NEWBIE: Needs advice

[W84Me]

I am 58 and have been diagnosed with severe stenosis after undergoing ultrasound echo and have my first appointment with the cardiologist tomorrow (Monday, June 26).

So as I understand from this very resourceful forum, I will have the option of either tissue valve or mechanical valve. The latter being a one-time procedure but with lifelong dependence on blood thinner as well more vulnerability to infection. And the former being a 10-year (or so) treatment that requires repeat of open-heart surgery but with no medicine dependence.

Am I getting it right?

I have no health-related issues including hypertension, weight etc. Always exercised using weights and never smoked. Alcohol consumption was also very rare. No family history of heart-related problems. Quite frankly, I am surprised to find my diagnosis with stenosis.

I will pose three questions:

1. How long was the recovery after the surgery?
2. If you had tissue valve replacement, how long did it last?
3. If you were in my shoes, which valve option you will prefer? I would like to have as much back to normalcy as possible (including staying fit using weights if possible).

Thanks to everyone for helping me in the right direction.

 

[pellicle]

Hi and welcome

I am 58 and have been diagnosed with severe stenosis after undergoing ultrasound echo and have my first appointment with the cardiologist tomorrow (Monday, June 26).

ok ... please let us know what they found.

So as I understand from this very resourceful forum, I will have the option of either tissue valve or mechanical valve.

pretty much

The latter being a one-time procedure but with lifelong dependence on blood thinner as well more vulnerability to infection. And the former being a 10-year (or so) treatment that requires repeat of open-heart surgery but with no medicine dependence.

more or less

Am I getting it right?

there are some subtle details but yes, that's ball park. First thing I'd point out however is that the 10 year (or so) at your age may well indeed be over 15 years. Age makes a difference in this equation. I'm seeing here people getting >18 years out of their valves. I would anticipate (I'm not a user of that tech) a Inspirs Resilia would be in the order of 15 ~ 20 years.

I have no health-related issues including hypertension, weight etc. Always exercised using weights and never smoked. Alcohol consumption was also very rare. No family history of heart-related problems. Quite frankly, I am surprised to find my diagnosis with stenosis.

its interesting. Have you had your Lp(a) levels checked?

Were you ever ill from something like Scarlet Fever (esp as a child or younger adult)?

I will pose three questions:

1. How long was the recovery after the surgery?

it varies, but I'd expect that you'd do at least as well as me when I had (admittedly my 3rd) OHS at 48. I struggled a bit more than some and eventually found that by 3 months I was running on the beach again with my wife

3. If you were in my shoes, which valve option you will prefer? I would like to have as much back to normalcy as possible (including staying fit using weights if possible).

its difficult for me to say, but knowing what I do and imagining a first OHS being more or less now (so around 10 years ago) I might be tempted to go the tissue prosthesis.

My reasoning is that if you choose mech and Anti Coagulation Therapy if you aren't a DIY sort of person willing to fight for your self management, then you will suffer some frustration to say the least. Further if you aren't self managing you simply won't get the best outcomes (best = age related risk of thrombosis or bleed event) that you could by taking charge and doing it properly. There is no room for "she'll be right" on INR management. Its not rocket science but you just must simply:

• take your pills without fail (meaning have a strategy of checks)
• test regularly
• adjust only as needed.

if you aren't that sort of person then you'll be better off with a tissue prosthesis.

However it is not unheard of to end up on ACT even if you pick a tissue valve. Such things as the development of arrythmias (eg AFib) or the development of valve related thrombosis (yes, that happens, and in particular when Structural Valve Degredation has set in (commonly around the 8~10 year point). From then you may find yourself needing to manage ACT.

