I have a 1% higher risk of stroke than the average
person due to my reduced AVA and has recommended I reduce intense exercise.
He said heart is still working/pumping normal.
2) He said my annulus in 20 mm and ideal annulus is 21 for a tissue valve.
He said I need to be at 23 for a TAVI though he thinks in the future they might lower the annulus size requirement to 21 for TAVI.

what this means in regards to valve selection is that if I get a tissue valve, when
it fails I will NOT be a candidate for TAVI and will need a 2nd surgical reopening
at a time when I may be too fragile-at which point I would expire.
I didn't know anything about annulus size until last week--do these facts and figures
and me not being a candidate for TAVI sound right ?
I have serious concerns around mechanical as well--ticking, managing INR (vegan, arthritis take a lot of herbs and supplements, high K diet, diet can change due to lots of travel).
Also concerned if I have an INR issue in a more remote area of Thailand/Asia/the World--not easy to reach doctors
easily here in Thailand between office visits.
So I am working on 3 things here:
1) Valve type
2) Where to do surgery--I am self pay so price is a consideration
3) Timing of surgery--I know sooner rather than later.
Thanks!

1) Valve type - Tissue. You are 60 and are afraid of warfarin
2) Where to do surgery--I am self pay so price is a consideration - Do it in Thailand where you live. What do you want money but your dead, or less money that you can spend while you are alive?
3) Timing of surgery--I know sooner rather than later. - You've been told you need 0-3 months that means you need it now. Take the first available opening.

 

[pellicle]

Wouldn't that be an interesting turn if OAC becomes recommended for those with tissue valves to help prevent SVD?

it indeed would.

I had to read that a few times to make sure I'd read it right. But interestingly Dr Schaff observes that if you follow a tissue valve patient long enough then by 10 years they are often on OAC anyway (for other issues).

Returning to the point of the possible benefits of OAC in tissue valves (bioprosthetics) delaying SVD in the broader population I can say that the benefits of a small dose of warfarin (keeping INR to < 3 is pretty clear to me; it essentially is prophylactic to you ever getting a stroke as happens to the general population, and has been found to be helpful in other less common areas.
https://www.valvereplacement.org/threads/a-members-survival-story.874083/post-874083
PS: you just know nobody is going to do that study, not least because it won't benefit sales.

 

[Gkeraney]

That is a remarkable finding:

"SVD was less frequently observed in patients treated with OAC at discharge and more frequent in patients with renal dysfunction or in those using a small valve size (<26 mm). Reduction of the incidence of leaflet thrombosis (LT) with OAC, which also decreases the mean transvalvular gradient, was reported in a meta-analysis [24]. It may suggest that OAC can prevent SVD by reducing LT. "

So, the evidence at this point suggests that anti-coagulation may help prevent SVD. This is TAVR, and I hope that they study this for normal tissue prosthetics as well.

Wouldn't that be an interesting turn if OAC becomes recommended for those with tissue valves to help prevent SVD? I'm sure that would be a dilemna for a lot of people, given the reason many, if not most, people choose a tissue valve to avoid anti-coagulation.

I believe that oac does indeed decrease/slow svd. Any echo technician has known for 20 and more years that velocities are decreased on folks taking blood thinners. The valve isnt taking as much of a beating to begin with. Then, the anti coagulants dramatically decrease the possibility of clots forming. When I was fighting to get my valve scanned for clots but they wouldnt do it, I put myself on combo of aspirin, tumeric, fish oil, nattokinase, serrapeptase, ginseng etc etc. I was getting nose bleeds. Maybe it worked some but I messed around enough to know that warfarin decreased my stenotic murmur much more than the basket of other things I tried...including eliquis. I got the tavr and a year later was on warfarin. We will see how it goes after around year 7 if it makes it that far.

For anyone wondering why the docs wouldnt do a ct scan, its because until about the last ten years, they truly thought the bio valves werent developing clots. Its been a bit of insanity. They didnt know because they wouldnt look for them. There has never been a comp of bio valves on warfarin vs a mechanical valves on warfarin that I can find. I think the gap would close some. However, since the tavi/tavr allows you to not get opened up or reopened, I think a lot of patients will eventually have tavi's but also be on warfarin. I had a doc tell me its too bad you are getting thrombus formation and having to do warfarin as the whole point of a bio savr or tavr is to avoid warfarin. Think about that. Really? With a tavi/tavr you avoid sternotomy but probably should take warfarin to allow that valve the best possibly chance to last. A lot of folks wont clot but if after the procedure the velocities arent very low warfarin is likely the correct move

 

[rich01]

TAVR in Patients With a Small Aortic Annulus​

The choice of transcatheter heart valve affects hemodynamics in patients with a small aortic annulus.

https://citoday.com/articles/2018-july-aug-supplement/tavr-in-patients-with-a-small-aortic-annulus

CONCLUSION​

Patients with a small aortic annulus deserve careful consideration by a heart team. If the patient is operable but the surgeon is not prepared to perform root enlargement surgery or implant a stentless or sutureless valve, then TAVR should be the preferred treatment option. The data are clear: hemodynamics and clinical outcomes are worse in patients with small aortic bioprostheses. Available data in patients with a small native aortic annulus support the use of TAVR over surgical aortic valve replacement and favor the use of self-expanding THVs with supra-annular leaflets to achieve optimal hemodynamics.

