It’s time to start thinking about Prosthetic or Biological Aortic Valve

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manuel_Scotland

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Hi Everybody,

It’s been a while since my last post. Last time I posted was to ask about the PEARS method as an alternative to fix my aortic aneurism, unfortunately that’s no longer the case. After the board of doctors following my case got together a few weeks ago they got to the conclusion that I’m not suitable for it. My dilation is “too high” in the aorta and my bicuspid valve is deformed as well. Really bad news as, although the valve is working great at the moment, they don’t think it would last.
The course of action at the moment, with a fully functional BAV and an aneurism bellow the UK threshold (I’m 53 mm and the threshold is 55mm), is just wait for periodic 6 month monitoring.

But the day will come, so it’s time to start thinking about the type of valve to go for, prosthetic or biological. I guess that, due to my age (39 years old) the answer should be pretty straight forward. Prosthetic. But the more I think/read, the more I’m gravitating towards biological. Let me present my reasons and please do not hesitate to challenge them (or agree). Most of you had the same questions and went through surgery already, you opinion is really priceless for me. Massive thank you in advanced.
This is my list of reasons:

- The lack of ticking. I know that everybody says that it’s not relevant and that, after a while you don’t even hear it anymore, but scares me. And, this may be sound silly, I’m not sure how it may affect my partner.

- Anticoagulants. I’m aware that biological valves sometimes need anticoagulants as well (but in a lower quantity). The fact of taking a pill a day is not an issue. The problem is that many other things can go wrong in the future that require a simple surgery (I’m thinking about dentist, unexpected tumours, etc.) that require the discontinuity of anticoagulants and, thereof, putting myself in the danger zone.

- Something going wrong. The Prosthetic put you in a constant risk of stroke, that’s why the anticoagulants. If that happens (I’m aware that the chances are really small) that would have devastating consequences. Honestly, becoming a charge for my family is my worst fear. While is something goes wrong with the biological (leaflet broken) it’s all a matter of reoperation (a risk itself I know) but which a more black or white outcome, I hope you know what I mean by that.

- Live expectancy of biological. I’m aware that the biological start degrading after 10 years (sometimes earlier). But for what I read the longest prosthetics won’t last more than 20. Been just 40 a reoperation will happen anyway so why not spend my “prime” as close to “normal” as possible and the in my 50’s or mid-50’s go for surgery again (and this time go for prosthetic). Or who knows, maybe by them the trans-catheter method is much more advanced.

Again, thank you for any comments/answers I may get.

Manuel
 

pellicle

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Hi Manuel

I think you are on the right track in considering this issue early. Give yourself time to learn, then to "grok" and then to come to a conclusion. It takes time

First up I'll point out that BOTH the mechanical and the "so called" biological are prosthetics. The biological valve is simply stated leather sewn onto a steel cuff. That leather may be from a pig or a cow valve or it may be pericardium (https://en.wiktionary.org/wiki/pericardium) ... neither is perfect.

The surgical guidelines makes the case that you exchange "valvular heart disease" for "prosthetic valve disease" ... one is managable (prosthetic) the other just results in death (valvular heart disease).

Mechanical can be managed to some extent by the owner (via proper anti coagulation therapy) the "biological" prosthetic is managed by replacement.

The other points you raise are important and you yourself need to come to terms with what you value and what is important to you. It may just be that if you got a mechanical that you would be "driven mad" by the ticking (I'm not, but then perhaps I was mad to begin with?) ... or you may have a biological prosthetic and on your redo surgery (some decade or two hence) find that you had some post surgical complications (and suddenly you'd feel happier with the ticking).

Only you can decide, and it is by asking questions that you learn. (I didn't see any questions, but your conjectures were good)

Best Wishes
 

themalteser

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Hi Manual_Scotland. Please may I ask, the decision for doctors not to give you a PEARS, was it because your valve is leaky or because the aorta is large? I know that there have been Marfan patients, whom their aorta was 54 mm or so and they still had PEARS. So I guess its because your valve is leaky? Is it leaking badly? When I talked to Tal, he said that all valves are slightly leaky and when you have a prosthetic valve, they will keep it mildly leaky to wash the pivots.

