Has tissue valve replacement become the new "preferred" for 40-50-60year olds?

[drivetopless]

Has tissue valve replacement become the new "preferred" for 40-50-60year olds?

Had my second consult for surgery this morning with a surgeon at Emory in Atlanta.
He was very careful not to "sway" my choice of valve, but when asked what he would do if he were faced with surgery today (we're close in age), he said he would go tissue valve as he is not a good "pill taker."

I'm paraphrasing from memory, so take these with a grain of salt. But I though I would share his comments.

He said that 10 or so years ago, mechanical VR as the obvious choice for some one between 40-60 years of age. Today, the new tissue valves have more longevity (though it is too soon to tell if that is really true). He sited a coumadin dosing complication/incident risk of 1-1.5%/year. This risk is cumulative over the years. The risk of second surgery in 10 or 15 years with the tissue valve is less than the risk of long term coumadin use.

He also said you can start tissue and then go mechanical on the 2nd surgery with no problems.

I'm still leaning toward mechanical and he was open to that. Said he would use whatever valve I wanted if I went mechanical. He discussed On-X vs St. Jude. He said St. Jude has a smaller profile and better hemodynamics and a longer track record. But On-X is OK, too. He just finds the On-X can be a little more challenging to fit. Emory is running the On-X study for reduced anti-coagulation therapy.

Anyway, just wanted to share what I learned. Do you think the tissue valves are going to replace mechanical valves as the valve of choice for middle age folks?

 

[Luana]

My surgeon's recommendation was mechanical.

 

[escargome]

I doubt it. Although I chose tissue, my surgeon and I had a long long discussion on the pros and cons of both. I even asked him which he would take and he refused to answer on the grounds that it might affect my decision (he and I are the same age). So when this decsion comes up I would only hope that each and every surgeon is open to discussion of both types of valves and just abides by the wishes of that particular patient. Good Luck to you on your upcoming surgery/recovery. You have made a strong informed decision.

 

[dick0236]

He sited a coumadin dosing complication/incident risk of 1-1.5%/year. This risk is cumulative over the years. The risk of second surgery in 10 or 15 years with the tissue valve is less than the risk of long term coumadin use.

He also said you can start tissue and then go mechanical on the 2nd surgery with no problems.

?

I have seen this "cumulative risk" of 1% -2% posted before on this forum. A couple years ago, a statistics professor, debunked this myth very well. Ross or some other computer savvy member can direct you to that post. There is no mathematical reason or evidence to make the "cumulative" statement. The risk may be 1 - 2%, but it remains relatively the same over the years. If he is correct, I'd better say my goodbys now because my risk, after 43 years with my valve, would now be approaching 50 - 90%:rolleyes2::rolleyes2:......and before some of you remind me that I have had a stroke, I will clarify......my stroke was due only to my misuse of the drug and not to drug itself. I was like this surgeon when he states "I am not a good pill taker". I wasn't either, but I learned to be a "good pill taker" pretty damn quick.

Regarding his comment about tissue now, mechanical later.....remember he is is the medical profession and has no trouble with the system. My wife is an RN and feels much the same way as him. Personally, I am not nearly that comfortable with the system.....remeber that I am retired from the health insurance business.
I have a neighbor who did the tissue valve(16 years) then mechanical valve(18 years and counting) thing, and it seems to be working out OK. I guess my question would be...if you plan, in the beginning, to get a mechanical valve when the tissue wears out, why not get the mechanical first....:confused2: His rational seems flawed. From what little I know, the problems with warfarin become greater with old age for many reasons. It would make more sense to go to a tissue valve at the older age, not the other way 'round......that's what I probably will do IF it becomes necessary.

 

[Ross]

This risk is cumulative over the years. The risk of second surgery in 10 or 15 years with the tissue valve is less than the risk of long term coumadin use.

This is very much untrue and mathematically impossible or all of us would have had something happen by now.

I will always disagree with the second half here. The problem with anticoagulation is not the drugs fault, it's those managing it. Most doctors to this day, do not understand how to dose nor manage a anticoagulation patient. Nearly all the bad things that happen are a direct result of a person either not being anticoagulated enough or too much. Now that home testing and self management are becoming more popular and more people are staying within their range more often, it will be a while, but your going to see the "Bad things" slowly subside. I was looking at a study this morning on the long term effects and the point jumped right out of the page like it was waving a red flag that said:

Of the major TE events occurring within 30 days, 100% of patients in both age groups were inadequately anticoagulated at the time of the event, and for events occurring more than 30 days after AVR, 45% in group 1 and 57% in group 2 were inadequately anticoagulated (INR less than 2.0).

What most people don't understand when I talk about the dangers of reops is, maybe it won't be your heart or the valves that cause you problems. It can be kidney failure, respiratory failure, infection, or any number of things. Why risk any of it if you don't have too? Clearly, there are times when tissue makes sense. I'm not saying that it's not, but when we get people in here that haven't even been through their first surgeries, planning their second, third and forth, somethings wrong. I'd like to remind people that some don't won't make it through their first surgery. It's happened before and I'm sure it will happen again. We have no crystal ball that tells us who's going to do fine and who's not.

 

[ALCapshaw2]

AH, yet another Medical Professional who does NOT understand Statistics !

