Should I choose a mechanical valve or a tissue valve?

[user 11863]

Thanks for all the comments and information - very useful.

Maybe I should add some more information:

I've had OHS before, so I understand what it entails and this is why I'm not so concerned about further operations.

I have discussed this with my surgeon. He brought up the possibility of a tissue valve and that is his recommendation - but surgeons aren't always right.

I don't have a "fear" of warfarin, just a preference not to have it.

I'm a keen climber. At least once a week I'll climb solo (i.e. without ropes). Most non-climbers would regard this as "foolhardy and unwise" and I wouldn't disagree with them

I have to admit that having read this thread I am reconsidering a mechanical valve. I'm pretty much sitting on the fence between the two at the moment. My surgery is in 7 weeks time, although I can postpone this for at least a year.

 

[pellicle]

Hi

Yes, all the time, but only when I know them well enough to do so! :thumbup:

yeah .. cultural differences and personal ones too .. Australians aren't afraid of calling a spade a dirty shovel or telling you what they think (even if not asked ...)

:rolleyes2:

but I do try to be 'nice'

I was giving you a hard time more than anything...

and I did try to not take it with a malicious intent ... (perhaps I failed) . So good to hear that

it was his first post here for goodness sake!

oh .. really ?? should notice things like that ... I probably have a mild amount of Tourettes syndrome

Anyway, you are easily the hardest member to "reply with quote" to, Pellicle, so I'm going to have to take another route here out of laziness more than anything!

yeah ... sorry about that ... I blame it on 20 years of internet forums and NNTP participation (and perhaps some OCD and too many years of debating)

As I said, you made good points, and what I didn't specifically mention, awareness of the stigma and fear of warfarin is perhaps the important issue to discuss. I think warfarin sentiment could easily take three or four forms. ...

may I say at this point that it has been very good to be able to have a discussion about this without tempers or name calling. I take my hat off to you!

<sweepingBowTiltingHat/>

I agree with what you have written and would like to simply say:
- I respect that we each have our own opinions, and am pleased that I am allowed to express mine and will defend anyone to have the right to express theirs.
- I understand emotional decisions are different to logical ones, both have their place in the world.
- I only ever argue the point over logical ones, as the emotional ones are not for me to interfere with.

It has been a pleasure chatting with you

 

[pellicle]

Hi

Thanks for all the comments and information - very useful.

I'm glad you found it so.

Maybe I should add some more information:

I've had OHS before, so I understand what it entails and this is why I'm not so concerned about further operations.

interesting ... actually if you've had more than one OHS already it is even more sincerely that I suggest that you look into the issues. When I had my 2nd I was 28 ... I bounced back from that like a punching clown.

The operation I had in 2011 saw me aged 48 .. I can assure you it was more of a struggle. I came home from hospital and felt sapped in comparsion. Previous to the operation I was a keen cross country skier. I lived in Finland and in winter would do at least an hour skiing 5 nights a week.

As a hobby my wife and I did trips towing sleds (ourselves). I am not what you would call a couch potatoe.

When I was diagnosed with my aneurysm (and mild regurgitation) I was told by my surgeon that many surgeons would not like to take on a patient like myself who had already had 2 AVR's and that he definately leaned towards a mechanical valve because the odds of survival went south with a 4th operation.

I'm a tough bastard (although certainly not the fittest or strongest), but I can say that I discovered that coming home after my 2nd debridment operation that I understood just how hard it must be for someone in the 70's to come home from their most recent OHS.

just ponder that is all I am saying....

 

[Agian]

Nigel, the surgeon I saw made suggestions but is willing to put in whatever valve I want (within reason, of course. I wouldn't want him to do anything he wasn't comfortable with). Yours has given you a choice between a specific mechanical and a specific tissue valve. I would ask him why he suggested these two, as opposed to let's say St Jude or On-X for mechanical and other types of tissue.

 

[user 11863]

When I had my 2nd I was 28 ... I bounced back from that like a punching clown. The operation I had in 2011 saw me aged 48 .. I can assure you it was more of a struggle.

I take your point. I was 13 last time I had OHS. I am expecting recovery from OHS to feel harder this time round.

I was told by my surgeon that many surgeons would not like to take on a patient like myself who had already had 2 AVR's and that he definately leaned towards a mechanical valve because the odds of survival went south with a 4th operation.

The operations to replace the tissue valve will all be TAVI procedures. Repeated TAVI procedures don't have increased risk like OHS does. Probably easier recovery than OHS as well.

Previous to the operation I was a keen cross country skier. I lived in Finland and in winter would do at least an hour skiing 5 nights a week.

I love ski touring. Not too much available in Sheffield (UK) but loved it in the French alps and the Berner Oberland.

just ponder that is all I am saying....

