Risk of Surgery vs Risk of Coumadin?

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R

rcatalano

Hello all,

To get right to the point, my question is:
What is the risk of 30+ years of coumadin compared to the risk of a 3rd surgery?

I'm 45 yrs old, just told I'll need a second AVR in the coming months. I had a homograft put in 14 years ago. Was told then it would last 8-10 yrs or more.

My surgeon said I should avoid the 3rd surgery at all costs due to the risk involved. I understand his point, and don't necessarily disagree. But I just looked at the Cleveland Clinic web site, in 2002, only 11% of the aortic valves they replaced were mechanical. The trend for mechanicals there is consistently going down (Cleveland Clinic Surgical Outcomes for 2002). It seems my surgeon has a different philosophy than Cleveland Clinic.

Are my chances of getting a serious head injury in the next 30yrs much less than the risk of a 3rd surgery?

Am I guilty of not understanding coumadin? I've done research on this site, www.warfarininfo.com, and others, but have not seen this question specifically addressed.

I'll be asking my cardiologist this week, but just want to see if this is even a relavant question.

TIA,

Rob
 
Rob,
That is a tough decision you are facing.
There are people here who have been on Coumadin for around thirty years with no problem.
There is also a new drug on the horizen which may replace it sometime in the not too distant future.
It would not have the problems Coumadin can present at times such as having surgery for whatever.
If you read some of the current posts you will see what I'm referring to.
Personally I have been on it for almost seven years and it really hasn't been a problem.
I agree with your doctor about the risks for a third surgery.
Additional surgries can also be much more difficult when you reach an advanced age.
You have already been there once so just imagine what it might be like if you were in your sixties and older.
Best of luck to you whatever your choice may be.
 
My opinion-30+ years of Coumadin is far less risky then a 3rd surgery sometime down the road. I've been through 2 surgeries and I know I would not make it through a 3rd. Mind you, both of my previous ones turned into nightmares. I'm so loaded with scar tissue, lung problems, etc., that a 3rd would certainly do me in.

Coumadin is not bad at all. I had the same fears your experiencing and they were unfounded. As long as you do what is required of you and don't do foolish things, you should be fine with Coumadin and a mechanical valve.
 
Rob, you are at that cusp age that is awkward for making the decision whether to go biological or mechanical.

There are more complications inherent in a 3rd surgery. There is more scar tissue and blood vessels to mess with. There is also the damage that comes from continuing to cut out the old valve to put in a new one.

It's a tough decision for everybody, but you could go either way. A mechanical could allow you to never have to face a third surgery, however, there this could still happen with a mechanical too. It is far more rare though.

A biological valve would need to be replaced again sometime between your 55th and 65th years. The older we get, the slower the calcification process stagnates movement in the valve. If you are lucky, you would be able to get 20 years out of your next one, but you would still need that third operation.

Aside from a few days post-op, I have never been on coumadin. Many of the members here say it's no big deal, yet the stuff I read about it makes it sound frightening to me. If you read some of the medical journal stuff that's out there, you'll note that the risk of a thrombolic episode goes up significantly when you are on coumadin for a very long time. This doesn't mean these people die, just that they have a bleeding problem or the opposite. From what I gather, if one takes care to monitor themselves, there generally don't have many problems.

It's a tough decision. I just had my second operation coming on two years now and I still question whether I made the right decision for myself.

I always think of it as a mechanical valve spreading the risks over many years, where the biological concentrates the risk onto the operating table and recovery process.

No matter what you choose, you win. Both options allow us all to enjoy healthy and active lifestyles.

Good luck in your decision. It's not an easy one, but keep your positive attitude - that is truly what will get you through this next round.
Keep well.
Kev
 
Hi Rob-

My husband has been on Coumadin for 25 years and has also had a third heart valve surgery.

He had rheumatic fever as a teen and had his aortic valve replaced in 1977, his mitral replaced in 1999 and his mitral repaired a year after. He has two mechanicals. He has also had 2 lung surgeries.

