Hello all - New Member scared and confused please help

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I had my aortic replace at age 36, 9 years ago. I was placed on coumdin/warafin and have a pretty active lifestyle. I weighed the same as you at surgery, but I am shorter, 5' 2". But I did lose the weight to 200 and procrastinated and up to 160. You should have surgery, because, I bett you do not always feel good. After surgery, you will feel tons better than before. We all know what that is like. You will be fine with the mechanical valve, mine is a St Jude's. It is still keep ticking away. I hope to live a long time. You will be fine. Just come in here for information and comfort. We have all been there where you are right now. Welcome to a wonder place with wonderful people.
 
Clydesdale -

You said that your Surgeon told you that THE mechanical valve "is a no brainer".

You need to know that there are Several Manufacturers of Mechanical Valves.
The Top 4 made in the USA are manufactured by ATS, Carbomedics, On-X, and St. Jude.
They all have websites describing their valves.
See the Valve Selection Forum for LOTS of information on the different valve options.

'AL Capshaw'
 
Welcome to the family... you will find many answers here ... this is scary stuff but honestly it is not as bad as you think ... I was pleasantly surprised at how little pain I had and how quick I was up and about ... I'm sure all will go well for you!
 
Clydesdale - You had excellent advice and counseling from this forum and from your heart surgeon. I know it is scary and confusing but it is clear that surgery is in your best interest. Keep always in mind that surgery is not the problem. It's the solution to give you back your life. If you want a more detailed discussion on valve choices and their implications, I'd suggest this link: www.bigappleheartsurgery.com/page7.php

Heartdoc -

The reference you cite implies that the Risk of complication from AntiCoagulation Therapy is Cumulative based on your example of multiplying a 2% risk by the number of years. You need to know that this a Mathematical IMPOSSIBILITY. Based on this calculation, with an initial risk of 2%, the annual risk would reach 100% in 50 years. At 51 years this calculated number would be 102%. There is NO SUCH THING as a 102% risk.

FYI, we have some members who have been taking Coumadin/Warfarin for Long Periods of time (30 and 43 years for two I am aware of) who have had NO Serious Bleeding Problems.

There are many examples of Bleeding Issues from AntiCoagulation Therapy that occurred in the Bad Old Days when Prothrombin Time was measured using Reagents that exhibited considerable variability in their characteristics. The INR (International Normalized Ratio) technique which was created in the early 1990's cancels out the reagent characteristics which reduced variability and improved ACT management considerably.

One of our members (Bradley White) who teaches (taught?) statistics at Notre Dame University wrote an explanation of the correct way to analyze the risk that a patient may have had ONE event over time. A copy of that post is reproduced below.

from www.ValveReplacement.com - Valve Replacement Forum - 2007.2
thread: I'm only 24! - reply #35

Coumadin Risk is NOT Cumulative

QUOTE:

I cannot stress that when risk for ACT complications is given on a "per annum" basis it is not to be taken as cumulative. This is true of any statistic which is laid out as "the risk per patient year is X%". This is a quite basic principle in all biological sciences, especially medicine. I find it astounding that any surgeon would try to say the risk is cumulative!!!! It just makes no sense.
Scary how little medical professionels understand about basic statistics.

If risk were cumulative then that would imply at a risk rate of 3% at 35 years of anti-coagulation the risk would be greater than 100%. This simply isn't true or possible, it is not how statistics works. These risk events are always observed in patient years, one could not reasonable extract that data and attempt to add it up and say that after 35 years everyone would have had an event. That's simply not how statistics works. Anything whose risk is finite in a per year basis will never be 100% over any course of time. It will approach 100% but never reach it.

The cumulative nature of anti-coagulation risk is that every year there is a 3% risk. That means that every year there is a 97% chance of not having an event. As time goes on the chances that you won't have experienced an event decrease due to the recurring risk of 3% per year. You can calculate this risk by taking .97 and using the amount of years you are interested in as the exponent and then subtracting that number from 1 to figure out your chances of HAVING an event in X years:

I have made the following calculations based on a 1%, 2%, and 3% risk at 10 thrugh 50 years. The number represents the chances that you WOULD experience an event by this year if you were on ACT for mechanical valve.

