What type of valve is best for me?

[ChicagoMammy]

I'm a 36 year old female and had my aortic and mitral replaced last month with mechanical valves. I had my mitral done when I was 28 with a tissue valve because I wanted more children. I had decided on mechanical before I met with my surgeon this time because my first surgery was very tough and I couldn't imagine having to go through it all again a third time in the future. When I met him this time (two months ago) he recommended mechanical too so he wouldn't have to go back in and I was done having kids. I am not very active or a huge sports player. I have never had any other issues with Coumadin and I have been on/off it for 8 years. I've had a little trouble getting and keeping it within range this time after surgery which I've heard other people have had trouble with but mostly I get tested once/month and it rarely goes out of range.

My tissue valve only lasted seven years. That's on the low side, but screw that - no way I'd have surgery every seven years. As the others said only you can choose though.

 

[epstns]

I could be wrong, but I don't think the Cleveland Clinic guidelines would be to use mechanical valves until a patient's 50's. I thought the recommended age cutoff had been lowered to 40 or 45.

Page 30 of this report says that in 2011, Cleveland Clinic used tissue valves in 92.7% of valve replacements. I had my valve replaced with a tissue valve at age 41 and my surgeon told me that's what he would have done in my situation.

http://my.clevelandclinic.org/Documents/heart/Outcomes/2011/05-valve-disease.pdf

I might be a bit out of date in my assessment. I remember that prior to my surgery, they were lowering their cut-off to mid-50's, but it looks like they went quite a bit beyond that. I hope it doesn't backfire on anyone. These things may not last "forever" so all of us tissue recipients are playing the odds that our valves will last "long enough."

 

[tom in MO]

Some passionate responses in this thread...it's a difficult emotional subject. As has been said, the best decision is life, which is either type of valve.

The risks with a tissue valve is not only the repoperation. Your replacement tissue valve will deteriorate just like the one your mom/dad gave you at birth. Your quality of life may/may not suffer. You may blow out the valve before you realize it needs replacement, this is rare if you get tested as told. With a tissue valve you absolutely must maintain your health insurance, because it will be a pre-existing condition. You also must have a job and family that will support you for the next two OHS, both emotionally and financially. Most people are out of work for about 2 months. Finally, sometimes the reoperation is not as straightforward as the first since there will be scar tissue from the previous operation.

At 55 I faced the same decision. I had 3 operations before for other things. I had complications with each so I learned to be wary of the promises of doctors. I have experienced doctor and nurse errors, plus my father and a cousin both died due to doctor error. I wanted to avoid another surgery if possible. In addition, my career is not stable thus I could not depend upon health insurance to continue unbroken to my Medicare days.

I wanted tissue and no drugs, but the more I thought about it my choice was mechanical. Warfarin is no problem and should not be for you either. My INR is maintained at 2-2.5. No I don't have an OnyX, just an old model St. Jude. My model is well studied and about two years ago they dropped the recommended range from 2-3 to 2-2.5.

 

[neil]

hi and welcome, i was 51 very active and choose tissue, my cardio favoured tissue as he said you dont want to be on warfarin the rest of your life, my surgeon said mech as he said you dont want re ops further down the line so go figure that out lol, it basically means you pick your poison and take it lol, seriously both save your life and are a lot better than the one you have, remember its your choice nobody else, so go with what you feel is best for YOU,

 

[chaconne]

I chose mechanical because I didn't want repeated surgeries. I took the risk that I would be bothered by the clicking of the valve and have complications on Warfarin. It turns out that neither are a big deal, just a part of my routine now, like brushing my teeth and hearing the gentle and reassuring "click" in a quiet room. I figured I could get used to a new normal more easily than having big disruptions to life with surgery every 10-15 years. I do have to be careful I don't hit my hear hard or get out of INR range for an extended period, but so far, my lifestyle includes hiking, mountain biking, riding in traffic and home construction. The only think I notice about Warfarin is more bruising.

