Bob - thanks, this is a great distillation of information from many sources. Also, I found this paper about valve choice for people under age 60 to be interesting:
http://circ.ahajournals.org/cgi/reprint/116/11_suppl/I-294.pdf
Best,
pem
For reops: are you glad you started with tissue?
- Thread starter pem
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Bob - thanks, this is a great distillation of information from many sources. Also, I found this paper about valve choice for people under age 60 to be interesting:
http://circ.ahajournals.org/cgi/reprint/116/11_suppl/I-294.pdf
Best,
pem
Simon Booker
Well-known member
Good luck with the procedure!
Valve choice is always hard, and the choice must always be a personal one. We went through the same long decision process with my Dad, and of course it is possible that we might all have regrets in the future. But tissue or mechanical - there are pros and cons with both. These are all well documented on this excellent site.
All I can add is that don't assume that because you see posts here from people that have had tissue re-op's and gone mechanical - that this is a commonplace occurance. Indeed - it could simply be explained that the sucessful tissue-ers out there are simply getting on with living their lives now, and obviously not posting about the need for a re-op or their re-op experiences.
Lots of things to consider, and your choice, no-one here would think to tell you what you should do. But a couple of things that helped me:
- Tissue was a 'do and forget' (in a 'very broad sense'! opportunity);
- Re-op risk - lots of data on this, but mostly from older valves (clearly - as to prove longevity today the valve must have beenimplanted 10, 15, 20 years ago). Valve manaufacture and integrity improves all the time - I (rightly or wrongly) err towards the long term durability projections on leading tissue valves implanted today; and
- Speed of medical technological advancement in this field. OHS and VR is pretty amazing today - imagine what it will be like in 10 years time should you need a replacement tissue then? Again, lots of posts on this, but you can readily imagine the procedures currently being offered to vulnerable patients here in the UK (remote implant via Femoral Artery) and beating heart replacement - as practiced in India, becoming commonplace for all. VR in the future is something we can all be optimistic about and the experiences of today may not be those of the future!
Best of luck.
Valve choice is always hard, and the choice must always be a personal one. We went through the same long decision process with my Dad, and of course it is possible that we might all have regrets in the future. But tissue or mechanical - there are pros and cons with both. These are all well documented on this excellent site.
All I can add is that don't assume that because you see posts here from people that have had tissue re-op's and gone mechanical - that this is a commonplace occurance. Indeed - it could simply be explained that the sucessful tissue-ers out there are simply getting on with living their lives now, and obviously not posting about the need for a re-op or their re-op experiences.
Lots of things to consider, and your choice, no-one here would think to tell you what you should do. But a couple of things that helped me:
- Tissue was a 'do and forget' (in a 'very broad sense'! opportunity);
- Re-op risk - lots of data on this, but mostly from older valves (clearly - as to prove longevity today the valve must have beenimplanted 10, 15, 20 years ago). Valve manaufacture and integrity improves all the time - I (rightly or wrongly) err towards the long term durability projections on leading tissue valves implanted today; and
- Speed of medical technological advancement in this field. OHS and VR is pretty amazing today - imagine what it will be like in 10 years time should you need a replacement tissue then? Again, lots of posts on this, but you can readily imagine the procedures currently being offered to vulnerable patients here in the UK (remote implant via Femoral Artery) and beating heart replacement - as practiced in India, becoming commonplace for all. VR in the future is something we can all be optimistic about and the experiences of today may not be those of the future!
Best of luck.
JulieS
Well-known member
I'm just curious. Has anybody on this forum had their tissue valve of any kind last 20 years? I can't remember ever reading this to be true.
For what it is worth, I was 31 went with my first aortic tissue valve, lasted just shy of 11 years. Reop in 1.5 weeks - I am a very active person.
For what it is worth, I was 31 went with my first aortic tissue valve, lasted just shy of 11 years. Reop in 1.5 weeks - I am a very active person.
dfelder
Active member
My tissue valve was implanted when I was 16 and it lasted 12 years. Two years longer than what my surgeon told me. Never heard anything about tissue valves lasting much longer than 10 years.
I was told that my valve would last approximately 10 years.
However, I heard a surgeon say that he had done a re-do on a patient whose tissue valve had lasted 30 years (but this was an isolated case).
However, I heard a surgeon say that he had done a re-do on a patient whose tissue valve had lasted 30 years (but this was an isolated case).
