Still not sure!

[StretchL]

I know the ACT turns people off but the majority of docs seem to think that the risks associated with it are less than that of a re-op later in life.

Because I've not surveyed the majority of docs out there, I can't say that your statement is absolutely false, but it's a big enough generalization that I feel compelled to set the record straight. A number of world class surgeons with whom I consulted (Stelzer, Pettersson, Oswalt, Elkins, et al.) stated very clearly that with today's technology, the risks from reoperation are less than the risks from lifetime anticoagulation therapy. (Note the word "lifetime." The ACT risks become significantly greater as a patient ages.)

I can post direct quotes from some of these men if you like.

The Coumadin/re-op risk debate is a huge can of worms here on the board, and as laymen, many of us have differing opinions. But then again, we're not cutting open peoples' chests.

.

 

[StretchL]

If he were to go with a tissue valve, he'd be going against his cardiologist's & surgeon's advice, though.

Hey... I don't know how practical this is for you, but... if my surgeon wasn't comfortable with my valve choice, I'd go shopping for another surgeon.

Wait... that's what I did!

My cardio recommended the chief of surgery here at MCV in Richmond. Chief recommended mechanical, with tissue (I forget which one) as a grudging fall back.

Me: "Thank you very much, I appreciate your time, I'll be in touch." And I continued looking for the right surgeon.

Thanks be to God that I found him.

 

[Ross]

Because I've not surveyed the majority of docs out there, I can't say that your statement is absolutely false, but it's a big enough generalization that I feel compelled to set the record straight. A number of world class surgeons with whom I consulted (Stelzer, Pettersson, Oswalt, Elkins, et al.) stated very clearly that with today's technology, the risks from reoperation are less than the risks from lifetime anticoagulation therapy. (Note the word "lifetime." The ACT risks become significantly greater as a patient ages.)

I can post direct quotes from some of these men if you like.

The Coumadin/re-op risk debate is a huge can of worms here on the board, and as laymen, many of us have differing opinions. But then again, we're not cutting open peoples' chests.

.

I'll still dispute this claim. No one can convince me that reop is less dangerous then a lifetime on Coumadin. Sorry, I don't buy it.

 

[Lynlw]

Posts like SBAV's are making these types of discussions worthless. I'm considering never ever reading anything again having to do with valve selection.

Wow this thread is why I never recomend this site to people i know choosing valves, anymore, OR IF they have questions, I tell them there is some good information found here, BUT it isn't really friendly about what the main thing new people come here for, to learn about different valves. I like Karlynn alot, we have become friends off this site, and when I ead her post, I had the same thoughts as Susan, BUt I just blew it off, so I don't understand why everyone who jumped on Susan that she should have given karlynn the benifit of the doubt, didn't do the same for Susan.

Karlynn, back to the thread topic, I know you had an awful time for years before surgery and since were in such bad shape going into surgery, I've often wonderred IF you docs really listened to you, and you had surgery when you first started feeling bad and should have had it, instead of having a few bad years, if it also would have made your recovery a little easier since you would be going into surgery in better shape. IMO only I know there is atime before surgery (2nd, 3rd what ever ) that your valve is starting to have problems, but I would think since you would be going to the cardiologist yearly w/ a known valve replacement, if they would operate before you had years of symptons, Most of the people that I know of that have had 2nd and 3rd surgeries, aren't even that symptonatic when they had surgery.
Also not answerring anyone's comments just a genral statement. There have been several threads that reops and coum balance out for the most part, and that is why many of the doctors in some of the leading centers to recomend tissues for younger people, so I really doubt the majority of of people that go tissue must be going against medical orders, I know there are a few members here that go to the best hospital and have had more than one tissue valve already and I know quite a few other young people that have tissue on their docs recomendation,
I really understand it is frustrating to hear blanket statements about coumadin, but it can be eaqually frustrating to hear things about tissue and reops that just aren't true either and there has been plenty of post /research ect saying the risks are the same
It is really sad that when people try to dicuss valves it goes downhill, right when they really need information, and personal experience to help during one of the most scarey and confusing times of their lives.
Well I'm going to go watch tv, with my son who is sick, BTW thank you to the people that responded when i mentioned he is having heart problems and needs a cath

 

[Karlynn]

Karlynn, back to the thread topic, I know you had an awful time for years before surgery and since were in such bad shape going into surgery, I've often wonderred IF you docs really listened to you, and you had surgery when you first started feeling bad and should have had it, instead of having a few bad years, if it also would have made your recovery a little easier since you would be going into surgery in better shape.

