Review of Valve Choices

[Wise]

Differing opinions are simply based on different information, understanding, etc. . You all have something to contribute to those of us in the early stages of our learning process. We are all ultimately responsible for making our own minds up as to what type of valve is right for us individually. I'm saying this from a novice's perspective to remind you that there are many people out there who are just learning about their condition and dealing with the possibility or certainty of surgery. Options are what we are looking for. What are our options, what can we consider for our own future? Let us know it all. Of course, we should do our own research. I just want to experience vr.com to it fullest. Thank you again for this thread which has been helpful to me. Wise

 

[Karlynn]

This thread is brimming with bias. Many tissue valves in fact DO NOT require anticoagulation. They have some other quality-of-life advantages. I make no pretense of being an expert, but I can do a Google and provide plenty of citations for that if we want to do dueling medical references.

Mechanical valves are best for some people; tissue values are the best choice for others. VR.com is at its best in presenting both sides, but sometimes the bias on this most personal of selections is a turn-off.

Hi Bob,
I think we all know the feeling of thinking we are being told that we made the wrong choice. You are a newer member, so haven't been around much for all the debate on mechanical vs. tissue. I'm pretty thick skinned, but felt that many posts have intimated that the ticking I had going on inside of me was the wrong choice and I was either going to bleed to death or throw a clot at any moment. So I can understand how you must feel. Most of us, after a time here, have come to know that each person's choice is the right choice for them as you said, if it is made with full knowledge. Which I believe most are.

To be fair, I think we have had quite a few members joining who have been given horribly erroneous information about Coumadin (mostly by doctors) that some of us feel keeps them from weighing their options with correct knowledge of the valves available, thus disallowing them from making a truly informed choice. I think we all just want people to go into their replacements fully equiped with correct knowledge.

To be honest, I think this is the first thread in quite a long time that actually has given a positive weight to mechanicals in the Tissue vs. Mechanical debate. Nothing wrong with that, I'm sure someone will come up with another pro-tissue article. It's all information to take in.

 

[Guest]

Don't forget that it is an evolving field. Tomorrow there could be an article that goes completely against what this one said.

The thing about valve choices is that there is no wrong choice. You decide, but the surgeon reserves the right to use the type that looks best once they get inside.

At my clinic we have had the statistician on our QA team look at quite a few factors.

We found no statistically significant increase in bleeding with the INR less than 5.0 and the person was checked about every six weeks. (This is why I hate to see a post "my INR spiked to 3.X and the doctor reduced my dose. It just proves that the doctor does not understand warfarin.)

Our minor bleeding (anything less than needing 2 units of blood) is 1 event per 1.5 patient years. Is it really that hard to accept a bloody nose every 18 months - on average.

Our major bleeding (anything requiring 2 units of blood or more, or any bleed into the brain) rate is 1 event for every 33 patient years. To me that says that most people will never experience one.

We considered all clots to be major. (My clinic takes all warfarin patients, so I have not worked the valvers out of this but I have no reason to suspect that they are that much different.) This rate was 1 in every 100 patient years. OK if valvers are twice as likely to clot, could you accept 1 clot for every 50 patient years?

The right choice is the one that you can live with.

I never try to talk anyone into or out of a choice. I see my job as providing info.

Every time I buy a new car, I wish I had bought one with ... whatever the latest, greatest gizmo is. I can't imagine how much harder it must be to select a valve.

 

[PapaHappyStar]

The fact that we chose what we did for our surgeries almost guarantees some level of bias, I can only tell you why I chose what I did, and even though I would recommend my way I dont think its necessarily the "right" choice.

I agree with the point of view that if one is modifying the body one should do it in as benign a way as possible without having to counteract too many side effects. All mechanical valves currently cause increase in rates of thromboembolism ( even the On-X ) -- this is the side effect of the mechanical valve that needs to be counteracted with coumadin ( or aspirin ). The increased tendency for A-Fib is a side-effect of OHS and is also related to the age of the individual and the condition of their heart before surgery -- I dont think it has anything to do with having a tissue valve. I would like to see what kind of statistical analysis is done in this article but wasnt able to find the full text in my university library. I think its possible to do an actuarial analysis but even then I dont think it would enable such a clear statement ( if it did, the choice would probably be obvious to everyone )

 

[Guest]

You are free to e-mail the author. He is a government employee and his e-mail address is included with the article. (In the fiirst post of this thread.) He may have a reprint that he can send, or even the original that he sent to the journal.

 

[Nancy]

It doesn't matter which valve you finally decide on.