AT THE 1% RISK LEVEL

10 YEARS = 9.6%

20 YEARS = 18.2%

30 YEARS = 26%

40 YEARS = 33.1%

50 YEARS = 39.5%

AT THE 2% RISK LEVEL

10 YEARS = 18.3%

20 YEARS = 33.2%

30 YEARS = 45.5%

40 YEARS = 55.4%

50 YEARS = 63.6%

AT THE 3% RISK LEVEL

10 YEARS = 26.2%

20 YEARS = 45.6%

30 YEARS = 59.9%

40 YEARS = 70.4%

50 YEARS = 78.2%

If anyone doesn't understand how I calculated those risks I can send them the excel file. The thing that stands out the most is the huge long term risk change when one goes from a 1% per annum event rate to a 3% per annum event rate. At 30 years, less than half of those at 3% per annum event rate will have not experienced an event, while at the 1% per annum event rate 74% of individuals should not have experience an event. This a significant reduction in the long term risk of anti-coagulation and represents the major medical reason why self-testing is such a huge advance since it has been shown to decrease the event rate from the 2-3% per annum category to around 1% per annum.

Trust me surgeons and doctors are not infallible, especially when it comes to math. I teach pre-med students a 300-level Fundamentals of Genetics course (decent working knowledge of statistics) at Nortre Dame and it scares me to death to think that some of them could one day be my doctor based on their complete incomprehension of statistics (among other things) at this point in their eduction.

Brad (a.k.a. Bradley White)
Ross Procedure, Dr. Quintessenza, All Children's Hospital, St. Petersburg, FL -- 9/12/2000

Aortic Root and Valve Replacement with 23 mm Homograft, Dr. Joseph Dearani, Mayo Clinic, Rochester, MN -- 12/7/2006

END QUOTE
 
Thanks Al for retrieving the Notre Dame professors post. I PM'd Heartdoc with my concern over his claim of "cumulative risk" since it is incorrect and serves only to frighten new patients. I scanned several of his links to "Bigappleheartsurgery" and my feeling is that he is "trolling for patients" by using very unflattering pictures of full valve surgery and making statements very skewed towards "minimally invasive surgery" for ALL although most of his pictures appear. to be "older" patients who normally are better candidates for "biological" valves. His comment that mechanical valvers have their valves re-replaced after 15-20 years makes me laugh.
 
Yeah, I saw his name and signature, too.
Anyone who has to troll here to get new patients is not someone I'd want to handle my surgery. Thanks, but my surgeon is too busy doing surgery to lurk here.
 
Thanks for the stat advise and thanks for the kind words and positvie re-enforciing comment all everytime im feeling down i read these post and it gets my head back in the game.

Also I was wondering about heartdocs comments and his motivations. In Canada we have our surgeries and most procedures and medications paid for by our healthcare system introduced by a visionary named Tommy Douglas born early in the 20th century.
 
Yeah, I saw his name and signature, too.
Anyone who has to troll here to get new patients is not someone I'd want to handle my surgery. Thanks, but my surgeon is too busy doing surgery to lurk here.


I noticed his web link when I was posting the welcome to new members (http://www.valvereplacement.org/forums/showthread.php?36615-Wow-just-look-at-all-who-have-joined......welcome) and wondered the same thing especially to...............


....................

Also I was wondering about heartdocs comments and his motivations. In Canada we have our surgeries and most procedures and medications paid for by our healthcare system introduced by a visionary named Tommy Douglas born early in the 20th century.
 
Yeah, I saw his name and signature, too.
Anyone who has to troll here to get new patients is not someone I'd want to handle my surgery. Thanks, but my surgeon is too busy doing surgery to lurk here.

I PM-ed Hank to have a look. Let's not be too hasty to judge, please. Corrections and calls for clarity -- yes! Al -- that was awesome bringing in Brad's post. Excellent. It is certainly not necessary to catapult anxious "newbies" into frightening and inaccurate depictions of a surgery that so many of us have managed with strength and surprising ease.

I'm glad that Clydesdale was able to get our reassurances quickly in response to Heartdoc's post.

It appears that Heartdoc has paid to be a member. He has started his own thread regarding minimally invasive surgery to which several people have very appreciatively joined in the conversation. He is new to our forum. My thinking is that he might be able to use our wisdom to increase his own! He might become a very valuable member if we could just calmly educate him to our sensitivities and our values. What d'ya think?