Will do. Thanks for your advice Pellicle

 

[user 11863]

I would ask him why he suggested these two, as opposed to let's say St Jude or On-X for mechanical and other types of tissue.

He suggested a tissue valve because "warfarin is a pain in the butt". No more, no less.

He's not convinced of the benefits of an On-X valve (I don't believe On-X have FDA approval for reduced anti-coagulation yet), but he's happy to fit that valve or an ATS

 

[Agian]

.... And fair enough.

You're right, it doesn't have FDA approval at this stage. FDA only applies to America anyway. This will be the first step. Then they'll have to convince the authorities in other countries. Having said that, your doctor theoretically can prescribe whatever he or she wants.

One thing is for sure; things will get easier and more sophisticated with time. It's not just TAVI. We may see more robotic procedures in the future, as well.

 

[OldManEmu]

My advice is don’t fixate on the surgeon they usually only see patients when surgical intervention is required. All other valve associated problems are normally dealt with by your cardio from working with other doctors on your health care to pacemakers. I have always been more inclined to follow my cardios advice to that of the surgeon if there is conflicting opinions.
The cardio sees all patients with valve problems and follows them for a life time dealing with all associated issues with their management not just those issues that require VR.

 

[Sten Osis]

There's always a chance that one could end up on warfarin no matter what valve one chooses. For me, avoiding repeat surgeries was the deciding factor. I just don't want to go through another 8 weeks of lifting restrictions.

 

[dick0236]

He suggested a tissue valve because "warfarin is a pain in the butt". No more, no less.

Really????? I guess I have been on it for so long I've forgotten if it's a "pain in the butt". That may be HIS opinion but I've had to undergo only one surgery.....and that's worth a little "pain in the butt".

 

[user 11863]

That may be HIS opinion but I've had to undergo only one surgery.

I agree. That's why I started this thread. The only people qualified to comment on long term warfarin use are the users. Like most things, once you get used to it I guess it probably doesn't bother you so much.

 

[ElectLive]

He suggested a tissue valve because "warfarin is a pain in the butt". No more, no less.

Well, at least he's honest... :rolleyes2:

In a perfect world, surgeons would lead with the medical reasons, not the convenience reasons. The associated risks over time can be weighed against the more isolated risks of surgery. Of course, it's by no means easy, since both change either through increased exposure (like multiple surgeries or heightened risk after an initial event) or simple things like just getting older (deterioration of tissue). The most complete evidence is also the most outdated, and in the end, some complications are just more patient driven than treatment driven anyway. But fortunately there is at least some better evidence now being generated, under far more relevant conditions (On-X PROACT and home monitoring). Anyway, when places like Cleveland Clinic do explain the reasoning behind their affinity for tissue valves, it very often is along those lines.

Back to you specifically Nigelp, you probably realize this, but your climbing habits (or more importantly your ability to avoid injury!) are something to consider. Obviously, head trauma and warfarin are not at all a good combination. Then again, head trauma isn't that good under any circumstances so you'll just have to be the judge! :wink2:

He's not convinced of the benefits of an On-X valve (I don't believe On-X have FDA approval for reduced anti-coagulation yet), but he's happy to fit that valve or an ATS

There are many not convinced...not because of doubts of the quality of the On-X, but there just isn't enough definitive evidence compared to the other valves. There are innovative features, there are innovative protocols being studied, but there's simply not the proven record. Yet. It probably goes without saying, but with banners flying overhead, perhaps not: St. Jude, ATS, etc are not (to use an old favorite phrase where I'm from) chopped liver! :biggrin2:

 

[SuzanneSLO]

My advice is don’t fixate on the surgeon they usually only see patients when surgical intervention is required. All other valve associated problems are normally dealt with by your cardio from working with other doctors on your health care to pacemakers. I have always been more inclined to follow my cardios advice to that of the surgeon if there is conflicting opinions.
The cardio sees all patients with valve problems and follows them for a life time dealing with all associated issues with their management not just those issues that require VR.

When discussing valve options with my physicians, my cardiologist clearly deferred to the surgeon. If this is common, I think it is understandable that surgeons are more likely to discount the impact of multiple surgeries than other health professionals. I think this bias by surgeons is due more to inherent confidence than to possible impacts on the surgeon's pocket book.

The mechanical valve recipients on this board certainly make a case that extended warfarin use is neither a lifestyle issue nor a significant health issue. However, my personal experience was that many people, including many health professionals, have a fear of extended warfarin use. Based on experiences reported here, this fear may not be rational, but it certainly exists.