IF the risks of Coumadin were indeed cumulative, you would eventually reach a point where the risk would be 100%.
We KNOW that is NOT what happens. (and what would be the risk in the Next Year? 102% HUH?

I've got a copy of the Long Post where the Notre Dame Instructor detailed his analysis of the Coumadin Risk.
I'll try to find it and either copy it or provide a link.

The Risk of having an "event" does increase with time, just as the risk of having had a Car Accident rises the longer you drive, but that risk is NOT CUMULATIVE.

'AL Capshaw'

 

[MarkU]

He said that 10 or so years ago, mechanical VR as the obvious choice for some one between 40-60 years of age.

That was me ten years ago at 47. Both my cardiologist and surgeon strongly urged me to choose a mechanical, mostly to reduce the probabiity of future reops. I trusted in their recommendations, and nothing in the past ten years has caused me to question my decision.
Coumadin wasn't really a concern to me then, and hasn't been a major issue over the past ten years (the biggest hassle has been dealing with other medical professionals who didn't have a clue about Coumadin therapy).

I feel very lucky and blessed to be able to live a full and active life. Considering that I was given three year's life expectancy without my AVR, I try not to take any day or anything for granted.

I do take exception to the comment: "He also said you can start tissue and then go mechanical on the 2nd surgery with no problems."
I have to assume he was implying that you can replace a tissue valve with a mechanical, not there were "no problems" having major surgery for the second time. I was told that mortality basically doubled for every reop; that had a significant influence on my decision ten years ago.

With the advancement in tissue valves in the past ten years it would probably make my decision more difficult if I had to make it today, but I think I would still chose a mechanical valve.

Mark

 

[Mentu]

I quite agree with Dick. Why would anyone select a valve that even before the first surgery they plan to replace with a different valve in a second surgery. Ok, a woman who wants fewer complications with child bearing might very properly make such a choice but for almost anyone else it sounds absurd. Like people in other fields, Doctors sometimes say things that make little sense when viewed from outside their profession. Second surgeries are generally less risky now than in the past but one can have no idea what your state of health will be in the future. That phrase "generally less risky" may not include you or me a couple of decades from the present.

Larry

 

[neil]

yep think tissue is the new preferred choice, well i would say that wouldnt i lol, hope this isnt gonna turn into another i love mech or i love tissue argument,cricky havnt we had enough,come on guys lets argue over whether dark choclate or milk choclate is better, now THATS an issue

 

[Ross]

Well Neil I have a problem. Where is the beer? I need a beer. Give me all your beer!

 

[neil]

ross am busy trying out dark choc and milk choc, give me a break, this is hard work,

 

[Superbob]

yep think tissue is the new preferred choice, well i would say that wouldnt i lol, hope this isnt gonna turn into another i love mech or i love tissue argument,cricky havnt we had enough,come on guys lets argue over whether dark choclate or milk choclate is better, now THATS an issue

Good one, Neil! I say dark chocolate. Of course, I am a Porky Pigger, too.

 

[mainframe]

He also said you can start tissue and then go mechanical on the 2nd surgery with no problems.

How come nobody told me this?

Milk chocolate!

 

[Kathy McCain]

Well folks, again I say it is a PERSONAL decision after a CAREFUL consultation of the pros and cons with your Dr's. PERSONALLY though my opinion is, people that have a health issue that would make taking coumadin risky, or a women of child bearing age, and anyone over 50yrs, should probably go tissue.

Hopefully the medical community will advance, and improve BOTH valve types within the decade.

 

[Kathy McCain]

Oh, I kind of agree with Neil and some others, but I'll put it this way. Gee folks, (pardon the expression, I'm a real dog lover) haven't we "beat this dog to death?"

 

[heartman77]

heck i already have a new valve....i want to know where the free chocolate is to test I have read tho that the AMA has found that 73% of Mechanical heart valve recipients of Kazakhstan decent who wear leisure suits prefer dark chocolate. Michael

 

[drivetopless]

I knew I could count on you guys for some great debate. Has anyone seen any research on the "new" tissue valves?

Well, Kathy and Neil, I suspect this dog will never die no matter how many times we beat it because there will always be pre-ops like me wanting reassurance when they start second guessing themselves after a conversation with their surgeons. Thank you all for your continued willingness to repeat yourself.

And this Doc considered me a women of child bearing years at 46. I just laughed--not if I can help it.

Mark, the "no problem" was my para-phrasing, not Doc's. I specifically asked him about switching valve types with a reop. I was just curious about it.

I realize there's no wrong or right choice here. A new valve, whatever type, is better than the current one that will surely kill me witinin 5 years so whatever I choose- it's a win. I just like to read all of your excellent arguments. You, the voice of real experience, all seem so confident and self-assured.



Milk chocolate. Beer chaser.

 

[kpearse]

My surgeon's recommendation was mechanical. I was 50 and thought that was the way for me to go.

 

[Kathy McCain]

Hi driving topless,

I completely understand your need for assurance when it comes to valve selection. My intention was not to be insensitive. Have faith, you will choose the RIGHT valve for YOU.

Good luck and God bless

 

[Kathy McCain]

Michael and Neil,

Love your sense of humor!! This thread certainly needed some comic relief!

Neil,
I personally LOVE Hersheys DARK Chocolate, it's just the best !