Valve type and sport

[RunMartin]

Does anyone know whether a tissue valve is better (more efficient etc) than a mechanical valve. i.e. does a tissue valve give a better sporting performance?

 

[tprice54]

The best I can tell, there are no actual studies regarding sports and valve types. You have to try and extrapolate from existing data in regards to valve hemodynamics, but how they really relate in the real world to sports....that's undecided.

 

[Bean Counter]

Like Tom said, I have not found any studies done on this. I met with 3 different surgeons before my surgery and asked all 3 of them if they think I can get back to my previous level of fitness after the surgery. They all said yes, but one of them added in that I could with a tissue valve. I have seen success stories over on Cardiac Athletes dot org with both types.

 

[RunMartin]

The reason for asking is that I do not seem to be improving even thought I am trying to run further and harder. I still find running up hills much harder and this has not changed over the past 4/5 months. I have done two 5K races - one month apart - and did exactly the same time. This was 24 minutes. I used to be able to do about 19 minutes.

 

[scott.eitman]

Could it be that you are so old I say that with a smile as I am 47.

I am wondering if some medications have an effect. Of course, I am just coming up to 5 months post-op so I know I have a ways to go for a full recovery. I am on Lisinopril and pushing to be taken off it next week when I see my cardio.

 

[tprice54]

I remember wondering when I would get back in shape when I was only 10 months post op! I'm 3 years out and still find hills difficult (along with cold). Again, no serious studies, but based on posts over at CA, to achieve your former fitness can take 2-3 years, if ever. I stopped worrying about it this year, and just enjoy my runs.

 

[ski girl]

Hi Martin I'm two months post-op with a tissue valve (cow) and already doing as well as if not better than a year pre-op before I started to feel like something was going wrong. I've trained with a GPS since July '09 so I know exactly what I was doing before, and now I'm working less hard (HR lower) on the bike than I was a year ago. I rode up a hill last weekend without stopping - first time ever on that stinkin' hill.

I may have unrealistic expectations but when I can start paddling and get my paddling fitness back, I'm expecting to be a fair bit faster than I was before - neither my surgeon nor my cardiologist has contradicted me when I say that.

I'm not on any meds though which might make a difference - but I don't understand why we shouldn't perform better when we start getting all the blood our hearts are trying to pump out!!?!???!?

 

[normofthenorth]

Nice story, Ski Girl, and at TWO MONTHS post-op!?! Unfortunately, I've seen a lot of reports that are much less "nice" -- including a recent exchange here about "heart vs. brain" or some such.

RunMartin, I'd think that enough studies have been done on the hemodynamic performance of both kinds of valves, that it should be pretty easy for somebody (with free access to the studies and the data) to answer your question.

E.g., I've discussed and linked a study that seems to prove that the extremely durable and well-tested Medtronicks Hancock II pig valve (which I just got, in AV position), has maybe 12% WORSE hemodynamics than the (almost as durable and well-tested) Carpentier-Edwards Perimount cow valve. And I'd assume that On-X and the others are cloberring each other with statistics, every chance they get. Between the two of them, the data should be available to answer your Q, even if nobody's exactly set out to answer it.

Another factor: I think lots of old and sick people with CHD (like my Dad in his 90s) get Coumadin, because it makes the blood easier to pump -- sort of equivalent to improving the hemodynamics of that person's valves, etc. So I'd assume that the nuisances and maybe even disadvantages of ACT, with the mech valves, may be accompanied by a significant hemodynamic advantage, which a jock might well notice...

Just a long shot: Did you remember to take the parking brake off your mech valve?

 

[normofthenorth]

Here's one: At ats.ctsnetjournals.org/cgi/content/full/72/4/1217 there's a 2001 Israeli study apparently geared at your concern.

