Choices!

[jj3]

Hello.

I thought that there really wasn't going to be much choice. I am 40 yrs old; a larger guy -- 6'6", 245lb; and still desire to be somewhat active. So, my local cardiologist has always said the way to go would be a mechanical valve.

Also, I have a bleeding disorder and the original thought of the hematologist was that the mechanical valve on coumadin would be better than a biological valve and asprin.

So, the surgery is set for 1/27 and I am thinking mechanical -- when I get a call from the hematologist who indicates that they had a meeting and the cardiologist who did my recent heart cath (who I only met that day and have not had any real conversation with . . .) feels that today's biological valve would be the better choice for me -- apart from the blood issue [no need to worry about coumadin management, options should be greater in 15+ years when that valve would need to be replaced, etc.]. And, the hematologists said that, though there really is no definitive answer as to which valve would be best with my blood disorder, she would actually lean in the favor of the biological valve -- but that the choice would really be mine and to not make the decision solely on the matter of the blood disorder.

Well -- at first, I was still thinking mechanical. But, then I find myself dwelling on the mater and I do wonder if it might be simpler to have the biological valve put in, recover for the 8-12 weeks, and then not really have to worry about things for another 10-15-18 years ?!?!?!?!

So -- my questions would be:

1. Are there people in my age range making the decision to use a biological valve? -- and what has been your feeling after the surgery?

2. What are the increased risk of re-operation. I have read the low morbidity rates for the initial operation; and I saw one web-site address concerns with multiple operations and a poor mobidity rate for a third operation. But, what about that second surgery???

3. Can anyone point me to studies regarding the better biological valves of today (and what are they???) and any estimates for there longevity in people my age range???

(This was so much simpler when I didn't feel there was a real choice!)

Thanks,
Joe

 

[geebee]

Hi Joe,
I would always make a choice that could result in the fewest number of surgeries over a lifetime. I say "could" because there are no guarantees that even a mechanical will last a lifetime. There are always issues that can occur and you may need a second surgery regardless of which valve you choose.
That being said, the chances of a mechanical lasting 20 years or so is very good. The valve itself does not usually malfunction but the sewing ring can be a problem down the road requiring resurgery.
Also, with your "bleeding problem", I assume clotting is not considered an issue so a mechanical would work even better for you.
A biological guarantees a second surgery as they are prone to the same problems that caused your original need for VR. That second surgery can be anywhere from 8-15 years depending on your situation, everyone is different.
Multiple surgeries can be dangerous because scar tissue is difficult to cut through and makes seeing things such as arteries, etc. difficult for the surgeon to see. I almost died during my second surgery because the pulmonary artery was severed while cutting throught the adhesions from my first surgery. Luckily, God had other plans for me and the surgeon stopped the bleeding. Just wanted to give you an example of the problems that can occur.
I hope this helps.
Smiles,
Gina

 

[tobagotwo]

There is a fairly large population in your age group that has used biological valves. Some women of childbearing age have deliberately chosen them to take them through anticipated future pregnancies and childbirths.

There is some evidence that pregnancy abuses biological valves, so their valves may have had a shorter lifespan than you might get. And the new anticalcification treatments are, well, new, so we don't have good data for them in younger people, pregnant or otherwise.

I would think the bleeding disorder would be a consideration, which ever way that is pointing (I was unclear on that). I also note that, while frequently employed, long-term aspirin therapy is not required for biological valves, per many cardiologists and surgeons. This excepts some form of anticoagulation therapy during the first three months, while the epithelium heals around the new valve, maybe six months with dacron aortic replacement as well.

Results similar to Sheyla's mention of the statistics of multiple surgeries have been published on this site before. Yet everyone's experience with surgery is different. I might vary slightly with Sheyla's comment regarding bleeding, inthat my understanding is that the numbers given are a combination of the risk of bleeding events from warfarin and clotting events from the mechanical valves.

Risks over time for both types appear to be functionally equal in a very large study done a few years ago.

As such, it really boils down to your bleeding disorder, your healing ability and general health, your personality, and perhaps even whether the coin lands heads or tails...

Best wishes,

 

[RCB]

Attribution?

Attribution?

Psychology or statistics ? both are compelling.

Statistically, a new journal articel in the Annals of Thoracic Surgery came out advocating tissue valves over mechanical in younger (under 60) patients since the risk of operative mortality at re-operation is now the SAME as the risk at initial surgery, which in most good centers is 1-2%. Your risk of a major problem is likely greater getting your tonsils removed. This is the generally recognized risk among surgeons today. (many will tell you it's more like 1%).