Lyn, it's certainly a question I've asked myself many times (why not surgery sooner). However, this was 22 years ago when all the problems started (with the pregnancy for my daughter). Now, I'm pretty certain that if it were today, they would not have let me go over 5 years before doing something. My cardio was probably one of the most respected cardios in the field at the time. I had cardiac surgeons describe him as "the closest thing to God as far as cardiologists go". My cardio took only 100 patients and spent the rest of his time doing research. I had 2 very well-respected cardiac surgeons look at my cath report and tell me it wasn't time yet. And I was BEGGING for the surgery. I truly believe that my cardio and my surgeon were being cautious because they were concerned about me. My biggest problem was arrhythmia, and at the time, they were not thinking that replacement was going to aleviate it. Fortunately it did, and hind-sight being 20/20, a VR 2-3 years prior would have saved me a lot of grief. It wasn't that my cardio was just sitting around waiting to see what happened. He tried about every antiarrhythmic available then. None ever worked fully. I had 3- 1 week stays in CICU to put me on drugs that could only be started in the hospital due to possible "very bad" side effects.

You know how we say that surgeons never know exactly what they'll find until they get in there? 6 mo prior to my VR, the cath showed my valve to be highly prolapsed and regurging mod/severe, but not enough to the point of surgery (at that time). 6 mo later when my cardio gave me a thumbs up for surgery, the surgeon got in there and found basically no valve left at all. I have one of the largest St. Judes available because there was basically no natural valve ring left.

Thankfully, most doctors are not so hesitant to act anymore. But technology and training has greatly improved in the last 20 years. I'm confident that I received excellent care 'back then', particularly compared to the 4 cardios I saw prior to finding the Big Guy (because they wouldn't listen to me). Would I let anyone allow me to get that ill again - no way. I'm the first one to start squawking when someone reports they have SOB, fatigue, swelling etc etc, and a doctor that won't pay attention to them.

Now aren't you glad you asked?

 

[Bridgette]

One thing we can be sure of, whatever valve type we get, is that we cannot predict what will happen down the track, right?
I think you just have to go with what feels right, and suits your circumstances, after you have done your research.

Hey Stretch, I read your post in another thread about your follow up with your cardio and how well things have turned out for you, with your decision to have the Ross validated. That's great, and I am really happy for you

You can hear my "but" coming though can't you? Lol. I think you have to be careful about posting Dr Stelzer's and others opinions, and presenting them as the gospel truth about the dangers of a lifetime of ACT, when they are personal opinions, backed up by some studies/research maybe, but not the definitive answer. For every study done on anything, you can guarantee there will be another study done that will counter or argue the findings of the first.
I think all surgeons and cardios have differing opinions on valve suitability etc - I read somewhere here on this forum that some surgeons are saying that tissue valves can last 20-25 years? My surgeon told me that he would not give me a tissue valve because "it will only last 12-15 years at the most"
So, who is right? No one can say for sure.
Anyway I am not trying to fuel the fire so to speak - I just hope Shei and her husband come to a decision that they feel comfortable with, and don't feel pressured and anxious because of what they have read on this forum.

Thanks
Bridgette

 

[Lynlw]

One thing we can be sure of, whatever valve type we get, is that we cannot predict what will happen down the track, right?
I think you just have to go with what feels right, and suits your circumstances, after you have done your research.

Hey Stretch, I read your post in another thread about your follow up with your cardio and how well things have turned out for you, with your decision to have the Ross validated. That's great, and I am really happy for you

You can hear my "but" coming though can't you? Lol. I think you have to be careful about posting Dr Stelzer's and others opinions, and presenting them as the gospel truth about the dangers of a lifetime of ACT, when they are personal opinions, backed up by some studies/research maybe, but not the definitive answer. For every study done on anything, you can guarantee there will be another study done that will counter or argue the findings of the first.
I think all surgeons and cardios have differing opinions on valve suitability etc - I read somewhere here on this forum that some surgeons are saying that tissue valves can last 20-25 years? My surgeon told me that he would not give me a tissue valve because "it will only last 12-15 years at the most"
So, who is right? No one can say for sure.
Anyway I am not trying to fuel the fire so to speak - I just hope Shei and her husband come to a decision that they feel comfortable with, and don't feel pressured and anxious because of what they have read on this forum.