I am currently deciding whether to go now for surgery at 47mm to do PEARS or wait a bit more since its been stable for a while.

Has your aorta enlarged or remained stable at 53mm for some time?

Sorry for all these questions.
 

manuel_Scotland

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Hi themalteser,

please don't worry at all for the questions, happy to answers them.

My valve is perfectly fine at the moment, not leaky at all, fully functional. But they pointed out that it felt quite abnormal and with a high risk of degeneration in the few years. And yep, when you look at it on the scan is not "rounded" but more like a melon, kind of enlarged.

Regarding the reason for not recommend PEARS is that it's design for aortic ROOT enlargement, but my enlargement is not at that level but at the ascending aorta part and continues dilated very high up to the take of the arm and neck branches. I have asked for a second opinion down in London but in the Team that look at my case in Scotland was a doctor that perform a PEARS and didn't recommended it either. I still keep my fingers crossed for that method though.

Regarding the enlargement, my story is pretty curious. I had no idea that anything was wrong with my heart till 1,5 years ago, right after crossing the finishing line of my 3rd Marathon (3h31min BOOM! :) ) a weird sensation in my chest appeared. I had myself checked and, surprise, BAV and dilated ascending aorta (with no family history at all). It was then measured 5,3 cm and it has remained the same till today. For your info, I obviously decreased my training regime but I'm still running 10km's and doing spinning classes keeping my HR below 155-160 and NOT doing weights. Never stopped and it's totally stable.

Let me know if something I wrote it's not clear (I'm actually Spanish so my English it's not exactly the best) or if I can answer any other question.
 

themalteser

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Hi Manuel, your English is perfect! I'm Maltese and live in the UK, now moving to the Netherlands :) I was in Dunblane a few weeks ago, stayed at the Hydro park Double Tree. Beautiful area. I also loved Glasgow, but not so much Edinburgh.

What a story! 3rd Marathon and at 3 hours 31 mins! That's fantastic! So that sensation has led you to check and you found out the BAV and the dilation. Have you talked to Tal to check his opinion? My dilation is at the root, and my valve is functional, but doesn't mention about the shape, etc. I know it 'domes' a little and has a mild regurgitation. Just like you, no family history, but they are now checking for genetics, etc.

Is it Dr pepper who is looking after you? Or Dr Conal ?

Will you go back to Marathons after you get it fixed ? I think you should!
 

leadville

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Great Marathon time, you're faster than me :)

Personally the mechanical option was better as i didn't want a 2nd OHS

The ticking was also a big potential issue, i did consider my wife too, however the ticking i now find reassuring, although it is ever present i don't mind it at all, neither does my wife.

I race bikes and warfarin was a problem after a huge crash, getting an anaesthetist to do the surgery was a little problematic
but the INR control before and after shoulder surgery was non eventful.

The more i read and try to learn about INR control the less i feel it's a potential future problem & self monitoring
i find better than using the nhs clinic.

My fitness post surgery was a worry as i wondered if i could still race, i won't kid you it's an easy recovery but you should return to full fitness.
Lifting in the gym is okay too, however i would avoid maximal lifts to stop the BP spiking..

i don't take BB now ( i used them for 3 months post OHS )

it's never an easy choice it's a personal decision you have to live with.

best of luck
 
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dick0236

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manuel_Scotland;n878889 said:
This is my list of reasons:

- The lack of ticking. I know that everybody says that it’s not relevant and that, after a while you don’t even hear it anymore, but scares me.

- Anticoagulants. I’m aware that biological valves sometimes need anticoagulants as well (but in a lower quantity). The fact of taking a pill a day is not an issue. The problem is that many other things can go wrong in the future that require a simple surgery (I’m thinking about dentist, unexpected tumours, etc.)

- Something going wrong. The Prosthetic put you in a constant risk of stroke, that’s why the anticoagulants.

- Live expectancy of biological. I’m aware that the biological start degrading after 10 years (sometimes earlier). But for what I read the longest prosthetics won’t last more than 20.

