I'm 45 years old. Two prior cardiac surgeons assumed that if I ended up having to repair my valve, I should go with mechanical, due to my age. The third surgeon said that he would choose a tissue valve for me. When i asked him why and he said something about advancements in tissue valve means that it would be unlikely to need another surgery and I could remain off coumadin. Anyone else receive this advice? Where can I look for real data on how long these things last and how bad would it be to live on coumadin? Thanks so much!
Why did my doc say that he would choose a tissue valve for me?
- Thread starter Heartsong
- Start date
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almost_hectic
Well-known member
I say 2 out of 3 doctors are correct in this situation. Others on here will give feedback as well but I dont know of any tissue valve advancement that will give you one replacement to last you the rest of your life. At 44 (last year) I chose mechanical, my surgeon said that was the best choice. New mechanical valves require lower coumadin levels making it safer and newer testing methods make it easy to maintain. Ive found it very easy.
Hi Heartsong. My doctor presented tissue as an option for me, even though this will be my 2nd valve AVR, because of new advancements, valve in valve surgery, etc. I have not considered tissue for my 2nd surgery because I am hoping the next one will be the final one. I simply don't want to continue having surgery and the risk of complications that may arise. I will be 44 in February and my current valve will be 13 in March. Heartsong, it's a tough decision. Either one is great. I'm sure some folks will be along to give you all sorts of data, links, statistics, etc. I just want to say good luck in figuring things out. I hope you stay in the waiting room!
Trinalovescats
Well-known member
Coumadin isn't a death sentence,you just have to watch your Vitamin K intake and get your blood checked regularly.
Do your research on mechanical and tissue valves,don't be afraid to ask questions here either.Everyone here is very welcoming.
I had Mitral Valve Replacement and Tricuspid Repair on May 3,2016 and chose Mechanical.Im glad I chose it and the ticking makes me feel better,I'm 31 and the doctor said I will live a better life with Mechanical.
If I were you I'd chose mechanical,if taking Coumadin is a small sacrifice then I'd take it.
Do your research on mechanical and tissue valves,don't be afraid to ask questions here either.Everyone here is very welcoming.
I had Mitral Valve Replacement and Tricuspid Repair on May 3,2016 and chose Mechanical.Im glad I chose it and the ticking makes me feel better,I'm 31 and the doctor said I will live a better life with Mechanical.
If I were you I'd chose mechanical,if taking Coumadin is a small sacrifice then I'd take it.
pellicle
Professional Dingbat, Guru and Merkintologist
Hi
to answer the question posed in the thread title I'll say probably because:
certainly, but not me. My surgeon (this time) cautioned me about my choices and said while I could pick anything I wanted that a mechanical would be the only option that was likely to avoid repeat surgeries (it being a certainty otherwise). As I was going to be fronting up for my third he said clearly that "noone will be lining up to do your fourth" - because it will be complex and risky.
as this is a common question I've compiled some answers from my own readings and research on my blog so you can start there and from those articles chase down further ones.
http://cjeastwd.blogspot.com/2014/01...r-choices.html
about life on coumadin well ... 90% of what you will read against is is just myth. As mentioned above the people on it are usually not the ones saying how bad it is. The people who aren't on it don't like it for reasons which I can only speculate on.
Basically your food will have no impact and if you manage yourself (something which is common place outside of the USA) you will learn about yourself and be able to do a good job.
Again from my blog, some posts which will help you
http://cjeastwd.blogspot.com.au/2014...ng-my-inr.html
and
http://cjeastwd.blogspot.com/2015/10...r-example.html
Lastly the third surgeson you dealt with may well have had the experience that as his patients were older that a 2nd redo would "last them their lifetime" because perhaps they died before needing a third. That scenario is discussed in my first blog post where I also review the work of a Mayo Surgeon who is a supporter of Mechanical and questions the use of Tissue in all cases.
My own surgeon was in his 50's when he did my homograft surgery in 1992 when I was 28, he is retired now. So what are the chances that the surgeon you spoke to is not seeing many patients who are under 50 and will review them over 30 years? To a 60 year old 30 years is a long time, to a 30 year old its not.
