mechanical or tissue valve and an active lifestyle?

[RDISH]

Hello All!

I am new to this site and very thankful I found you guys. I have a consultation appointment with a surgeon tomorrow to see about an aortic valve replacement. I’m not 100% sure what all of my options are but an obvious question that will come up is mechanical or tissue valve. I’ve been reading all the forums but this board seams to have a demographic that is most like me (41, active male) and I wanted to ask, What swayed you to decide mechanical or tissue? From most of your personal information it looks like a good number of you are young that decided to go with a tissue valve. I am leaning/hoping that is a viable option for me. I have been active for years until lately becoming mildly symptomatic. I have jogged for years (about 25 mi/weak) ride Mountain Bikes, ski snow and water and until 5 years ago or so played rugby nearly year round. All that said if told I could not do several of those thing I guess I could live with it, although I would like to have the option. To be frank, the maintenance of anticoagulation drugs coupled with the restrictions that come with the mechanical valve has me thinking tissue valve heavily unless compelling evidence convince me otherwise. Did the expectation of new technology, either surgical or valve weigh on your decision? I know this is somewhat off topic in this discussion board but felt this group could have possibly better insight as to how to weigh a active lifestyle in this decision.

Any advice would be greatly appreciated.

RDish

 

[bigsidster]

My choice was mechanical for an aortic valve replacement.The reason I took mechanical was because I only wanted to do this once.Taking coumadin for me is a small price to pay to be alive and also not to have to undergo another major surgery.

 

[epstns]

Age is a major factor in the choice of a replacement valve, especially the aortic valve. From what I've read, younger patients tend to calcify tissue valves faster than do older patients, thus the higher likelihood of re-operation during your lifetime. In the past, most of the surgeons have used age 65 as the turning point -- recommending mechanical valves for younger patients, tissue for older. I am now preparing for aortic valve replacement (due to aortic stenosis) at age 63 and my surgeon says that at Chicago's Northwestern Memorial Hospital over 85% of the aortic valves they now implant are tissue. (The percentage might be higher - working from memory here.) Without hesitation he recommended a tissue valve for me, indicating that of the current ones a very high percentage are still in place after 15 or more years.

At your age I imagine that they will recommend mechanical, although many surgeons will do as the patient chooses.

Then there is also the possibility that by the time the new tissue valves begin to fail the percutaneous valve implants (via catheter) will be a mainstream procedure.

 

[Lily]

I have never been an athlete so my experience probably won't help. But there are lots of athletes here who seem satisfied with either valve and I'm sure you'll hear from them soon. Anyway, I just wanted to welcome you to the site.

Take care and post again

 

[ALCapshaw2]

RD -

When you speak of the "limitations" placed on mechanical valve recipients, it would help to know exactly what you have been told or what your understanding is of these "limitations". We have MANY very athleticly active mechanical valve recipients (Runners, bicyclists, Tri-Athelon, etc.). Contact Sports are generally discouraged.

At your age, chances are 'probably' greater than 50% that you would 'wear out' a tissue valve in 12 years or less. Some have had to be replaced in 5 years or less, including some early failures in 1 year or so. There have been many advancements and improvements in Tissue Valve Technology with the HOPE of getting greater longevity but it's too soon to KNOW for sure.

The Big Question I have about Percutaneous Valve Replacement which would be of particular interest to Athletes is: How much Blood Flow can be achieved from a valve that is sewn INTO another valve already in place, i.e. what would be the Effective Valve Area of the Percutaneous Placed Valve compared with the Previous Valve that it is sewn into. I have not seen an answer to this question.
It is hard for me to believe that Blood Flow from a Percutaneously Placed Valve would NOT be less than what the patient had from his/her previous valve.

'AL Capshaw'

 

[mainframe]

Sorry you have to be here and ask this question. Much like you before my first AVR at 45, I "was active" and didn't want to be inconvenienced by anti-coagulation medication. During the life of the tissue valve I rarely thought of having an AVR on a day to day basis. I knew that in the 12 - 15 years I was told the valve would last there certainly would be advancements in valve technology and surgical techniques and that my second AVR would be a easy as my first.

Unfortunately all of the above wasn't the case. My valve only lasted 7 years. The options 8 years ago and 1 year ago were virtually the same. My second surgery was much tougher on me than the first surgery.