-Mine used to sound like a "ping pong ball". Haven't heard it in decades.....nor has anyone else.

-What if none of those things occur. I've had no additional surgeries and routine dental work has never been a problem.

-It is true that there is a 1% or 2% annual risk of stroke with Prosthetic valves......but a stroke risk is there for the general population as well. Heart attack and stroke are one of the leading causes of death worldwide. ACT is commonly prescribed for many cardiovascular conditions as we age.

-I have the longest lasting prosthetic valve ever implanted (50+ years) and have known, or read about, others who have had mechanical valves last well beyond 20 years.

This is a difficult choice.....especially now that so many alternatives are available. As leadville says "it's a personal decision".
 

pellicle

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themalteser;n878897 said:
Hi Manuel, your English is perfect! I'm Maltese and live in the UK, ...

Ahhh, that explains the name

All this time I thought it was these [IMG2=JSON]{"data-align":"none","data-size":"full","src":"https:\/\/upload.wikimedia.org\/wikipedia\/commons\/thumb\/4\/48\/Maltesers-Pile-and-Split.jpg\/220px-Maltesers-Pile-and-Split.jpg"}[/IMG2]

https://en.wikipedia.org/wiki/Maltesers
 

themalteser

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pellicle;n878905 said:
Ahhh, that explains the name

All this time I thought it was these [IMG2=JSON]{"data-align":"none","data-size":"full","src":"https:\/\/upload.wikimedia.org\/wikipedia\/commons\/thumb\/4\/48\/Maltesers-Pile-and-Split.jpg\/220px-Maltesers-Pile-and-Split.jpg"}[/IMG2]

https://en.wikipedia.org/wiki/Maltesers

Thats funny, Pellicle. :) I'm a Maltese sir!
 

pellicle

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manuel_Scotland

a good read: http://circ.ahajournals.org/content/119/7/1034.full

Despite the marked improvements in prosthetic valve design and surgical procedures over the past decades, valve replacement does not provide a definitive cure to the patient. Instead, native valve disease is traded for “prosthetic valve disease,” and the outcome of patients undergoing valve replacement is affected by prosthetic valve hemodynamics, durability, and thrombogenicity. Nonetheless, many of the prosthesis-related complications can be prevented or their impact minimized through optimal prosthesis selection in the individual patient and careful medical management and follow-up after implantation. The purpose of this article is to provide an overview of the current state of knowledge and future perspectives with regard to optimal prosthesis selection and clinical management after valve implantation.

With respect to "management and follow-up" the introduction modern Point Of Care INR machines and the ability to more accurately target your INR and self manage your INR (or at the least be a part of it) is the biggest step forwards in the area of mechanical valves. This single aspect moves the risks of injury from mismanaged anticoagulation (which are bleeds or strokes) to about that of the age related population risks. As Dick mentions above, we are ALL at risk and more at risk as we age. So this is a very significant development with respect to mechanical prosthetics.

as you are younger I'd also read this part of that document properly and use that as the basis for asking yourself more questions (and seeking answers for them)
Structural Valve Deterioration

Incidence of SVD

Mechanical prostheses have an excellent durability, and SVD is extremely rare with contemporary valves, although mechanical failure (eg, strut fracture, leaflet escape, occluder dysfunction caused by lipid adsorption) has occurred with some models in the past (Figure 6C).

The rate of SVD in bioprosthetic valves (Figure 6D) increases over time, particularly after the initial 7 to 8 years after implantation. With conventional stented bioprostheses, the freedom from structural valve failure is 70% to 90% at 10 years and 50% to 80% at 15 years.[SUP]6,43,50,62,66[/SUP]

Predictors of SVD

Risk factors previously found to be associated with bioprosthetic SVD include younger age, mitral valve position, renal insufficiency, and hyperparathyroidism.[SUP]43,62,66[/SUP] Hypertension, LV hypertrophy, poor LV function, and prosthesis size also have been reported as predictors of SVD in bioprostheses implanted in the aortic position.[SUP]66[/SUP]