He has never had a major bleeding problem that could be attributed to Coumadin. For him, Coumadin is the least of his medical problems. It is a non-issue for him. I really don't know where these scare stories come from about Coumadin. I suspect that they are because those unfortunate people either have a doctor monitoring them, who doesn't understand Coumadin management, or they haven't taken their medication correctly, or they have some other medication interraction.

Joe eats pretty much what he wants. He doesn't go crazy with greens, but he does eat some. We have healthy eating habits, to make sure he gets his full compliment of vitamins.

I can tell you that scar tissue and adhesions are a major problem in additional heart surgeries, and the recovery takes an enormous amount out of you as your body ages. The other thing that happens is that most cardiologists have to take into account the risk to benefit ratio when recommending a third surgery, so you will be very much sicker when sent for the third surgery, because the risk is greater. I also believe that there is a lot of collateral damage that goes on inside the body with subsequent surgeries, no matter how highly skilled the surgeon. It's just that the body is such a finely tuned instrument, and we humans cannot hope to put it back together again with surgery without additional unplanned and subtle damage.

You will be considered a high risk patient for the third surgery.

I urge you to look far into the future when thinking about the choices. People today are living much longer, so multiple surgeries are a reality.

You might also have to be on Coumadin for other issues, even with a tissues valve, as some of out members have found.

I wish you all the best in your studies on the valve issue. It's is a very difficult thing to try to sort through.
 
Thank you all for your thoughtful comments. I assure all that I have been doing my homework, though some information is hard to come by.

I think Kevin summed up my thoughts exactly:
"a mechanical valve spreading the risks over many years, where the biological concentrates the risk onto the operating table and recovery process."

I truly believe that, generally speaking, I would have no problem with Coumadin. However, I've read several studies indicating the serious issues with even minor head trauma. It's like Coumadin is a lifelong 'complication' that one just learns to live with.

I couple these thoughts with the trend at Cleveland Clinic away from mechanical valves. Would I be in the 11% minority that Cleveland Clinic would have given a mechanical valve to last year? I don't know...

But I do know its my decision and I really can't make a 'wrong' choice.

Thank you all again. I have a call in to my cardiologist to get things going, want to see if I can schedule this at the end of the summer. I think the next time I'll see the surgeon is after the catherization, and I'm sure I'll change my mind daily on which way to go.

Rob

1989 homograft
Balboa Naval Hospital, San Diego
 
My curiosity will drive me insane until you tell us what your final decision is, so please let us know when you decide. :)
 
Con't have you going insane over this?

By the time I make my decision, I'll have driven my entire family nuts, so you won't be alone. Just don't want to piss off the surgeon, must have him thinking nice thoughts when he stops my heart from beating!

Rob

1989 homograft
Balboa Naval Hospital, San Diego
 
Rob, I was just thinking about this 11% figure that you mentioned.

That statistic may be true, but remember that mechanical valves have been placed for many, many years and the procedure is far more common and has far more reliable results.

Even though Clevland may only have 11% of its installs as mechanical valves, when you add up all the functioning mechanical valves that are out there, I'm pretty sure they far exceed the biologicals.

This figure could be attributed to other factors, such as Clevland being one of the more progressive cardiac hospitals in the U.S..

A lot of research and use of newer techniques could alter the composition of what types of valves are currently being used.

Other hospitals may show the exact opposite - many mechanical valves - few biologicals.

I just thought you might consider this when thinking about this figure.

I am not trying to convince you to go either way, but even those 11% at Clevland were put into people because they were probably the best choice given their medical health, age, etc.
Kev
 
Figure in the age

Figure in the age

of the recipient and I think you will find the picture changes. A great many aortic valves get replaced for aortic stenosis which becomes more common as people get up in their 70's. A person in his seventies isn't realistically thinking of valve that will last him another 30 or 40 years. I hope all goes well whatever you choose...............................................................Betty
 
I was wondering how they came upon that figure, was it 11 percent of all valve surgeries, or 11 percent of all valve replacements?

CC does a high proportion of valve repairs in lieu of valve prostheses.
 