Blessings on your search and decision

 

[clay_from_nj]

My choice of a mechanical valve was not to avoid reoperations so much as the possible decline in health brought on by a failing tissue valve prior to the next replacement. Before my AVR, I was suffering pretty badly with CHF and absolutely did not want to revisit that territory. A year and a half after surgery, my LVEF is still in the upper 40s, so I don't really have a lot of "reserve" which just makes me all the surer of my choice.

 

[avr8913]

I was 44 when I had my functionally bicuspid AVR. At first, I thought I wanted tissue. I did not want to be tied down to daily taking a pill, as that seemed a loss of freedom and carefree type of living. On top of that, you read of all that fear folks have of bruising and bleeding, clots and strokes, etc. Then I realized nearly everyone in the medical community I knew or encountered said they would choose mechanical, due to the longevity of the valve and less chance of having 2 more surgeries. Plus, none of them were fearful of blood thinners. All mentioned, though, it was a choice that was up to me.

Similar to Clay, though, I wound up with CHF. I went downhill so much, I had the surgery earlier than scheduled. I was scheduled to have minimally invasive surgery, but I was too far gone to take that chance. I knew I was in trouble, and not going to make it much longer. You can feel it when your body starts to shut down. All I can say is, after that, I have no desire to experience or feel that again. Going through the process of a valve deteriorating or failing a second time, is something I simply would not want to go through again, especially by choice, now that I have been through what I experienced.

I am semi active, and experienced a severe quad pull a couple months ago. Sprinting at 45 is not a good idea, especially after not being active for a while. It was torn in two places. I bled a lot internally from it. My leg was bruised some in front and back, down to mid-calf. My knee was swollen, too. It took nearly 6 weeks to recover well enough to walk without limping. Sure, it was a minor inconvenience to bruise a little more than normal, but it was nothing life threatening. I have been cut, bruised, etc. and can say that while I bruise more easily, and do not clot as fast as before, it is not as bad as some may fear.

I, personally, would prefer to fix somewhat major heart issues once, rather than knowingly have to fix something at least twice. If I had been closer to 60, I would have chosen tissue, though.

 

[cldlhd]

My choice of a mechanical valve was not to avoid reoperations so much as the possible decline in health brought on by a failing tissue valve prior to the next replacement. Before my AVR, I was suffering pretty badly with CHF and absolutely did not want to revisit that territory. A year and a half after surgery, my LVEF is still in the upper 40s, so I don't really have a lot of "reserve" which just makes me all the surer of my choice.

Do you know what your LVEF was before the mech valve? Mine is 63% and think i'll have the option of repairing my BAV as it has leakage but no stenosis. It's either that or mechanical for me. I'm a little curious if the % will go up with a repair or with a mechanical replacement and if so will one raise it much more than the other. Thanks.

 

[Heart Of The Sunrise]

Do you know what your LVEF was before the mech valve? Mine was 45%. Dr. Bavaria said that it would go up to 60%. It did indeed go up to 60%.
I see him tomorrow!:thumbup:

 

[cldlhd]

Do you know what your LVEF was before the mech valve? Mine was 45%. Dr. Bavaria said that it would go up to 60%. It did indeed go up to 60%.
I see him tomorrow!:thumbup:

That's a hell of an increase, congrats. That's great to hear also because that's one of the things I plan on asking him about. Which choice is likely to give me a higher increase. Not that it's the major consideration but I assume that's what measures how efficiently your heart is doing what it's supposed to do - pump blood

 

[clay_from_nj]

Do you know what your LVEF was before the mech valve? Mine is 63% and think i'll have the option of repairing my BAV as it has leakage but no stenosis. It's either that or mechanical for me. I'm a little curious if the % will go up with a repair or with a mechanical replacement and if so will one raise it much more than the other. Thanks.

