Age old question..... tissue or mechanical

[pellicle]

Hi

pellicle, Just wanted to comment on your response to my post, When I say that heart surgery can be performed over and over again, I am going on people like you who have been opened up a few times and are doing great.

well as it happens I'm doing well on the outside but it is highly dependent on luck. You see I still have no idea if I have the infection (and it is being held in check by antibiotics) or if it is clear. The infection control specialist still has me on 500mg Amoxicillin 3 times a day (yes every 8 hours) which I have been taking daily since 2012.

So IF I was not someone who was tolerant of antiboitiics (and there are many) I may indeed have a very different outcome. As you perhaps know, the reason for me remaining on the antibiotics is that the risk of my prosthesis becoming infected is high. Should it become infected you can pretty much write me off. There are people here who have had to have their sternum totally removed to treat their infection. That brings with it many issues (all of which can be dealt with in the fight to stay alive).

So in a sense I'm lucky.

Also as I am on Anti Coagulation Therap (ACT) you could also take the view that I'm an excellent example of why there is no worry about being on Warfarin.

My primary told me of a girl who unfortuetely is on drugs and has had to have three valve replacements. But I do see here many people who have gone under the knife more than twice. I did not say it gets any easier, but you can survive

indeed, but your words made it seem trivial .. you know,you can just do it again and again ... they did not sound cautionary.

All operations, especially open heart have their risks.

and indeed those risks compound with each and every redo. You will note also that I never quibble about people choosing tissue valves when they are over 60, its the ones who are under 40 that I provide cautionary advice to.

I believe strongly that we who speak here have an obligation to newbies and lurkers who are trying to become informed to be factual and not just be hopeful.

As far as being on ATC, I know of people that have passed from a bump on the head, internal hemorage. On ATC, any bumps, falls, or forgetfullness can be life treatening. My grandfather died from masive hemorage so I know that being on ATV as an elderly person can be dangerous.

exactly, and being on ACT is indeed not to be dismissed as without problem. You will note that I almost always say "without other factors" ... indeed such factors can come up even later in life which makes it difficult to then "stop" being on ACT .... so its no clear path that's for sure.

But like going to the casino its all about probabilities. For someone who is younger and in good health the probabilities of multiple reops causing problems are high.

But probably not too many elderly people aren't on some kind of blood thinners.

a point I often also make ... you may choose a valve with the express intention of avoiding ACT but be placed on it for other reasons ....

They decided to do TAVR on my mother because of a number of reasons. She is on maintenance doses of chemo for lung cancer that is in remision. She had a masectomy(sp?) years ago and an implant, they cannot access her body or do anything through that arm,. Her veins are very small and she bruises very easily

I'm sorry to hear of your mothers health problems. I wish that we could all go through aging without these dramas. I asked because so often the words people use when saying things can mislead people to think things that are not quite right. For instance saying "we chose TAVI" makes it sound to someone who is anxious about their OHS that you had a simple choice of A or B and you chose A for no other reason than you felt like it. From what you've said TAVI was a choice based on the significant risks associated with more regular OHS.

She is alive and moving well.

I'm glad to hear that, I know only too well what it means to loose your loved ones.

Best Wishes

 

[pellicle]

Hi Steve

I think we also need to remember that virtually ALL of the published statistical data relates to tissue valves of the generation prior to the current.

very true, but as that article was 2010 they are indeed starting to capture that. Its interesting to me that I not seeing any significant change in numbers in the newer studies, which are by definition on newer tissue valves.

looking at the graphs its hard to not see that big drop off for people in <40 YO ... sure for those >60 its fine, but not for the younger ones.

 

[ottagal]

I think we also need to remember that virtually ALL of the published statistical data relates to tissue valves of the generation prior to the current. In other words, in order for the researchers to have long-term data, the valves have to be in service for a long time. The valves in these studies are called "second-generation" tissue valves, and IIRC, the current ones are considered "third-generation." There are differences in how the valves are treated to slow calcification, as well as possibly some mechanical differences which may change the expected number of cycles a leaflet may last before material fatigue occurs.

So, for all of us tissue valvers, the only information we have on which to base our decisions is the track record of the prior generation of valves, along with the beliefs and expectations of the manufacturers regarding their newest products.

Also, not trying to disparage any statistics, but don't forget that the data above are the mean lifespans of the valves. This is an average, meaning (pun?) that there are values above and values below the mean. So, as Roberta noted, none of us can know where we will fall within that statistical distribution.

Steve,
I was thinking the same thing regarding the current valves and how what apparently seems to be the same valve that was implanted 10 years ago, may indeed not be the same at all.

Take for example, the CE perimount valve. On the Edwards website it states that the CE perimount valve is "now available with ThermaFix advanced tissue process - the only tissue process that removes both major calcium binding sites.". Someone who had this perimount valve implanted 10 years ago would not have had the added protection.