"Conclusions. Stentless valves behave similarly to normal aortic valves in that there is almost no increase in gradient at exercise. Both mechanical valve groups showed increased gradients at exercise, suggesting that these valves obstruct blood flow. Our data add further evidence that stentless valves are hemodynamically superior to mechanical valves in the aortic position."

(They did NOT explain why THIS jock just got a STENTED tissue valve. . .!)

And On-x has their take -- remarkably one-sided in favor of mech! -- at www.onxlti.com/mechanical-vs-tissue-valves.html#valve-comparison , bottom of the page.

 

[Lynlw]

Nice story, Ski Girl, and at TWO MONTHS post-op!?! Unfortunately, I've seen a lot of reports that are much less "nice" -- including a recent exchange here about "heart vs. brain" or some such.

RunMartin, I'd think that enough studies have been done on the hemodynamic performance of both kinds of valves, that it should be pretty easy for somebody (with free access to the studies and the data) to answer your question.

E.g., I've discussed and linked a study that seems to prove that the extremely durable and well-tested Medtronicks Hancock II pig valve (which I just got, in AV position), has maybe 12% WORSE hemodynamics than the (almost as durable and well-tested) Carpentier-Edwards Perimount cow valve. And I'd assume that On-X and the others are cloberring each other with statistics, every chance they get. Between the two of them, the data should be available to answer your Q, even if nobody's exactly set out to answer it.

Another factor: I think lots of old and sick people with CHD (like my Dad in his 90s) get Coumadin, because it makes the blood easier to pump -- sort of equivalent to improving the hemodynamics of that person's valves, etc. So I'd assume that the nuisances and maybe even disadvantages of ACT, with the mech valves, may be accompanied by a significant hemodynamic advantage, which a jock might well notice...

Just a long shot: Did you remember to take the parking brake off your mech valve?

I have NEVER heard of people getting Coumadin to make their blood easier to pump. Taking Coumadin shouldn't play any role in the hemodynamics of a valve

 

[normofthenorth]

Lyn, AFAIK, my Dad didn't have a bad valve, BAV or otherwise. He did have a bout with Rheumatic Fever as a kid, and a couple of bouts with BE in old age. He never had heart surgery. As his circulation started fading toward ~90yo, he got some symptoms of CHF, and was put on Coumadin. Daily pills and weekly INR tests. We were all told it was to make his blood thinner, so it was easier to pump.

Maybe I'll start Googling THAT, after I finish on the mech-tissue hemodynamic stuff!

 

[normofthenorth]

Near the bottom of www.onxlti.com/pro-con-heart-valve-replacement.html#pro-con-valve-replacement , On-x says :

"Homograft tissue heart valves Pro's:
Best efficiency of all valves on the market, tissue and mechanical.62-64"

So even On-x concedes that ONE tissue valve -- from a human donor -- beats their invention in hemodynamics.

So if Arnold Schwarzenegger is still running at top speed, that's probably why!

 

[Lynlw]

Near the bottom of www.onxlti.com/pro-con-heart-valve-replacement.html#pro-con-valve-replacement , On-x says :

"Homograft tissue heart valves Pro's:
Best efficiency of all valves on the market, tissue and mechanical.62-64"

So even On-x concedes that ONE tissue valve -- from a human donor -- beats their invention in hemodynamics.

So if Arnold Schwarzenegger is still running at top speed, that's probably why!

I would probably check pubmed for a few studies, chances are a valve compnay cherrypicked the data to show their best vs others probably worst studies. Like they do for their pro/con sections, where they use stats from other kind of valves and don't mention the dat for tissue valves is based on old valves not in use anymore

 

[Lynlw]

Lyn, AFAIK, my Dad didn't have a bad valve, BAV or otherwise. He did have a bout with Rheumatic Fever as a kid, and a couple of bouts with BE in old age. He never had heart surgery. As his circulation started fading toward ~90yo, he got some symptoms of CHF, and was put on Coumadin. Daily pills and weekly INR tests. We were all told it was to make his blood thinner, so it was easier to pump.