Remarkable. This is a great example of how means and medians are not destiny. For anyone interested, there is a fantastic essay on that topic written by Stephen Jay Gould (a famous evolutionary biologist and writer), who was diagnosed with terminal cancer and beat the odds:
http://cancerguide.org/median_not_msg.html
normofthenorth
Well-known member
My fave tissue-valve-durability article -- entitled "Hancock II Bioprosthesis for Aortic Valve Replacement: The Gold Standard of Bioprosthetic Valves Durability?" by Tirone E. David, MD, Susan Armstrong, MS, Manjula Maganti, MS, in Ann Thorac Surg 2010;90:775-781, abstract at ats.ctsnetjournals.org/cgi/content/abstract/90/3/775? -- documents how long "my" pig valve has been lasting after "my" hospital complex (in Toronto) implanted it. Only THREE of the patients who got it 25 years earlier were still "at risk" (their way of saying "alive and kicking and still with the valve"). Of course, the vast majority of the 1100-odd patients received their valves more recently. And most of the patients that DID get valves 25+ yrs ago were pretty old then, and would be pretty special if they survived to now.
This study found, once again, that the valves last longer in older patients than younger ones, for reasons that SEEM to have a lot to do with blood chemistry and little or nothing to do with activity level.
There weren't many tissue valves implanted 30 years ago, but an otherwise healthy/lucky 60-ish patient who got one then could well be facing "structural valve deterioration" 30 years later, based on that paper. (Should be a candidate for TAVI, I'd think!)
This study found, once again, that the valves last longer in older patients than younger ones, for reasons that SEEM to have a lot to do with blood chemistry and little or nothing to do with activity level.
There weren't many tissue valves implanted 30 years ago, but an otherwise healthy/lucky 60-ish patient who got one then could well be facing "structural valve deterioration" 30 years later, based on that paper. (Should be a candidate for TAVI, I'd think!)
normofthenorth
Well-known member
That SJGould essay is fantastic, pem!
Elcarim
Well-known member
see below...
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Elcarim
Well-known member
Yup.
5 years from my tissue valve. Ended up with complete heart block after my second surgery. And PTSD. And six months of my life that I can't remember. Not all beer and skittles.
My tissue valve only lasted 5 years, but I was able to have two uneventful pregnancies in that time.
I would not wish OHS on my worst enemy, but it was worth it to have my two wonderful sons. If I were a man under about 60yo, or for that matter anyone for whom having babies was not an issue, I would say mech valve from the beginning. ACT does not stop me from doing anything I want to do. I still do yoga and ride horses and garden and raise goats. I had more complications with my second OHS than my first. While I would not change the way things were done, I would do pretty much anything to avoid another OHS.
To suggest that “there isn’t any data. . .” about mechanical valves lasting 20, 30 or a lifetime just isn’t correct and research was offered to this forum years ago:
http://www.valvereplacement.org/foru...ighlight=Starr
Or perhaps you are suggesting that newer valves wear characteristics are inferior to first generation valves which have a proven track record of the kind of data you say doesn’t exist. Are you also suggesting the newer valves haven’t been stress tested for a “lifetime” of service? Medical literature is replete with Structural Valve Deterioration (SVD) studies of tissue valves, yet it is extremely rare for a mechanical valve to be replaced for wear. If you are suggesting this, by all means let’s have some citations which support your claims.
To argue that the durability of currently implanted mechanical valves is without “any data” as to the proof of their “lifetime” service is simply absurd and ignores the scientific record established by previous studies of the earlier generations of mechanical valves upon which all current valves have evolved from.
I didn't read Lyn's post the same way Luana did.
I thought Lyn stated that only the St. Jude has been in use as long as the three tissue valves mentioned. I took her point to be that until other mechanical valves, currently in use, are followed for 30 years, one can't state categorically that they will last a lifetime.
I thought Lyn stated that only the St. Jude has been in use as long as the three tissue valves mentioned. I took her point to be that until other mechanical valves, currently in use, are followed for 30 years, one can't state categorically that they will last a lifetime.
ElectLive
Well-known member
Percutaneous
Percutaneous
This thread has jumped all over the place, hope no one minds if I kick it around a little too. I specifically wanted to comment on the percutaneous issue that a few have mentioned.
Oh, the grand new world of percutaneous surgery...this will change everything for tissue valvers. Right? Right? You know what, I'm even lucky enough to be a size 27 valve…big enough for two valve in valve percutaneous procedures. Woohoo! (sarcasm, let me now explain...)