It's true that a tissue valve might be less limiting on your lifestyle, but my 2nd surgeon told me "no restrictions". You won't have to take anti-coagulation medication, unless you get post surgical afib, DVT or another issue in which case what valve you have doesn't matter.

But do be aware by choosing a tissue valve at your relatively young age you will be back for a 2nd surgery. Could be 5 years, could be 10. They are now claiming younger folks should now get 15 years from a tissue valve, but there is nobody I'm aware of on this board that got their valve at a young age and has it last for that amount of time.

Steve mentions percutaneous valve implants but the study I was looking at required a patient have a native valve. Is anyone aware of anybody that got a percutaneous valve who had previously had a prosthetic tissue valve?

 

[ALCapshaw2]

It's true that a tissue valve might be less limiting on your lifestyle, but my 2nd surgeon told me "no restrictions". You won't have to take anti-coagulation medication, unless you get post surgical afib, DVT or another issue in which case what valve you have doesn't matter.

HUH? Are you saying that after receiving your Carbomedics Top Hat Valve that you do NOT take any type of anticoagulation medicaiton?

I'm *assuming* that the Carbomedics Top Hat is a Mechanical Valve. Is that correct?

What am I missing here?

'AL Capshaw'

 

[Lynlw]

HUH? Are you saying that after receiving your Carbomedics Top Hat Valve that you do NOT take any type of anticoagulation medicaiton?

I'm *assuming* that the Carbomedics Top Hat is a Mechanical Valve. Is that correct?

What am I missing here?

'AL Capshaw'

I was confused too.
BTW there should be a few posts about percutaneous valves and the EVA, with better details but,
for first time valve replacements at least they can have a larger area than a traditional valve that is sewn in, since the leaflets are attatched directly to the stents and they don't have a sewing ring that takes up space.


Also percutaneous valves are used inside old tissue valves, (they can NOT be used in old mechanical valves, they would still need surgery)

 

[RDISH]

Thanks for the replies this is exactly the feed back I was looking for!

I agree 100% that the advice from the surgeon will most likely be for the mechanical valve based on my limited knowledge. However at 41 I think I am looking at a 2nd valve replacement even with a mechanical valve. I think I would rather have that at 50-55 than 65-75 if I'm lucky enough to make it and if percutaneous becomes the standard (I hope) it will be less of an issue in 10 years or so. At 50+ I could always go mechanical then couldn’t I? If I were 50< or >65 I think I would also lean toward a mechanical valve, I have 2 young children and another on the way, all this could not have come at a worse time , but then again there is never a convenient time to have a valve replaced nor do we get to chose.

As for limitations with the mechanical valve , I have in the last 2 years played a rugby match, if someone were to tell me “no more of that”, it would probably be a relief that I didn’t have to admit I’m to old for that stuff any more. If you were to tell me that I’m likely to have a stroke because my diet and lifestyle is too random or if I do have the misfortune of wrecking my motorcycle or getting hit in the head with a soccer ball at a kid’s game, I am likely to die from bleeding. That will be something I weigh heavily at my age.


Thanks again for the kind wishes.

RD

 

[mainframe]

Yes I take anticoagulation medicine and I certainly was not saying that I or anyone else with a mech. valve doesn't take anti coagulation medicine. The no restrictions was with respect to activities only. I was also trying to point out that getting a tissue valve is no guarantee that of an anti-coagulation free existence.

 

[Lynlw]

Thanks for the replies this is exactly the feed back I was looking for!

I agree 100% that the advice from the surgeon will most likely be for the mechanical valve based on my limited knowledge. However at 41 I think I am looking at a 2nd valve replacement even with a mechanical valve. I think I would rather have that at 50-55 than 65-75 if I'm lucky enough to make it and if percutaneous becomes the standard (I hope) it will be less of an issue in 10 years or so. At 50+ I could always go mechanical then couldn’t I? If I were 50< or >65 I think I would also lean toward a mechanical valve, I have 2 young children and another on the way, all this could not have come at a worse time , but then again there is never a convenient time to have a valve replaced nor do we get to chose.

As for limitations with the mechanical valve , I have in the last 2 years played a rugby match, if someone were to tell me “no more of that”, it would probably be a relief that I didn’t have to admit I’m to old for that stuff any more. If you were to tell me that I’m likely to have a stroke because my diet and lifestyle is too random or if I do have the misfortune of wrecking my motorcycle or getting hit in the head with a soccer ball at a kid’s game, I am likely to die from bleeding. That will be something I weigh heavily at my age.