One of the reasons this site is so important is that it presents some facts that we would never have access to in our daily lives. Most of us do not know a whole group of people who have had valve surgeries. Here, there are over a thousand! I do believe that every member wishes to impart what they know from a personal point of view. It is all excellent information.

Making a choice with open eyes and an open mind is the best. Look at all the sides of the problem. Think about the future. Learn all about your particular condition because that should be a BIG part of your decision. Not everyone has the same set of conditions. For some, having the valve fixed up will be the only medical attention they will ever need. For others with something like rheumatic fever in their past (which never leaves the body) medical problems will be a life-long issue, and could get more difficult as you age. Then you will develop co-morbidities. Then re-operations are definitely a problem. And it is possible that you will need anticoagulation for other issues, even if you have a tissue valve.

If I hadn't been intimately involved in my husband's medical care for the past 6 years as he went from one terrible problem to another, I might have a different view. But I have seen what can happen. And I know full well what re-operations do to the human body.

It's a very serious decision, this valve stuff. Learn all you can, think hard and try to project into the future. Take everyone's experiences into account. Then when you are confident that you have learned as much as you can, make your choice AND then discuss it with your primary care physician, cardiologist and surgeon and get their views.

 

[catwoman]

Wouldn't someone with a mechanical mitral valve, like myself, require a higher dose to attain a higher INR than someone with a tissue valve and/or a-Fib? And with a higher INR, increased hemmorage risk?

Barry:
A friend who also has a St. Jude mitral valve only takes 2-2.5mg of warfarin daily. I take 6.0X7. We're both in range (my INR was 3.5 two days ago).

Difference?
He's more sensitive to warfarin and doesn't like broccoli, asparagus, etc. I love big salads (good fiber & weight control); my friends laugh when I order a "plateful of vitamin K" in restaurants. I'm also a little more active.

 

[tobagotwo]

While recently published, this is not new information, and it carries a legacy from an error commonly made in earlier valve studies.

This essentially mirrors the numbers from the study that Al published a year or so ago (and has popped up from time to time), declaring a near-dead-heat for thrombosis rates over time between tissue and mechanical valves. The difference is that this writer didn't read the caveat that accompanies many of the original study articles now ( http://www.valvereplacement.com/forums/showthread.php?t=7782 )

The thromboembolism rates for mechanical and tissue valves are equivalent. This is basically what the study had said. This was heavily discussed at the time it was posted, as it was antipathetic to numerous other studies available both then and now. I complained that it didn't factor for age at the time, because the mean age of tissue recipients is decidedly older than that of mechanical recipients. This was particularly true in older studies, as that had been the habit of surgeons for years. But it was Burair who some months later picked up this independent comment that had been tacked to the original web version by the publisher:

There is a commentary to this paper which raises the point (for aortic valve):
"The group of patients receiving bioprostheses would be older than the group with mechanical prosthesis, so the incidence of stroke in the bio-prosthesis patients would be higher due to aging related causes not coupled to their valve prosthesis. This, in the opinion of the commentator, is indistinguishable from valve related stroke. I did see an age related correction factor in their analysis but am not familiar with their technique ( they seem to use a linear fit to the data, to come up with the independent probability estimate and correct their data for independent risk factors for stroke ). This would be a systematic error overestimating the incidence of stroke in the bio-prosthesis group."

( http://www.valvereplacement.com/forums/showthread.php?p=94256&highlight=stroke+risk#post94256 )

During their lives, many recipients of tissue valves receive anticoagulation therapy due to comorbid conditions. This doesn't mention percentages, but ACT gets into serious numbers (≈25%) at about age 75-80 for everyone. "During their lives" not only introduces another age-related factor as being valve-related, but also includes people who are on warfarin or Plavix for six months for an initial afib/arrhythmic problem that goes away on its own - along with the resulting ACT.

The anticoagulation-related blood loss rates associated with mitral mechanical valves and mitral tissue valves are equivalent, whereas the blood loss rates associated with aortic tissue valves are less than those associated with aortic mechanical valves. This says that there are more bleeding episodes with mechanical aortic valves than tissue aortic valves (expected), but that the bleeding events happen about evenly with both types in the mitral position (I don't know why/how that would/could be - mitral usually has a higher INR requirement than aortic).

Again, that fits with Al's earlier study, wherein there was a minute advantage to tissue aortic valves over time. But for practical purposes, no difference.

However, that hole in the age-correction logic, which put the writeup of the posted study into question, lives on in this rehashing of the old literature as well. It doesn't fit with numerous other, age-corrected studies that do show a difference. And because of this logical omission, it also diverges from the recent studies that show that over time, the risks of mechanical and tissue valves are a dead heat.