Best Wishes
Heartsong;n868721 said:
to answer the question posed in the thread title I'll say probably because:
- individuals (even experts) have biases, some towards mechanical some towards tissue
- patients are pains in the arse for doctors and pharmacists. They frequently fail to take their medications, they're disorganised and frankly stupid. I've got friends who are pharmacists and pathologists who reiterate this. Here you will find people saying what amounts to "I could never be bothered being organised enough to take a pill every day". So as a result a tissue valve seems an attractive way to kick the can down the road and by the time they realise what the costs to them really are its 20 years later.
- mechanical valves don't fail: they are obstructed by thrombosis (blot clots like mud) always associated with inadequate AntiCoagulation therapy, in the past this has resulted in valve surgery again, however no the approach is to clear that using a chemaical calle tPA. This seems quite effective and has become the gold standard: however many surgeons don't know about it because its not their field
- surgeons are risk averse, the data they find paints a bleak picture of AC therapy. This is actually compiled and presented to them by the people who buy them lunch (shock) the valve makers.
- There is more repeat business and better profit for the valve makers to make and distribute tissue valves than mechanical valves
- if you have complex health issues and require other medications then coumadin can make managing your life more complex. if you happen to be well described by the above generalisations then perhaps its smart to avoid it (or smarten up?)
certainly, but not me. My surgeon (this time) cautioned me about my choices and said while I could pick anything I wanted that a mechanical would be the only option that was likely to avoid repeat surgeries (it being a certainty otherwise). As I was going to be fronting up for my third he said clearly that "noone will be lining up to do your fourth" - because it will be complex and risky.
as this is a common question I've compiled some answers from my own readings and research on my blog so you can start there and from those articles chase down further ones.
http://cjeastwd.blogspot.com/2014/01...r-choices.html
about life on coumadin well ... 90% of what you will read against is is just myth. As mentioned above the people on it are usually not the ones saying how bad it is. The people who aren't on it don't like it for reasons which I can only speculate on.
Basically your food will have no impact and if you manage yourself (something which is common place outside of the USA) you will learn about yourself and be able to do a good job.
Again from my blog, some posts which will help you
http://cjeastwd.blogspot.com.au/2014...ng-my-inr.html
and
http://cjeastwd.blogspot.com/2015/10...r-example.html
Lastly the third surgeson you dealt with may well have had the experience that as his patients were older that a 2nd redo would "last them their lifetime" because perhaps they died before needing a third. That scenario is discussed in my first blog post where I also review the work of a Mayo Surgeon who is a supporter of Mechanical and questions the use of Tissue in all cases.
My own surgeon was in his 50's when he did my homograft surgery in 1992 when I was 28, he is retired now. So what are the chances that the surgeon you spoke to is not seeing many patients who are under 50 and will review them over 30 years? To a 60 year old 30 years is a long time, to a 30 year old its not.
Best Wishes
Headstrong,
I applaud you for seeking multiple opinions!
When I had my surgery in 2008, my surgeon recommended tissue valves. I was 57 then and scared of another surgery. He assured me that replacements will not require OHS. I was too coward and too confused ... Unable to think right...with two bad valves...worried what my health would be at time of replacement!! I didn't want to believe him and I chose mechanical Valves despite his advice. But, my surgeon was/is right and so is yours.
Coumadin is not a big issue, once you learn how to handle it! Yet, when one needs a minor surgery, pulling a tooth, ....etc. one needs to go through a special routine/protocol which my surgeon wanted me to avoid then. He said I was young to be on Coumadin! I laughed!
I applaud you for seeking multiple opinions!
When I had my surgery in 2008, my surgeon recommended tissue valves. I was 57 then and scared of another surgery. He assured me that replacements will not require OHS. I was too coward and too confused ... Unable to think right...with two bad valves...worried what my health would be at time of replacement!! I didn't want to believe him and I chose mechanical Valves despite his advice. But, my surgeon was/is right and so is yours.
Coumadin is not a big issue, once you learn how to handle it! Yet, when one needs a minor surgery, pulling a tooth, ....etc. one needs to go through a special routine/protocol which my surgeon wanted me to avoid then. He said I was young to be on Coumadin! I laughed!
Last edited:
Agian
Well-known member
Take 100 patients on Warfarin. Most will be be testing infrequently, which means their overall risks of bleeds and clots will be higher.
The surgeons see this, and understandably see Warfarin as a 'bad thing', which in the majority of their patients may well be. Most people don't even complete a full course of antibiotics.
Remember, some of these guys have been around a while (since long before self-testing became hipster) and have seen some horror stories.