In addition, it would have been beneficial to dissect the numbers in the study to determine what the 'mean' lifespan would be for those who had valves implanted at subcategory ages of 40-45, 45-50, 50 to 55, and 55-60. This would make the data more reliable as 40 to 60 is a large span and who knows what percentage were closer to 40 than 60. I hope I am making sense! However, I presume it would have been too small a sample size to provide any reliable data for this study.

I also think an important point that Robert added from the authors is that "that patients between 18 and 60 years of age who select a bioprosthesis at the time of initial heart valve surgery have an increased reoperation risk but experience NO long-term survival detriment compared with patients who select a mechanical valve."

 

[pellicle]

Hey Roberta ...

Pellicle:
As a follow up, I decided to delve further into the research article. Here is the list of the aortic valves that were implanted and included in the study. Some of them must have been implanted in the 80's for the authors to do a long term follow up. It will be interesting to see what the next 20 years shows.

indeed ... should I even be around in 20 years time ;-)

Its a vexing thing that as researchers we are usually just custodians of the data and the process. We have often passed on before the information becomes of relevance.

anyway, thanks heaps for that data ...

The authors also stated "that patients between 18 and 60 years of age who select a bioprosthesis at the time of initial heart valve surgery have an increased reoperation risk but experience NO long-term survival detriment compared with patients who select a mechanical valve."

its an interesting point, but I being more the St Thomas type I always want to look at things in more detail. I for instance don't usually satisfy myself with just the abstract, but read the methods. I guess its something which really got hammered in well doing my research masters. I keep coming back to the point that its mortality driven - long term survival. That they may have been more or less crippled and been on a host of drugs / antibiotics / pacemakers is not mentioned.

Its that sort of details I'd really like to know ...

of course for me its only academic ... I'm going to be with this valve "till death do us part".

 

[pellicle]

Lots of data and graphs being thrown around. Bottom line is do you fancy a re op down the line or being on warfarin and the problems that may occur with that.

That is a very true bottom line. Some people buy a car based on colour, some based on tech specs ... its up to each buyer, what is important to them and how they consider things. It may or may not make any particular choice better or worse in the long run anyway (you may still get a lemon). But still people like to evaluate.

You choose based on your preference, let others discuss their preferences as they wish.

 

[Northernlights]

Re TAVI I think it will end up much like stents v. bypass, and there is the same power struggle between interventionists and surgeons fearful of losing their share. This means there is some propaganda going on both ways - I don't think that Cartagena surgery blog was exactly impartial. TAVI is a brilliant advance, and as a primary therapy delivers better gradients than most surgical valves, but at present has more stroke problems (mother's memory problems?) and more residual regurgitation. I'm sure it will improve in those aspects. However, as a valve-in-valve future possibility for those with failing tissue valves, the valve-in-valve registry showed it only worked properly with the TAVI valve placed within a large tissue valve (25 mm or more): in smaller valves the gradients were much higher, as was the 12 month death rate. Putting a valve inside a stented tissue valve will inevitably make it smaller and more obstructive to blood flow than the original and no advances will get round this basic principle - in fact the valve- in-valve registry commentators suggested surgeons should stop inserting small valves, and make much more use of root enlargement.
Re tissue / mechanical we all have our own individual priorities, and the choice is often not clear-cut, but TAVI is often held out unrealistically as a future solution even to those of us with small valves.

PS wonderful Caravaggio!

 

[pellicle]

Northernlights

Have you seen

http://www.imdb.com/title/tt3089388/

Fascinating look into Vermeer

 

[skeptic49]

in fact the valve- in-valve registry commentators suggested surgeons should stop inserting small valves, and make much more use of root enlargement.

Excellent idea...I will mention this to my surgeon.

 

[epstns]

Pellicle - Thanks for the graph. It really puts a picture to the story. Of course, I'm relieved to have been in the "over 60 at implant" group.

I still wonder, though, if it would be possible for us to graphically show the date ranges during which the various generations of valves were implanted. The reason I think of this is that my valve was implanted in early 2011. Your graph shows data published in 2010 - so those valves that are, as of publication date, in their 15th year, were those implanted in 1995 or so. I'm pretty sure that still represents the generation before the current valves, at least for CE.

I imagine that the valve manufacturers are collecting is for current valves, but we won't see that for years.

 

[pellicle]

Hi Steve

Pellicle - Thanks for the graph. It really puts a picture to the story.

no worries, its actually out of the article that Roberta posted earlier ... here

If you are interested in reading the full article, here is the link.:

http://circ.ahajournals.org/content/...ppl_1/S75.full

"We examined the need for reoperation in 3975 patients who underwent first-time bioprosthetic aortic valve replacement (AVR) (n=3152) or mitral valve replacement (MVR) (n=823).

(returning to Steve...)

I still wonder, though, if it would be possible for us to graphically show the date ranges during which the various generations of valves were implanted. The reason I think of this is that my valve was implanted in early 2011. Your graph shows data published in 2010 - so those valves that are, as of publication date, in their 15th year, were those implanted in 1995 or so. I'm pretty sure that still represents the generation before the current valves, at least for CE.

totally with you on that ... data data data ... I believe that the medical groups are poor (but getting better) at reporting stuff.