I know some percutaneous trial results have already been posted. I don’t have them handy, but what I do know is that approximately 200 trial patients at my hospital had the procedure at/by the time of my surgery, all very old, all super high risk, and zero died. Now, that’s impressive.
But…isn’t it just funny how things work sometimes. Wouldn’t you know, one of the drawbacks of the percutaneous approach so far is…stroke! Argh! It must be a cruel joke. Choose tissue valve for reduced (in comparison) stroke risk, grand new easy surgery to implant new tissue valve and make reop more desirable, whoops, sorry, just raised your stroke risk, might as well have done mechanical to begin with! Can’t help but shake my head a little at this one.
Relative to this stroke issue, numbers are early and I’m sure a little unreliable but 3 times as high risk was the indication in a Lars Svensson - Cleveland Clinic webchat in May. I quote:
"The main reason being that the percutaneous valves crack the calcium in the aortic valve which is then pushed aside for the new valve with the potential risk of pieces of calcium breaking off and going to the coronary arteries to the brain"
He did say that filtering devices and techniques are being studied to reduce this over time, though, so I guess let’s not give up hope yet. But there's another unknown: the lifespan of these percutaneous tissue valves. My surgeon said durability is looking good so far, but cautioned not to bank on comparable lifespans (normal tissue valves) either given the nature of the compressed device.
I certainly don't mean to make light of this very important advancement. I'm a tissue valver, so obviously I want to hope as much as anyone. But as of right now, I'm still a skeptic. Just doesn't sound like it's going to be "standard" anytime soon. Great for high-risk, yes, no doubt. Tell you what, though, either way, I still feel great about continual improvements in standard valve replacement and valve technology of all types - mechanical and tissue.
Percutaneous
This thread has jumped all over the place, hope no one minds if I kick it around a little too. I specifically wanted to comment on the percutaneous issue that a few have mentioned.
Oh, the grand new world of percutaneous surgery...this will change everything for tissue valvers. Right? Right? You know what, I'm even lucky enough to be a size 27 valve…big enough for two valve in valve percutaneous procedures. Woohoo! (sarcasm, let me now explain...)
I know some percutaneous trial results have already been posted. I don’t have them handy, but what I do know is that approximately 200 trial patients at my hospital had the procedure at/by the time of my surgery, all very old, all super high risk, and zero died. Now, that’s impressive.
But…isn’t it just funny how things work sometimes. Wouldn’t you know, one of the drawbacks of the percutaneous approach so far is…stroke! Argh! It must be a cruel joke. Choose tissue valve for reduced (in comparison) stroke risk, grand new easy surgery to implant new tissue valve and make reop more desirable, whoops, sorry, just raised your stroke risk, might as well have done mechanical to begin with! Can’t help but shake my head a little at this one.
Relative to this stroke issue, numbers are early and I’m sure a little unreliable but 3 times as high risk was the indication in a Lars Svensson - Cleveland Clinic webchat in May. I quote:
"The main reason being that the percutaneous valves crack the calcium in the aortic valve which is then pushed aside for the new valve with the potential risk of pieces of calcium breaking off and going to the coronary arteries to the brain"
He did say that filtering devices and techniques are being studied to reduce this over time, though, so I guess let’s not give up hope yet. But there's another unknown: the lifespan of these percutaneous tissue valves. My surgeon said durability is looking good so far, but cautioned not to bank on comparable lifespans (normal tissue valves) either given the nature of the compressed device.
I certainly don't mean to make light of this very important advancement. I'm a tissue valver, so obviously I want to hope as much as anyone. But as of right now, I'm still a skeptic. Just doesn't sound like it's going to be "standard" anytime soon. Great for high-risk, yes, no doubt. Tell you what, though, either way, I still feel great about continual improvements in standard valve replacement and valve technology of all types - mechanical and tissue.
Oops, wrong link. Correction.
normofthenorth
Well-known member
Is anybody still getting that Starr-Edwards mech valve, the one with the 30-year record in patients?
I think the only dispute about mech-valve durability is whether the testing of newer models proves that they'll last a lifetime in patients, or not, before the real-life durability data is gathered -- which obviously takes a long time. I'm a satisfied tissue guy myself, but I have no trouble believing that -- barring nasty surprises like recalls -- today's mech valves will last longer than any of us. That doesn't eliminate all the other sources of problems and future OHSs, but the actual valve life is a non-issue with mech valves IMHO (and still a huge issue with tissue valves, of course). My $0.02, of course.