While we follow the advances in TAVI and PROACT, I wonder whether the next really big change in the tissue v mechanical equation will result from a better understanding in the healthcare community of the true risks of warfarin when INR is well managed through home testing or otherwise.

I admit I felt a distinct lack of a safety net in my local small town when it came to monitoring my INR. That was certainly one of the factors that caused me to choose tissue for my first AVR at age 54. Given the current perception of warfarin use, I am fine with my valve choice and the surgery/recovery was actually less of an issue than I anticipated.

When its time for my next AVR, I will certainly consider a mechanical valve at that time in light of the facts and circumstances as they then exist. -- Suzanne

 

[ElectLive]

may I say at this point that it has been very good to be able to have a discussion about this without tempers or name calling.

I've got two young girls, so I have more than enough tempers and name calling to deal with as it is. :thumbup:

 

[user 11863]

your climbing habits (or more importantly your ability to avoid injury!) are something to consider. Obviously, head trauma and warfarin are not at all a good combination.

I've never had any head injuries from climbing, and they are not as common as people think. There is a culture of wearing helmets in climbing and I usually wear one (even though I'm not currently taking warfarin). Lower leg injuries are the most common trauma for climbers. I've been in contact with a few climbers who are on warfarin, they tell me it's a bit of a hassle but not a deal breaker.

In my experience skiing on warfarin is potentially more dangerous. I wear a helmet but I have had two accidents where I have hit my head hard enough to cause concussion and recurring dizzy spells for the rest of the day. I suspect that had I been on warfarin one or both of these accidents would have been fatal. Not a deal breaker either, but something to consider.

 

[Luana]

I think the BIG THREE for me are: endocarditis, stroke and bleeding.

Big three for what?

Since you didn't use Reply With Quote, I have no idea what you're referring to or whom you may be responding to.

 

[BarbATS]

Hello, NigelP-

Read with interest your query and the many responses here.

Let me say I have had an ATS mitral valve since 2000, with no problems and do my own home testing of INR levels with ease and no "issues". The ATS valve was said to be quieter than
the gold standard at that time, the St. Jude valve. My surgeon had discussed all aspects of the impending surgery and the suggestion of the ATS valve. It was in clinical trials at that time.

I am totally satisfied with that choice and my overall health and well-being throughout my post-op years. I feel very glad that I made the decision to go the mechanical route and do not have to
be concerned about future surgeries down the road. I know it can be difficult to envision how we will handle surgery as older citizens, but it wasn't a walk in the park at age 55, let alone 65-70 or
beyond...

Hope to hear your thoughts as you move along your decision-making continuum.

All the best!

 

[ski girl]

"In my experience skiing on warfarin is potentially more dangerous. I wear a helmet but I have had two accidents where I have hit my head hard enough to cause concussion and recurring dizzy spells for the rest of the day. I suspect that had I been on warfarin one or both of these accidents would have been fatal. Not a deal breaker either, but something to consider. "

Nigel - I got whacked by a kayak in the surf zone hard enough for me to see stars and get a massive egg on my noggin. It took me half an hour to paddle back to the start, half an hour for someone to find an ambulance in the small town, and a further hour before I got medical help. And . . . it was not fatal. (I did not feel great for the rest of the day and possibly was slightly concussed.)

And if you fell while soloing, warfarin wouldn't make you any more or less likely to die - the ground would do a good job of that for you! I used to climb at a reasonably high level and I can't see how warfarin would have any impact on your climbing. Go forth and live your life!

 

[Agian]

Big three for what?

Since you didn't use Reply With Quote, I have no idea what you're referring to or whom you may be responding to.

I meant that for me these are the three most concerning complications. I wasn't responding to anyone in particular.

 

[Gail in Ca]

Some very good points are made here. Having had both types of valves, I can say that going from tissue to mechanical was not the easy transition I thought it would be. I wasn't expecting to hear it so loudly, and learning to deal with Coumadin was just one more thing. Now, I've been on Coumadin for 13 years and I can say it is no big deal. I take a pill, I test weekly, and my INR has been very much in range. I really don't think about it much.
I would like to comment on the multiple surgeries that many have stated that they are not concerned about. My surgeon for my last 2 surgeries, has always felt that the least amount of surgeries the better. He states that the scarring from multiple surgeries is the cause of the risk. I saw the deep concern on his face when I was facing my 3rd surgery due to endocarditis. And it took them 3 hours to cut through the scar tissue. My surgery was long!
Also, I recently talked to my cardiologist about tissue valves and he said that they tell patients to expect 8-20 yrs from tissue. But, I think average is 12 or so.
I am very glad that you are weighing your options. Remember, new advances seem to go slower than we would expect. So, I would recommend making a decision on what's available now, not what might be available 12 yrs from now.