Mechanical vs Tissue - need help deciding

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vitdoc

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Warfarin is taken for essentially two reasons following mechanical valve surgery. First if no anticoagulants are used the valve may clot and lock up.
Second small emboli form around the valve or through areas of irregular flow through the valve. These emboli travel downstream and sometimes lodge in some blood vessel. Depending on which vessel determines the symptoms.
If the embolus is small it can brake up and the symptoms diminish hence a TIA. In my case I have had small transient blockages in retinal vessels where part of my visual field goes dark in one eye. Fortunately all have passed usually within 5 or so minutes. This is not migraine which affects the field in both eyes. But any part of the brain can be affected so many different symptoms could occur. Anticoagulants markedly decrease the chance of these events but like many things in medicine they don’t eradicate them.The recommendations for INR levels are based on a balance of reducing vascular issues vs increasing your possible hemorrhagic issues. Probably no microparticles from the valve but the mesh on the valve gets covered by tissue growth after several months and this could decrease potential emboli.
 

LondonAndy

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In the first couple of months after surgery, I had a few episodes to the blockages above 2.5 INR, so my cardiologist asked me to keep my range between 3-3.5. No blockages since. I’d been toying with the idea that issues I had before were related to how close I was to surgery, microparticles (if that’s a thing) or something similar. Can anyone comment on that? I’d like to move to a little larger and lower INR range. I’m talking to the cardiologist soon, but experience from members here is sometimes as (or more) valuable than the cardio’s.
There are others here who can give better advice than me I think - I have only been a Warfarin addict for less than 5 years so far, with a therapeutic range of 2.5 to 3.5 for a St Jude 29mm aortic valve. My thinking is that a lot depends on our lifestyles:

  • If you are the outdoors hiking, cycling, hockey playing or lumberjacking kinda person, where injuries are more of a risk, I would want to get my INR to be as low as is considered safe.
  • If you are an office working, indoorsy Monopoly or Scrabble playing type, where even if you get hit by the boat in Monopoly the injury risk is lower, then I would be inclined to a higher range.
I realise that there may also be other health issues at play, but I don't know how those would affect things. So as an office working nerd I aim for my INR to be 3.0 to 3.5. I shall, of course, most likely be run-over by a London double decker bus now that I've said that, especially on route 121 in north London where the buses appear to have only been fitted with "go" and "stop" pedals with no graduation ...
 

vitdoc

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Probably not micro particles . More likely potential emboli from peri valvular issues. The mesh on the valve ring slowly gets covered by tissue. Theoretically that may decrease clot formation.
 

pellicle

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.... No blockages since. I’d been toying with the idea that issues I had before were related to how close I was to surgery, microparticles (if that’s a thing) or something similar. Can anyone comment on that? I’d like to move to a little larger and lower INR range. I’m talking to the cardiologist soon, but experience from members here is sometimes as (or more) valuable than the cardio’s.
to the best of my knowledge there is no specific filtration system in the body, but the fine capillaries and the lungs would surely clear up any debris not caught by the phagocytes within a few days (no?) .

As to your larger range, was it determined (say, d-dimer testing) that your obstruction was thrombosis or platelet aggregates? Are you taking any anti-platelet? (aspirin for instance)

My view is that you could (perhaps) widen your range (if not lower it), for instance this study (results graph) suggests that as long as your perhaps tolerant of a bit more bruising that you could go higher without significant extra risks:



The problem with INR readings is that there can be quite some variance found in "method", this Roche publication makes that point.

 

pellicle

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@egar

.... More likely potential emboli from peri valvular issues.
that's what I'd go with too.

As to ongoing, I've seen cases where the only explanation was either platelet activation (from multiple round trip cumulative damage) or that the person had a lower threshold of triggering thrombosis and there is "jet pressure" on opening and closing of the valve. For all manner of reasons your threshold may be closer (@egar )
 

zelic

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Hopefully this hasn’t been posted before. An excellent discussion between aortic valve surgeons. Also includes discussion on a new mechanical TAV which doesn’t require anti-coagulant treatment. I didn’t realise that warfarin is needed because of the open / close nature of the mechanical valve as opposed to it being a foreign body.

Nice article on the tri-leaflet mechanical valve that is mentioned in the video. Should be interesting to follow...
 

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Keithl

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Nice article on the tri-leaflet mechanical valve that is mentioned in the video. Should be interesting to follow...
Awesome video and the promising on the tri-leaflet mechanical that may only need aspirin. Interesting how they say that those that home test had less issues becasue they took control of their control. I like the comment at the 22 minute mark where they said if you don't have a thrombolytic events at 15 years with a mechanical you will never have one and the thought of lowering the anti-coagulation since the risk is almost non-existent. Great find thanks!
 

tom in MO

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Inconveniently that's not what I read here ... I'll have to start fishing out and naming you in the threads where people who live in the USA ask:
  • where can I buy my own machine
  • where can I buy my own supplies
  • I was told I can't buy supplies because they require a preseciption
you say:


So unless you mean the black market or buying overseas I suggest that the medical system seems to have Gimped the US non insured citizens.