Finally, the studies and literature used reflect a mélange of different tissue valves used over the last two decades. Many of those valves, such as the St. Jude porcine valves (popular mainly because hospitals got their mechanical valves there), had useful lifespans of only 6-8 years. While the St Jude mechanical valve didn't change over the last two decades, tissue valves have evolved enormously. With (quite conservatively) double the mileage, reops and their associated risks would be cut in half. That would have an effect on the equation.

What was said about Al is true, by the way - Al seldom says anything that would push someone one way or the other, although he could certainly have an axe to grind if he were minded to. Credit where credit is due.

Best wishes,

 

[RCB]

SO GORDY- My Surgeons recommended.....

SO GORDY- My Surgeons recommended.....

My surgeon (very highly respected heart surgeon) also recommended a tissue valve for me. At age 48 I know I will probably go through another surgery later on in life, but right now my anticoagulation therapy is one aspirin a day. More and more of the well-known surgeons are opting for tissue valves. I would listen closely to what they say.

a mech valve, what does that make them...CHOPPED LIVER!!?

 

[Guest]

Remember that no study reflects the life of one person. They are only part of the process in determining what is best for you. If you were the "average" person, you would not be reading this.

 

[Wise]

If you were the "average" person, you would not be reading this.

That says it all, does it not?

 

[Don Giaquinto]

Well, I have read every post here about the subject of valves and can see that this controversy has been going on long before I joined this sight.

Everyone who has had OHS where a valve replacement is concerned wants to think they are making the right decision based on the long term effects that this will have on the rest of their lives.

I can tell you that it took me about 30 seconds to make a decision in going with the black onyx. What I really took my time on {months} was who was going to be cutting me open and who I felt that I could trust. Once that was done, and I felt that based on my research I had the right team taking care of me, then the valve choice was easy.

I had just turned 49 at the time of the surgery and when I was told that there was a high likely hood that I would need another OHS in my life time if I went with the tissue valve, it was a no brainer.

Also, and more influencing, was the question posed to my surgeon {also about the same age as me} by my wife and I. "If it was you doc, what would you do?" That was it for me. All of us {other than those of you who are about to have OHS} have been faced with this decision and approached it in our own way. We want to believe that we made the right choice. I read some of your posts and can see that a lot of research went into your decision?s. Some of you might read this and say 'what an ass, he made his choice based on his doctors choice?'

I feel that I did the right thing for not only myself but my family as well.

Knowing what I know now {6 weeks post op yesterday} I believe we made the right choice. Once is enough

I rushed this post so excuse the mistakes.

Don G

 

[Barry]

After seeing how hot the rather technical topic of valve-selection can get, I now understand why the administrators here didn't want me starting threads on subjects that anyone would consider controversial.

 

[Barry]

Remember that no study reflects the life of one person. They are only part of the process in determining what is best for you. If you were the "average" person, you would not be reading this.

I've heard this stated as "group statistics don't apply to individuals", with the example that the average IQ is 100, but that doesn't mean that any one individal's IQ is 100 - that, in fact, IQ's vary widely.

All studies, including studies on valve-selection, are essentially based upon averages of one sort or another. And an average does represent the best guess if one knows no more about the individual. While IQ (and optimal valve-selection) will vary by individual, if I knew no more about you and was asked what your IQ is, my best guess would be 100.

 

[Wise]

That says it all, does it not?

Just to clarify myself, I was agreeing with Al's statement. We valvers are definitely not average, being that the average person doesn't have one of our many conditions. I read my initial reply again and just wanted to be sure that I didn't miscommunicate. I want to reiterate again, albeit with some differences among posts, that this thread has been very helpful to me, an individual in the early stages of considering valve selection if my situation ever warrants valve replacement.

 

[tobagotwo]

The upshot of all that doesn't change the balance of the types. They are still at a draw for safety over time, still have the same strengths and drawbacks. Neither has been lessened. They each still have their individual appeals and niches.

As far as chopped liver, RCB: absolutely not. A world without mechanical valves would be a world without some of the best people on this site, particularly those who might not have endured another surgery, or who live with the constant burden of myxomatous tissue. There is certainly nothing second class about mechanical valves, period.

I think that sometimes it has been something of an issue for tissue valves to be acknowledged as standing side-by-side with mechanicals on the site. It's understandable, as there have been disappointments in the history of tissue valves, and manufacturer's tactics that are not helpful to anyone, much less to determining what information is accurate. However, history has been changed for the leading models of these valves. They have greatly improved their track records of durability and reliability, and now represent a fully viable alternative for those whose situations make them appropriate.