Thanks
Bridgette

I just wanted to say surgeons aren't just saying tissue valves can last 20-25 years, http://valvereplacement.com/forums/showthread.php?t=19289&highlight=CEP+years Tobag has posted that 90% of the CEP valves were still implanted at 18 years and that was the ones pre anticalcification.
I personally think it is helpful to post what different surgeons opinions, especially when you use their name or hospital, I've learned alot over the years by people sharing what their doctors opinions were. Lyn

 

[Lynlw]

Thankfully, most doctors are not so hesitant to act anymore. But technology and training has greatly improved in the last 20 years. I'm confident that I received excellent care 'back then', particularly compared to the 4 cardios I saw prior to finding the Big Guy (because they wouldn't listen to me). Would I let anyone allow me to get that ill again - no way. I'm the first one to start squawking when someone reports they have SOB, fatigue, swelling etc etc, and a doctor that won't pay attention to them.

Now aren't you glad you asked?

Yes I am glad i asked, I thought about what you went thru alot, I could imagine being a young mom how hard that was especially trying to take care of little kids, I'm glad to know the docs were paying attention, I know how many times, females , especially youngs one, don't even get to a cardiologist , before their pcp has them convinced they are going nuts or it's just stress. I can see how it had alot to do with the technology at the time, when I had my ultrasound when I was pregnant with Justin they said theres a leg and I siad oh cool but couldn't make out a body part to save my soul, Now ultrasounds are so good you can see the baby's expression, so it's so much easier to get good looks of hearts (even tho wayy to many US miss heart defects even now in babies, but that's another thread) So I am glad they were at least believing you, just waiting for the best time.

 

[Bridgette]

Sure Lyn, point taken.


But let's have a range of surgeons/cardios/researchers opinions posted, so people can see all sides of the issue.

BTW Shei, I have an On-x valve implanted, and though it's early days yet, I am very happy with it. When I went for an echo recently, the doctor said, "it looks beautiful in there"

Bridgette

 

[tobagotwo]

As brought up, I have posted that the lifespan of the implanted CEPs is 90% at 18 years, and that's correct in context. But it doesn't apply to 36-year-olds. Most valve replacements are for older folks, the average being over retirement age. The lifespan of the valves therefore largely reflects that age group. Tissue valve don't last as long in younger patients. they are too chemically active.

My guess is that it would take two more ops after this one to get AkaShei's husband to the 76-78-year mark. Is that doable? Yes, I think so.

But he must decide if it's worth it.

Lots of people do fine with ACT. There are certainly many on this site who do. If there's a repair of the aorta that happens in the mix, or other thoracic surgeries, it does add to the risk level of multiple operations for a tissue valve. Then again, a repair of the aorta or other surgery is no picnic for someone on Coumadin, either, and adds significantly more risk of thrombosis.

There is also the choice of having a tissue valve now, and moving to a carbon valve the next time. That's not a light-hearted decision, either.

It's a lot to think about. And there are no right answers.

Best wishes,

 

[StretchL]

I'll still dispute this claim. No one can convince me that reop is less dangerous then a lifetime on Coumadin. Sorry, I don't buy it.

Ross, believe it or not, I totally respect the fact that you're entitled to your opinion.

I freely admit that I've not read all the research out there, and I may have "cherry-picked my intelligence" (that seems to be going around these days) to validate what I wanted to believe. But I don't think so; I've tried to be very diligent and detached as I researched the tissue/mechanical options, and from everything I've read, current opinion among the world's top cardiothoracic surgeons disagrees with your opinion.

That doesn't mean you're not entitled to your opinion and to defend your opinion, of course.

As I said, we're all laypeople here, myself included, of course. As laypeople we owe it to ourselves and our readers to own up to the fact that our opinions indeed have the value of laypeople debating enormous issues for which we have no formal education whatsoever.

On many Monday mornings every winter, hundreds of thousands of Americans debate over the office water cooler the strategy and execution of two NFL teams' game plans the day before. Many of these Monday morning quarterbacks sound, on Monday morning, as if they could reasonably direct one of those very same two teams to the Super Bowl.

