4 Days to decide between bio and mechanical aortic valve

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mikeccolella

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In response to Pellicle's inquiry the following is an excerpt from the study cited and Which swayed me to choose a tissue valve at 63. It should be noted the advantage swings over to the mechanical valve after 10 years. It is also notable what they conclude wrt careful monitoring.

"In contrast, mechanical valves are associated with a reoperation rate of 0.6% per year, bleeding rate of about 1.5% per year and thromboembolism rate of 0.6% per year[SUP]4[/SUP] – in a young patient this amounts to over 20% risk of major complication in the first decade post valve replacement. Several approaches to improved anticoagulation, such as use of novel anticoagulants, home International Normalized Ratio (INR) testing, and lower INR targets have not transformed to reduction in morbidity with mechanical valves[SUP]7, 8[/SUP]. In one recent trial a bleeding rate of 3.3% per year was noted in patients receiving conventional anticoagulation[SUP]9"

the above is from the first page section 2

​​​​​​Article from the JACC summarizes the data and comes to these conclusions:[/SUP]

Patients faced with the decision of prosthesis type.
Biological Vs Mechanical Valves – Key Points
  • Long-term survival is equivalent
  • Mid-term morbidity is worse with mechanical valves
  • Reoperation rates are low with biological valves and are not insignificant with mechanical valves
  • Reoperative aortic valve replacement has similar mortality to primary valve replacement
  • Complications of mechanical prosthesis are more devastating than those of biological valves
  • Mechanical valves can have substantial negative impact on daily quality of life
 

pellicle

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Hi Mike

firstly I want to be clear I'm not questioning your choice, but attempting to have a discussion on how people read and intrepret research.

mikeccolella;n877946 said:
In response to Pellicle's inquiry the following is an excerpt from the study cited and Which swayed me to choose a tissue valve at 63. It should be noted the advantage swings over to the mechanical valve after 10 years. It is also notable what they conclude wrt careful monitoring.

given that the article is written towards younger people (such as perhaps the age I was when I had my second surgery) I was a bit concerned when (as one always finds) the followups were the 12 year mark (on average) ... when I was 26 twelve years wasn't what I thought was appropriate.

There is also the very valid questioning of how well off you are on warfarin and what the management regime is like (usually dismal unless you're totally incompetent). There should be a much more keen conversation in the medical groups about exactly this point (but its not "important" so there isn't).

Again, I'm not attempting to question your decision, I'm discussing this openly mainly because many lurk here and read. Few question what they read and so I wanted to discuss it from that more general perspective (and considering we do get under 40's asking).

Best Wishes

:)
 

mick1807

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I'm due for surgery in October and as a 40 yo was/am leaning towards mechanical as I believe managing warfarin will be no big deal. Take a tablet a day, get a test a month seems fine.
i also believe once you're stable it's pretty easy to stay stable. So my doc tells me.......
After reading the "key points" in Biological V Mechanical it again has me questioning my decision but trust my doc and surgeons advice & stay with mechanical....I think. Lol
 

dick0236

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mikeccolella;n877946 said:
[TD]Biological Vs Mechanical Valves – Key Points
  • Long-term survival is equivalent
  • Mid-term morbidity is worse with mechanical valves
  • Reoperation rates are low with biological valves and are not insignificant with mechanical valves
  • Reoperative aortic valve replacement has similar mortality to primary valve replacement
  • Complications of mechanical prosthesis are more devastating than those of biological valves
  • Mechanical valves can have substantial negative impact on daily quality of lif


  • Mike, you made a good choice for a man of 63......and the points you listed may be appropriate for a senior age(63).......but for me at age 31 when I had the surgery, not so much:
    *Long-term survival: No tissue valve has come close to lasting 50 years.
    *Mid-term morbidity: Not sure what this means, but I don't think it has happened yet.
    *Reoperation rates: You can't get better than none after 50 years.
    *Reoperation mortality: Obviously you can't do better than zero since no re-op has been necessary.
    *Complications: Pretty sure I've had fewer than if I had needed 3-5 reops rather than my one, and only, valve implant.
    *Quality of life: At 81 I still go to gym three times per week and golf twice per week. Shot 42 today (9 holes). Don't play 18 anymore...not a heart issue, old bones are the problem.