But psychologically, there is no data, no study, which can make you feel good about going under the knife again. Then again, you MAY not go under the knife again, but there is the 2-4% bleeding risk associated with a mechanical valve each year.

The choice is individual and very personal. The data isn't everything, alas.

Since this study departs from the ACC recommendation for heart valve
selection can you please give the citations of the study in Ann. Thor. and
bleed risk statistic.

For clarity, bleed risk is not to be confused with mortality rate or are you intending it to be?

 

[Ross]

Psychology or statistics ? both are compelling.

Statistically, a new journal articel in the Annals of Thoracic Surgery came out advocating tissue valves over mechanical in younger (under 60) patients since the risk of operative mortality at re-operation is now the SAME as the risk at initial surgery, which in most good centers is 1-2%. Your risk of a major problem is likely greater getting your tonsils removed. This is the generally recognized risk among surgeons today. (many will tell you it's more like 1%).

The people writing these statistics have never had the surgery themselves, therefor their opinions should not be considered in my opinion. This is not a game to be played as many times as possible. One time around at this is too much. Until these people have had the surgery themselves, I think they should shut up about these statistics.

Sorry but I want no one thinking this is a big old walk in the park. It's the furthest thing from it!

 

[Mary]

Way to go Ross!

 

[geebee]

Sorry, but I do not agree with the statement that re-operations are no more dangerous than having your tonsils removed. I don't even care if "statistics" back it up, one OHS is way too much for anyone, more than one is unfortunate and should be avoided whenever possible. I would hate to think that someone is receiving information indicating it's no big deal or not something to worry about.
Smiles,
Gina

 

[Karlynn]

I would also caution against hedging your bets on technology being so far advanced in 15 years to have the "miracle" answer for your next valve replacement. It may and it may not be. When they first started with the mechanical heart as an alternative to heart transplants the physicians at the time were projecting that it would be a viable alternative for long time use within the reasonable future. We still aren't there yet. Progress has been made in using the technology for some of the most critical patients but science and technology has been unable to affect a progression to the extent of the original intent.

It's a tough choice and unfortunately none of us have a crystal ball. You need to weigh the options yourself based on your current life and do some guessing about the future. Then make a choice, have the surgery and live your life and enjoy it.

 

[Ross]

I would also caution against hedging your bets on technology being so far advanced in 15 years to have the "miracle" answer for your next valve replacement.

Exactly! When I went for my last surgery and asked the surgeon where he saw things 15-20 years from now, he's response was, "We don't worry about tomorrow, we deal with today."

 

[Les]

Until these people have had the surgery themselves, I think they should shut up about these statistics.

If only that would happen...

 

[RCB]

Watch out!

Watch out!

Sorry, but I do not agree with the statement that re-operations are no more dangerous than having your tonsils removed. .
Smiles,
Gina

Geebee,
If you look carefully at ST's carefully crafted statement, she does not state that. Although stating that valve surgery risk is "likely greater
(than) getting your tonsils removed" is true, the comparison is contemptible.
The same thing could be said of the risk childbirth and a bad period- while true, to make it shows a lack of empathy.
There seems to me to evangelizing going on where you have to parse
every statement very carefully.

 

[Ross]

Geebee,
If you look carefully at ST's carefully crafted statement, she does not state that. Although stating that valve surgery risk is "likely greater
(than) getting your tonsils removed" is true, the comparison is contemptible.
The same thing could be said of the risk childbirth and a bad period- while true, to make it shows a lack of empathy.
There seems to me to evangelizing going on where you have to parse
every statement very carefully.

I'm not into tricky statements and parsing anything. I'm telling people just exactly how it is with no sugar coating and no hidden meanings. Some people do not like me for that. I've had some say so, but they later came back to let me know how right I was!

 

[geebee]

I meant no disrespect nor did I intend to misquote. Maybe the statistical mortality risk IS greater when having your tonsils removed than when having a second OHS. However, I do not really believe that analysis is appropriate when trying to assist someone in making choices about future OHS.
I am sure the statistics quoted were meant to comfort someone concerned about how dangerous a second surgery is (or is not) but I think a better analogy could have been chosen.
Smiles,
Gina

 

[Karlynn]

I had to laugh at the "tonsils" analogy. Meaning no disrespect to ST, for I think we are fortunate to have her studied opinion. However, it struck a personal chord for me because my husband's response to my severe apprehension over having OHS was "It's no worse than having your tonsils out." (which he had done as an adult) I'm sure he was speaking statistically. But those of us who've had OHS are quite sure, even though we may not have had our tonsils out, that given the choice, we would choose the tonsils!

