New member - choosing a valve

[Erwitchin]

I am a 51 year old woman with a bicuspid aortic valve, which now has severe stenosis. I have found a surgeon (in Dallas) and have scheduled my replacement surgery for June (I am a teacher). This will be SAVR, but via mini-thoracotomy, so I am thrilled to avoid a rib-spreader, but now I have to choose a valve. I am concerned about both ticking sounds (I can not sleep if there is an analog clock in the house) and having to take Coumadin forever, since I bruise often and keep large dogs. I would also prefer to avoid a repeat surgery, so I am torn about selecting a bio-prosthetic.
Anyone have an On-x? Or an Edward's Inspiron (spelling?) Are you happy with the choice?

 

[Chuck C]

Welcome to the forum.

Choosing a tissue or mechanical valve is not an easy decision. There are pros and cons for each valve.

When I was 53 I chose mechanical because I wanted to be one and done. Being on warfarin is no big deal, but important that you pay attention to it and are diligent about taking your medication. The ticking has never bothered me. I rarely hear mine unless I breath deeply or exercise hard.

But, you might be much more sensitive to the ticking sound:

I can not sleep if there is an analog clock in the house

If you are that sensitive to ticking, you really do want to take this into consideration and it might tilt the scales in favor of getting a tissue valve.

I would suggest getting your Lp(a) tested. Anecdotally, there have been patients who have high levels of Lp(a) who go through their tissue valves much more quickly than typical. Just last month a study was published which found that those who had early bioprosthetic SVD had significantly higher levels of Lp(a), compared to those who did not experience early SVD. It has been know for years that Lp(a) correlates with early aortic stenosis of native valves, but this is the only study which looked at the correlation between SVD of a bioprothetic valve and Lp(a). I've linked the study below. There was another study published about 2019 which seemed to indicate the same thing, but it did not reach statistical significance.

Anyway, it is a simple test, similar to a blood lipid panel, and would be good for you to know. If you knew that your level of Lp(a) might cause your tissue valve to fail early, you might want to take that onboard with respect to your decision.

Role of lipoprotein(a) concentrations in bioprostheticaortic valve degeneration

https://heart.bmj.com/content/heartjnl/110/4/299.full.pdf

I don't believe the fact that you have large dogs should factor into the equation. Many of us on warfarin are very physicall active.

Besides your sensitivity to ticking sounds and your level of Lp(a), another consideration:

- be honest with yourself about how consistent you are in taking medications that you have been prescribed. Warfarin is not one in which you want to sometimes forget to take or sometimes take a double dose. Personally, I find taking my daily pill easy and am systematic about it, but a significant number of people do not take consistency seriously in this regard.

Best of luck in making your decision. Please feel free to ask any questions that you may have. We are here to help.

 

[Bionic Orange]

Welcome to the forum.

Same here.

. . . . . I wanted to be one and done. Being on warfarin is no big deal, but important that you pay attention to it and are diligent about taking your medication. The ticking has never bothered me. I rarely hear mine . . . .

Same here. I'm 65.

 

[Beach77]

Welcome! Deciding on a valve is hard! I have an On-X and it's been almost 3 1/2 years now. I turned 65 in the hospital and I wanted to avoid a 2nd surgery if possible. Warfarin (Coumadin) is manageable. I don't hear my valve much, but if I do hear it in bed, I barely need to move, to not hear it. I was worried about that too but it has not once bothered me. No one else has ever heard it, even my husband. Good luck with your decision and surgery! Ellen

 

[Bionic Orange]

Welcome! Deciding on a valve is hard! I have an On-X and it's been almost 3 1/2 years now. I turned 65 in the hospital and I wanted to avoid a 2nd surgery if possible. Warfarin (Coumadin) is manageable. I don't hear my valve much, but if I do hear it in bed, I barely need to move, to not hear it. I was worried about that too but it has not once bothered me. No one else has ever heard it, even my husband. Good luck with your decision and surgery! Ellen

This is pretty much the exact same as me (age, On-x, warfarin ease, one & done, rare ticking), except that I am a male. My wife can only hear my valve when she is really close to me and says it's the most beautiful sound she's ever heard.

 

[christopherj]

Nice to have you with us @Erwitchin. I don’t have much to add in terms of valve choice, that @Chuck C didn’t already say, but I understand agonizing over valve choice and can promise you are not alone.

I will say this is the guideline that influenced me. Find the full article here.