Hi Rob

Hi Rob

Whatever valve you choose will be good..however, it always amazes me that people never think about the recovery time for Open-heart surgery....It takes a good 1 year to get to feeling like your better life....I had mine at age 61..and was lucky to have a good hubby to care for me... Would hate to think about another surgery at age 75..and he not be here....Who would help me for at least 6 months. ..:eek: :eek: Bonnie
 
Here's what it said on the Cleveland Clinic site:
"Aortic valve replacements totaled 1007, with bioprosthetic valves accounting for 79%, homografts 13%, and mechanical valves 11%." There is a similar trend with MVRs. (The numbers add up to 103%).

I admit, without more details on the numbers I may be drawing a faulty conclusion. I don't think it a stretch to say that CC definitely favors the bioprosthetic valves, but in all likliehood I would be in the 11% with mechanicals.

Regardless, I appreciate all your comments and take them all 'to heart'. I can't disagree with any of them.

Thank you all,

Rob
1989 homograft
Balboa Naval Hospital, San Diego
 
The surgeon who performed my (previous) Bypass mentioned the possibility of cumulative risk from 'bleeding events' from being on Coumadin.

I wonder if some of those statistics aren't based on Long Term Data that originated 10 or 20 or 30 years ago, BEFORE INR became the standard for regulating Coumadin levels. In the 'early days', patients were often found to have VERY HIGH INR levels.

There is a German Study someone cited some time ago about using LOWER INR levels (2.0 to 2.5) with fewer bleeding events and no change in the occurance of strokes. It would be reassuring to see more and larger studies conducted to substantiate those findings.

'AL' (St. Jude Mechanical AVR with Coumadin Therapy at age 58)
 
Hi Rob

Hi Rob

Just an opinion on the 11% figure from CCF. Alott of folks travel to CCF to get procedures that are not available in their home towns. For example: Me. I received the Ross Procedure at Cleveland and while I was there.....there was only one patient on the floor I was on that had a mech. valve. This was due to here specific situation.

Valve choice is such a personal and individual decision......it is hard for anyone to help you, even a spouse.
What you are doing by asking the questions and doing your own research is the most effective way to come to a decision that suits you best.

Each of us here at VR.com have our own opinion on what is best or the best hospital or surgeon, yet our opinion may not fit you at all.

God Bless and God Speed with your decision and up comming surgery.

Ben Smith
 
One more comment on Valve Selection.

EVERY valve has it's positives and it's negatives.

When I was making my decision (which was dismissed by my surgeon) I came to the conclusion that it came down to what set of undesired effects could I best live with.

Keep up the research and good luck with your decision.

'AL'
 
Decision Made

Decision Made

Looks like this won't be such a tough decision after all.

My cardiologist and surgeon talked. While both wanted a mechanical valve, my cardiologist was willing to talk it over with the surgeon. My surgeon says he did a research paper on the risks of multiple valve surgeries, years ago, and the mortality rate of the 3rd surgery was 5 times that of the 2nd. Now, he admits this was some years ago and is certain the numbers have improved. But he still stands by the fact that the risk in the 3rd surgery is much higher than the 2nd.

So, looks like I'll be stocking my medicine cabinet with coumadin sometime in late August.

Thanks to everyone for their input.

Rob

1989 homograft
Balboa Naval Hospital, San Diego

2003 ?some type of mechanical?
Morristown Memorial, NJ
 
Hi Rob-

I'm glad the decision has been made. Your surgeon is right on with the numbers, that's what we were quoted before Joe's third.
 
Our information confirms the comments already made. The risk for a 2nd surgery is much higher than the 1st surgery. The risk for a 3rd surgery is much higher than the 2nd surgergy, etc. The older you are, the more scar tissue, the longer you are on the pump, and other additional medical issues make the problems more serious. How many older patients need to be concerned about bleeding injury?

We were also told by one source that once you have a mechanical valve, the options have been eliminated. You must stay with mechanical valves. We do not know if that is accurate information.

I think that there should be a new organization. CLA (Coumadin Lovers of America).
 
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