Thanks again for the kind wishes.

RD

What the surgeon suggest at your age, has alot to do with where you go for the surgery. Some Centers like Cleveland for the most part reccomend tissue valves to their patients 40 and up others would reccomend mechanical. Whatever makes you feel most comfortable is the right choice for you.

 

[RDISH]

Chris,
Your case is exactly my dilemma, at 45 you opted for a tissue valve (BTW, did your surgeon steer you in that direction or was that your strong preference?) that didn’t work out as you had planned but if you had gone with a mechanical valve at that time don’t you think you still would likely have needed that replaced at 65 or 70? OHS at that point would be difficult to come back from. The number of surgeries is a big factor for me but I just see me needing 2 regardless, and why not make the most out of the next 10 years or so without having to be worried about the anti coagulation drugs and hope for improvements in the field.
My Uncle had a valve replaced in Lexington Ky. last year at 58. He opted for the tissue valve( haven’t quizzed him on all the details yet) and in the end also needed a pacemaker so he had to go on anti coagulation anyway, so you are right there are no sure bets I just hope to find out as much as I can and at least go in armed with as much information as I can.

 

[Mentu]

RDish, welcome to our community. Many of us have found a lot of comfort in learning that others have shared our concerns and fears upon learning that surgery is necessary. Either type of valve will serve you well and so far studies indicate that there is no significant difference in life expectancy between those with mechanical or tissue valves. Both types of valves bring their own baggage and, working with your surgeon, you need to select the "package" with which you are most comfortable. When you hear or read something about a valve, it would be a good idea to maintain some skepticism and check to see if the concern is real. I have read a lot in the last year and a half and I've never heard of a anyone on ACT dying from being struck in the head by a soccer ball. Quite the opposite, as your health improves, you should be able to do most of the things you have done in the past. The current mantra is that all tissue valve have a limited working life but the newest tissue valve don't have a long enough track record that anyone can definitely say how long they will last. One thing that you must accept is that in selecting a valve just as in making any other decision in life, there are no certainties. My Uncles mechanical valve had to be replaced at 10 years due to tissue growth and you will find among our current members those whose tissue valve failed in even less time. There is no way to know where your experience will fall. What is certain is that your future with a valve replacement will be much brighter than if you went without one. As you have started to do, ask your questions here and read the experiences of people in VR so you can make a decision based on knowledge. When you have talked with your surgeon and made your selection, turn to the future and don't look back to second guess yourself. Which ever you choose, your new valve will be so much better than the one that is failing. Let us know how else we can help you.

Larry

 

[normofthenorth]

RDISH, it sounds as if you already have the requisite info to make an informed decision using your own personal preferences and values. At 41, I suspect you're on the young side of "where the lines cross" in terms of life expectancy in the various retrospective studies -- older tissue-valve patients live longer than mech patients, and younger mech-valve patients live longer than tissue patients, and in-between it's a saw-off. Both options keep getting better, and neither comes with a guarantee. Mainframe's personal experience is a good reminder of that sad fact on the tissue side, and we have several posters here who've gone mech and still had a second OHS -- in one case because of an inability to maintain a stable INR, IIRC(!). (Guarantees would REALLY be nice!)

Ironically and unfortunately, one possible outcome from EITHER choice is that you'll end up with EXACTLY what you were trying so hard to avoid: Some mech-valve patients end up having to go through OHS all over again, for all kinds of reasons (though hardly ever because the valve itself breaks down), and some tissue-valve patients end up on ACT, for all kinds of reasons. In addition, there are the main known risks on each side: elevated risk of clots and bleeding events on the mech/ACT side, and the risks of living with a "mortal" replacement valve, including the risk of one or more re-ops.

The good news is that some recent studies on some well-established (=~ older-design) tissue valves have shown very impressive long-term durability stats, but the durability does seem to drop fast when you're as young as you are. Unfortunately, the stats are always presented in big fat "tranches" of age groups, and 41 is usually part of the "under 60" tranche, which isn't very informative for you. They haven't re-sliced the stats to answer your obvious question (i.e., what's the expectation at YOUR age, based on the data), and I'm certainly not a good enough statistician to do it myself. But looking at the recent (2010) "gold standard" article on the long-term durability of "my" valve, implanted at "my" hospital, the under-60 crowd as a whole had around 90% "freedom from structural valve deterioration" until about 10 years, and then it started falling almost linearly: 54.5% at 15 years and 29% at 20 years. I know their <60 group had a 19-year-old in it, but I suspect it was heavily loaded with 50-somethings, who would have significantly better expectation for valve durability than you at 41.