 

[newarrior]

1) Valve type - Tissue. You are 60 and are afraid of warfarin
2) Where to do surgery--I am self pay so price is a consideration - Do it in Thailand where you live. What do you want money but your dead, or less money that you can spend while you are alive?
3) Timing of surgery--I know sooner rather than later. - You've been told you need 0-3 months that means you need it now. Take the first available opening.

thx

 

[pellicle]

The choice of transcatheter heart valve affects hemodynamics in patients with a small aortic annulus.

an interesting paid opinion piece ... however seems scant on data. If you're already sold on the idea then just read the conclusions which support ones preference, Myself I'm not sold on it, so rather than just take the blue pill I'd be looking for key evidence such as:

• durability broken down into groups based on patient age
• what options were at end of life

I didn't see anything like that, not even average ages.

I saw this:

The most recently published data of more than 78,000 surgical aortic valve replacement patients from the Society of Thoracic Surgeons database between 2007 and 2010 demonstrated that 38% of patients received a 19- or 21-mm valve.​

which passes for information about those questions in no way, save to say that nearly 40% of surgery in an area which focuses on old people used TAVI. Further it discusses this from the perspective of "intermediate risk" patients, so my view is this isn't people who are low risk. Indeed their first reference points to this article

https://pubmed.ncbi.nlm.nih.gov/25442986/
which interestingly did stratify (but by risk) but didn't venture long term outcomes

Conclusions: Nearly 80% of patients undergoing SAVR have outcomes that are superior to those by the predicted risk models. In the most recent era, early results have further improved in medium-risk and high-risk patients. This large real-world assessment serves as a benchmark for patients with aortic valve stenosis as therapeutic options are further evaluated.​

noteworthy in the conclusions SAVR not TAVR looks more favourable, yet the opinion piece (written by interventional cardiologists, not some detached not profiting from this group) somehow drew the view that TAVR was better?

I note that they don't actually say better, but say "deserve careful consideration by a heart team"

Doesn't ring out as good reasons to go that way, looks like something that if you are higher risk of death in surgery could bear consideration.

Directly under that is this less than encouraging point:

Many of these patients will have prosthesis-patient mismatch (PPM) with high gradients that may predispose to early bioprosthetic valve failure from increased leaflet shear stress.​

Dunno ... what am I missing here?

 

[Superman]

That is a remarkable finding:

"SVD was less frequently observed in patients treated with OAC at discharge and more frequent in patients with renal dysfunction or in those using a small valve size (<26 mm). Reduction of the incidence of leaflet thrombosis (LT) with OAC, which also decreases the mean transvalvular gradient, was reported in a meta-analysis [24]. It may suggest that OAC can prevent SVD by reducing LT. "

So, the evidence at this point suggests that anti-coagulation may help prevent SVD. This is TAVR, and I hope that they study this for normal tissue prosthetics as well.

Wouldn't that be an interesting turn if OAC becomes recommended for those with tissue valves to help prevent SVD? I'm sure that would be a dilemna for a lot of people, given the reason many, if not most, people choose a tissue valve to avoid anti-coagulation.

I suspect a positive for tissue valvers would be that any OAC would be available vs just warfarin (mechanical valvers). So no monitoring or testing, but much more expensive drugs.

 

[Gkeraney]

Hello Beautiful Cardiac Friends from Thailand my home since 2017,
I have some updates and questions after doing a follow up with a surgeon
1) My AVA is .87 cm 2 He recommends surgery in the next 0-3 months.
My LVEF is 73%. He said I have a 1% higher risk of stroke than the average
person due to my reduced AVA and has recommended I reduce intense exercise.
He said heart is still working/pumping normal.
2) He said my annulus in 20 mm and ideal annulus is 21 for a tissue valve.
He said I need to be at 23 for a TAVI though he thinks in the future they might lower the annulus size requirement to 21 for TAVI.

what this means in regards to valve selection is that if I get a tissue valve, when
it fails I will NOT be a candidate for TAVI and will need a 2nd surgical reopening
at a time when I may be too fragile-at which point I would expire.
I didn't know anything about annulus size until last week--do these facts and figures
and me not being a candidate for TAVI sound right ?
I have serious concerns around mechanical as well--ticking, managing INR (vegan, arthritis take a lot of herbs and supplements, high K diet, diet can change due to lots of travel).
Also concerned if I have an INR issue in a more remote area of Thailand/Asia/the World--not easy to reach doctors
easily here in Thailand between office visits.
So I am working on 3 things here:
1) Valve type
2) Where to do surgery--I am self pay so price is a consideration
3) Timing of surgery--I know sooner rather than later.
Thanks!

Some clarifications. Are you 60 or were 60 in 2019? Its a first surgery? High volume surgery center I hope, either way? If you are 60, and it's the first procedure, and you expect to live into late 80's, I would not do a tavr. You should get through a savr just fine. If you are 64, it's a tougher call. A tavr at about 65 could be followed by another tavr at 75+. I get all the concerns about small size

 

[newarrior]

Some clarifications. Are you 60 or were 60 in 2019? Its a first surgery? High volume surgery center I hope, either way? If you are 60, and it's the first procedure, and you expect to live into late 80's, I would not do a tavr. You should get through a savr just fine. If you are 64, it's a tougher call. A tavr at about 65 could be followed by another tavr at 75+. I get all the concerns about small size

I'm 60 right now. My valve opening is smaller so I'm starting to think about getting mechanical over tissue but I'm worried about the ticking at about my INR I have no problem taking pills but I've got a high vitamin K vegan diet that varies great in the after breakfast and even more when I travel because I don't know what kind of you know selection I'm going to have a food when I jump over to Vietnam Singapore or other parts of thailand. Also I'm self-pay so the idea of getting a mechanical is good one surgery one out the mechanical valve here runs about 900 the best tissues about 5500 also of course I'm dreading a second surgery trying to find the fence either way working with my Physicians here in Thailand to drive the thing to a close still have a small window to maybe go back to America and do it as well