Some additional reading
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6306127/
https://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/s13019-020-01155-6
https://www.ahajournals.org/doi/10.1161/JAHA.120.018506#d1e702


HTH

 

[Gail in Ca]

After each of my 3 surgeries in 20 yrs, the recovery time followed what I was told after surgery. I was sickest (congestive heart failure) going into 2nd surgery and coming home too soon, really, but I recovered about the same. After 3rd surgery, I actually drove sooner than recommended since it was only 8 minutes to my cardiologist.
My tissue valve lasted 11 yrs, I got it in ‘89 at age 34.
I would choose mechanical if I had to do it again in my 50’s. (I was 54 for my 3rd surgery). I recovered fast. I was used to warfarin and self testing from my 2nd surgery. No big deal there. I ended up in chronic a-fib so I would’ve needed blood thinners even if I had chosen tissue for my 3rd. Good luck with your choice.
I would say that when you haven’t yet had open heart surgery, you don’t know what you’re going to go through. It’s a lot even for us that recover pretty uneventfully.

 

[Superman]

Mechanical valves have a greater vulnerability to infection? I haven’t heard that one. Always open to new info - just don’t recall that being mentioned before.

 

[pellicle]

Hi

Mechanical valves have a greater vulnerability to infection? I haven’t heard that one. Always open to new info - just don’t recall that being mentioned before.

I'm sort of surprised at that. Its been discussed here before and not so long ago. One such discussion here:
https://www.valvereplacement.org/th...h-and-5-sternotomies-later.889064/post-924285
I had the impression that in the case of emergency valve surgery that a mechanical valve was the go to for cases of active Infective Endocarditis .

A search revealed this:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7475423/

 

[W84Me]

Thank you so much for all your insights. So after my today’s initial appointment with a cardiologist, I have been referred to the actual surgeon who will be doing the surgery. My appointment with the surgeon is scheduled on July 20. In the meantime, I have to have my cardiac catheter exam done.

The cardiologist whom I saw today practically discouraged me from mechanical valve because he believes the dependence on blood thinner is a pain in the ass. I was told that you can have minimally invasive surgeries when tissue valves wear out.

His recommendation directly contradicts the recommendation of preferring mechanical valves in this forum. I am so confused. I will have to settle on a decision by the surgery date.

 

[DebbyA]

Recovery rates vary and you'll get lots of information here about that. I'm speaking up as an outlier from the "age matters" in valve choice. I got a tissue valve at 60 and it failed in 6 years. If it had lasted the promised 15 years, I would be facing another replacement now. Even as a healthy modestly active person I can tell you that recovery from anything takes longer at this age. The prediction that we'd all be getting that second valve replacement with TAVR has not panned out. There are no guarantees, but the most likely outcome with a mechanical valve is that it will last and your main concern will be annoyance with whoever is "managing" your anti-coagulation if you're not one of the lucky ones who stay consistently in range.

Your statement about infection with mechanical valves was a surprise to me too. I was given antibiotics for dental work, colonoscopies and any surgery as soon as I was diagnosed with a valve problem. This past year I had cataract surgery and broken wrist surgery and neither required antibiotics, though they're still prescribed for dental work.

Just curious, but what prompted the echo to begin with?

 

[dick0236]

Welcome W84Me. I used to think "tissue" valves were an OK choice for folks close to 60 if they wanted to avoid the anti-coagulant (warfarin). There is no guarantee that you will not be on ACT anyway.......as you approach old age. In my early 80's I was diagnosed with "chronic a-fib" and a year ago I was diagnosed with "pulmonary hypertension". The preferred medication for both of those problems is an anti-coagulant. Since I was already on warfarin for my mechanical valve it was not necessary to add any medications to the ones I take each day.

I think the more logical question to ask is "How old will I be if I choose Tissue and need it replaced". I can't believe that surgery at 75 or 80 will be much fun.

I am now 87 and warfarin is the least of my concerns.

 

[DebbyA]

I would run from that cardiologist, and possibly from the doc who referred me to him.

 

[W84Me]

Actually the cardiologist whom I saw today will not have any say when I see the actual surgeon on July 20. But I truly am leaning towards mechanical valve due to its longevity. Blood thinners may be something that require consistent monitoring but nowhere close to the inconvenience of repeat heart surgeries.

