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Hi Jeff
'm asking because I don't know anything about this subject.
Is the risk of stroke still increasing by 1% every year even if we use warfarin and monitor inr properly?
no, it doesn't work like that. Instead its a year on year thing. Probability is best explored through dice roll and coin flip; where each event is independent of the other events.

If you roll the dice then your next roll may or may not be the same number, but it will be independent of the previous (and not in any way predictive of the next) outcome.

People get confused about this when comparing the probability of cards. Each time you take a card the probability of a Jack of Clubs on the next draw increases as we reduce the pack with each draw from 52, to 51 ... eventually if it doesn't turn up beforehand we can be certain that the last card is the Jack of Clubs.

Stroke risk is like the dice roll.

I won't go into it but using the probability theory is all we have for this. The probability is defined in "that graph" I usually post as (if you are in INR sweet spot range) less than 3 events per 100 patient years.

This can be either if you have 100 years on warfarin or if 100 patients have 1 year.
PS: I am not a medical professional but I have been around the subject of heart valves, stroke survival and warfarin protocols a long time.........so, take what you need and leave the rest.
I do exactly that too (in fact I think Medical professionals do too) ... but keep the pile of other stuff in my database of references to re-read over the years when answering questions. There is nothing like teaching to help you to learn this stuff (should you be so inclined towards either).
I target an INR of 2.5, and I consider the "super low INR" as an extra safety margin. I need to ask the Mayo Clinic why they gave me an On-X valve and not a St. Jude valve....
I have a friend that got a ball-in-cage Aortic Valve 42 years ago, she never had a problem, the noise yes you can hear; St Jude is a very good Valve nothing wrong with it, OnX is an upgrade of the St Jude, " facts not opinion, no polemics please" , OnX is the ONLY mech valve that opens 90 degrees and that helps with the movement of the blood, My surgeon in Canada, #2 in the country, IF uses a mech valve ONLY uses OnX for the above reason, and MAYO clinic is the non plus ultra of medicine and technology for heart surgery. So, you are fine with your Onx, St Jude would do also, but OnX is a newer design created by people that came from St Jude.
The only controversy regarding OnX is the 1.5 -2 INR range using ASA 81mg, I did it for 18 months but dropped it because if INR went up i did not care, but if it went below 1.5, and it did, that could be a problem, SO, I use the same range as St Jude, 2 - 3 , some people use 2.5 - 3.5, your cardiologist will tell you, Further more, if you test weekly at home, 1.8 - 2.8 is ok according to some study papers, see attached; If my surgeon gave me the choice between Tissue and St Jude i would have choosen St Jude, but he ONLY offered me OnX, he plainly told me he does NOT use a mech valve other than OnX; I am saying this JUST because want to share with you that no need to worry about your OnX; either one is fine, but, ... the 90 degrees opening ONLY applies to OnX, so , that should tell something..... And as per the Aspirin, i stopped it when i dropped the 1.5 - 2.0 range, but, ONCE a week take 1 asa 81 mg, just my thing, as per noise, when i go for ultrasound tests, the technician asks me if i am sure i have mech valve because can not hear it, my wife does not hear it either :)


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The only controversy regarding OnX is the 1.5 -2 INR range using ASA 81mg

I do agree that its an adequate modern valve and also that there is controversy over its INR protocol

OnX is an upgrade of the St Jude, " facts not opinion, no polemics please" ,
I see ... so do you have a reference to support your claim? I mean before I even say its wrong, claims require evidence. Facts not opinions or marketing please, no polemics.

OnX is the ONLY mech valve that opens 90 degrees
no, its the only one that claims it does, but no measurements support that claim. Please read this post and its associated Medical Journal citation:


I do wish people would stop being so blindly tribal. Right here at this time code this guy says this so well and its about cars:

Best Wishes
I have a friend that got a ball-in-cage Aortic Valve 42 years ago, she never had a problem,........
There are quite a few of those old "ball-in-cage" valves still around.......I also have one. Tell your friend about this forum. I have learned a lot since joining because "ole dogs can learn new tricks". Going thru OHS in those "olden days" was like walking thru a graveyard at nite.....whistling and hoping you made it to the other side.

I don't have a "dog in the fight" regarding the advantages or disadvantages of the newer mechanical valves. My initial reaction is "flip a coin" when choosing between St. Jude and Onyx. That said, if I chose Onyx, I would not subscribe to a low INR target. Such low targets might work in a lab-controlled testing environment........but will it work after the newness of the surgery wears off and the patient rejoins the "real world"? Striving for a super low INR is, in my opinion, a foolish and dangerous target.........and to what end? Blood cells (bleeds) can be replaced, brain cells (stroke) can't. I've had, probably 10,000+ cuts since my surgery and survived them all without incident and have had only one stroke that irreversibly altered my life.

A quick risk analysis for you:

Using the US Social Security life expectancy table, at 48, male, you should live to 82 years old or 34 additional years.