The surgeons see this, and understandably see Warfarin as a 'bad thing', which in the majority of their patients may well be. Most people don't even complete a full course of antibiotics.
Remember, some of these guys have been around a while (since long before self-testing became hipster) and have seen some horror stories.
Agian
Well-known member
Me too!Eva;n868741 said:
I got treated like a freak for 'doctor shopping'.
I interviewed four surgeons and checked with three cardiologists before my surgery. People thought I was exaggerating, but I didn't care, nor should anyone! It's our health and this is the best shopping we ever do.
Agian
Well-known member
We're expected to be coy and deferential? Screw them Eva!
That's what I like about Americans; they always want to speak to the Manager and they know their rights.
That's what I like about Americans; they always want to speak to the Manager and they know their rights.
Agian
Well-known member
I'm really worked up now.
OK now have a heart Pellicle . . . . "I could never be bothered being organised enough to take a pill every day" . . . if you only knew how much effort goes into remembering to take pills every day for some of us . . . I will have to have EVEN MORE alarms and reminders and routines than I have now when I need to be on Coumadin because I still miss pills on occasion. I can totally see someone knowing themselves well enough to know they can't vouch for consistency. Whereas for others with a different personality that seems absurd and like it must be willful. I assure you, the struggle is real!
A few points:
Anticoagulation management isn't just getting a blood draw when an 'anticoagulation clinic' decides you should get one. In my experience, many of these 'experts' either don't really know what they're doing; or follow outdated protocols or, in my experience, don't even know how to handle the blood so that it is accurately tested.
Having your own meter and supplies is empowering. You don't have to follow an often inadequate schedule for blood draws. If you make changes in diet or activity that you think may have some effect on your INR, you can test for those changes -- clinics probably don't know or care much about these changes - unless they show up in your monthly blood draw.
I'm great at ignoring things. BUT I have a routine before I get to bed each night - I take my warfarin. We're all 'creatures of habit.' If we get into the habit of taking Warfarin before going to bed, once the habit is imprinted on us, it's hard to NOT do it. To say that a person should get a tissue valve just because that person may not take warfarin as directed doesn't do the patient justice. (And, if the patient is really concerned about forgetting to take a dose, that patient can use a pill dispenser with a dose for each day. It'll be clear if a dose is missed just by opening the dispenser. Again - getting into the habit of taking warfarin at the same time (time being 'bedtime' and not necessarily the position of hands on a clock) should reduce some of the concerns about non-compliance with dosing.
Forgetting to complete a course of antibiotics is different from forgetting to take a daily dose of warfarin. In the case of antibiotics, people don't like continuing to take a medication once the symptoms disappear. It's understandable - "I'm feeling fine NOW, why would I have to take more pills?". In the case of warfarin, there's no similar 'feeling fine' reason to stop it...we take it because we KNOW that we have to.
Getting a tissue valve because SOME TIME IN THE FUTURE, AND BEFORE YOUR CURRENT VALVE WEARS OUT, THERE WILL BE A PROCEDURE TO FIX THE VALVE is putting a lot of faith in the future. What if the 'procedure' isn't actually developed in time to help you? What if the procedure works with bovine valves but yours is porcine? You're betting your life (or, at least the possible need for another surgery that could have been avoided if you chose a mechanical valve) on the possibility that a new repair will be developed before your tissue valve becomes too big a liability to NOT replace it.
I'm not a proponent of any particular type of valve. I have a 25 year old St. Jude valve ticking in my chest. I take warfarin daily. I have meters (yes, more than one) for testing my INR and usually test weekly. I recently went through an unexpected drop in INR, increased my dose, and do daily testing to see that my INR is back in range, and to confirm that my new dose isn't going to kick my INR out of range. I just started an antibiotic, and will probably continue daily testing to see what effect the new antibiotic will have on my INR. I'm running through a lot of strips - but I am able to confirm my INR levels.
I had my OHS when I was 41 years old. At that time, mechanical valves were the only choice for someone my age. If I needed a valve replacement today, I'm not sure that I wouldn't make the same choice (mechanical versus tissue). If a tissue valve fails me when I'm in my 70s or 80s, I may not be a good candidate for another OHS. I'm not sure that a less invasive repair will have been developed. Anticoagulant management is not that big a deal -- the new valves have less risk for developing clots - and newer, much more expensive (and perhaps equally effective) anticoagulants may eventually come available that would reduce the 'nightmare' of having to take warfarin and test my INR.