    I'm not looking for a fight over this issue and I now believe that tissue is the way to go for those in mid-60s+.......but most of the folks that come to this forum for info are younger than us old geezers......and frankly, I think that the above argument equating mechanical and tissue valves in younger people is misleading. BTW, I'm still waiting for any of these studies to contact me for my experience.......after all, I've had my valve longer than anybody......so far.
 

LondonAndy

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dick0236;n877926 said:
LondonAndy.....are you confusing Crestor with Coumadin? In the US Crestor is a statin.

Ooops! Sorry Dick and Pellicle, you are quite right. And I even take it!! See my new post about missed Warfarin dose - I think I am over-tired at present.
 

pellicle

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mick1807;n877951 said:
.... Take a tablet a day, get a test a month seems fine.
I would suggest you look to testing weekly, not monthly. Why? Well if you are out when you test you don't know
  • by how long that may have been or
  • how far out you may have gone or
  • from what direction (and which is it going)
At $6 per test one has to ask why you would skimp on it? What would you be saving? One lunch out?

Testing weekly gives you a much clearer picture from which to work and if nothing else a better idea of what sort of dose changes you may need (if any) to respond to being "over / under" on a test.

Testing weekly gives you a quick "heads up" for any changes (such as a new medication you took which you didn't expect to have an effect).

Naturally its up to the individual, but I'm not in favor of arguing for greater or increased risks.

The data is quite clear ... the greater percentage of time you are in range the less likely you are to have any injuries.
 

Superman

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mikeccolella;n877946 said:
In response to Pellicle's inquiry the following is an excerpt from the study cited and Which swayed me to choose a tissue valve at 63. It should be noted the advantage swings over to the mechanical valve after 10 years. It is also notable what they conclude wrt careful monitoring.

"In contrast, mechanical valves are associated with a reoperation rate of 0.6% per year, bleeding rate of about 1.5% per year and thromboembolism rate of 0.6% per year[SUP]4[/SUP] – in a young patient this amounts to over 20% risk of major complication in the first decade post valve replacement. Several approaches to improved anticoagulation, such as use of novel anticoagulants, home International Normalized Ratio (INR) testing, and lower INR targets have not transformed to reduction in morbidity with mechanical valves[SUP]7, 8[/SUP]. In one recent trial a bleeding rate of 3.3% per year was noted in patients receiving conventional anticoagulation[SUP]9"

the above is from the first page section 2


So this is the study itself that is suggesting annual statistics are cumulative? Seems odd. Or am I misreading?
 

dick0236

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Superman;n877960 said:
So this is the study itself that is suggesting annual statistics are cumulative? Seems odd. Or am I misreading?

No Superman, this argument of a cumulative risk is wrong. Each year is an independent risk from the earlier years and each event(.6% reop, 1.5% bleed, .6% clot) is independent from the others. It's like flipping a coin, or three coins......the chance of a "head" on the first flip is 50%/coin and the chance of a "head" on the tenth flip is 50%/coin.......,so your risk of one of these heart events happening in the first year is .6%, 1.5%, .6%, not 2.7%.....and the risk at the end of the first decade remains(might change a little due to other factors) .6%, 1.5%, .6%.....not 2.7% x 10years = 27%

There is an older post done by a professor at Notre Dame (I think) who did a very good statistical presentation explaining the cumulative fallacy of this type of argument. He also noted that his pre-med students where notoriously poor at Statistics.....LOL.

Now, if you will excuse me, I need to lie down as my current risk is 2.7%++ x 50 = 135%+++.......so I gotta be very careful........:Tongue:
 

Superman

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dick0236;n877964 said:
No Superman, this argument of a cumulative risk is wrong.

I fully agree - I was just wondering if anyone else read that the study was presenting as if cumulative. Coming up on 73% odds myself. So far I'm on the 27% good side.
 

rakesh1167

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dick0236;n877964 said:
No Superman, this argument of a cumulative risk is wrong. Each year is an independent risk from the earlier years and each event(.6% reop, 1.5% bleed, .6% clot) is independent from the others. It's like flipping a coin, or three coins......the chance of a "head" on the first flip is 50%/coin and the chance of a "head" on the tenth flip is 50%/coin.......,so your risk of one of these heart events happening in the first year is .6%, 1.5%, .6%, not 2.7%.....and the risk at the end of the first decade remains(might change a little due to other factors) .6%, 1.5%, .6%.....not 2.7% x 10years = 27%

There is an older post done by a professor at Notre Dame (I think) who did a very good statistical presentation explaining the cumulative fallacy of this type of argument. He also noted that his pre-med students where notoriously poor at Statistics.....LOL.