 

[d-mac]

Just leaving the issue for a moment

Just leaving the issue for a moment

Just looked at your history in your signature block RCB.

What an inspiration you are. Amazing to see your progress and I am looking forward to a similar story, God willing.

 

[inlaguna]

Joe,

Choosing is a fun process.......huh. I am 41 and went through the same thing 8 weeks ago. If I can weigh in on your questions.


As the longevity of tissue valves has increased I believe more folks under 60 are considering. Cardiologists and surgeons are bringing it up as an option and I don't think they did that 5-10 years ago. They did not with me.
I have had a carpentier-edwards magna tissue valve in me for 7 weeks now. Hardly makes me an expert, but I feel well. Like you, I was told 10-20 years for that valve.

This was my second surgery and I tolerated both well. So my choice involved me getting a third surgery down the road.That does not mean that there were not risks ( see other posts) and a considerable amount of pain for me to deal with during my first two. I still have pain in the sternum area and do not expect that to go completely away for weeks or months. There are many, many other types of surgery I would stand in line for before OHS, but, as I said, I opted to do it again.

I feel that there will be advances in 15 years ( either lower risk drugs or valves that require no anti-coagulation therapy that go the distance). If that's not the case I am not sure if I raise my hand for a 4th surgery or not.....probably not.

There are many choices on tissue valves and as Bob had mentioned new processes make them ( in theory) go longer than the older versions. Carpentier-Edwards has a web site, but reading this site ( as you can see) gives you the "no-spin" version of what various valves are like. Lots of real world examples.

Not an easy choice. I am completely comfortable with mine now that it is done.


Dan

 

[Ross]

I nearly died in my first two, so I'm not about to raise my hand for anymore.

I cannot dishonor the memory of Chevyman, Englander nor Mrs. McCombe, all of which now look down on us and tell someone to go through this time and time again, when two of them died on their first and one shortly after.

I realize that one valve may not be suitable for all people. The reality is, you do not want to have to do this time and time again. You can't sit and say to yourself, "Well gee, 15-20 years down the road........" You have to decide on the hear and now. Some people have no problems going through surgeries. Some have problems every time. Some don't make it through one. That is the stone cold, hard truth without sugar coating. No one likes to think about it, but think about it you must.

 

[Bionic Valve Tim]

I don't have much to add to the discussion of re-surgery, but even in my situation (31 years old, overall good health and pretty active/athletic) the surgery was a bear! And I say that even though I have the impression my recovery was smoother and less painful than what others seem to have endured. FWIW, YMMV, etc, etc.

As someone who also had to make the choice at a young age, my advice would be to spend some time in the Coumadin forum and educate yourself about anticoagulation treatment.

There's a lot of misinformation/misunderstanding out there regarding coumadin--once you learn a little about it, you can make a sound decision about how that aspect would affect your life(style). Of course there are other issues to consider in your decision, but most people obviously cite coumadin as the main disadvantage of a mechanical...

Tim

 

[Les]

I cannot dishonor the memory of Chevyman, Englander nor Mrs. McCombe, all of which now look down on us and tell someone to go through this time and time again, when two of them died on their first and one shortly after.

How dare anyone not having endured OHS to make any statement discounting the trauma of repeated surgeries. These were "Our People" who didn't survive their first...and they would beg to differ. May they always be at peace...

 

[PapaHappyStar]

It is very inaccurate to compare mortality rates from tonsillectomy ( 1:16000 ) http://www.ispub.com/ostia/index.ph...vol2n2/palatal.xml#documentHeading-Discussion
to heart surgery.

If a hospital were to claim that their mortality rates from open heart surgery were comparable to their mortality rates from tonsillectomy I wouldnt go there because their tonsillectomy mortality rates were too high!

This said, my opinion is perhaps risking a second surgery in some cases may be a valid choice to avoid the use of coumadin. Mechanical valves are still thrombogenic and there is a non-trivial risk of stroke events:
http://www.sciencedirect.com/scienc...d=864464&md5=8af488bba7fa11eb3b3e7780ce3100d1
Nowadays perhaps the risk is lower with newer valves and a better understanding of how to regulate medication -- but I dislike the thought of risking a stroke more than a second heart surgery, plus I am bad at remembering regular tasks....

But this is my opinion now and perhaps if I have to get my aortic valve redone I will opt for a mechanical valve.