Host-Related Factors

Bioprosthetic SVD is strongly influenced by the age of the patient at the time of implantation.[SUP]43,62[/SUP] The rate of failure of bioprostheses is <10% at 10 years in elderly patients (>70 years of age) but is ≈20% to 30% in patients <40 years of age.[SUP]43,62[/SUP] Several studies also suggest that bioprosthetic structural failure is more frequent in the mitral than in the aortic position.[SUP]43,66[/SUP] This difference is likely related to the higher mechanical stress imposed on the valve leaflets of mitral bioprostheses during systole. Likewise, SVD of aortic bioprostheses may be accelerated by systemic hypertension, possibly as a result of a chronically increased diastolic closure stress.
 

mikeccolella

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http://www.acc.org/latest-in-cardiol...-young-patient

As current guidelines suggest, the choice of valve prosthesis should be based on discussion between the clinician and the patient. However, the strong differences in patterns of use of one prosthetic choice over another in different clinics suggest that physician bias remains a strong factor, and that patients may not be well- informed participants in the choice. All practitioners involved in guiding patients on choice of prosthesis should be aware of the above six factors and discuss them with young patients faced with the decision of prosthesis type.
Biological Vs Mechanical Valves – Key Points
  • Long-term survival is equivalent
  • Mid-term morbidity is worse with mechanical valves
  • Reoperation rates are low with biological valves and are not insignificant with mechanical valves
  • Reoperative aortic valve replacement has similar mortality to primary valve replacement
  • Complications of mechanical prosthesis are more devastating than those of biological valves
  • Mechanical valves can have substantial negative impact on daily quality of life
 

DJM 18

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Although a study of younger / healthier patients this is certainly very interesting / encouraging for patients considering a Mechanical Heart Valve. And it puts again emphasis on the importance of well managed Anticoagulation therapy.


Survival Comparison of the Ross Procedure and Mechanical Valve Replacement With Optimal Self-Management Anticoagulation Therapy


http://circ.ahajournals.org/content/123/1/31

Abstract

Background—It is suggested that in young adults the Ross procedure results in better late patient survival compared with mechanical prosthesis implantation. We performed a propensity score–matched study that assessed late survival in young adult patients after a Ross procedure versus that after mechanical aortic valve replacement with optimal self-management anticoagulation therapy.

Methods and Results—We selected 918 Ross patients and 406 mechanical valve patients 18 to 60 years of age without dissection, aneurysm, or mitral valve replacement who survived an elective procedure (1994 to 2008). With the use of propensity score matching, late survival was compared between the 2 groups. Two hundred fifty-three patients with a mechanical valve (mean follow-up, 6.3 years) could be propensity matched to a Ross patient (mean follow-up, 5.1 years). Mean age of the matched cohort was 47.3 years in the Ross procedure group and 48.0 years in the mechanical valve group (P=0.17); the ratio of male to female patients was 3.2 in the Ross procedure group and 2.7 in the mechanical valve group (P=0.46). Linearized all-cause mortality rate was 0.53% per patient-year in the Ross procedure group compared with 0.30% per patient-year in the mechanical valve group (matched hazard ratio, 1.86; 95% confidence interval, 0.58 to 5.91; P=0.32). Late survival was comparable to that of the general German population.

Conclusions—In comparable patients, there is no late survival difference in the first postoperative decade between the Ross procedure and mechanical aortic valve implantation with optimal anticoagulation self-management. Survival in these selected young adult patients closely resembles that of the general population, possibly as a result of highly specialized anticoagulation self-management, better timing of surgery, and improved patient selection in recent years.



"It is remarkable that for the duration of the follow-up period, survival after aortic valve replacement was comparable to that of the age-matched German population in both Ross patients and mechanical prosthesis patients. This observation supports the hypothesis that late mortality after aortic valve replacement is driven mainly by patient characteristics and that prosthesis selection plays only a minor role, if any.