Anticoagulation management isn't just getting a blood draw when an 'anticoagulation clinic' decides you should get one. In my experience, many of these 'experts' either don't really know what they're doing; or follow outdated protocols or, in my experience, don't even know how to handle the blood so that it is accurately tested.
Having your own meter and supplies is empowering. You don't have to follow an often inadequate schedule for blood draws. If you make changes in diet or activity that you think may have some effect on your INR, you can test for those changes -- clinics probably don't know or care much about these changes - unless they show up in your monthly blood draw.
I'm great at ignoring things. BUT I have a routine before I get to bed each night - I take my warfarin. We're all 'creatures of habit.' If we get into the habit of taking Warfarin before going to bed, once the habit is imprinted on us, it's hard to NOT do it. To say that a person should get a tissue valve just because that person may not take warfarin as directed doesn't do the patient justice. (And, if the patient is really concerned about forgetting to take a dose, that patient can use a pill dispenser with a dose for each day. It'll be clear if a dose is missed just by opening the dispenser. Again - getting into the habit of taking warfarin at the same time (time being 'bedtime' and not necessarily the position of hands on a clock) should reduce some of the concerns about non-compliance with dosing.
Forgetting to complete a course of antibiotics is different from forgetting to take a daily dose of warfarin. In the case of antibiotics, people don't like continuing to take a medication once the symptoms disappear. It's understandable - "I'm feeling fine NOW, why would I have to take more pills?". In the case of warfarin, there's no similar 'feeling fine' reason to stop it...we take it because we KNOW that we have to.
Getting a tissue valve because SOME TIME IN THE FUTURE, AND BEFORE YOUR CURRENT VALVE WEARS OUT, THERE WILL BE A PROCEDURE TO FIX THE VALVE is putting a lot of faith in the future. What if the 'procedure' isn't actually developed in time to help you? What if the procedure works with bovine valves but yours is porcine? You're betting your life (or, at least the possible need for another surgery that could have been avoided if you chose a mechanical valve) on the possibility that a new repair will be developed before your tissue valve becomes too big a liability to NOT replace it.
I'm not a proponent of any particular type of valve. I have a 25 year old St. Jude valve ticking in my chest. I take warfarin daily. I have meters (yes, more than one) for testing my INR and usually test weekly. I recently went through an unexpected drop in INR, increased my dose, and do daily testing to see that my INR is back in range, and to confirm that my new dose isn't going to kick my INR out of range. I just started an antibiotic, and will probably continue daily testing to see what effect the new antibiotic will have on my INR. I'm running through a lot of strips - but I am able to confirm my INR levels.
I had my OHS when I was 41 years old. At that time, mechanical valves were the only choice for someone my age. If I needed a valve replacement today, I'm not sure that I wouldn't make the same choice (mechanical versus tissue). If a tissue valve fails me when I'm in my 70s or 80s, I may not be a good candidate for another OHS. I'm not sure that a less invasive repair will have been developed. Anticoagulant management is not that big a deal -- the new valves have less risk for developing clots - and newer, much more expensive (and perhaps equally effective) anticoagulants may eventually come available that would reduce the 'nightmare' of having to take warfarin and test my INR.
pellicle
Professional Dingbat, Guru and Merkintologist
dornole
firstly I think its important to remember what I was answering (as I actually even wrote first up):
which as a reminder is: Why did my doc say that he would choose a tissue valve for me?
so if I was asked to answer what is 4 and 5 and I said 9 but others said 20 then its not that they are wrong, its that they're answering a different question.
dornole you wrote:
and I agree ... I think I DO know how much effort is required and I (like you) have alarms all over the joint and methods to prevent me forgetting. But that's exactly the point. You and I are not stupid, and indeed I don't think anyone even posting here is, but there ARE stupid people out there, there ARE people out there who can't manage themselves. The Doctors SEE THEM and react. They are (hopefully) most concerned with the best outcomes for the patient.
For those patients (and others of different reasons) then I can see that a tissue valve will be the best option. If you could step outside of your own experience and think for a moment about the people you've met in the street who you shake your head about and go "****, I'm glad I'm not like that" we all know people like that (and if you don't trust me they're there) .. well they may need a valve too? Should they be expected to be what they can't be? I agree that they would be better served by smartening up, but maybe they cant?
