Introduction - AVR

[Sparafucile]

Hello!

I'm a 65 year old male who has been diagnosed in the past month with aortic valve stenosis: my valve only opens to 0.8 cm/sq.

I'm a lawyer with a sedentary job, overweight and not particularly active. I researched the reputations of both my cardiologist and surgical team - as well as the hospital - before choosing them, and am confident about their skills and the hospital.

My valve replacement surgery is scheduled for Tuesday April 3, and each doctor has outlined the pros and cons of tissue vs. mechanical valve, and informed me that in the next decade, aortic valve replacement via catheter may become commonplace - but that's not guaranteed. If so, that would seal the choice for me for a tissue valve.

I've downloaded and read a number of articles on the subject from medical journals.

I'm not thrilled with the notion of the life complications that ensue with the use of an anti-coagulant - that simple dental surgery becomes complicated, that a moderate cut requires medical care - not to mention the complications of internal bleeding if I were to be in an accident...

Nevertheless, I have not decided which valve - I have another two or three weeks to make my decision.

I'd be interested in hearing about how others have grappled with this decision and how people asses the possibility of future catheter valve replacement - if anyone is interested in sharing their thoughts and feelings. [Yes, I've already searched this forum and read old posts]

Thanks!

 

[dick0236]

I'm not thrilled with the notion of the life complications that ensue with the use of an anti-coagulant - that simple dental surgery becomes complicated, that a moderate cut requires medical care - not to mention the complications of internal bleeding if I were to be in an accident...

Nevertheless, I have not decided which valve - I have another two or three weeks to make my decision.

I'd be interested in hearing about how others have grappled with this decision and how people asses the possibility of future catheter valve replacement - if anyone is interested in sharing their thoughts and feelings. [Yes, I've already searched this forum and read old posts]

Thanks!

Fortunately, I never had to make a decision like this since only one valve was commercially available (as far as I knew).

I have been on anti-coagulats (warfarin) for 45 years and have not experienced any of problems you've outlined with denal work, cuts or accidents......and I have experienced a few of each event....plus a few ohers. Personally, I find the drug predictable and easy to deal with. My only advice is that once you go on the drug you must "take the drug as prescribed and test routinely".....otherwise you probably will have problems.

BTW, welcome to this forum. It is, by far, the best site I know of for info and support from folks who have "been there, done that".

 

[Mentu]

Serge, welcome to VR. It sounds as though you are confident in your doctors and, fortunately, your wait is not a long one. I'll let others address the issue of anti-coagulation therapy other than to say there are a lot of myths about it and tens of millions of people use it without incident while living normal lives. With respect to the Dentist, regardless of the type of valve, you will require prophylactic anti-biotics before any dental care to reduce the possibility of contracting endocarditis. As far as the type of valve is concerned, developing technologies are notorious for not following a neat schedule otherwise we would all be living with a small fusion reactor in our garage. I would encourage you to make your choice based on how you live today and with todays options. Either type of valve is likely to serve you well.

Your age is not too different from my own and my recovery went astonishingly well. The early weeks of recovery can be a good time to initiate some different habits so if weight is an issue, it could be a good time to begin shifting your diet and increase your daily exercise. Walking several times every day after you come home will get your lungs working more quickly and leave you feeling better. It is not a bad habit to develop and does not need to stop after your recovery is largely complete three or four months after surgery.

I, too, found I was becoming more and more sedentary during the time I was unaware my valve was deteriorating. It was a kind of self censorship that left me doing less and less. After the valve replacement, I found I had more energy than I had known in a long time and it feels good to exploit it. You will not return to your "normal" life after surgery so much as define a new state of normality.

Let us know how we can help.

Larry

 

[Fundy]

Some stats I've come across regarding tissue valve in a 65 year old which you may have heard already but if not, they seemed fairly important to me in making a tissue vs mechanical decision.
From my surgeon, 80% of the time a tissue valve will last 20 years at least.
From a video on heart surgery, (one with with Drs .Cooley and Ott) that 85% of the time will exceed 15 years in someone 65 years of age.

To me, that almost means a tissue will last most of a 65 year old's lifetime and if not, the transcatheter method may be fully available by then. So its possible you may never need another OHS after the first even if you go with a tissue.