But I doubt if there's a team owner or player out there who would trade, for a season, the untrained decisions of an average Joe for those of even the "losing-est" but very experienced NFL coach in the league, no matter how reasonable Joe's Monday morning opinions sound on their face.

I also want to tell you, Ross, that as much as you and I disagree, I appreciate all you do to keep this board running, and I sympathize with, and don't want to minimize, the problems you've had with your own OHS and ACT experiences.

.

 

[StretchL]

Hey Stretch, I read your post in another thread about your follow up with your cardio and how well things have turned out for you, with your decision to have the Ross validated. That's great, and I am really happy for you

Thanks!

You can hear my "but" coming though can't you? Lol. I think you have to be careful about posting Dr Stelzer's and others opinions, and presenting them as the gospel truth about the dangers of a lifetime of ACT, when they are personal opinions, backed up by some studies/research maybe, but not the definitive answer. For every study done on anything, you can guarantee there will be another study done that will counter or argue the findings of the first.
I think all surgeons and cardios have differing opinions on valve suitability etc - I read somewhere here on this forum that some surgeons are saying that tissue valves can last 20-25 years? My surgeon told me that he would not give me a tissue valve because "it will only last 12-15 years at the most"
So, who is right? No one can say for sure.

I think we're confusing the two issues. Valve choice for each individual is a very personal decision and, as we've read here many times, the only really "wrong" choice is to not have the surgery.

The issue isn't which valve is best for a particular individual. The issue is simply this: Is the risk of lifetime anti-coagulation therapy greater, less than, or equal to the risk of re-operations to replace a valve?

I'm saying that, from what I've read, current opinion among the worlds top surgeons seems to indicate that the risk of lifelong ACT is greater than the risk of re-ops.

How much value one gives to the opinions of these men is, again, a matter of personal opinion.

.

 

[Ross]

Wow this thread is why I never recommend this site to people i know choosing valves, anymore, OR IF they have questions, I tell them there is some good information found here, BUT it isn't really friendly about what the main thing new people come here for, to learn about different valves.

People this puts me in a bad position. While it's true that to a point, some of these posts should have gone to Pm's so that the differences could be worked out without being public view, I can't justify deleting any of them. In my earlier days, I'd simply delete them and that would be that, but even with the heated discussions, there are lessons to be learned and information to gained. I would hope that you would recommend they come here, but prepare them in advance that when it comes to valve choice, people will furiously defend their positions. It takes the blend of all of us to make this place work the way it's supposed too. I don't want to have to resort to deleting posts or threads simply because we disagree on things. We can argue about stats, we can argue our experience, but one thing that will not be tolerated is flaming another member or openly provoking a fight, over disagreements. We are big people now. We should have the respect and honor to keep it that way.

The choices have been laid forth. It's up to the person to choose. Everything else is simply additional ways of looking at things. We can perpetuate the fighting or we can move on. Lets keep it civil and backed by our own experiences. Our experiences are the true indicators of how things really work.

 

[lance]

Wow health care based on cost, Glad I'm not under that policy.

According to Health Canada every valve recipient under the age of 70 will be given a mechanical valve to avoid the additional cost of replacing a tissue valve so there was no incentive to honestly and accurately inform me about ACT.

On the other hand ................
We didn't have to mortgage the farm to pay for it.
Health Canada cannot dictate which valve is chosen that is left to the surgeon and patient. Had my surgeon fully informed me about ACT I would have a tissue not mechanical. It was the surgeon who recommended the mechanical and I was too stupid to know any better.

 

[Karlynn]

On the other hand ................
We didn't have to mortgage the farm to pay for it.
Health Canada cannot dictate which valve is chosen that is left to the surgeon and patient. Had my surgeon fully informed me about ACT I would have a tissue not mechanical. It was the surgeon who recommended the mechanical and I was too stupid to know any better.

Lance - do you mind if I ask how old you are? I notice from your profile that you are retired. And that you had your replacement in 1999.

We often tell new members that someone in their 50's is in the gray area of which valve is the best choice. We have younger members choosing tissue with the hope that additional surgeries will go well, but we also have older members who have chosen mechanical to avoid the possibility of having surgery when they are possibly more frail. So it's not always a decision based on age. There are just factors that can make a it a worthy consideration.