Marguerite
 
Dear Clydesdale,
I had AVR nearly two years ago, I found this site about the same time and it helped me hugely. I only knew about my heart problem, even though I was born with it, not long before my operation. I have a mechanical On-X valve. To start with I was terrified, had loads of questions and fears for my future and the thought of using Warfarin for ever and bleeding and generally wrapping myself in cotton wool ! Now two years on I live a full and active life, travelling the world, working hard, playing hard, eating what I want and drinking what I want. I have my INR tested every 6 to 8 weeks and never worry as long as it's between 2 and 4, although it's generally within a few points of 2.5. I'm much more concious about my health, but in a good way, so I exercise much more and have a better diet. I've been knocked out twice whilst Surfing and knocked off the road by a lorry whilst cycling. I'm a carpenter, so always cutting myself and bashing myself. All my initial fears were unfounded. Taking the Warfarin is about the only routine I've ever had and it's not been a problem, I just take it at bed time each night. The odd time I've forgotten has been if I've been to a party or something and come home a bit too drunk to remember and going straight to sleep ! A good tip, if you're going out for the evening, take it before you go ! This is a scary time for you, but rest assured, life will go on, you'll appreciate it all the more and it sounds like you have some amazing years to look forward to. Justin.
 
Do not back out unless you have a damn good reason for it.

I'm on coumadin and I don't have a mechanical valve. In fact I've never had open heart surgery. It doesn't bother me, and I feel safer on it because I'm thrombophilic. Thank God for it.

A mechanical valve is not a guarantee of not having a reop, but it appears to give a person a better chance of being reop free for longer.

I have a relative who had AVR 3 years ago, and she chose a porcine valve. Her median valve gradient is in the 30's already. She doesn't know it, but that's not a good sign.

We could all give you anecdotes of horrifying situations, but in the end valve choice is very personal and only YOU know best what's going to make you feel more at ease. We all have our own preference and in this venue I think it kind of surfaces via our conversations.

The end result of the choice may even be a wash statistically...
 
Heartdoc -

The reference you cite implies that the Risk of complication from AntiCoagulation Therapy is Cumulative based on your example of multiplying a 2% risk by the number of years. You need to know that this a Mathematical IMPOSSIBILITY. Based on this calculation, with an initial risk of 2%, the annual risk would reach 100% in 50 years. At 51 years this calculated number would be 102%. There is NO SUCH THING as a 102% risk.

FYI, we have some members who have been taking Coumadin/Warfarin for Long Periods of time (30 and 43 years for two I am aware of) who have had NO Serious Bleeding Problems.

There are many examples of Bleeding Issues from AntiCoagulation Therapy that occurred in the Bad Old Days when Prothrombin Time was measured using Reagents that exhibited considerable variability in their characteristics. The INR (International Normalized Ratio) technique which was created in the early 1990's cancels out the reagent characteristics which reduced variability and improved ACT management considerably.

One of our members (Bradley White) who teaches (taught?) statistics at Notre Dame University wrote an explanation of the correct way to analyze the risk that a patient may have had ONE event over time. A copy of that post is reproduced below.

from www.ValveReplacement.com - Valve Replacement Forum - 2007.2
thread: I'm only 24! - reply #35

Coumadin Risk is NOT Cumulative

QUOTE:

I cannot stress that when risk for ACT complications is given on a "per annum" basis it is not to be taken as cumulative. This is true of any statistic which is laid out as "the risk per patient year is X%". This is a quite basic principle in all biological sciences, especially medicine. I find it astounding that any surgeon would try to say the risk is cumulative!!!! It just makes no sense.
Scary how little medical professionels understand about basic statistics.

If risk were cumulative then that would imply at a risk rate of 3% at 35 years of anti-coagulation the risk would be greater than 100%. This simply isn't true or possible, it is not how statistics works. These risk events are always observed in patient years, one could not reasonable extract that data and attempt to add it up and say that after 35 years everyone would have had an event. That's simply not how statistics works. Anything whose risk is finite in a per year basis will never be 100% over any course of time. It will approach 100% but never reach it.

The cumulative nature of anti-coagulation risk is that every year there is a 3% risk. That means that every year there is a 97% chance of not having an event. As time goes on the chances that you won't have experienced an event decrease due to the recurring risk of 3% per year. You can calculate this risk by taking .97 and using the amount of years you are interested in as the exponent and then subtracting that number from 1 to figure out your chances of HAVING an event in X years:

I have made the following calculations based on a 1%, 2%, and 3% risk at 10 thrugh 50 years. The number represents the chances that you WOULD experience an event by this year if you were on ACT for mechanical valve.