“the balance between valve durability and risk of bleeding and thromboembolic events favors the choice of a mechanical valve in patients <50 years of age, unless anticoagulation is not desired, cannot be monitored, or is contraindicated.”

Being under 50 (barely) and not concerned with anticoagulation I decided to follow the statistics for best long term outcomes.

 

[pellicle]

Hi and welcome

some excellent answers already well cover things, so I'll try not to repeat their points but suffice to say I'm 100% in agreement, and most of all wish to underscore and emphasise the importance of chucks point about Lp(a)

I would also prefer to avoid a repeat surgery, so I am torn about selecting a bio-prosthetic.

as Nobog recently observed

I have personally seen tissue valves last 6 months - or 20 years. So roll your dice.

and that 6 months end is almost certainly due to Lp(a) which your calcification is perhaps an indicator of. A search here will find quite a many "oh my, my bio didn't last as long as I'd hoped" posts as well as a few who have done bio, it failed and they decided (reluctantly) to go mech.

Myself I picked a mechanical for my last OHS which was at 48years old. It was my 3rd OHS (first was repair as a kid, second a replacement with a homograft in my late 20's) Its served me now flawlessly for 12 years and there is no indication of it packing in or having any trouble. That same can be said for some people with a bioprosthesis too, but just that's not the statistical norm. As you may be aware Dick here has had an old generation 1 type ball and cage valve rattling around for well over 50 years (and approaching sixty). That's never going to happen with any bio ever.

However here's the thing (assuming you do not have high Lp(a) picking a mechanical requires a commitment from you towards managing your anticoagulation therapy. IFF you manage it properly you will be rewarded by a valve that will last you a lifetime (nod to @Superman for citation of source of that gag) and you will have the best possible chances of lower than expected thrombosis or bleed events of any other valve.

If you haven't read / listened to these yet, I'm going to say grab a notepad and your preferred beverage and take notes.


click the image or https://www.medscape.com/viewarticle/838221



more current video


Lastly it doesn't matter if you pick an On-X or a St Jude or an ATS, they are all so close to each other that only a marketing manager can explain to you the differences (a table and a study showing the differences). On-X knowing that it had no cards in its hand on being the latest of the same thing on the market paid for a study to demonstrate that their valve is "safe" at lower INR levels. There is hardly a critical thinking cardiologist or surgeon on the planet who doesn't see that as "marketing jism". When it comes to claims from them think "consumer washing machine TV commercials" as there is no evidence that it confers anything. Actually its worse, there is evidence that being "smug in the safety net of the On-X" can lead you into deep waters of unsafe INR practices a worthy read here.

Remember, there is no definitive cure to valve disease, all we can do is exchange a fatal disease for prosthetic valve disease; of which there are two types; one is managed by redo-surgery as they wear out the other is managed by a weekly blood test (about as convenient as what diabetics do) and then on the basis of that administering pill daily

Best Wishes

 

[Dodgy Ticker]

Hi Natchitoches (LOVE that name!!!)

In addition to all the scholarly issues covered above, I would (unfortunately) have to add one additional matter to complicate your decision... but it is important that you are 100% informed.

Being on anti-coags is not REALLY an issue (just a change in habit), and the ticking will fade into the distance with time (took me 6 months), however anti-coags mean that you are severely limited in your potential future drug-taking, and that needs to be borne in mind.

I myself have developed a severe spinal problem and am not able to take the usual meds precisely because I am on warfarin. Nothing I can do about it, and the issue was not foreseeable at the time of my emergency valve replacement.

I frequently wonder whether I would have chosen differently had i known at the time, but in my case (somewhat specific) I could not have done any better by not having a mechanical, as opening up my rib cage would have done further damage to my spine anyway.

So just bare this in mind...

Good luck

 

[BillDaThrill]

Hey Erwitchin,
Had my valve/aneurysm replacement surgery 2.5 years ago at age 52 and opted for the On-X. Am thrilled with it! Am really upping my exercise and seeing good progress. The warfarin thing has been super easy for me and have not had bruising. Re: sleeping, I've always used a fan/humidifier in the room and rarely every hear my ticker. I could not be happier the way surgery has worked out for me.
If you go tissue valve, give a close look at the Inspiris Resilia- people have been saying good things.
Wishing you success whatever valve you choose.