What I find interesting is how some doctors push for tissue valve.

To answer your query, the echo cardiogram was done because my chest X-ray (for a skin infection) showed mild cardio megaly. When I told my primary care physician that I was having shortness of breath, he ordered the echo.

 

[W84Me]

One additional note: The cardiologist today (who was discouraging me from mechanical valve) was the one who had interpreted the echo cardiogram results. Should I be skeptical? Makes me wonder.

 

[pellicle]

His recommendation directly contradicts the recommendation of preferring mechanical valves in this forum

to be clear I'm not recommending one to you, I'm just presenting the facts and what conditions I see each type having a benefit.

I can't know for sure but I think you may have had a takeaway from my first post which wasn't my exact message if you think I said "you should get a mech". I indeed suggested you'd get better life than you'd heard from a bioprosthesis.

First thing I'd point out however is that the 10 year (or so) at your age may well indeed be over 15 years. Age makes a difference in this equation. I'm seeing here people getting >18 years out of their valves. I would anticipate (I'm not a user of that tech) a Inspirs Resilia would be in the order of 15 ~ 20 years.

and then specifically

its difficult for me to say, but knowing what I do and imagining a first OHS being more or less now (so around 10 years ago) I might be tempted to go the tissue prosthesis.

I would grab a coffee and listen carefully to this presentation for how it relates to you and your situation



Some of what I wrote here may be of use to you
https://www.valvereplacement.org/threads/tissue-vs-mechanical.1212/page-2#post-925263
lastly make no mistake, if you don't take managing your INR seriously this can happen to you:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8202806/
its no joke at all, and the statistics suggest that many warfarin patients are non-compliant with their warfarin.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4720013/

Abstract​

Warfarin is a commonly prescribed oral anticoagulant in Saudi Arabia and yet patient adherence to warfarin therapy and its impact on anticoagulation control have not been well researched here. A cross-sectional survey was conducted over 6 weeks at the outpatient anticoagulant clinic on patients who were receiving warfarin. Adherence was assessed using the translated Arabic version of the Morisky Medication Adherence Scale (MMAS-8). Levels of adherence were classed as low (score ⩽ 7), or high (score = 8) based on the scores. Good anticoagulation control was defined as percent Time INR in Therapeutic Range (TTR) ⩾ 75% using the Rosendaal method. A total of 192 patients completed a questionnaire with a response rate of 68.1%. It was established that no association was found between adherence to warfarin therapy and INR control groups. Among the 89 (46.4%) patients who had high adherence, only 34 (38.2%) had an acceptable INR control. This was versus 103 (53.6%) patients who had low adherence but also 34 (33.0%) had good INR control. Multivariate logistic regression (MLR) analysis showed that when studying females and occupational status of unemployment, they were independently associated with poor INR control with an OR 2.31, 95% CI 1.10–4.92, and OR 2.71, 95% CI 1.12–6.61 respectively. MLR analysis also showed that age <50 years alongside no formal education was independently associated with low adherence to warfarin therapy with an OR 2.67, 95% CI 1.29–5.52 and OR 2.63, 95% CI 1.01–6.93 respectively. The demographic background influences adherence and INR control, but no association was found between adherence and anticoagulation control.​

Myself by self testing and self managing my dose I'm >95% TTR

Given the above I'm sure you can see why cardiologists are cautious to recommend mechanical valve. To my understanding however this tendency is more of a US tendency and strictly depends on age.


I'd specifically probe why your cardio isn't in favor of mech and if the above mentioned factors are part of it.

Best Wishes

 

[pellicle]

One additional note: The cardiologist today (who was discouraging me from mechanical valve) was the one who had interpreted the echo cardiogram results. Should I be skeptical? Makes me wonder.

my view is that one should always begin from a position of scepticism. Indeed the very foundation of science is that of "check what's said" (which given the replication crisis within pseudoscience's such as psychology bears out my reservations on its basis as a science).