Risk probability formula over the next 34 years using your doctor's 3.3% per year estimation over your 34 years expected life span:

(1-.967^34)=.68 or 68% probability that you will experience an "event" at some point over the next 34 years.

Roughly 2 out of 3 people.

What that event is, no one knows. It could be minor or it could be major. That's your risk/gamble.

If you manage your warfarin well and drop your risk to 1% per year, your risk is 29% at some point over the next 34 years.

A little less than 1 out of 3 people, much better.
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I'm 48, had OHS AVR and aneurysm repair in 2013. 11 years later and my Edwards Bovine is severely regurgitating. Time for surgery.

Had a quick 1st talk of many with the surgeon who gave me 3 possible options:

A) St Jude mechanical valve, which he uses most and pitched the hardest.

B) On-X mechanical valve, which he said he also uses often, but patients complain of loud ticking.

C) TAVR with a tissue valve, which he said would only last 3-4 years for me, and he was against for my case.
This was told to be an impossibility for me until I met the surgeon yesterday.

Dr also stated the risk of stroke only goes up .33% each year with mechanical St Jude, on a big study that he uses as a standard.

1 year = .33%
2 years = .66%
3 years = 1.00%
4 years = 1.33%
etc, etc, etc

I am going to do my own research and own searching around on this forum for information. But, if anyone can chime in with an opinion I would greatly appreciate it ......good or bad.

Thank you
As a solidly biological side valve guy, my opinion on what I would do in your shoes facing a second surgery at 48 years old?

It would be a close call but I would go with the St Jude mechanical valve because, at your age, you would be facing a 3rd surgery at some point if you couldn't do TAVR next time.

Dealing with a mechanical valve would not be fun with the warfarin, bleeding risks, ticking, life restrictions, diminished skills going into old age and trying to deal with self management, current restrictions using some medications like anti-inflammatories, possible restrictions using new medicines currently coming down the pike, etc.,etc., but dealing with the damage to your heart going through 3 surgeries would probably be worse than dealing with the mechanical valve issues.

Good luck to you.
I had a second sirgery after my bio valve wore out after only eight years. i dont think your heart nevessarily gets damaged from a second surgery. I am fitter than ever. But surgeries really arent fun. It can take a long time to return to what you perceive as normal.

I think the mechanical valve is a no brainer in your case. warfarin management isnt bad. You can live a completely normal life. Finally, did you know that at age 50, your lifetime probability of a stroke is 25%? that is also the reason why if you look at randomised control studies, the risk of a stroke with a bio valve and mech valve are the same. The only difference is the higher bleeding risk with the mech valve. In other words, warfarin pretty much completely negates the stroke risk from a mechanical valve, if it is well managed.

Also, stuff happens in life and you only get three relatively risk free attempts at OHS. Best to keep one in reserve and hope you never need it
Sometimes genetics seem to add to the stroke risk. My father died of a stroke. His mother had a stroke. From what I was told, his father died of a stroke (he was in his 50s). My mother's father died of a 'heart attack.'

With the history of strokes on my father's side of the family, I expect that my risks may be heightened, proper anticoagulation or not.

I had a TIA (actually, it may have been a stroke) more than a decade ago when my INR dropped to 1.7 or so, and my meter told for weeks that it was 2.6. Regular testing couldn't overcome the results of trusting a bad meter.

In September last year, with an INR in range for years, and with weekly testing or testing every other week, I had a TIA. I have no real idea why. It was, fortunately, transient - I was back to where I should have been in about 3 days.

So - although anticoagulation can possibly reduce the risk of stroke or TIA, it's not necessarily going to PREVENT you from having a stroke, even if you maintain an INR that's within range.

FWIW - I saw a presentation that Pellicle posted a few months ago that showed the author's research on aspirin, and the conclusion that aspirin reduces cancer risk. I'm taking 81 mg aspirin daily - cuts and other minor injuries don't seem to cause more trouble than just anticoagulation (and for small cuts and shaving nicks, I don't give it a second thought).
B) On-X mechanical valve, which he said he also uses often, but patients complain of loud ticking.

I think maybe that sentence should read like this:

On-X mechanical valve, which he said he also uses often, but SOME patients complain of loud ticking.

How many make up that "SOME" amount though? 1%? 10%? 50%? What?

Because without it that statement means ALL patients complain about that. And that is definitely NOT the case.

I cannot hear my On-x AT ALL. But I can hear a wall clock without a sweep second hand that I have click every second from 20 feet away (I had to move it out of my bedroom because it was annoying me). I don't know what the factors at play are that cause some folks to hear theirs (size or position of the valve? body weight? what hemisphere they live in? full moon? or what) but think it varies patient to patient.

And I'm not trying to stick up for On-x by saying this, but is it a well known fact that NO PATIENTS complain of ticking with St. Jude valves? Is this JUST an On-x issue? Because again, the way I interpret what your Dr told you is that no one with a St. Jude can hear it but everyone with an On-x complains about it....