 

[Dano64]

Erwitchin,

I had my aortic valve replaced 2 years ago at 58, along with a replaced ascending aorta. This was my second OHS. The first was in 2001 when I received a homograft. I did great with that for 21 years until my aneurysm developed. I chose tissue and now have an Inspiris Resilia valve. Given advancements in medicine and the chance for a TAVR procedure for the next replacement, that was my personal decision to avoid the clicking and the warfarin and continue what seemed normal to me. So far so good, but I am only two years out and the data on this valve is still pretty new. Good luck with your decision.

 

[Erwitchin]

Welcome to the forum.

Choosing a tissue or mechanical valve is not an easy decision. There are pros and cons for each valve.

When I was 53 I chose mechanical because I wanted to be one and done. Being on warfarin is no big deal, but important that you pay attention to it and are diligent about taking your medication. The ticking has never bothered me. I rarely hear mine unless I breath deeply or exercise hard.

But, you might be much more sensitive to the ticking sound:


If you are that sensitive to ticking, you really do want to take this into consideration and it might tilt the scales in favor of getting a tissue valve.

I would suggest getting your Lp(a) tested. Anecdotally, there have been patients who have high levels of Lp(a) who go through their tissue valves much more quickly than typical. Just last month a study was published which found that those who had early bioprosthetic SVD had significantly higher levels of Lp(a), compared to those who did not experience early SVD. It has been know for years that Lp(a) correlates with early aortic stenosis of native valves, but this is the only study which looked at the correlation between SVD of a bioprothetic valve and Lp(a). I've linked the study below. There was another study published about 2019 which seemed to indicate the same thing, but it did not reach statistical significance.

Anyway, it is a simple test, similar to a blood lipid panel, and would be good for you to know. If you knew that your level of Lp(a) might cause your tissue valve to fail early, you might want to take that onboard with respect to your decision.

Role of lipoprotein(a) concentrations in bioprostheticaortic valve degeneration

https://heart.bmj.com/content/heartjnl/110/4/299.full.pdf

I don't believe the fact that you have large dogs should factor into the equation. Many of us on warfarin are very physicall active.

Besides your sensitivity to ticking sounds and your level of Lp(a), another consideration:

- be honest with yourself about how consistent you are in taking medications that you have been prescribed. Warfarin is not one in which you want to sometimes forget to take or sometimes take a double dose. Personally, I find taking my daily pill easy and am systematic about it, but a significant number of people do not take consistency seriously in this regard.

Best of luck in making your decision. Please feel free to ask any questions that you may have. We are here to help.

Thank you! I will ask my cardiologist to include LPa in my next round of blood work next week.
Historically, I have been terrible about remembering any medication, but I have a new ADD official diagnosis, and I credit taking my Adderall with getting myself appropriate medical care and finding the stenosis before it damaged my heart wall. (My doctors and surgeon agree that I should continue the adderall because it doesn't elevate my heart rate and the benefits on executive function are worth it)

 

[Erwitchin]

Hi Natchitoches (LOVE that name!!!)

In addition to all the scholarly issues covered above, I would (unfortunately) have to add one additional matter to complicate your decision... but it is important that you are 100% informed.

Being on anti-coags is not REALLY an issue (just a change in habit), and the ticking will fade into the distance with time (took me 6 months), however anti-coags mean that you are severely limited in your potential future drug-taking, and that needs to be borne in mind.

I myself have developed a severe spinal problem and am not able to take the usual meds precisely because I am on warfarin. Nothing I can do about it, and the issue was not foreseeable at the time of my emergency valve replacement.

I frequently wonder whether I would have chosen differently had i known at the time, but in my case (somewhat specific) I could not have done any better by not having a mechanical, as opening up my rib cage would have done further damage to my spine anyway.

So just bare this in mind...

Good luck

Thanks for your input. The town is pronounced Nat-ke-tish (the t blends into the k and isn't audible) in case anyone is curious

 

[Erwitchin]

Thank you so much! All y'all have been super helpful.
I will definitely have my LPa checked, and then decide.

Hi and welcome

some excellent answers already well cover things, so I'll try not to repeat their points but suffice to say I'm 100% in agreement, and most of all wish to underscore and emphasise the importance of chucks point about Lp(a)

as Nobog recently observed

and that 6 months end is almost certainly due to Lp(a) which your calcification is perhaps an indicator of. A search here will find quite a many "oh my, my bio didn't last as long as I'd hoped" posts as well as a few who have done bio, it failed and they decided (reluctantly) to go mech.