AT THE 1% RISK LEVEL

10 YEARS = 9.6%

20 YEARS = 18.2%

30 YEARS = 26%

40 YEARS = 33.1%

50 YEARS = 39.5%

AT THE 2% RISK LEVEL

10 YEARS = 18.3%

20 YEARS = 33.2%

30 YEARS = 45.5%

40 YEARS = 55.4%

50 YEARS = 63.6%

AT THE 3% RISK LEVEL

10 YEARS = 26.2%

20 YEARS = 45.6%

30 YEARS = 59.9%

40 YEARS = 70.4%

50 YEARS = 78.2%

If anyone doesn't understand how I calculated those risks I can send them the excel file. The thing that stands out the most is the huge long term risk change when one goes from a 1% per annum event rate to a 3% per annum event rate. At 30 years, less than half of those at 3% per annum event rate will have not experienced an event, while at the 1% per annum event rate 74% of individuals should not have experience an event. This a significant reduction in the long term risk of anti-coagulation and represents the major medical reason why self-testing is such a huge advance since it has been shown to decrease the event rate from the 2-3% per annum category to around 1% per annum.

Trust me surgeons and doctors are not infallible, especially when it comes to math. I teach pre-med students a 300-level Fundamentals of Genetics course (decent working knowledge of statistics) at Nortre Dame and it scares me to death to think that some of them could one day be my doctor based on their complete incomprehension of statistics (among other things) at this point in their eduction.

Brad (a.k.a. Bradley White)
Ross Procedure, Dr. Quintessenza, All Children's Hospital, St. Petersburg, FL -- 9/12/2000

Aortic Root and Valve Replacement with 23 mm Homograft, Dr. Joseph Dearani, Mayo Clinic, Rochester, MN -- 12/7/2006

END QUOTE

Dear Al and Brad,

Thank you so much for your detailed and valid statistical analysis of cumulative risk. I truly enjoy the mathematical order behind statistics. It can lend itself to endless academic discussions. Most patients, though, are not inclined to complex statistics and mathematical speculations when they are faced with personal health decisions. Most surgeons want to make sure they educate their patients effectively about their options. Please note that the simplistic, easy to understand 2% per year cumulative risk estimate used by most heart valve surgeons roughly mirrors the "real life" risk estimate described in your 3% risk level table. The risk described includes thromboembolic events (major and minor) and bleeding events (major and minor). I hope this explanation helps you reconcile your valid statistical objections to the common practice of heart valve surgeons. We are indeed talking about the same numbers. Having said that, I'll gladly keep a copy of your risk level tables as a reference for the rare patient inclined to discuss finer statistical assessments.

Here is a link to a good review article on coumadin therapy risk in different prosthetic heart valves and positions (mitral vs. aortic):

http://chestjournal.chestpubs.org/content/119/1_suppl/220S.long

For all mechanical valvers, a strict coumadin protocol along with improved mechanical valve designs is generating improved outcomes (less risk) and this is reflected in recent literature. This will change our risk assessment in the future. The duty of a heart surgeon is to give you the facts. The ultimate decision maker on the type of valve is always the patient.

Thank you for your thoughtful intervention..I stand corrected!

Best,

Heartdoc
www.bigappleheartsurgery.com
 
AL, while many coumadin managers and surgeons and papers across the Internet frequently use the term "cumulative" in regard to Coumadin risks, I've never been sure that defining the term can be so cut and dried as Bradley defined it. In my mind, there must be many variables. Anyway, upon further search, I also found this link, which you may also find interesting: http://www.uwsp.edu/geo/faculty/ozsvath/lectures/Cumulative_Risk.htm
 
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After reading the AntiCoagulation Forum for several years, I've come to the conclusion that The (or at least one of the) Major Risk Factors faced by patients on Anti-Coagulation Therapy is relying on Anti-Coagulation Care Providers who are either Poorly Trained or using Out-of-Date Guidelines. Over-Reacting to slightly out-of-range INR readings is a leading contributor to the Unstable Roller Coaster Effect. Fear of Bleeding Events and indifference to Stroke Risks is another contributing concern.

Studies have shown that patients who Home Test have the Most Stable INR Histories, followed by patients who use managers at Dedicated Anti-Coagulation Clinics. The Worst History of unstable INR Histories comes from isolated Individual Providers, including Doctors and Nurses who typically have few patients on anticoagulation.