Tobagotwo mentions another issue we rarely speak of, and that's having a plan involving more than one type of valve. He mentioned tissue then carbon (mechanical) when the tissue wears out. Although, personally, I would choose the reverse. But this could be due to the fact that A. I already have a mechanical and B. I had young children at the time of my replacment. My mechanical got me through the busiest years of my kids lives without having to face the cycle of a valve wearing out, surgery and recovery. Thankfully it's still looking "mah-ve-lous" and there are no signs of it needing to be replaced any time soon. But if/when it does I would highly consider choosing a tissue for my senior years, understanding that older people can have more chances of bleeding issues.

Then there's Lynw's teenage son and they planned a different course of options they feel best fits his life going forward (I'll let Lyn explain, because I'd just screw it up.)

Shei, I also wanted to mention that it's possible that our anti-coagulation forum may give a distored view of Coumadin. While there are issues to be aware of with ACT (Anti-Coagulation Therapy) and that forum will give you info on what some of the issues can be, I also want you to understand that people don't post when their ACT is going well, only if they have problems. It's kind of like the tech support at a computer company. They don't hear anything from people who's computers are working well.

 

[akaShei]

Great Feedback! Thanks everyone!

Great Feedback! Thanks everyone!

I never expected to stir things up like this, but with that said, I also want to add that all the differing viewpoints have been very insightful and appreciated! This is a very personal decision, but your comments will no doubt help Nick make his final one.

Yes, his surgeon is very familiar with the On-X valve and said that for his valve-only patients (no root available), he's been using it exclusively. When we asked his surgeon about the other options (tissue or Ross), he said that to avoid a re-op (and any possible complications that could be associated with one), he would recommend going with a mechanical. His cardiologist said the same thing & also mentioned that Nick shouldn't have any issues with ACT, but knowing my husband, he'll think he has to be so careful about everything he does (at least in the beginning).

What is clear is that regardless of the choice of valve, the outcome is unknown, but what I keep wondering is "which valve carries more unknowns?" Which one would be more of a gamble? Long-term ACT with a mechanical or repeat surgeries with tissue. The comments favoring both "sides" are very valid, so weighing the pros & cons is so stressful! If the risks were really equal, then the choice would be to do it just once (hopefully just once) with mechanical, but there's no way to really weigh the risks, is there?

The 26th seems like an eternity away, yet too soon at the same time!

 

[Ross]

Everyone is different and surgery is the same. With any surgery there are risks, but you have to realize that your now talking about stopping and restarting the heart. The risks will go up with each additional surgery, so in my opinion, and I'm giving it to you because I had a very hard time and in no way ever want to go through it again nor can I, is to go the route that is going to keep you off the table the longest. Mechanical could be a lifetime thing. There just aren't any guarantees.

Tell him that he will not bleed to death from cutting himself shaving. Paper cuts aren't going to send him to the ER nor a bunch of other baloney that he's probably heard. Find the truth out about ACT( www.warfarinfo.com ) before condemning it. I think it's a small price to pay for a chance at never having another heart surgery.

Surgery can go very well and recovery with minimal complications or there is the flip side like I had. No one knows but God just how it's all going to turn out. We can appreciate your questioning as we all have faced the same things. It's no easier for us when we are presented the idea of surgery again either, so you know your in the right place.

 

[Lynlw]

People this puts me in a bad position. While it's true that to a point, some of these posts should have gone to Pm's so that the differences could be worked out without being public view, I can't justify deleting any of them. In my earlier days, I'd simply delete them and that would be that, but even with the heated discussions, there are lessons to be learned and information to gained. I would hope that you would recommend they come here, but prepare them in advance that when it comes to valve choice, people will furiously defend their positions. It takes the blend of all of us to make this place work the way it's supposed too. I don't want to have to resort to deleting posts or threads simply because we disagree on things. We can argue about stats, we can argue our experience, but one thing that will not be tolerated is flaming another member or openly provoking a fight, over disagreements. We are big people now. We should have the respect and honor to keep it that way.

The choices have been laid forth. It's up to the person to choose. Everything else is simply additional ways of looking at things. We can perpetuate the fighting or we can move on. Lets keep it civil and backed by our own experiences. Our experiences are the true indicators of how things really work.