Myself I picked a mechanical for my last OHS which was at 48years old. It was my 3rd OHS (first was repair as a kid, second a replacement with a homograft in my late 20's) Its served me now flawlessly for 12 years and there is no indication of it packing in or having any trouble. That same can be said for some people with a bioprosthesis too, but just that's not the statistical norm. As you may be aware Dick here has had an old generation 1 type ball and cage valve rattling around for well over 50 years (and approaching sixty). That's never going to happen with any bio ever.

However here's the thing (assuming you do not have high Lp(a) picking a mechanical requires a commitment from you towards managing your anticoagulation therapy. IFF you manage it properly you will be rewarded by a valve that will last you a lifetime (nod to @Superman for citation of source of that gag) and you will have the best possible chances of lower than expected thrombosis or bleed events of any other valve.

If you haven't read / listened to these yet, I'm going to say grab a notepad and your preferred beverage and take notes.

View attachment 890044
click the image or https://www.medscape.com/viewarticle/838221



more current video


Lastly it doesn't matter if you pick an On-X or a St Jude or an ATS, they are all so close to each other that only a marketing manager can explain to you the differences (a table and a study showing the differences). On-X knowing that it had no cards in its hand on being the latest of the same thing on the market paid for a study to demonstrate that their valve is "safe" at lower INR levels. There is hardly a critical thinking cardiologist or surgeon on the planet who doesn't see that as "marketing jism". When it comes to claims from them think "consumer washing machine TV commercials" as there is no evidence that it confers anything. Actually its worse, there is evidence that being "smug in the safety net of the On-X" can lead you into deep waters of unsafe INR practices a worthy read here.

Remember, there is no definitive cure to valve disease, all we can do is exchange a fatal disease for prosthetic valve disease; of which there are two types; one is managed by redo-surgery as they wear out the other is managed by a weekly blood test (about as convenient as what diabetics do) and then on the basis of that administering pill daily

Best Wishes

 

[3mm]

Anyone have an On-x?

I have an On-X aortic valve. I rarely hear it; any noise from outside my body overwhelms the valve's sound.

opening up my rib cage would have done further damage to my spine anyway

I've never heard of this issue. Can you explain how this happens, what kind of damage, etc? Does this apply to everyone who has a sternotomy, or is your skeleton unique? Thanks for this information!

 

[Gail in Ca]

It seems most that have mechanical valves say they don’t hear it or it’s just in the background of everyday living.
I have a Carbomedic top hat aortic valve that’s 15. It’s loud and I do hear it. Over time, I’ve gotten used to it but it’s always present. I’m thin, so maybe that affects the loudness. I would just say that when you choose tissue, you choose another procedure in the future. A clarinetist in the group I play in got his aortic valve done a couple of years ago. His doctor told him in about 10 years he would have a TAVR. He was 60. I asked my cardiologist how long he tells patients the tissue valve lasts and he said 10-20yrs. You know yourself, and I think you’ll make a good choice for you. My 1st valve was porcine and it was like I’d never had surgery! But, it only lasted 11 years. Then my mechanical replacement had to be redone in 8 1/2 yrs due to bacterial endocarditis!! I thought I knew the future was no more surgeries, but the universe had other ideas for me.
Good luck with making your decision.

 

[Erwitchin]

Hey Erwitchin,
Had my valve/aneurysm replacement surgery 2.5 years ago at age 52 and opted for the On-X. Am thrilled with it! Am really upping my exercise and seeing good progress. The warfarin thing has been super easy for me and have not had bruising. Re: sleeping, I've always used a fan/humidifier in the room and rarely every hear my ticker. I could not be happier the way surgery has worked out for me.
If you go tissue valve, give a close look at the Inspiris Resilia- people have been saying good things.
Wishing you success whatever valve you choose.

Those are the 2 my surgeon uses... so if I do go bioprosthetic, it would be that one. I feel like longevity should trump annoying noise, but also need to remain at least as sane as I am currently.
Thanks for your help!

 

[pellicle]

but also need to remain at least as sane as I am currently.

I observe people deny themselves agency in this. Perhaps some people have none (we called it self discipline once) and so in that case you should absolutely choose a tissue valve.

Assuming you're Lp(a) does not contra indicate your choice there is nothing wrong with picking a path based on personal criteria which would preclude you from being responsible and disciplined in INR management (such as say a personality which precludes being properly and genuinely engaged with INR management. I know some diabetics who are suffering because they "pretend" that they can't manage their disease and refuse to give up drinking booze).