Indeed your own discussion seems to suggest this too:
https://www.valvereplacement.org/threads/couagchek-test-strips.886294/
As someone who lives in Finland and Australia, you are ignorant of the US medical system. However, you seem to enjoy putting down the US medical system. That's a shame. Aren't we here to help each other? A US citizen isn't eligible for Australian or Finish care. I have no idea of how medicine works in Germany, Britain, Australia, China, India, etc. but I would never presume to say it's inferior to any other country's system.
 

pellicle

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Hi

As someone who lives in Finland and Australia, you are ignorant of the US medical system.
quite probably, certainly the details. However as anyone with a pair of eyes and a brain I can read things here and while you perhaps dont see huge problems they exist.

However, you seem to enjoy putting down the US medical system.
you misunderstand my motivation. I try to draw awareness to its problems when I'm confronted by someone who appears to preach "you can get anything" in a way as to not be seeing where it lets people down.

The best way to do something about change is to bring awareness of the need for change.


Aren't we here to help each other?
we are ... and you may observe me doing much to help others. This help goes beyond saying "its ok mate, she'll be right" but to actual tangible help. Helping people do things. Helping people learn how to do things for themselves too.

I understand it if you refuse to see me doing that because of your plain dislike of me.

A US citizen isn't eligible for Australian or Finish care.
this is not strictly correct, if you (I presume a US Citizen) are in Australia or Finland you will not be turned away from a hospital (as you may be back in your native USA). You will however be expected to pay. Its even entirely possible that (if you didn't have travel insurance) that you would not be billed for ER work done to save your life.

You may find this interesting reading:


I have no idea of how medicine works in Germany, Britain, Australia, China, India, etc. but I would never presume to say it's inferior to any other country's system.
While I understand your point of view, another is that countries outside the USA look at each others health care systems and see how they can improve them if they can. The premise of doing this is the position of saying "our service is inferior to this, how can we improve it, how can we afford to improve it in a sustainable way.

So when I see you call out stuff that's wrong (like you can buy anything if you want to) I make a mention of it. Just as I do when I see people call out stuff that's wrong about warfarin.

Best Wishes
 

maggiemay

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I'm a 48 year old male; 6'-3" height and 275lb.

I have AVR in my very near future, and need to decide my path forward : Mechanical (On-X) valve or Tissue valve.

I'm very nervous about the prospect of hearing something tick in my chest for the rest of my life.

Is there anyone out there that can shed some light on the noise concern - and perhaps share their experience?

Any feedback / recommendations greatly appreciated


Holley650

(because I feel like I'm having a carburetor serviced on a V-8 engine)
 

maggiemay

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I'm a 48 year old male; 6'-3" height and 275lb.

I have AVR in my very near future, and need to decide my path forward : Mechanical (On-X) valve or Tissue valve.

I'm very nervous about the prospect of hearing something tick in my chest for the rest of my life.

Is there anyone out there that can shed some light on the noise concern - and perhaps share their experience?

Any feedback / recommendations greatly appreciated


Holley650

(because I feel like I'm having a carburetor serviced on a V-8 engine)
Hi, I have had a st jude aortic valve in my chest for the last 26 years, I was very grateful when the surgeon operated on me when I was 60 years of age. At the time I had only weeks to live, so I was very happy to have the mechanical valve, of course I have been on warfarin for the 26 years, I have been self testing for the last 9 years, with the backing of the blood dept at the local hospital. Still going strong at 86 years of age, I wish you well and trust that you will decide which is your best option. Margaret
 

maggiemay

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Hi, I have had a st jude aortic valve in my chest for the last 26 years, I was very grateful when the surgeon operated on me when I was 60 years of age. At the time I had only weeks to live, so I was very happy to have the mechanical valve, of course I have been on warfarin for the 26 years, I have been self testing for the last 9 years, with the backing of the blood dept at the local hospital. Still going strong at 86 years of age, I wish you well and trust that you will decide which is your best option. Margaret
I heard the ticking to begin with, and when I spoke about it to the surgeon he smiled and said it is comforting to hear it, and it will settle down and it did.
 

Keithl

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Apr 20, 2019
Messages
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I'm a 48 year old male; 6'-3" height and 275lb.

I have AVR in my very near future, and need to decide my path forward : Mechanical (On-X) valve or Tissue valve.

I'm very nervous about the prospect of hearing something tick in my chest for the rest of my life.

Is there anyone out there that can shed some light on the noise concern - and perhaps share their experience?