Maybe I'll start Googling THAT, after I finish on the mech-tissue hemodynamic stuff!

My Dad is on coumadin for AFib, maybe your Dad had that? Coumadin does NOT make blood "thinner" is just slows the time kit takes to clot, so that doesn't make much sense. but if you find anything I'd love to read it

 

[Bina]

We are humans, we are all different; no particular valve can be named as the 'best' in every way.
A woman here in my town had a double valve swap and guess which one crapped out first a few short years later?
The homograft human donor valve. .....We just never know.

 

[normofthenorth]

1) Bina, On-x didn't say the human/homograft valve LASTS a long time, but that it has good HEMODYNAMICS. (You'd think the two would go together, but they often seem not to.)

2) About the ACT/Coumadin and CHF, here's a reference from a 2006 study (I can't get the older ref -- #50 in this study):
"A retrospective analysis from the SOLVD[50] showed that anticoagulant therapy was associated with a significant reduction in all-cause mortality [adjusted hazard ratio (HR) 0.76, 95% confidence interval (CI) 0.65-0.89, p = 0.0006] and death or hospitalisation for heart failure (HR 0.82, 95% CI 0.72-0.93, p = 0.0002). In addition, patients with non-ischaemic heart failure also demonstrate a 70% risk reduction. However, long-term warfarin was not associated with a reduction in the total number of (fatal and non-fatal) thromboembolic events." [http://www.medscape.org/viewarticle/529204_5 , para. 2]

From my reading of that conclusion, ACT lowered mortality, and death or hospitalisation for heart failure, quite significantly in these CHF patients. But it did NOT significantly reduce total number of (fatal and non-fatal) CLOTS.

There are other similar conclusions cited in this study, though the results are mixed, and that study itself says the case for the use of ACT isn't clear. Anyhoo, my Dad got it, and I don't think it was for anything BUT CHF.

A Google for "chf coumadin" (no quotes) gets >500,000 hits, many of them studies on the subject(s).

 

[normofthenorth]

RunMartin, I've just noticed a bunch more articles that raise another "concern" -- or maybe a LACK of concern. Here's my new speculation:

There are a lot of articles measuring the hemodynamic performance of competing valves (incl. mech vs. tissue) for use in patients with small aortic roots. Basically, if you naturally have a small AR and a small AV, then a relatively minor amount of stenosis or obstruction -- e.g., from the stent on your tissue AVR or the design features of your mech valve -- would be a bigger deal than if you naturally have an average-size AR & AV.

Obviously, an elite cardio athlete like a champ marathoner would be expected to "live" closer to max loading of her AV than a couch potato, all other things equal. But for any individual athlete, modest changes in AV hemodynamics may have a direct effect on actual athletic performance, or may not. You don't make a chain any stronger by strengthening a stronger-than-average link, type thing.

My impression of the reports here of post-OHS return to sport etc., and of my own not-yet-settled-down heart-rate post-OHS, suggests that the heart's "control systems" are at least as important as the heart's "mechanical parts" in determining the outcome. OHS probably always disrupts the electrochemical systems that "tell" our heart how fast and how vigorously (etc.) to beat. Sometimes the disruption is severe enough to need pacemaker pacing afterwards, but it always seems to be there. With luck, the heart and brain and spine. . . re-program themselves to accomplish the amazing dance they normally do.

Training and drugs both obviously effect those "control systems".

At any rate, getting a "firehose" huge-opening valve installed in your AV position probably can't hurt your Olympic campaign, but it might be minor, or even strengthening a meaningless link in your own chain.

