NEWBIE: Needs advice

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How did you get this...possible another surgery at 78-88? What would be the cause for that?
maths. Addition from his age plus the statistically demonstrated probablity of replacement. Due to the well established point of valve degredation called SVD

https://academic.oup.com/ejcts/article/25/3/364/380558?login=false

Abstract​

Objectives: Reoperation is a relatively common event in patients with prosthetic heart valves, but its actual occurrence can vary widely from one patient to another. With a focus on bioprosthetic valves, this study examines risk factors for reoperation in a large patient cohort
 
Hi Superman,

Your anecdotal example is not a case of a mechanical valve wearing out, but rather a second surgery being required for a different reason.
Agree!

Can you find or cite an example of a mechanical valve being replaced due to wear and tear on the valve? I’m sure all would be interested. I believe there have been failures, but they are random and extremely rare isolated incidents. Not typical wear and tear.
I was not implying that I heard of a mechanical valve being replaced specially for "wear and tear" or even some failure (I really hope not because my wife has 2 and she has many, many years years of life to get out of them).

The person I mentioned that had both their AV and MV St Jude valves replaced due to pannus did have a "frozen" leaflet but this was due to the pannus growth. btw, this individual had her mechanical valves for 27 years before they were replaced.
 
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I was told mine has a lifetime guarantee.

Your anecdotal example is not a case of a mechanical valve wearing out, but rather a second surgery being required for a different reason.

My second surgery was required due to an aneurysm, not due to the valve wearing out.

Can you find or cite an example of a mechanical valve being replaced due to wear and tear on the valve? I’m sure all would be interested. I believe there have been failures, but they are random and extremely rare isolated incidents. Not typical wear and tear.
I personally know of 3 people who had to get another open heart after mechanical valve replacement, all within 30 years, and all because of pannus formation and very elevated velocities. In 2 of the cases there was an aneurysm formed in the aortic arch also so it, the arch, had to replaced. When there is a problem in the arch it may be somewhat pre ordained from this originally being a bicuspid valve at birth, although one of these individuals was told at a large hospital in Seattle that it was from the jet caused by the bi leaflet mechanical valve.

So in summary, the mechanical valve should be expected to itself last forever. Having an issue with the valve itself is so incredibly rare that it shouldn't even be a consideration, in my opinion. It's better than all other choices. However, re-surgeries do happen from valve malfunction due to pannus formation primarily. The older the patient at implant the more likely it will last forever. In Europe I believe the guidelines are up to age 75 for now and in the USA I believe they are 65. A 58 year old getting a mechanical valve is following the guidelines as far as I know.
 
To "valve in valve" replace a bioprosthetic the following happens
  1. a catheter (think guide tube) is inserted down your artery (usually the femoral artery)
  2. a smaller one is inserted and a complex and tiny mechanism is inserted down there
  3. a net is deployed to prevent debris leaving the chamber and floating off with the blood to lodge in your brain (killing you)
  4. a small set of scissors and pincers is deployed and the tissue valves are cut off (consider that they are coated in brittle calcium which will flake off)
  5. these are then pulled back down the tube and disposed of
  6. a new valve is then pushed through the tube to sit in place and is sprung loaded and "origami style" unfolds into place
Hi pellicle,
I have also heard that in stead of steps 4 and 5 to remove the old, defective valve/leaflets, they can deploy and position the new valve over top of the old valve (actually crushing it).
 
Hi pellicle,
I have also heard that in stead of steps 4 and 5 to remove the old, defective valve/leaflets, they can deploy and position the new valve over top of the old valve (actually crushing it).
yes, but I thought that was when you did the placement over a calcified native valve (in someone quite elderly), rather than when doing a valve in valve of a previous bio-prosthetic.

That is the context / scenario I thought we were discussing here.
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).
however I'm keen to get additional information and clarification.
 
yes, but I thought that was when you did the placement over a calcified native valve (in someone quite elderly), rather than when doing a valve in valve of a previous bio-prosthetic.
Sorry, I don't know enough about TAVR to know about this.

That is the context / scenario I thought we were discussing here.
Probably, I must of glazed over this.
 
Now I don't know if Aspirin is same as warfarin since they both are blood thinners.
it is not, it works entirely differently and underscores why I dislike the fully incorrect "simplification" of "Blood Thinners"

No actual thinning occurs as thinning implies. The only thing that occurs is the response to coagulation.

Aspirin is an anti-platelet agent, it damages the platelets so that they can not form rafts.

Warfarin is an anticoagulant which works on the "coagulation cascade". It slows down the rate at which (a large and complicated molecule) thrombin ties together.

From my book (probably never be published) manuscript

What is INR?
INR is a form of measurement, but it's not in simple units. We can measure how long blood takes to form clots in time, but that’s not always helpful. But measuring clotting is actually not a straightforward thing as there are two components to this clotting:

  1. Blood platelets get activated and stick together, triggering also,
  2. Activation of a molecule called prothrombin that is in the blood plasma.