You see I do have a heart, despite my blunt words I do actually care. I care that they get the "BEST" treatment and for them if one is sure they won't smarten up or "pull up their socks" then its easy to see why a surgeon will recommend a tissue valve.
Is the OP that person?
No, I don't think so. But I didn't answer that question , I answered the question that was asked.
a point made just now by protime is:
and I agree, self management does require thought and effort, its not perfect or even a good idea for many. Also for people who are not competent or not willing to do this, better outcomes may be had with a tissue valve.
I have heard stories from my friends of people taking the entire bottle of warfarin before an appointment ... so they could say to the Dr "yes sir, I took all my pills" (and then being hospitalised with an INR which was off the scale).
Myself I'm an engineer, I'm a prefectionist (though you may not think so to look around my house, so its clearly topic related) and I am smart enough to manage myself. I speak a lot with my mate who runs a pharmacy (a pharmacist himself and part time lecturer) and he assures me that many patients are not missing "a dose here and there" but missing "a week here and there". For some drugs that's not a big issue. For a heart valve patient on warfarin that's a big issue.
All points which should be considered carefully
even if I do sound harsh
and indeed I'm not disagreeing with you, I'm just explaining why so that you (and others) can understand my words better ... it is only ASCII text after all
firstly I think its important to remember what I was answering (as I actually even wrote first up):
which as a reminder is: Why did my doc say that he would choose a tissue valve for me?
so if I was asked to answer what is 4 and 5 and I said 9 but others said 20 then its not that they are wrong, its that they're answering a different question.
dornole you wrote:
and I agree ... I think I DO know how much effort is required and I (like you) have alarms all over the joint and methods to prevent me forgetting. But that's exactly the point. You and I are not stupid, and indeed I don't think anyone even posting here is, but there ARE stupid people out there, there ARE people out there who can't manage themselves. The Doctors SEE THEM and react. They are (hopefully) most concerned with the best outcomes for the patient.
For those patients (and others of different reasons) then I can see that a tissue valve will be the best option. If you could step outside of your own experience and think for a moment about the people you've met in the street who you shake your head about and go "****, I'm glad I'm not like that" we all know people like that (and if you don't trust me they're there) .. well they may need a valve too? Should they be expected to be what they can't be? I agree that they would be better served by smartening up, but maybe they cant?
You see I do have a heart, despite my blunt words I do actually care. I care that they get the "BEST" treatment and for them if one is sure they won't smarten up or "pull up their socks" then its easy to see why a surgeon will recommend a tissue valve.
Is the OP that person?
No, I don't think so. But I didn't answer that question , I answered the question that was asked.
a point made just now by protime is:
and I agree, self management does require thought and effort, its not perfect or even a good idea for many. Also for people who are not competent or not willing to do this, better outcomes may be had with a tissue valve.
I have heard stories from my friends of people taking the entire bottle of warfarin before an appointment ... so they could say to the Dr "yes sir, I took all my pills" (and then being hospitalised with an INR which was off the scale).
Myself I'm an engineer, I'm a prefectionist (though you may not think so to look around my house, so its clearly topic related) and I am smart enough to manage myself. I speak a lot with my mate who runs a pharmacy (a pharmacist himself and part time lecturer) and he assures me that many patients are not missing "a dose here and there" but missing "a week here and there". For some drugs that's not a big issue. For a heart valve patient on warfarin that's a big issue.
All points which should be considered carefully
even if I do sound harsh
and indeed I'm not disagreeing with you, I'm just explaining why so that you (and others) can understand my words better ... it is only ASCII text after all
Pellicle's reference back to the original question brought me back to the original question. The first answer is, ask the doctor.
The point about some people being too dumb to be able to assure that they take their pills daily is, for some, valid.
The point that not everyone can self manage (or, indeed, do a valid self-test) is also valid. For these people, there are services that, at a much higher cost to the user (or the insurer), will nag the patient until a test is run (or at least until the patient calls in a result, whether or not it's accurate, or even current), can do the management and dosing recommendations.