Any feedback / recommendations greatly appreciated


Holley650

(because I feel like I'm having a carburetor serviced on a V-8 engine)
I will tell you I just went through this last month. I never thought about hearing the valve as the people I knew with mechanical never heard theirs. I only found this forum a few days before my OHS, but I was pretty much set on mechanical and hopeful to get an On-X. Roll forward and I do hear some clicking occasionally, but it is not obnoxious and it has faded into the background when I do. Even with a ambient noise machine I hear it as times when I am trying to sleep, but again have paid it no attention. That said the surgeon said they have done reops on people that could not take the noise. To me, while tissue valves have progressed a long way I am too nervous about another OHS and decided mechanical and coumadin were fine. This is against most conventional wisdom today as at 58 my local docs pushed tissue, but I was clear that there is still unproven data on TAVR durability once I would need that in 10-20 years while mechanical has long proven history of 30+ years.

I am fortunate, my recovery at 3.5 weeks is great, smoother than I could have imagined, my INR seems to be stabilizing on a dosage that is now close to dialed in and while there are days I say what if I went tissue, I quickly realize that in all likelihood they will never crack my chest nor touch my heart again. If I am lucky it looks like something other than my heart will kill me eventually.

You have to decide what is important, the video that was posted with interviews with some doctors has a very key point. The american doctor said it is a conversation with the patient and almost always the #1 question/concern is survivability, how long with this last and provide care free longevity and the risk of further operations. To me this was the primary decision factor, i wanted lowest possible risk of another operatoin and tissue assured me I woudl have at least a TAVR at some point if possible.

There is no right answer, it is what is important to you and hopefully you surgeon has an unbiased conversation with you providing you information to help your decision.
 

dick0236

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Hi, I have had a st jude aortic valve in my chest for the last 26 years, I was very grateful when the surgeon operated on me when I was 60 years of age. At the time I had only weeks to live, so I was very happy to have the mechanical valve, of course I have been on warfarin for the 26 years, I have been self testing for the last 9 years, with the backing of the blood dept at the local hospital. Still going strong at 86 years of age, I wish you well and trust that you will decide which is your best option. Margaret
Hi Maggiemay......great screen name:). Welcome to the forum and it's great to have another "success story" on this forum. There are lots of new pre-surgery folks that come here and it's important that they hear the facts about living successfully while on warfarin. After you have been on here for a little while you'll be amazed at some of the weird stories you'll hear about the unsubstantiated "horrors" of warfarin.
 

dick0236

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You have to decide what is important, the video that was posted with interviews with some doctors has a very key point. The american doctor said it is a conversation with the patient and almost always the #1 question/concern is survivability, how long with this last and provide care free longevity and the risk of further operations. To me this was the primary decision factor, i wanted lowest possible risk of another operatoin and tissue assured me I woudl have at least a TAVR at some point if possible.
Welcome Keithl. Glad you found this forum........it is a very good source of info. I have gotten a ton of practical info from the folks on here........more than I ever got from my cardios over the years.
 

JaneyJJ

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Hey Holley ,
Like a few others, who have already given you their experiences, I’m now 43 and had my St Jude mitral value since I was 10. The idea of a continuous ticking was tough to imagine, but actually it’s not so noticeable after a while and if anyone asks I always say it’s my watch.
Talk to your surgeon and see what your options are. I was offered a tissue valve, but didn’t want to have to go through additional surgeries ( this was my second open heart surgery) my last surgery was in 1986 in Sydney and I’ve been fine ever since, I run at least 3 times a week and love mountain biking. In my case it was the best solution and extremely grateful to my awesome heart surgeon ❣ cheers Jane
 

ottagal

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Nice article on the tri-leaflet mechanical valve that is mentioned in the video. Should be interesting to follow...
Interesting...will continue following that. Will see how things transpire and wait for more studies. Looks promising...
 

pellicle

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Interesting...will continue following that. Will see how things transpire and wait for more studies. Looks promising...
@Warrick , didn't you say recently that this was ceased?

anyway, I found this of interest:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3570260/

Polymeric heart valves (PHVs), fabricated from advanced polymeric materials, offer the potential of durability and hemocompatibility. Unfortunately, the clinical realization of PHVs to date has been hampered by findings of in vivo calcification, degradation and thrombosis. Here, the authors review the evolution of PHVs, evaluate the state of the art of this technology and propose a pathway towards clinical reality.​
when I was under 50 durablity was a high priority (and you know, even more so when I was 25).
 

ottagal

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@Warrick , didn't you say recently that this was ceased?

anyway, I found this of interest:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3570260/

Polymeric heart valves (PHVs), fabricated from advanced polymeric materials, offer the potential of durability and hemocompatibility. Unfortunately, the clinical realization of PHVs to date has been hampered by findings of in vivo calcification, degradation and thrombosis. Here, the authors review the evolution of PHVs, evaluate the state of the art of this technology and propose a pathway towards clinical reality.​
when I was under 50 durablity was a high priority (and you know, even more so when I was 25).
Thanks Pellicle. This in- vivo study is from December 2018 (5 months ago) on trileaflet mechanical valves. I understand this is in the infancy stages. Was there some new information on this that I missed? The study you quoted is from 2012. Not sure if advances were made since then. Hmmmm
 
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