I just don't think that a life-or-death decision should be based in any way on what the future might hold. Get a tissue valve because your are not good with taking regular medication or are a martial arts enthusiast or plan on a future pregnancy or might not be able to handle the clicking noise of a mechanical or any other reason based on known facts and information. But, don't choose a biological valve sure that you'll avoid future OHS with a TAVI valve. There are still too many unknowns and if you start out at a young enough age to need two or three future replacements, they surely won't all be TAVI. If one of your primary considerations is avoiding future surgeries, you probably want to consider a mechanical
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I don't believe anyone at least here, who chooses a tissue valve is "
sure that you'll avoid future OHS with a TAVI valve" They do so planning on having at least 1 more OHS, if they are younger than 50, and plan on out living a tissue valve they would get now. BUT based on the info available today,not in the future, they also know that when THIS valve needs replaced in 15-20 or even 10-20+ years from now, there IS a very real possibility that TAVI valve in valve MIGHT be an option for them.
I DO believe that anyone choosing a tissue valve right now, should discuss with their surgeons which tissue valves in use today, look like they will be the best bet of being able to have a percutaneous valve implanted in it when the time comes, to increase their chances of being able to take advantage of that. I think it is pretty important, but rarely see it discussed. OF course TAVI will NEVER or at least in the next decade or so replace ALL surgical valve replacements, some people will always need open heart surgery for first or second valve replacements, but some valves are already known to be easier to implant valves in and some are much harder, IF they are even able to have another valve placed inside them safely.w/ the available valves and deployment systems.
Also IF you are young enough that you will need to need two or three future replacements, you are either very young, 30s or younger- or very unlucky - and still choose a tissue valve, today, when this valve needs replaced, you will make the best choice of available options when the time comes and aren't locking yourself in to numerous ( 3 or more) surgeries.
I DO agree If one of your primary considerations is avoiding future surgeries, you probably want to consider a mechanical. BUT for MANY 1st and 2nd OHS patients they rather the risks of at least 1 more OHS, than getting a Mechanical valve and requiring Anticoagulants and everything that goes along with that, possible ticking, bloodwork, (even home testing) increase chances of (Clotting OR bleeding stroke, bleeds possible issues effecting Vit K from doing all its jobs etc, the rest of their lives.
Luckily in this day and age both choices are very good and gives you the chance of a long and happy life, and Millions of dollars are being spent to make improvements in valves, tissue or mechanical, how the valve is replaced, surgery or cath and Meds like all the new anticoagulants that HOPEFULLY make all choices and lives better.
As far as hemodynamics, I think that just measuring up to surgically implanted valves is an accomplishment, to claim that TAVI is superior seems to be pushing it at this stage. In fact, the real superiority of TAVI is being able to implant it without surgery - I don't think it was ever conceived as a better valve per se, just an alternative way to get the valve into a patient who may need it and not be able to tolerate regular OHS. If they were more sure about the viability of valve-in-valve, maybe, but doesn't that surely necessarily reduce the effective opening? Still way too many questions to bet my life on it
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Again I agree that just measuring up to surgically placed valves as far as hemodynamics IS an accomplishment, but many studies show that the hemodynamics ARE better for TAVI valves compared to surgically placed, most likely because they dont have the large sewing ring taking up space, the leaflets are sewn right onto the very thin wire stents. OF course nothing is 100%, but even in the 1 article you linked to
http://shvd.org/abstracts/2011/C42_43.cgi from the un of Pa (Justin's doctors
"Hemodynamic Comparison of Aggressive Supra-annular Surgical Aortic Valve Replacement Versus Transcatheter Aortic Valve Implantation"
the opening sentence was "Transcatheter aortic valve implantation(TAVI) has been purported in many large cohort series to provide improved hemodynamics versus traditional aortic valve replacement(AVR) likely due to the absence of an obstructive sewing ring"
and concluded with
"CONCLUSIONS: TAVI and open AVR can show similar hemodynamics with the application of aggressive oversizing of the open AVR prosthesis. Both techniques show hemodynamic improvement at one year and further long-term follow-up is warranted"
So pretty much to get the surgical valve to be equal to the hemodynamics of the TAVI valve, involved
aggressive oversizing of the open AVR prosthesis (my bold)
Now these were valves implanted from 2007-2009 and alot of improvements have been made to percutaneous valves and placement in the following 5 ish years.
YES when they do valve in valve, since the old leaflets are basically smushed open, that could make a very small difference (the thickness of the leaflets) in the valve opening area, but when you watch videos of TAVI placement, its amazing how little difference it makes. still less than a sewing ring.
I'm also not sure I agree with your statement that "I don't think it was ever conceived as a better valve per se, just an alternative way to get the valve into a patient who may need it and not be able to tolerate regular OHS."
I agree they probably weren't making the percutaneous valves Better, but are hoping they are equal or at least, "Noninferior" to valves surgically placed, BUt disagree they mainly planned on them being used in "not be able to tolerate regular OHS" people, since already they are using them (in Trials" in the US and approved in other countries) in lower and lower risk patients needing Aortic valve replaced You figure since they already have done 60,000 TAVIs, world wide they couldnt all be highest risk or inoperable patients. I "Think" right now the patients in trials only have a 15% chance of mortality in surgery, Yes that is higher than most 1st-or 2nd valve OHS, but would be considerred great stats for many of the more complex heart surgery patients. and obviously they have some other comorbidities, that raises their risk of surgery
"And of course, the most important thing in all of this (IMHO) is being able to match the therapy to the needs of the individual patient. The transcatheter approach gives us yet another tool and a greater chance of providing the best and most appropriate treatment to each.
http://www.ncbi.nlm.nih.gov/pubmed/21982276;
http://shvd.org/abstracts/2011/C42_43.cgi;
http://dare.uva.nl/document/457644;
http://www.medscape.com/viewarticle/776724 (5 years +, good news so far);
http://cardioegypt.com/cardioeg/CE2012-Presentations/27-2-2012/006007.pdf;
http://www.valvexchange.com/physicians/ (just plain fascinating).[/QUOTE]
I agree its all good news and anything that makes more people live improved lives, new better valves, percutaneous valves, and different accesses for them, new drugs is only a good thing.
BTW Clay, I want to make sure you don't think I am picking on you or attacking anyone on this thread, I personally try NOT to highjack scared Newbies threads where they are trying to make the best decision for them with long back and forth discussions like this, especially since alot of things here are just our thoughts or opinions and we arent doctors. so this looked like a good thread to discuss this
Since either choice really IS a good choice, I don't want to scare new patients or drive them off at a time they are looking for and need support from people who have been there.