There probably are people, then, who can't be trusted to accurately do the warfarin thing - even if it's a matter of paying enough attention to take a pill or two (or whatever) at the same time part of the day, every day. For these people, the outcome of non-compliance can be fatal. For these people, even the idea that they can live 10 or 15 years using a tissue valve is probably better than the risk of stroke or other issue that can result from forgetting to take warfarin according to professional advice or, as Pellicle noted, overdosing to compensate for a missed dose or missed doses. Dead in 10 (with a tissue valve) is a better outcome than dead or seriously brain injured in weeks or months, or bleeding out, as a result of anticoagulation errors.
The ultimate decision should not be the surgeon's to make -- although as an expert, the advice should be carefully considered. If the surgeon has doubts that a patient with a mechanical valve would be able to comply with the requirements (daily dosing, frequent testing, following an 'expert's' dosing recommendations), the only option may be a tissue valve -- even if the valve may require replacement in a decade or so. Second opinions may be helpful, and consultation with family is probably also a good idea (but not always). (If every expert's opinion was the best opinion possible, and if ALL experts have the SAME opinion when given the same data, why would there even be a need for second or third opinions?)
The point about some people being too dumb to be able to assure that they take their pills daily is, for some, valid.
The point that not everyone can self manage (or, indeed, do a valid self-test) is also valid. For these people, there are services that, at a much higher cost to the user (or the insurer), will nag the patient until a test is run (or at least until the patient calls in a result, whether or not it's accurate, or even current), can do the management and dosing recommendations.
There probably are people, then, who can't be trusted to accurately do the warfarin thing - even if it's a matter of paying enough attention to take a pill or two (or whatever) at the same time part of the day, every day. For these people, the outcome of non-compliance can be fatal. For these people, even the idea that they can live 10 or 15 years using a tissue valve is probably better than the risk of stroke or other issue that can result from forgetting to take warfarin according to professional advice or, as Pellicle noted, overdosing to compensate for a missed dose or missed doses. Dead in 10 (with a tissue valve) is a better outcome than dead or seriously brain injured in weeks or months, or bleeding out, as a result of anticoagulation errors.
The ultimate decision should not be the surgeon's to make -- although as an expert, the advice should be carefully considered. If the surgeon has doubts that a patient with a mechanical valve would be able to comply with the requirements (daily dosing, frequent testing, following an 'expert's' dosing recommendations), the only option may be a tissue valve -- even if the valve may require replacement in a decade or so. Second opinions may be helpful, and consultation with family is probably also a good idea (but not always). (If every expert's opinion was the best opinion possible, and if ALL experts have the SAME opinion when given the same data, why would there even be a need for second or third opinions?)
No worries, Pellicle, I'm not offended at all. We agree. I'm not convinced that intelligence is the core issue with self-management vs. personality type and coping skills, but whether a patient can self-manage is definitely a critical call for the doc, and for us as patients, which I feel a bit nervous about looking at this decision as I AM scatterbrained. I've also watched very smart people do very dumb health things from emotional causes like anxiety or denial. Just saying that the capacity for medical dumbness lies in us all and "I can't be bothered to take a pill" is probably the least likely explanation behind forgetfulness, anxiety, stress, co-managing a lot of conditions, or just not being the sharpest tool in the shed through no fault of your own.
Trinalovescats
Well-known member
Some people are just scared of how their lives will change after the surgery.I spent 2 hours the night before surgery trying to myself out it,but in the end my parents convinced me this is the only way to get better.Im glad I did because I can breathe and walk better
knotguilty
Well-known member
IMO, you can go to 12 different courts and get 12 different verdicts. I have a tissue valve and it is hard to find someone with a very long lasting valve like you see here with people with mechanical valves. Maybe they don't last as long or maybe people go on living their lives. Also there is no guarantee on either valve for failure although both unlikely. But with your age, and all the studies, I would be a little reluctant to go with a tissue valve, at least I would have to really think about it. I would not bet on future developments with my life. They also have studies on reduced coagulation studies with the newer mechanical valves. I chose tissue because all the doctors I spoke to recommended tissue as the one they would chose for themselves and all the same reasons people put up on this site. My doctors think I may never need another surgery and are treating me likewise. But it is a tough decision and a personal one. Go with your heart (pun intended), and don't look back. Good luck to you.
absol spot on knot, I may be wrong but most on here seem to have a mech and lots of the threads are about warfarin etc , a lot who choose tissue seem to just go and a lot don't come back, I think knot like you say ask 12 courts and you get 12 different verdicts,