Before surgery, my LVEF was down to as low as 15%. With medication, I was up to the mid-30s at the time of my surgery. I am confident that over the next few years, I will continue to get it up further. More important to my surgeon and cardio is that my LV size has decreased and stroke volume has increased. After years of dealing with doctors who, for the most part, see EF as the golden measure of heart health, I currently have a cardio who literally scoffs at it, puts more importance on other measures, and the most importance on my overall fitness and health. BTW, my aortic valve was both stenotic and leaky.

 

[cldlhd]

Before surgery, my LVEF was down to as low as 15%. I never knew what LVEF. With medication, I was up to the mid-30s at the time of my surgery. I am confident that over the next few years, I will continue to get it up further. More important to my surgeon and cardio is that my LV size has decreased and stroke volume has increased. After years of dealing with doctors who, for the most part, see EF as the golden measure of heart health, I currently have a cardio who literally scoffs at it, puts more importance on other measures, and the most importance on my overall fitness and health. BTW, my aortic valve was both stenotic and leaky.

I guess with stenosis the decision between repair or replace is made for you.I never knew what LVEF was until 2 months ago so this has been a crash course for me.

 

[river-wear]

My EF is 50% on a good day. That's the lower limit for the decision to intervene, according to the AHA. I was at 55% a year ago.

You might find this video interesting: http://my.clevelandclinic.org/heart/disorders/heartfailure/ejectionfraction.aspx

Chris (Heart of the Sunrise), good luck with Dr. Bavaria tomorrow!

 

[Marco]

My choice of a mechanical valve was not to avoid reoperations so much as the possible decline in health brought on by a failing tissue valve prior to the next replacement. Before my AVR, I was suffering pretty badly with CHF and absolutely did not want to revisit that territory. A year and a half after surgery, my LVEF is still in the upper 40s, so I don't really have a lot of "reserve" which just makes me all the surer of my choice.

Clay, I am 40 and my sugeon has tentatively recommended an aortic repair as a first option (which he may or not confirm next week after he's seen my CT scan) . I see you you had an aortic repair at age 10 that lasted quite long - am I right? I would be grateful if you could share your experience with repair (does it allow you to lead a normal active life?)and how/when your doctors decided that you needed a re-operation? Would you recommend repair over replacement if that option is given to you?

 

[pellicle]

Hi

not intending to answer for Clay ... I thought I would add my own experience for you

...you had an aortic repair at age 10 that lasted quite long

my repair was done at about the same age (10 yo, but back in 1974) and lasted till I was about 28, when it became stenotic due to calcification. It was replaced then.

Would you recommend repair over replacement if that option is given to you?

personally I've always been guided by the surgeon, however if you felt that you'd like to explore other options then research / reading / asking here can give you more questions to ask your surgeon. If you really wanted option X and the surgeon was emphasizing option Y, I would go get another surgeons opinion. It could simply be that your surgeon prefers option X due to their experience base being centered around that.

Ultimately the tests pre surgery are not as good as looking with your own eyes, what the surgeon anticipates from the tests may or may not prove to be what they find when they are actually looking at your valve.

I would want my surgeon to make the best decision for my long term outcomes on the spot and not mind too much what they'd said to me in consultation.

HTH

 

[Marco]

Hi

not intending to answer for Clay ... I thought I would add my own experience for you



my repair was done at about the same age (10 yo, but back in 1974) and lasted till I was about 28, when it became stenotic due to calcification. It was replaced then.



HTH

Thanks for your input pellicle. Is becoming stenotic and calcification - as far as you know- a typical risk of repaired valves, or was this a condition you already had prior to your first repair?

 

[pellicle]

Thanks for your input pellicle. Is becoming stenotic and calcification - as far as you know- a typical risk of repaired valves, or was this a condition you already had prior to your first repair?

It is as far as I know the end point for all misformed valves (including ones which got damage from rheumatic fever iirc). I can't recall (being young) what levels of calcification were reported when I was 10, but when I was 28 it looked a mess ( I got to see it as they kept them for study back then).

Like so many things the calcification rate depends on so many factors. I believe the why of it is still a subject of research and conjecture.