I think the only dispute about mech-valve durability is whether the testing of newer models proves that they'll last a lifetime in patients, or not, before the real-life durability data is gathered -- which obviously takes a long time. I'm a satisfied tissue guy myself, but I have no trouble believing that -- barring nasty surprises like recalls -- today's mech valves will last longer than any of us. That doesn't eliminate all the other sources of problems and future OHSs, but the actual valve life is a non-issue with mech valves IMHO (and still a huge issue with tissue valves, of course). My $0.02, of course.
The Ball and Cage heart valves are no longer produced or sold by Edwards. Below is list summarizing U.S. Heart Valve Manufacturers and types of valves sold.
U.S. Heart Valve Manufacturers:
Carbomedics (Sorin Group) - Mechanical and Biological Valves (bovine). Headquarters: Italy (U.S. Sales and Marketing – Arvada, CO) www.sorin.com
CryoLife, Inc. – Allografts. Headquarters: Atlanta, GA www.cryolife.com
Edwards Lifesciences - Biological Valves (porcine and bovine). Headquarters: Irvine, CA www.edwards.com
Medtronic - Mechanical & Biological Valves (equine & porcine) (Note: Medtronic acquired ATS in 2010). Headquarters: Minneapolis, MN www.medtronic.com
On-X Life Technologies, Inc. - Mechanical Valves. Headquarters: Austin, TX www.onxlti.com
St. Jude - Mechanical and Biological Valves (porcine and bovine), also Alllografts. Headquarters: Minneapolis, MN www.sjm.com
Note: Biological is simply another name for “Tissue”, and Biological Valves are either Bovine (cow), Porcine (pig), or Equine (horse). There are also valves called “Homografts” or “Allografts” that are from cadavers.
Note: Mechanical heart valves today are all the “Bileaflet” design except for the Medtronic “Hall Easy-Fit Heart Valve”, which is the “Tilting Disc” design. In the past there was also the “Ball and Cage” design, but do not believe that the ball and cage design is sold anywhere (it is definitely no longer sold in the U.S.)
Note: Some of the above also sell products for valve repair (versus valve replacement)
normofthenorth
Well-known member
Thanks, dtread. I could be wrong, but I think “Allografts” are (as you say) from cadavers, but “Homografts” are from the same patient, primarily using the Ross procedure (swapping the patient's pulmonary valve into the Aortic position).
Given that the only multi-decade direct, in-patient evidence of mech-valve longevity is for a valve that's apparently now discontinued, I think we're still left with a theoretical lack of irrefutible direct proof that today's mech valves will last a lifetime in patients. OTOH, I think I'm satisfied with the indirect and logical "proofs" that (IMHO) convincingly establish that it's so. At the very least, it seems to me that focusing on THAT aspect of the choice of mech valves -- the mechanical "life expectancy" of the valve itself -- is a distraction from more important issues, like overall outcomes (patient well-being and survival/mortality), noise levels, complication rates, ACT/INR, and hemodynamics (esp. for those with "patient-valve mismatch", i.e., unusually small valves per body size). For a patient under ~60 who's getting a tissue valve, I think it's rational to focus primarily on valve durability; for a patient who's getting a mech valve, . . . not so much.
Given that the only multi-decade direct, in-patient evidence of mech-valve longevity is for a valve that's apparently now discontinued, I think we're still left with a theoretical lack of irrefutible direct proof that today's mech valves will last a lifetime in patients. OTOH, I think I'm satisfied with the indirect and logical "proofs" that (IMHO) convincingly establish that it's so. At the very least, it seems to me that focusing on THAT aspect of the choice of mech valves -- the mechanical "life expectancy" of the valve itself -- is a distraction from more important issues, like overall outcomes (patient well-being and survival/mortality), noise levels, complication rates, ACT/INR, and hemodynamics (esp. for those with "patient-valve mismatch", i.e., unusually small valves per body size). For a patient under ~60 who's getting a tissue valve, I think it's rational to focus primarily on valve durability; for a patient who's getting a mech valve, . . . not so much.
daveguy14
Well-known member
Allografts and homografts are the same thing--valves from another human being. Your own valve being transplanted from one position to another (like in the Ross procedure) is an autograft.
normofthenorth
Well-known member
Oops! Thanks, Dave. Sorry to doubt, dtread!
JUST-WAITING
Well-known member
I had surgery in Jan 2011- with the ATS valve and I find out two weeks ago that my valve is leaking "real bad"- Waiting for surgeon to call after he reviews my last films and reports. I am pretty disgusted and depressed- but Did I make the wrong decision ? - NO there are no perfect decisions- and I must move forward.