For our purposes, we are only interested in point two (2) which focuses on the time it takes for prothrombin to thicken and form a sort of glue. This is because warfarin affects prothrombin and of course prothrombin time (PT). This is what is influenced by our taking of warfarin. As an aside, aspirin, for instance, is also known as a blood thinner, but it works on point one (1) so let's leave that out of this.

Put simply, PT is measuring how fast prothrombin forms a glue. I want to again emphasise that these details are for background understanding; they aren’t critical to the method. If you read more about the topic you’ll find it's quite the rabbit hole.
 
I personally know of 3 people who had to get another open heart after mechanical valve replacement, all within 30 years, and all because of pannus formation and very elevated velocities.
interesting (and sad).

Would you mind letting me know how they fitted in with the risk criteria I posted above? Knowing so many valvers personally (and not via here) is rather uncommon so its good to get some information if you're willing to share it.

Also were attempts made to address the Pannus growth prior?

On-X adds what it calls a Pannus Guard to its unit. I'll be interested to see how effective it is. Pannus is a problem for all valves AFAIK. Still if the people got 30 years on the valve that's good. In my case I was "opened up" to fix an aneurysm and my homograft valve (still functional) was removed and replaced at that time. I was 28 on the placement of the homograft and 40 on the placement of the mechanical and aneurysm fix.

Also, on this forum if you look for it you can find member stories where redo OHS was done because of pannus and even obstruction caused by blood-clot build up (hence the need for anticoagulation to be consistent. The primary focus of many is stroke, but indeed thrombosis is a problem
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1861363/
this is now more commonly treated with tPA administration as mentioned in that article

Best Wishes
 
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.

I want to give you my very, very strong opinion on question 3. If you get a tissue valve replacement, at 58 years old, you are
guaranteed of going through this again. The average life of a tissue valve varies, but you will be very lucky to get more than 12 years. So you’ll be facing this again as an older, less healthy person.

My father was very healthy, and died shortly after his second valve replacement. The valve just wore out. The surgeon walked out, shaking his head, saying that the stenosis, scar tissue and calcification made things very difficult.

There are people who will tell you that the technology available for the catheter valve. replacement will only get better. I wouldn’t take that chance.

I got a carbon fiber valve in 2013, and never looked back. Yes, warfarin is a discipline that you have to stick with, but it’s simple to do.
My surgery was performed at Emory University Hospital in Atlanta. I’m not sure of the technical term, but they made a smaller incision in my chest, which made the healing process much easier and faster. They didn’t break open my chest as extensively as in a normal procedure. You definitely want to inquire about that.
 
Although it's fair to think about the mechanical valves as not wearing out, scar tissue does get in the way and they may have to replaced and from everything I have looked at, it's sensible to imagine getting 25 years out of one, and hoping for the home run of living very long and not needing another heart surgery. As I said earlier, one could have bad luck, like having it last 30 years and needing another surgery then. If I could do it over again, starting at 58 instead of 40, it would be a toss up for me between mechanical or Bio, knowing that making the bio choice created a path to bio, bio, tavr. Or possibly, bio, tavr, tavr. My own experience with tavr at age 60 was it was basically like nothing though I was pretty anemic for a few weeks. I was back at work the next week. But I ended up on warfarin anyway as clots developed.

There just nothing easy about the decision but starting warfarin at age 58 instead of say 38, is useful.

In a ideal situation, you get a bio valve at 75 and tavr at 88 and never end up on any blood thinners. We just can't plan these things in the real world
Uh, I got my St. Jude's aortic leaflet valve at 33, am still fine with it at 58, no need to replace it. Been on Warfarin since 36 in 2001. Does not mean I will be getting a replacement anytime soon. I am on warfarin due to the Mechanical valve. That is also real world. I would never do anything over, since the aortic valve had a defect when I was born. You are right, you cannot predict when things will happen.
 
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.

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).
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 was 53 when I had my open heart AVR. !2 years later now at 65 it seems to be doing well. I was in relatively good health otherwise but was about 75 lbs. over weight. My surgeon also recommended the tissue valve for me over the mechanical. He said life style would be easier to deal with. with tissue valve no need for warfarin blood thinners and frequent INR testing. When you first start warfarin, you may need to have blood tests every few days or weekly. When your INR and warfarin dose are stable, blood tests are often done every 2 to 4 weeks, sometimes longer. If your dose changes you may need to have your INR tested. When on warfarin you also have to be cautious of not eating certain foods as they can have an effect on your INR levels. I think his thought was that "for me" at my age, the quality of life with tissue would be better. If I needed a re-do in 10 - 20 years I would still only be in my 60's or 70's and given I remained healthy could tolerate a re do open heart surgery. No a days they are doing Trans Catheter minimally invasive procedures see link (Transcatheter aortic valve replacement (TAVR) - Mayo Clinic). My initial recovery after surgery was 4 - 6 weeks. It was tolerable. The mechanical vs. tissue valve is a very personal decision. I say at your age, and with your otherwise good health I would go with the tissue option. What ever you do, get a surgeon who has performed a lot of these surgeries. While I am sure there are many good surgeons across this nation, this is a big deal and if you have the ability and resources to go to one of the best facilities to get it done you owe it to yourself to do so. If you have any other questions and want to reach out you are welcome to email me. I am not an medical professional but I have been thru this and learned a lot n the process. All the best to you. [email protected]
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.
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).
 