So at least for that "under-60" group as a whole, we do have stats showing much better than 12-year durability for a tissue valve ON AVERAGE, but if we had numbers for a 41-year-old, they might be closer to 12 years than the 16-17 years for the whole group.

My cardiologist just told me yesterday that he doesn't think that anybody who's on ACT should ski downhill -- though he knows I'm going to Whistler in a couple of weeks, during my 3-month ACT session from my recent MV repair. And I think several mech-valve bloggers here do skiing or mountain biking or similar crazy things. Any "trauma" or "bleeding event" is likely to be much more serious if you have an elevated INR, and I've recently posted one link to a study that quantifies the effect, starting with INR as low as TWO(!). And the ACT doesn't eliminate the elevated risk of clotting events, either, it just keeps them down to "acceptable" levels. Maintaining a steady INR, e.g. through self-testing, probably helps a lot, but it doesn't eliminate either risk.

On the tissue side, going for re-ops (and dreading them and waiting for them) is a serious psychological and physical burden, though the actual death toll from the re-ops seems to be dropping fast (down to roughly the risk of first-time ops, and much lower than those first-time risks were 10 or so years ago), especially at centers that do a lot of them.

One of the guys here just opted for a new-fangled Medtronics pericardial (tissue) valve that lends itself to minimally invasive surgical implantation, and even comes in a (an even newer-fangled) sutureless version that's implanted like a stent, through a catheter(!). The makers claim unusually natural hemodynamics, and have reasons to hope for good durability, though there's never any statistics on the new valves.

Good luck, whatever you decide. If I were going for a mech valve, I would have wanted On-X until about two days ago, when I started reading the competitive literature from medtronics/ATS in favor of their mech valve, e.g., atsmedical.com/Physicians.aspx?id=2476 , "Summaries of key clinical experience articles for ATS Open Pivot Mechanical Valve with low does anticoagulation therapy and the On-X Mechanical Valve with normal anticoagulation therapy."

It's all interesting, it's all important, no valve is perfect, and they're all better than the one you have now!

 

[neil]

good luck with whichever one you pick

 

[mainframe]

I went into my first surgery with the idea of not being on anti coagulants. That was the most important thing for me at the time. (regardless of how misguided I think that decision might be now, for me). My first surgeon would have implanted anything I wanted and as a matter of fact I went to him with the idea of a Ross procedure. They agreed and up until a couple of days before surgery that was the plan. Seem due to my dialated aorta that wasn't an option. I then requested a porcine valve. During surgery because of the layout of my coronary arteries, the surgeon felt like a bovine valve would be my best option. That's what I woke up with.

When I made the decision to get a tissue valve the first time I was working out 6 days a week, had body fat at 7 percent and was a Body for Life finalist the year before. It was pretty easy to think when I needed a re-op that would also be the case. It wasn't. I had gained a fair amount of weight, my tissue valve leaked severely and I barely survived the second surgery. You just don't know what your circimstances may be when it time for the re-op.


I have to guess about whether I'd need another surgery or not, had I got a mechanical. The statistics say probably not as mechanicals are designed to last a very long time. Sometimes it doesn't work that way as a member Robthatsme recently had to have his St. Jude replaced. It does happen, but not often.

Like other folks are saying, theres no best choice, there are no guarantees and we all have to live with the valve choice we make. Just because I had a tough re-do doesn't mean you will, or just because it was "easier than the first" for someone else doesn't mean it will be for you. We just don't know.

 

[dick0236]

Hi Chris, and welcome. Like your Uncle, I had my surgery in Lexington, KY. Mechanical valves are designe and tested to last a couple of lifetimes. Whether this is true remains to be seen since the surgery has only been around for 50 years. I spoke with Dr. Starr, the co-inventor of my valve, a few years ago and he told me there were "quite a few" patients still doing well with this valve after 40 years. You don't see too many posts since this age population (70s+) is a pre-computer generation. My valve has seldom interfered with my lifestyle. At age 31, I was "more or less" beyond contact sports like tackle football and I have never had the valve or ACT interfere with occupation or hobbies. ACT does require following a regimen, although it is a pretty simple regimen...."take the medication as prescribed and routinely test". Although the testing is sometimes a hassle, it has caused me to maintain a regular contact with doctors over the years. Maybe that is why I am now 75(almost) and as "healthy as a horse".