I noted however that in that article they seem to include that:

Analyses were subsequently restricted to include only contemporary prostheses. In this study, contemporary stented aortic bioprostheses included the Carpentier-Edwards Perimount (Baxter Healthcare Corp, Irvine, CA) and the Medtronic Hancock II (Minneapolis, MN). Contemporary mitral bioprostheses included the Edwards Lifesciences Pericardial (Baxter Healthcare Corp), Medtronic Hancock II, and Medtronic Mosaic

(returning again to Steve...)

I imagine that the valve manufacturers are collecting is for current valves, but we won't see that for years.

and if they don't like it you won't see it either ... I feel we have already seen that with stuff like Dabigatran where they cherry pick their results and ignore studies.

Verges on falsification but isn't....

 

[cldlhd]

I guess not telling isn't quite the same as lying.....

 

[neil]

Of course data and information is good and everybody wants to know the ins and outs. What I am saying is sometimes you can have so much info it makes your head spin and can cloud your choice. You can use data to argue the case on both sides . What the bottom line is do you want a reop or warfarin. I will tell you something true. We all wish we didn't have to make the choice

 

[tom in MO]

I like the quote applied to Aristotle "It is the mark of an instructed mind to rest easy with that level of precision which the decision requires, and not to try an exactness which is unnecessary for the problem." When it comes to warfarin vs. reoperation, I believe we all make that decision based upon fear, not data, however we try to make it logical so as to believe it is correct. The reason I say it is based upon fear, is we all know that each person is an individual, and although the statistics go one way, we could go the other.

That said, don't worry, be happy, both choices are for life.

 

[neil]

Well put tom. Spot on mate

 

[pellicle]

Of course data and information is good and everybody wants to know the ins and outs.

which stunningly enough is what the OP wanted to know .... in case you didn't read the OP's question it was actually this:

... the TAVR procedure he believes that a faulty tissue valve ten years down the road can be replaced using the new procedure. What does everyone think, Do I buy into this "future possibility" and get the tissue valve or go with the mechanical and the coumadin that would be necessary? I definately would like to avoid further OHS in my future if at all possible.

so again I ask you to allow others to discuss things as they feel inclined.

 

[neil]

Here we go again . am not going to bite as we have been down this road before. I was voicing my opinion which I believe is allowed on here. Stop being so patronising and let's move on

 

[pellicle]

..Stop being so patronising and let's move on

if only you would take your own advice

Lots of data and graphs being thrown around. Bottom line ....

I'm sorry you don't understand maths or know how to understand graphs, but you can express your opinion without the patronising refs about the graphs.

Try taking your own so it seems to me your opinion is "Neils opinion is the only one to listen to, so stop with the graphs, and just get a tissue"

after all, the OP's question was (to quote your answer) what do I do "as I don't fancy a re op down the line or being on warfarin and the problems that may occur with that."

Do you come here to provide support to the question askers or just quarrel with people who answer in ways you don't like?

If anything it seems to me you are out to undermine any opinion which provides supporting data to differentiate the risks between A or B. You cry the martyr about having the ability to express your opinion, well it cuts both ways.

I don't in any way try to dissuade you from your opinion but you always seem to feel compelled to belittle any answers which are technically supported.

As well you seem to have glossed over my saying your bottom line was exactly right ... or were you too busy formulate a quip to read the opening sentence?

 

[neil]

Wow you really love your own voice. I have been on this site a long long time and if people want to go through all my posts there will find my main aim is to support. I find you a bully in the way you conduct yourself if anybody has the cheek to question your thoughts. Dont you dare question my reasons for coming on this great site. Wind your neck in for once.

 

[neil]

I apologise for people having to read all this as this is not the reason this site is here. Maybe anything else you want to say just pm me instead of getting into this slanging match we seem to get into. Then everybody hasn't got to read our differences. Hopefully that's the end of it

 

[pellicle]

Neil

Wow you really love your own voice.

so you now start with the attacks on me when we were having a debate. You totally evade the points which I made about yourself acting dismissive of our discussion while accusing me of being dismissive in tone. You have not addressed any point nor engaged directly but instead start with attacking me personally.

For those reading this (and sadly so too). I prefer not to make it private message based where people can hide behind a veil of invisibility where all manner of accusations can be made. This is classic passive aggressive behavior

Passive-aggressive behavior is the indirect expression of hostility, such as through procrastination, sarcasm, stubbornness, sullenness, or deliberate or repeated failure to accomplish requested tasks for which one is (often explicitly) responsible

in this case the task is to engage in discussion not just slang counter points around and be dismissive of fail to acknowledge the points of others.

You are totally entitled to your opinion, but you seem to ignore that others are too. So please by all means express your points (which I supported too) but please do not denigrate or be dismissive of the discussions which others were participating in willingly and with interest.

I will post no more on this thread and regret that again the angst that many people have over valve choice spills over into the disruption of reasonable and rational discussion which the original poster requested.