Importantly scepticism is not "denial" but a requirement that you seek verification or validation or reasons.

HTH

 

[W84Me]

I never said that your experience is a “recommendation“ of any sort. What I meant is that based on so many good experiences of people with mechanical valve, it equates to a good validation of the valve over tissue ones (in terms of duration) considering my age. So if I survive till 80, there will two additional surgeries needed whereas mechanical valve will eliminate those. Of course, anti-coagulant will be required. Speaking for myself, that discipline will be strictly kept.

As I mentioned, the doctor does not advocate mechanical valve because it requires blood thinners.

 

[Beach77]

I was considering a TAVR for my surgery. The 3 doctors I talked to before my surgery, said either would be good for me, because of my age. My heart team wanted me to talk with the TAVR surgeon and the OH surgeon for the mechanical, to be sure I understood the choice they gave me. I was 64 and turned 65 on the day I was released from the hospital. I decided on a mechanical. (On-X) Best decision! I'm hoping only 1 OHS! Good luck with your decision! I feel like that was harder than the actual surgery!

I agree with @DebbieA "I would run from that cardiologist, and possibly from the doc who referred me to him"

Warfarin has been okay, I've had no problems.

Ellen

 

[W84Me]

How long have you been now with the mechanical valve? How about the noise issue that I hear about? How inconvenient is it?

 

[pellicle]

How long have you been now with the mechanical valve? How about the noise issue that I hear about? How inconvenient is it?

If you don't reply to a person it's hard to know if you are asking someone specifically as the phrasing suggests.

So in case that was me, speaking for myself, I got my mech valve in November 2011 (it's in my bio).
The "noise" isn't noise to me, it's my heart beat. It's part of me and actually I find it helpful. For instance I'm aware of my HR without needing to take my pulse.
I can tune into it as I wish but frequently don't.
When my arrhythmia began (just over a year ago) I was onto it early. That be the fact that I was already on ACT was helpful IMO because I didn't fear a stroke.

I believe my arrhythmia was a result of COVID exposure (because it was clearly associated in time)..

My view is that life presents changes, one either adapts to thees or becomes angry at that which is beyond our control.

Best Wishes

 

[Superman]

I never said that your experience is a “recommendation“ of any sort.

Thank you for saying this. Just so you know where the disclosures and caveats come from, people have come in to these forums accusing certain posters of having a specific “agenda” when it comes to sharing experiences. Valve choice is a tough decision and an emotional one. Not a lot of room for buyers remorse. We all try to make the best decision for our own situation. Some people have been very defensive about that choice and view any positive talk about a different choice as an attack on their own.

 

[Nick Drew]

probably wrong to say do this or do that but i had my mechanical at 64 and the ticking or the warfarin quite simply-do not bother me.
The ticking is there but i just zone it out(it can be done) and warfarin i take after home checking(important if you can get that) really didn't fancy another op when i was in my 70s

 

[LondonAndy]

Welcome W84Me - I agree, lots of useful info on this forum, and I wish you well with your decision. A couple of points from me:

1. I had my mechanical valve inserted in 2013, at the age of 48. I have had no regrets, and do not find the Warfarin management difficult, though there is a learning curve.
2. When people say about the need to test regularly, ideally this means weekly. If you have your own meter, a hand held device that uses a finger-prick of blood and gives results in under a minute, it's easy. It is not unusual for clinics to be testing only monthly or even bi-monthly.
3. Whilst the "one and done" approach was my reasoning, not fancying further surgeries as I got older and frailer, a downside of mechanical is that it can limit what pain meds you can take. So if you have a family history of things like arthritis that could be an issue.
4. Whatever type of valve you gets leaves us at higher risk of atrial fibrillation, which can mean 'blood thinners' even on a tissue valve. However, for tissue valves they can prescribe novel anticoagulants like Eliquis, that do not need regular testing.
5. When you have the operation, whatever you choose, be sure to take ear plugs - you would not believe how much noise there is in hospitals, and how little they seem to value a patient's sleep!