This observation implies that in patients who are good candidates for both a Ross procedure and mechanical aortic valve replacement, the choice for a particular treatment strategy should be determined by patient preferences. One patient's unacceptable risk may be another patient's acceptable risk; for some, a reoperation in the distant future may be more acceptable than the limitations and risks imposed by anticoagulant treatment, whereas others prefer the opposite. With the ongoing improvement in the current anticoagulant treatment and the introduction of novel anticoagulant drugs, the rates of bleeding and thromboembolic events may decrease further.[SUP]14,34[/SUP] As a consequence, in the future, patient preference may more often shift toward a mechanical valve."
 

dornole

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Do keep in mind, when they say "old" in these studies including the one cited above, they mean 70 or older . . . and "younger" seems to mean 60. An additional factor to consider is that tissue valves degrade faster in "very young" people such as yourself. We've definitely had people on here facing replacement after just 4 or 5 or 6 years. That makes it seem less worth it to go through another surgery in order to delay A/C therapy for a few years. Only you can decide though. You seem to have a realistic handle on pros and cons.
 

pellicle

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DJM 18;n878948 said:
Although a study of younger / healthier patients this is certainly very interesting / encouraging for patients considering a Mechanical Heart Valve. And it puts again emphasis on the importance of well managed Anticoagulation therapy.


And indeed that is the key to pushing mechanical above equality to tissue prosthetic. But it's a willingness to take on that dedication.

Speaking for myself, I'm willing :)
 

Eva

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Manuel,

In my opinion, big factor on the choice depends on one's life style too in addition to other factors! So, discuss your life style with your cardio or surgeon. They are the best to advise you on the proper choice.

In my situation, I chose mechanical despite that two surgeons I interviewed recommended tissue. Reason: I was 57 years young in 2008! In addition to my husband and taking care of step son then and taking care of my oldest sister living with us who was 76 then, I chose mechanical only to avoid another surgery which could happen at time I would be most needed by people depending on me. I was afraid about my health situation after ten year or so! And who would take care of my sister and others?! If I wasn't married, without responsibilities then, I would have chosen tissue valve to avoid dealing with anticoagulants, especially that my surgeon was on the team experimenting with TAVR and promised me that he would do the valve replacement when need with TAVR,

Though it's not a big deal to be on warfarin after you become familiar with its management, yet I could have had less stress when I needed to pull a tooth, when I binged on greens (since my diet is not consistent), or wanted more than one drink now and then.

Despite all, and as mentioned earlier, as long as you can manage adjusting your medicine according to circumstances, warfarin is not a big deal (just a small discomfort to me personally)!

good luck with your decision. This was my biggest dilemma to the extent my surgeon told me I could tell him about my decision on the morning before my surgery.

Keep us posted.
 
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Homeskillet

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dornole;n878950 said:
Do keep in mind, when they say "old" in these studies including the one cited above, they mean 70 or older . . . and "younger" seems to mean 60. An additional factor to consider is that tissue valves degrade faster in "very young" people such as yourself. We've definitely had people on here facing replacement after just 4 or 5 or 6 years. That makes it seem less worth it to go through another surgery in order to delay A/C therapy for a few years. Only you can decide though. You seem to have a realistic handle on pros and cons.

Indeed, my tissue mitral valve failed after merely 1 year...& no answer has ever been given why. Just happens some times (though extremely rare that they fail that soon :test:).
 

jcgtok17

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Manuel, My AVR surgery was recent (May 1st) in Japan (age 50). Each country is different, but the overall trend is clear, bioprosthetic valves are being used more often than mechanical ones. From the database maintained by STS 64% on AVR's used bioprosthesis in 2001 versus 86% in 2011. Improved durability and the broader adoption of TAVI procedures are the two factors most point to. Good luck with your decision. This board has lots of great info and perspective. Regards, JCG
 

neil

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[h=2]Better valve, better procedure among new guidelines for heart valve disease[/h] By AMERICAN HEART ASSOCIATION NEWS
0315-news-heartvalve_WP-1024x443.jpg

A new, less invasive approach for replacing malfunctioning heart valves is now recommended for certain patients, and younger patients can now receive natural tissue valves instead of mechanical ones,

havnt put the full page in but it makes very interesting reading, looks like there leaning more and more towards tissue at a younger age,
 

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