Mechanical valves and tissue valves are evolving toward each other, each working to obtain the advantages of the other type. Of course it's to ensure continued sales for the companies who make them, but most importantly, it's exactly what we want to happen.

We have an On-X valve that's on the threshold of breaking the warfarin barrier. While this one may or may not make it, the scent is there that one soon will. We have a pericardium-based valve that is approaching the 25-year useful life mark. It may or may not prove up to the task as well, but it portends that one will soon.

It's all good. We win. All of us.

Best wishes,

 

[Guest]

The other thing that I discourage people from doing is regretting their choice based on new information. You have to say, "I made the best choice based on what information was available at the time".

It would almost be better if people who have valves in place were not allowed to read this thread. (But we do need thier advice.)

 

[kcpub]

Encouragement

Encouragement

To be fair, I think we have had quite a few members joining who have been given horribly erroneous information about Coumadin (mostly by doctors) that some of us feel keeps them from weighing their options with correct knowledge of the valves available, thus disallowing them from making a truly informed choice. I think we all just want people to go into their replacements fully equiped with correct knowledge.

Karlynn,

Thank you for your balance and encouragment. My husband (43) just found out 6 days ago that he has to have AVR in the next two weeks and so we are having to digest an awful lot of information quickly to help him make his valve choice decision. I am grateful for a site like this to "meet" so many people who can share their experiences.

KC

 

[Karlynn]

The other thing that I discourage people from doing is regretting their choice based on new information. You have to say, "I made the best choice based on what information was available at the time".

It would almost be better if people who have valves in place were not allowed to read this thread. (But we do need thier advice.)

Last year, when I was a newer member, there was a lot of posting going on that made me feel like I had the "lesser choice" clicking away in my chest. But then I had to sit back and take stock of what that clicking has meant to my life, what I've done in the 13 years it's been in and how great life is. So now I can read of the "glories" of tissue valves and not feel like the ugly sister.

Al, you are so right. At 32 years of age with 2 small children, my St. Jude mech. was the best choice. I would even venture to say that still at 46 it's the right choice...for me.

KC - Welcome! I'm so glad you found us. What a shocker you are going through. I know that you and your husband have so much to take in and digest, let alone decide. Valve replacement is one scenario where it's beneficial to not have it thrust upon you, but many do. You will find your sanity returning in about 6 months. Your husband's health will most likely return much more quickly.

If you feel so inclined, share some of the details with us. Where his surgery is, who will be doing it, what valve type (when the decision is made). How you came to this point of replacement.

I know it's hard, but try not to get overwhelmed.

If you are thinking mechanical - know that Al is our resident expert in warfarin (Coumadin) management. For me, he is a priceless advocate to have. He has his own web site at www.warfarinfo.com . It's chock full of information.

Your husband cannot go wrong with any valve choice - it gives him a new lease on life.

 

[Randy & Robyn]

Last year, when I was a newer member, there was a lot of posting going on that made me feel like I had the "lesser choice" clicking away in my chest. But then I had to sit back and take stock of what that clicking has meant to my life, what I've done in the 13 years it's been in and how great life is. So now I can read of the "glories" of tissue valves and not feel like the ugly sister.

Even now, before my surgery, I can see how easy it would be to have that kind of attitude regarding your valve choice.

Choose a tissue valve and you could sit back and dwell on the fact that another surgery is likely looming in your future and wonder why you didn't choose a more durable mechanical valve. Choose mechanical and you could fixate on the difficulty that coumadin therapy brings to your life and wonder why you didn't choose a care-free tissue valve.

It's all in your point of view and your ability to focus on the positive rather than the negative.

I have yet to make my final decision. My two surgical consultations are later this week. But once I have and the surgery is over I will try to think of the positive aspects.

If I go mechanical, I will breathe easy that I have likely avoided another surgery and that, with a little dilligence, coumadin isn't all that bad. If I go tissue, I will be happy to live each day with no constant reminders of my condition and no restrictions and the thought that if I made it through one surgery, I can probably make it through another.

Granted, there are no guarantees. As others here have wisely said, you can go in thinking you will get one valve and end up with another, based on the surgeon's findings during the surgery. And just because you go mechanical does not mean a 100% guarantee against resurgery. Nor does a tissue valve mean no coumadin for every single person.

All we can do is make the best decision we can based on likely outcomes, roll the dice and take our chances. And then, most importantly, live the best we can.

Randy