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Good questions!
This was my third surgery & I went mechanical. Second surgery at 46 was bio prosthetic porcine valve that REALLY increased my appetite for bacon. Haha. The valve failed - leaflet broke - which made TAVR impossible - that works for stenotic failure/calcification if I understand that correctly.
Recovery was based on the broken bone healing(6-8 weeks for bone to heal). If you’re fit - good cardio, lifting weights, should be no problem.
For me Warfarin has not been an issue- I take my pill every day. I have the home test kit - eligible after 4 months with my insurance - and can test weekly. The clinic that I check in with recommended going to lower frequency. Mentioned that in a chat here and it gave me pause - weekly testing is in my case no big deal. Only big deal is if I manage to screw something up and not be aware.
The original surgeon who laid out the mechanical v pig choice for me originally was clear that this time it would have to be mechanical. Some people here have had longer success with the tissue replacement but looking back I would have gone mechanical from the start.
My aortic root was also replaced - I think that was with the pig valve - do I should be good there.
Good luck with your decision! Glad you are here!
 
interesting (and sad).

Would you mind letting me know how they fitted in with the risk criteria I posted above? Knowing so many valvers personally (and not via here) is rather uncommon so its good to get some information if you're willing to share it.

Also were attempts made to address the Pannus growth prior?

On-X adds what it calls a Pannus Guard to its unit. I'll be interested to see how effective it is. Pannus is a problem for all valves AFAIK. Still if the people got 30 years on the valve that's good. In my case I was "opened up" to fix an aneurysm and my homograft valve (still functional) was removed and replaced at that time. I was 28 on the placement of the homograft and 40 on the placement of the mechanical and aneurysm fix.

Also, on this forum if you look for it you can find member stories where redo OHS was done because of pannus and even obstruction caused by blood-clot build up (hence the need for anticoagulation to be consistent. The primary focus of many is stroke, but indeed thrombosis is a problem
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1861363/
this is now more commonly treated with tPA administration as mentioned in that article

Best Wishes
interesting (and sad).

Would you mind letting me know how they fitted in with the risk criteria I posted above? Knowing so many valvers personally (and not via here) is rather uncommon so its good to get some information if you're willing to share it.

Also were attempts made to address the Pannus growth prior?

On-X adds what it calls a Pannus Guard to its unit. I'll be interested to see how effective it is. Pannus is a problem for all valves AFAIK. Still if the people got 30 years on the valve that's good. In my case I was "opened up" to fix an aneurysm and my homograft valve (still functional) was removed and replaced at that time. I was 28 on the placement of the homograft and 40 on the placement of the mechanical and aneurysm fix.

Also, on this forum if you look for it you can find member stories where redo OHS was done because of pannus and even obstruction caused by blood-clot build up (hence the need for anticoagulation to be consistent. The primary focus of many is stroke, but indeed thrombosis is a problem
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1861363/
this is now more commonly treated with tPA administration as mentioned in that article

Best Wishes
In one case I believe this patient was non compliant with his warfarin monitoring. So that situation, his need for a redo, was probably on him. His redo was around 26 years. He had an arch replacement also. He chose a bio valve the second time and he was about 50 when he did that. I don't know the compliance on the other two cases at all. I think you have provided data here that suggests pannus is from poor inr control and I agree, and I think it's obvious. All three pateints got their valves under age 40. Mechanical valve+ excellent inr control will lead to the patient having that mechanical valve "last" even longer.
 
Uh, I got my St. Jude's aortic leaflet valve at 33, am still fine with it at 58, no need to replace it. Been on Warfarin since 36 in 2001. Does not mean I will be getting a replacement anytime soon. I am on warfarin due to the Mechanical valve. That is also real world. I would never do anything over, since the aortic valve had a defect when I was born. You are right, you cannot predict when things will happen.
did you not start the warfarin for 3 years?
 
I personally know of 3 people who had to get another open heart after mechanical valve replacement, all within 30 years, and all because of pannus formation and very elevated velocities.
Thank you for this information.

You mention that 1 case was due to Warfarin non-compliance. Would you by chance happen to know the type of mechanical valves that were used in these individuals? I ask, because on the On-X website (yes I understand it could be marketing hype), it says that with this type of mechanical valve, that the "flared inlet organizes flow and prevents pannus formation". I believe this type of valve has been used since 2001.
 
Thank you for this information.

You mention that 1 case was due to Warfarin non-compliance. Would you by chance happen to know the type of mechanical valves that were used in these individuals? I ask, because on the On-X website (yes I understand it could be marketing hype), it says that with this type of mechanical valve, that the "flared inlet organizes flow and prevents pannus formation". I believe this type of valve has been used since 2001.
Im sure non of them were on x because i know the hospitals they were at didnt use those back that long ago. Pretty likely St. Jude. A bit off topic but my opinion is that the approach to tissue valves and no anticoagulation has been an error. The medical community didnt think clots were forming on those valves because they werent looking for them until the last several years. All the more fuel for folks who got mechanical valves to feel justified they made the right choice.
 
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