Now, if you will excuse me, I need to lie down as my current risk is 2.7%++ x 50 = 135%+++.......so I gotta be very careful........:Tongue:

Chance of anything bad happening in 1 year = .02, chance of anything bad not happening in 1 year is 1 - .02 = .98. Total is always 1.

Let's say we are dealing with n years.

Chance that nothing bad happens during n years + Chance that something bad happens (in 1 or more years) = 1. There is no other possibility.

It is easy to calculate that "Chance that nothing bad happens during n years" is .98 multiplied n times = (.98) ^n.
So chance that something bad happens in n years = 1 - (.98) ^ n .
So it will move towards 1 (it means 100%), but it will never be greater that or equal to 1.

It is like throwing coins multiple times. Chance that you get head in atleast one of the try increases with each trial. But still there is a small chance that you will get all the tails and no head.
 

mikeccolella

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Hey the article says what it says. Their conclusions are what they are. Take 'em or leave 'em. I am certainly NOT trying to convince anyone one way or the other. Read it and draw your own conclusions. IAC, my purpose was simply to help out with the original question which any readers in the waiting room will have to deal with.
 

pellicle

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mikeccolella;n877970 said:
Hey the article says what it says. Their conclusions are what they are. Take 'em or leave 'em. .
agreed ... however when I did my masters by research we were EXPECTED to undertake critical analysis of EVERY journal article we cited. It was part of our lit review process.

My own experience is that many non academic trained people don't do such and thus find confusion in what appears to be contradiction in the literature; a lack of uniform consensus.

Some people respond to this with the abject "you can read anything you want into the data" and choose to dismiss it. However all researchers have some bias in their writing (say, to satisfy their funders) and so it is the duty of the readers to begin with the abstract and then examine the methods (which are required in the journal article) to determine if their particular angle on the methods coincides with the writers needs / angle.

So please don't take discussion personally ... its all about unpacking that ball of yarn and seeing what it is. This sort of analysis is critical in determining if the research "findings" are transferable to you. There is no black and white in research (that only exists in maths).

:)

PS: as was observed earlier, I think you made the right decision with your choice for you.

Best Wishes
 

mikeccolella

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Pellicle, it bugs me that we have to even discuss these things. I feel for those folks who are put in the position of making a tough choice on valve selection. I was there just a few months ago. I would rather it was a slam dunk. But like many others my surgeon threw it in my lap. I really appreciate the research though only wish there was enough to draw a much clearer picture, but thats how it goes. But there probably IS no clear picture. The choices are ultimately an individual thing.
 

pellicle

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Hi

mikeccolella;n877978 said:
Pellicle, it bugs me that we have to even discuss these things.

It is vexing that there seems such a lack of consensus, but looking at it another way in my lifetime we have gone from first trials with rudimentary devices, through to a highly developed system. This is a short time for the establishment of a uniform concept of best practice. Many other areas of medicine have taken much longer.

As is regularly observed tissue prosthetic forms the vast majority of valves placed in the aortic position in both Europe and the USA. I believe that this is because for the vast majority of patients that this represents the best compromise.

The issues always revolve around the "outliers", those of us who aren't over 60 and facing their first operation.

For instance those of us who are in the far less common situation of being perhaps under 30.

This is where there just simply isn't enough data or experience to make good rulesets of how to proceed.

But there probably IS no clear picture. The choices are ultimately an individual thing.

I agree, and for some that involves an intellectual decision and a process of learning, while for others that can only be an emotional decision.

I do my best to help those who want to work through the data and the evidence , who wish to come to an intellectual decision. For that is all I can do. The emotional decisions must come from with in themselves.

I have put my summary position forward here many times, but for those over 50 at their first OHS, I usually say that a tissue valve isn't a bad choice and you only likely face one redo.

For younger folks , I usually wish to engage them more to see more and know both their case and their temperament.

But in some ways its the duty of the surgeon to "throw it in your lap", for otherwise they play God as they once did.
 