 

[escargome]

Welcome to the forum Serge, almost 4 years ago at age 56 I decided for my own personal reasons on a tissue valve. I wanted a porcine valve but much to my surprise I woke up with a bovine valve (no big deal). I did research previous to my surgery, the I sat in my surgeons office for about 2 hours and discussed the pros and cons of each. He was very through and didn't try to sway me in either direction. However, I would like to say that when I made my decision it was with the clear knowledge that I would like need at least one more surgery and that doesn't bother me too much. If they in fact have pioneered doing this procdure via catheter, then more's the better. So as you seem to have already done, read, ask questions of your own doctors and follow your gut. Best Wishes to you as you begin this next chapter in your life blanket.

 

[Lynlw]

welcome, I know it is alot to wrap your head around when you find out you need heart surgey and have all kinds of decisions to make. As for what kind of valve in a 65 year old , FWIW even BEFORE they were talking about percutaneous valves, the general reccomendation for people 65 and up was tissue valves,(many of the leading centers are reccomending tissue valves in patients 50 and up) both because the odds are very high of them lasting 20 years or more in someone your age group. (80 % or higher) also since IF you did need a 2nd OHS the success rates of a REDO are pretty much the same as a first time surgery.
Since they already have approved a couple Percutaneous valves, and the Sapien Aortic valve is already approved for higher risk Aortic patients , with other valves going thru trials now, I think IF you did end up needing a tissue valve (you get when you are in you mid 60s) replaced I think the odds would be pretty high you would be a canidate to have it replaced by cath, if you were in your 70s or 80s.

Already I believe they have done over 40,000 percutaneous Aortic valves world wide and in 2011 in Europe 1/2 of the patients getting tissue valves, got them by cath, so things are moving along pretty well. Also one good thing is just from the Sapein and Corevalve trials, they are doing, so getting experience in percutaneous valve replacement in over 60 centers in the US. Which from our experience at least is quite a few centers being able to do a relatievely new procedure right when it is approved, so it doesn't look like it will be one of those things that will only be done at a handfull of places so unless you were lucky enough to live close you would have to travel, like hapens with alot of new things. Pretty much there will be experienced centers all over the country. So who knows how much better things would be in 15 0r 20 years.

 

[Bill B]

The statistics around this question are complicated by the fact that nearly all people who are 65 or older at the time of AVR die from something other than valve failure. So, the 80% 20 year tissue valve life statistic is only for those who did not die of something else in the interim, and in the studies on which this number is based, they took all comers. A high percentage of the patients had underlying coronary artery disease or other conditions that ultimately killed them, and very, very few reached 20 years. For example, in a study of 1000 AVRs in people over 65, only 5 lived 20 years. You can look at this several ways, and I don't pretend to know which is right. For example, if you die before the valve fails, it did its job as well as any valve could. My surgeon said I was so otherwise healthy that I would do better with a mechanical valve. I didn't understand this comment. But then I read this analysis: http://billsworkshop.com/Some_AVR_lit/risk_corrected_analysis_of_bio_v_mech.pdf

My interpretation was that, essentially regardless of age, if you are otherwise healthy, you would do better with a mechanical valve. Even so, it's a close call. If you have any other significant health problems, you might as well go tissue, again, regardless of age. Here's another relevant study that points out the impact of ancillary health issues. Again, it's a close call. http://billsworkshop.com/Some_AVR_lit/longterm bio v mech.pdf

Over all, there just isn't enough good data to answer this question conclusively and there probably never will be.

 

[Sarah_Louise]

Welcome to the boards,
I've had both mechanical and tissue valves in, as well as a few problems with anti-caogulation, but im young and an anomonly(sp) lol
Keep us posted,
Love Sarah xxx

 

[AgilityDog]

A moderate cut does not require medical attention just because you are on coumadin - unless you need stitches, which would apply with and without coumadin. You aren't going to bleed to death clipping your toenails or cutting yourself shaving.

You'll need serious medical attention in a bad auto accident anyway.

Gosh, there are just too many old wive's tales out there about anti-coagulants.

The main thing is don't fall and hit your head hard enough for an intercranial bleed. Oh, wait, that's good advice when you are NOT on anti-coagulants.

I've got 2 mech valves, my dog mauls me every morning, I fall down running agility-even if the little brat doesn't slam her brick hard body into my shins. I haven't bled to death yet.

Just remember, you might wind up on anti-coagulants for other reasons anyway. The decision is yours, but don't FEAR the anti-coagulants.