I am thankful to have the services of an Excellent AntiCoagulation Clinic associated with Huntsville Hospital and The Heart Center (25 cardiologists). They have 4 Well-Trained and Very Knowledgable CRNP's (Certified Registered Nurse Practicioneers) who oversee patient dosing for 1500 patients now using Coaguchek XS Finger-Stick INR instruments backed up by Lab Draws for INR readings over 4.5 that are read within 2 hours of the draw at the Hospital Lab.

'AL Capshaw'
 
My issue with this "one-sided" risk argument against ACT is "what is the cumulative risk of a major event having multiple surgeries?" I had my one and only major event seven years after my surgery and it was 99% my own fault. Back then, I was ignorant, and many doctors were also ignorant, of the necessity of following a simple regimen and I paid a significant price.....but the fault was mine and not due too a "warfarin attack". If we are to know the cumulative risk of warfarin use, we should also be given the cumulative risk of multiple surgeries. Lets take me as an example. I have now gone over 43 years on ONE valve and have suffered one significant event which I have overcome. Using the typical 10-15 year life of a tissue valve, I would, by now, have had 4 OHS and would be looking at #5. I would be interested in knowing the cumulative risk of having a major event going into, or out of, these 4+ surgeries. I would venture a guess that I have had far fewer problems. There is an often used phrase...."figures don't lie, but liars figure"....PEACE!!
 
Clydesdale, just to say that you will be in my prayers on Nov 1 and that I shall be sending many good and healing vibes your way. My surgeon said that I was still "young" at age 66 and that I will fly through the surgery. LOL!! That is just what happened. I feel 20 years younger! Imagine how much easier it will be at your age!! You will be a teenager again! :)
Please go into the surgery knowing that it will not only make you live decades longer but you will feel so much better. Not having the surgery is not an option..
The waiting and anticipation is the worst.
 
My issue with this "one-sided" risk argument against ACT is "what is the cumulative risk of a major event having multiple surgeries?" I had my one and only major event seven years after my surgery and it was 99% my own fault. Back then, I was ignorant, and many doctors were also ignorant, of the necessity of following a simple regimen and I paid a significant price.....but the fault was mine and not due too a "warfarin attack". If we are to know the cumulative risk of warfarin use, we should also be given the cumulative risk of multiple surgeries. Lets take me as an example. I have now gone over 43 years on ONE valve and have suffered one significant event which I have overcome. Using the typical 10-15 year life of a tissue valve, I would, by now, have had 4 OHS and would be looking at #5. I would be interested in knowing the cumulative risk of having a major event going into, or out of, these 4+ surgeries. I would venture a guess that I have had far fewer problems. There is an often used phrase...."figures don't lie, but liars figure"....PEACE!!

Many Doctors seem more concerned with Bleeding Events due to an elevated INR than with the risk of Stroke from a Low INR (<2).

Dick - It would be good to clarify that YOUR One Event was a Stroke due to forgetting to take your Coumadin with you on a (Hunting) Trip.

'AL Capshaw'
 
Here is a link to a good review article on coumadin therapy risk in different prosthetic heart valves and positions (mitral vs. aortic):

http://chestjournal.chestpubs.org/content/119/1_suppl/220S.long

For all mechanical valvers, a strict coumadin protocol along with improved mechanical valve designs is generating improved outcomes (less risk) and this is reflected in recent literature. This will change our risk assessment in the future. The duty of a heart surgeon is to give you the facts. The ultimate decision maker on the type of valve is always the patient.



Best,

Heartdoc
www.bigappleheartsurgery.com

Interesting paper you linked to doc; it was interesting to read about modern aortic valves, and different therapeutic INR levels relative to older valve designs as well as the use of aspirin concomitant with coumadin/wafarin. This is pretty much in keeping with what my surgeon and cardiologist have me doing currently: a target INR in the 2.0-2.5 range and 325mg ASA once daily. (I had the On-X valve implanted in June 2010) I'm four-plus months out and doing well. Good to read some of the science behind modern ACT, especially since it is hard to pin my guys down for an extended period of Q&A around ACT ;)
Thanks for the link.

--Dan
 
IT HAS BEEN SEVEN DAYS SINCE THIS THREAD WAS HIJACKED TO BE TURNED INTO ANOTHER :mad2:HEARTDOC FORUM AND SIX DAYS SINCE THE OP Clydesdale HAS BEEN HEARD FROM IF WE COULD MAYBE GET BACK TO THE PURPOSE OF THIS FORUM AND SUPPORT MEMBERS :thumbup:THROUGH THE JOURNEY

THANK YOU
GREG
 
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