Northernlights

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I'm not sure there is so much of a dichotomy between the 'intellectual' and the 'emotional' choice. We are all both intellectual and emotional beings and we make our choices through a mixture of the two. All articles contain a certain amount of bias, whether through funding ( easy to check , as conflicts of interest are stated), or through the influence on the surgeon/ cardiologist of his own experience with patients. The same goes for us readers - the choice of research we read and cite for other forum members comes through the filter of our own personal experiences and priorities, and, inevitably, the emotions they evoke, whether we recognise this consciously or not.

It was interesting reading people's personal reasons for choosing, and indeed this validates the emphasis on the importance of patient choice in the guidelines (class I). People will inevitably read and interpret research like the posted article in the light of their own preferences - and this is actually fair enough as the importance we give to particular aspects is always different. People's priorities and lives differ. The lack of medical consensus in the literature demonstrates that there is no perfect choice because there is no perfect prosthetic valve, just a selection of good ones - mechanical / tissue / homograft / Ross/ repair / TAVI- each with their own advantages and disadvantages which you have to weigh up for yourself. The only proviso is you can't have your cake and eat it e.g. if you don't want warfarin you need to accept the likelihood of reoperation, and it's no good pinning your hopes on valve- in- valve TAVI if you have a 21 mm valve!

Several people agreed they chose mechanical because they wanted to 'control their fate'. I was particularly interested in this in that I felt much more in control when I was able to choose not to have a mechanical! So to me the element of control lies in the ability to choose, not in what you choose, and I am actually grateful that there are so many possibilities. The bottom line is frank discussions with surgeon and cardiologist and establishing your own personal priorities. Mayo prefers mechanical, Cleveland tissue: both excellent hospitals!
 

neil

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absol spot on northernlights, top post, we cant choose a valve choice for somebody else we have to choose our own path, ive always felt statistics to a point are brill but then it gets into muddy waters, we can pull out statistics to prove or back our opinion on any subject, it can in many ways make your head spin, To me look at the basic plus and minus have a good natter with your surgeon and cardio then choose,
 

tigerlily

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jcgtok17;n877904 said:
Doug, Tough call. I recently went with a tissue valve (St. Jude Medical 28mm GT model). The AVR (BAV) operation was 5/1/17 and mechanical was not given much consideration in Japan, where I had the procedure, despite my age (50). Crown is a popular valve in Japan (average 22mm). I read that in Germany 70% of value replacements are now tissue values. I'm comfortable with my choice (no Warfarin) and recovery is going very well. I take Crestor and recent studies show use (statins) extends the life of tissue valves. Best of luck with both your decision and the operation/recovery. JCG

I never heard before that statins increase the life of tissue valves. I did read about a study though that high cholesterol increases the probability of calcification so maybe that does make sense. Interesting.
 

dcc617

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My porcine valve is failing after 5.5 years and is coming out in weeks not months. I was 57 when it went in and now...well...you do the math. hehe. At 62, I really don't want to take a chance and have it last another 5. Looks like mechanical for me. But those decisions are coming in a few weeks.
 

tigerlily

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One thing no one mentioned that could effect your choice is how many surgeries are you likely to have unrelated to your valve. I've never gotten a very clear picture of what a hassle it might be to come off of warfarin so you can have surgery but it must make things more complicated. If you happen to be one of those people who seems to go under the knife more often than most, it seems something to consider. My first valve replacement was done when I was 53 in 2006 and I chose tissue. I had never had surgery before then. Since then, I've had 5 surgeries. Of course, I couldn't have known it would work out that way and maybe going off of warfarin for each of those surgeries wouldn't have been that big a deal but I'm glad I didn't have to worry about it.

Now, I'm 64 and will be 65 in October. My tissue valve is showing moderate calcification and my surgeon thinks it will need to be replaced within a year. Facing a redo is a pretty big deal. Like the article said, my chances of surviving a second surgery, according to my surgeon, are very good but still, it's a scary prospect. If possible, my surgeon recommends another tissue valve. At this point, I want to mention that I find the article's statement that the average life expectancy after aortic valve replacement for a 60 year old to be 12 years... depressing! Even at my age, I find making a decision about what kind of valve to get difficult. My surgeon proposed that if I need a third valve replacement, he would do a TAVR. No one knows at this point how long a TAVR lasts since they are new technology and given to elderly patients most of the time. I hope they last a long time and I hope valve in valve would be no problem for me. I thought my current valve would last longer than it appears It's going to. I was hoping for 15 to 20 years. I guess I was too optimistic but it just goes to show that there are many ways things could go.
 
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