 

[OldManEmu]

Welcome aboard RDish.
I usually resist posting to these valve choice threads however as you are 41 the same age as I was at surgery I can’t resist this time.

Firstly I agree with Dick if you get a mechanical valve you are very unlikely to require surgery again.

I often think the term "active" is used in the wrong context when people evaluate valve choice, either valve will allow you extreme aerobic exertion post surgical recovery if you do not have any health issues limiting your cardiac output, as the surgeon put it. Neither valve is as good as a native valve as far as flow goes, however unless you are competing at professional level you shouldn’t notice it.
I believe Al with the comment "Contact Sports are generally discouraged" with mechanical valves went only part of the way, I was warned also of "any" sporting activity that carries the risk of a significant impact to the head. Helmets while good at preventing mechanical damage to the head such as a fractured skull are of limited value in stopping your brain moving inside the skull which is the cause of concussion and brain bleeding. My cardio actually cited several examples of her patients that had "bad outcomes" as she put it from these types of activities.
The other point I have not seen anyone mention with mechanical valves is the risk of overseas travel to non first world countries where different diet, upset stomach can interfere with warfarin and there is unlikely to be someone available with lovonox as a backup or a well equipped ER.
I found it interesting that my cardio favours tissue valves and the surgeon mechanical in this age group, the only thing I can put it down to is the cardio having a closer ongoing involvement post surgery with patients. Even the medical community is split!!

Lyn I have spoken to my surgeon about percutaneous valves as they are being done currently at the hospital I attend, however they are presently only being used on patients that are unsuitable for conventional surgery. I asked why and he indicated their performance (flow) was not as good as a conventional valve.

In the end it comes down to what are the negatives of each of the valve types you find can most easily live with.

 

[ALCapshaw2]

RD -

I'm curious, what makes you think you would need to replace a mechanical valve?

As others have pointed out, mechanical valves are designed and 'Accelerated Life Tested' NOT to 'wear out' for multiple lifetimes.

The leading reason for mechanical valve "explant" (i.e. replacement) is Pannus Tissue Growth where your own body tissue grows around the valve and eventually impedes the movement of the leaflets. I don't remember the numbers, but believe it is not overly common. We've had ONE member who recently had this done after 10 years with his St. Jude Master's Series Valve. The 'latest and greatest' mechanical valve design from Jack Bokros, Ph.D. (who was involved in the design of ALL the Bi-Leaflet Mechanical Valves made in the USA) has a barrier to retard or prevent Pannus Tissue Growth and is offered by his latest company, ON-X Life Technologies Inc.

Old Man Emu - Your surgeon's comment regarding Percutaneous Placed Tissue Valves that the "performance (flow) was not as good as a conventional valve" is exactly what I would expect from a valve that is placed inside another valve. Logically, it HAS to be smaller in diameter than it's predecessor/host and therefore would have reduced output.

'AL Capshaw'

 

[Philip B]

Active Lifestyle

Active Lifestyle

As others have noted there are excellent options on both sides of the valve selection issue. I opted for a mechanical despite the fact that my diet is random and I pursue an active lifestyle. Developing a brain bleed after getting hit in the head with a soccer ball would be an interesting quirk of fate.

I've sustained pretty serious injuries (including a traumatic brain injury) after being run over by a car... tumbled down rocky mountain slopes in bicycle crashes... been hit in the head hard enough with a sailboat boom to require stitches... broken bones... and I haven't developed a brain bleed even though I'm on coumadin. Maybe I just have enjoyed a streak of dumb luck.

Sometime back, we had a member who played rugby despite having an mechanical valve and being on coumadin. I don't remember who that was and don't know if he's still with us. Often members fade away as they get caught-up in the pursuit of their lives.

I know other folks with mechanical valve who've continued pursuit of their active lives without encountering limitations due to coumadin use. Some even pursue full contact martial arts.

Again, there are great choices. If you were to opt for a mechanical and got taken out by a soccer ball, I'm afraid that would be a pretty clear indication that God figured your time with us was up. What do they use to inflate those soccer balls your kids play with... lead? Good luck with your choice.

-Philip