Some people (there is a personality type) also prefer to focus on everything which is wrong and will keep scratching their irritation (so to speak) making it worse. Cue picture of a cat that can't resist the itch to scratch:

These things need to be honestly factored in. I believe (knowing quite a number of medical specialists as personal friends) that surgeons factor in directing people to bioprosthesis for exactly this reason: people are statistically crap a managing their drugs (and attempt to lie about it). This is well researched (one example). These lies are well known to physicians

I believe that most people do not like being managed, but a good many need to be. Apart from going to follow ups there is often "no involvement" needed on the part of the patient who picks a bio-prosthesis. Conversely there is a need to be involved with management of maintenance of a mechanical valve (either to be subjected to it, or to become a self manager). Its ludicrously simple, but we have so much evidence that its still not done.



Only you know you.

Ultimately I'm not interested (and that's a good thing) in what you choose, I'm not here to advocate for any particular choice of action. I'm only here to do my best to inform, which also means correcting misunderstandings.

Sadly the choice of a mechanical has a great many more misunderstandings than the apparently easy choice of a bioprosthetic.

Best wishes

PS, on the subject of INR management:
lengthy and detailed
https://cjeastwd.blogspot.com/2014/09/managing-my-inr.html

there's more where that came from ...

message me if so.

 

[Maso]

Welcome to the forum.

Choosing a tissue or mechanical valve is not an easy decision. There are pros and cons for each valve.

When I was 53 I chose mechanical because I wanted to be one and done. Being on warfarin is no big deal, but important that you pay attention to it and are diligent about taking your medication. The ticking has never bothered me. I rarely hear mine unless I breath deeply or exercise hard.

But, you might be much more sensitive to the ticking sound:


If you are that sensitive to ticking, you really do want to take this into consideration and it might tilt the scales in favor of getting a tissue valve.

I would suggest getting your Lp(a) tested. Anecdotally, there have been patients who have high levels of Lp(a) who go through their tissue valves much more quickly than typical. Just last month a study was published which found that those who had early bioprosthetic SVD had significantly higher levels of Lp(a), compared to those who did not experience early SVD. It has been know for years that Lp(a) correlates with early aortic stenosis of native valves, but this is the only study which looked at the correlation between SVD of a bioprothetic valve and Lp(a). I've linked the study below. There was another study published about 2019 which seemed to indicate the same thing, but it did not reach statistical significance.

Anyway, it is a simple test, similar to a blood lipid panel, and would be good for you to know. If you knew that your level of Lp(a) might cause your tissue valve to fail early, you might want to take that onboard with respect to your decision.

Role of lipoprotein(a) concentrations in bioprostheticaortic valve degeneration

https://heart.bmj.com/content/heartjnl/110/4/299.full.pdf

I don't believe the fact that you have large dogs should factor into the equation. Many of us on warfarin are very physicall active.

Besides your sensitivity to ticking sounds and your level of Lp(a), another consideration:

- be honest with yourself about how consistent you are in taking medications that you have been prescribed. Warfarin is not one in which you want to sometimes forget to take or sometimes take a double dose. Personally, I find taking my daily pill easy and am systematic about it, but a significant number of people do not take consistency seriously in this regard.

Best of luck in making your decision. Please feel free to ask any questions that you may have. We are here to help.

This is news to me and important, thank you. I do have Lp(a) and am about to pick a valve as well.

 

[pellicle]

This is news to me and important, thank you.

as the studies dates will show, its pretty cutting edge and I'd say more than 90% of cardiologists are yet across this. Chuck just happens to have:

1. high Lp(a) (and its familial)
2. an enquiring and scientifically grounded sense of how to do research
3. great critical analysis skills (meaning hes not a typical "googler"

Its also helpful that he's followed through with not just warnings but possibilities for how to reduce Lp(a) levels.

Go Chuck!

 

[slipkid]

there's more where that came from ...
View attachment 890050

I suppose the answer to your question depends upon whether the reader is:

(1) A Citizen

(2) A Civilian

or...

(3) A Bug (!)

Sorry, couldn't resist. Love that movie. Cool enough to have humans fighting a bloody war against a race of bugs but add in the perfect satirical skewing of over the top campy fascism and it makes for a very fun movie, although one that the joke was taken way too seriously when it came out & many people thought it glorified fascism....