 

[Mentu]

Martin, there are any number of things that could influence exercise performance other than the valve. We all want to see our hearts return to "Normal" after surgery but this is not really what happens, instead, our hearts establish a new level of function after surgery and it can take more than a year to do so. The issue that I am dealing with now is called diastolic dysfunction. Basically, the left side of the heart relaxes between beats and fills with blood; my heart cannot yet do so fully because it has stiffened and does not fully relax. This "stiffness" was caused by the years my heart spent compensating for the stenotic valve and is associated with the "mild hypertrophy" noted in each of my echo cardiograms. One of the primary effects this has is to reduce one's exercise performance. There is debate about how much the stiffness will abate but current thought seems to be that improvement can continue much longer than a year. Current treatment includes using a calcium channel blocker along with an ACE inhibitor; I am taking Verapamil and Lisinopril. I toss this out as a possibility. Take care.

Larry

 

[Lynlw]

1) Bina, On-x didn't say the human/homograft valve LASTS a long time, but that it has good HEMODYNAMICS. (You'd think the two would go together, but they often seem not to.)

2) About the ACT/Coumadin and CHF, here's a reference from a 2006 study (I can't get the older ref -- #50 in this study):
"A retrospective analysis from the SOLVD[50] showed that anticoagulant therapy was associated with a significant reduction in all-cause mortality [adjusted hazard ratio (HR) 0.76, 95% confidence interval (CI) 0.65-0.89, p = 0.0006] and death or hospitalisation for heart failure (HR 0.82, 95% CI 0.72-0.93, p = 0.0002). In addition, patients with non-ischaemic heart failure also demonstrate a 70% risk reduction. However, long-term warfarin was not associated with a reduction in the total number of (fatal and non-fatal) thromboembolic events." [http://www.medscape.org/viewarticle/529204_5 , para. 2]

From my reading of that conclusion, ACT lowered mortality, and death or hospitalisation for heart failure, quite significantly in these CHF patients. But it did NOT significantly reduce total number of (fatal and non-fatal) CLOTS.

There are other similar conclusions cited in this study, though the results are mixed, and that study itself says the case for the use of ACT isn't clear. Anyhoo, my Dad got it, and I don't think it was for anything BUT CHF.

A Google for "chf coumadin" (no quotes) gets >500,000 hits, many of them studies on the subject(s).

Have you found anything about coumadin making the blood pump easier or improving hemodynamics? That was the part that does not make sense to me. It might have helped hearts in CHF in some other way, which could make sense.
Was you Dad on other meds for his heart?

 

[nate_c]

There are a lot of articles measuring the hemodynamic performance of competing valves (incl. mech vs. tissue) for use in patients with small aortic roots. Basically, if you naturally have a small AR and a small AV, then a relatively minor amount of stenosis or obstruction -- e.g., from the stent on your tissue AVR or the design features of your mech valve -- would be a bigger deal than if you naturally have an average-size AR & AV.

Runmartin, I'm sorry to hear you're stuck. That's got to be frustrating. Two surgeons, as well as my own research prior to my AVR, suggested that stentless valves and the Ross Procedure (skillfully done) were the closest you could get to native performance. I was set to get a stentless valve, but when I woke up after surgery, I discovered that I'd gotten a stented porcine valve instead. My surgeon explained that my aorta was big enough (29mm) that a stentless valve would not have added much at all in the way of performance, but likely wouldn't have lasted as long. This would seem to dovetail nicely with Norm's research. I'm about 3.5 months out, and I've continue to see consistent improvement. I'm not back to pre-surgery levels yet, but I keep finding that I have sudden jumps in my pace and I'm only about a 1 to 1.5 minutes off my pre-surgery pace now. I know you're farther out from surgery than I am, but I really hope you've just hit a temporary plateau and your heart will find a way to work through out. I'd be curious to know if you're able to try any intervals to help your heart/legs "remember" what it's like to perform at a faster pace. I've been doing very short intervals of 1 - 2 minutes on some of my runs--nothing too crazy--just to try to keep up the feel of faster running, and I think it has been helping, though I have no real proof of that. I've also heard some people say that they don't feel completely back to normal for more than a year, so I think there's reason to maintain hope that the best is yet to come. Good luck!