 

[Bill B]

Oh, yeah, I don't consider cuts and contusions a big issue, and warfarin has not changed anything I do. I do all kinds of knuckle-bruising car repairs in my garage, race cars at high speed, ride motorcycles and still shave with a blade razor. Zero issues.

 

[epstns]

Serge,
I think the others have covered a lot of the pro's and con's. You've already made the most important decision - that of whether or not to have this surgery. Once past that, I don't think that there are any wrong decisions. All of the valves now in use will do the job and do it well. A lot of the choice is related to your personal view of the odds (of complications, need for re-operation, anti-coagulants, etc.). Another element of the decision is knowing which valves your chosen surgeon is comfortable implanting. I don't think I'd want mine to be the first of that type of valve for my surgeon.

In my case, at age 63, I opted for tissue. We discussed the likelihood of needing it replace again within my lifetime, and I concluded that while there is no certain answer, the odds are that I will not need another valve. The fact that percutaneous valve implants are becoming more common just makes me less worried about the possibility of needing another. Other considerations were that my surgeon was one of the developers of the valve I chose, and he has implanted thousands (I think) of them before mine.

As the others have said, take in all the facts, then throw the dart. Don't over-analyze the situation. There's just too much incomplete information and not enough hard facts available. (e.g. No long-term longevity studies on the newest generation of tissue valves yet. All the data to-date pertains to the previous generation, and the new ones are expected to do better. We just don't know how much better.)

 

[Lynlw]

The statistics around this question are complicated by the fact that nearly all people who are 65 or older at the time of AVR die from something other than valve failure. So, the 80% 20 year tissue valve life statistic is only for those who did not die of something else in the interim, and in the studies on which this number is based, they took all comers. A high percentage of the patients had underlying coronary artery disease or other conditions that ultimately killed them, and very, very few reached 20 years. For example, in a study of 1000 AVRs in people over 65, only 5 lived 20 years. You can look at this several ways, and I don't pretend to know which is right. For example, if you die before the valve fails, it did its job as well as any valve could. My surgeon said I was so otherwise healthy that I would do better with a mechanical valve. I didn't understand this comment. But then I read this analysis: http://billsworkshop.com/Some_AVR_lit/risk_corrected_analysis_of_bio_v_mech.pdf

My interpretation was that, essentially regardless of age, if you are otherwise healthy, you would do better with a mechanical valve. Even so, it's a close call. If you have any other significant health problems, you might as well go tissue, again, regardless of age. Here's another relevant study that points out the impact of ancillary health issues. Again, it's a close call. http://billsworkshop.com/Some_AVR_lit/longterm bio v mech.pdf

Over all, there just isn't enough good data to answer this question conclusively and there probably never will be.

Thats true the vast majority of people who have AVR at the age of 65 and older, usually die (from some other reason since the ave lifespan is less than 85) before 20 years post op, and before their tissue valve would need need replaced, that's the main reason most surgeons have reccomended tissue valves for that age group for the last couple decades. Since usually they would outlive their tissue valve the thought was/is since the main benefit of a mechanical valve is they decrease the chances of needing REDOS, why get a mechanical valve and everything that goes along with it, Coumadin, testing, extra dealing with medical people and ticking, if you would outlive a tissue valve anyway.
But it's good to know that out of the people, 65 and up at time of surgery, who ARE still alive 20 years later,80-90% of them their tissue valve still was working great. And that was the thinking way before replacing tissue valves by cath was a possibility, so then just the fact a first time REDO had about the same success rates as first OHS for the small percentage of patients who DID outlive their first tissue valve, was why tissue were usually reccomend for that age group. Now that the chances are pretty good if you get a tissue valve in your mid 60s, IF it does need replaced, it could be done in the cath lab and not need another OHS when you are in your 70s-80s Of course it isnt a guaruntee you could end up avoiding coumadin and another OHS by getting a tissue valve now. Also since so many companies are working on their own percutaneous valves and some have already been approved for highest risk patients, my bet would be on them being available for most people in the next decade or so.

 

[Sparafucile]

I'd like to thank everyone who replied for your willingness to share your experiences.

I've read all of the posts a few times and evaluated the information, and I think that the tissue valve is right for me. I will be talking this over with my doctor Wednesday night.

Now it's just waiting until April 2 for the surgery!

Thanks for your support!