Ross, I was in no way trying to put any pressure on you , about deleting thread ect, I simply was hoping IF it gets mentioned enough, then maybe, people will think about their replies before they post SO many threads on valve discussion doesn't end up nasty. Then you wouldn't even have to consider do you delete or not which I think would open an even bigger can of worms, why did you delete my post but not theirs,.
I've even mentioned before that I am an active member in about 5 heart groups and this is the ONLY one that is like this and it certainly isn't because other boards don't have choices to be made, IN MY OPINION, out of all my boards, valve choices is one of the "better" types of choices, since all options are pretty good, so I don't know why if people don't fight about choosing to let your baby die/multiple surgeries or transplant and no matter what you choose the percentages of not making it are much higher than any valve choice, and they just offer support and kindness, why something that is is basically win/win can't be as kind
as for MY experience, I use to recomend this place right away on either my parents groups or ACHA, but I got so much ugly feed back or people would post a few times or try to read threads only to have to pick thru long threads to find info in between nastiness, that they gave up and left wondering why, things are the way they are. So when people are already going thru stress and doubts especilally where the valve choice is just part of the decisions they have to make surgery wise, and they are talking to a few leading cardiologists and surgeons at leading centers, I don't surggest they try to weed thru the less than pleasant threads here. Hopefully someday things can change.
I DO however always recomend VR as a really good place to get info on coum management/home testing IF they or their child are on coumaden, those threads are very informative, supportive of each other and friendly
Again these are just MY experiences

 

[lance]

Lance - do you mind if I ask how old you are? I notice from your profile that you are retired. And that you had your replacement in 1999.

We often tell new members that someone in their 50's is in the gray area of which valve is the best choice. We have younger members choosing tissue with the hope that additional surgeries will go well, but we also have older members who have chosen mechanical to avoid the possibility of having surgery when they are possibly more frail. So it's not always a decision based on age. There are just factors that can make a it a worthy consideration.

Tobagotwo mentions another issue we rarely speak of, and that's having a plan involving more than one type of valve. He mentioned tissue then carbon (mechanical) when the tissue wears out. Although, personally, I would choose the reverse. But this could be due to the fact that A. I already have a mechanical and B. I had young children at the time of my replacment. My mechanical got me through the busiest years of my kids lives without having to face the cycle of a valve wearing out, surgery and recovery. Thankfully it's still looking "mah-ve-lous" and there are no signs of it needing to be replaced any time soon. But if/when it does I would highly consider choosing a tissue for my senior years, understanding that older people can have more chances of bleeding issues.

Then there's Lynw's teenage son and they planned a different course of options they feel best fits his life going forward (I'll let Lyn explain, because I'd just screw it up.)

Shei, I also wanted to mention that it's possible that our anti-coagulation forum may give a distored view of Coumadin. While there are issues to be aware of with ACT (Anti-Coagulation Therapy) and that forum will give you info on what some of the issues can be, I also want you to understand that people don't post when their ACT is going well, only if they have problems. It's kind of like the tech support at a computer company. They don't hear anything from people who's computers are working well.

Karlynn,

I was 59 when I received my mechanical valve. My INR is rarely, if ever, out of range--it is well monitored. Prior to implant my knowledge of ACT was that it was to be taken for life and required blood testing every month or so. At least what I shovel out of the barn is worth far more than that advice--it can be used to grow things. Even felons sentenced to life imprisonment don't usually serve their full life-long sentences--they can be paroled. I don't think this site distorts the facts about ACT at all. It informs and teaches. If I'm blunt and to the point it is becaise I don't believe patients should be misinformed about ACT. They need the full picture to decide. Had I been so informed I would have a tissue valve. ACT is a life-altering event that's for sure.

 

[starfish11040]

I was 59 when I received my mechanical valve. My INR is rarely, if ever, out of range--it is well monitored. Prior to implant my knowledge of ACT was that it was to be taken for life and required blood testing every month or so. At least what I shovel out of the barn is worth far more than that advice--it can be used to grow things. Even felons sentenced to life imprisonment don't usually serve their full life-long sentences--they can be paroled. I don't think this site distorts the facts about ACT at all. It informs and teaches. If I'm blunt and to the point it is becaise I don't believe patients should be misinformed about ACT. They need the full picture to decide. Had I been so informed I would have a tissue valve. ACT is a life-altering event that's for sure.

Lance,
You don't seem to have any problem monitoring your INR and keeping it in range. Yet you're obviously really down on ACT, but you don't specifically say why.
Why? And what were you misinformed about?