Stretch, check out the Fig 1 graph in the Petterson article. It doesn't compare to the numbers he gives in paragraph 2. I'm figuring it's a mistake in the graph, but I zoomed in on it and it shows Mechanical as being the vast majority of replacements in 2001 (grey dots, and bio are white dots).
The article agrees with what we've always said here. You want a Ross expert if you are going for a Ross. But I also agree when he says you want a surgeon that can do the others well also because they ultimately don't know what they are getting to work with until they open you up.
I will say that Petterson is not giving correct ACT protocol when he says that INR testing is 1 -2 times a week. It is once a month (mostly those that lab test) to 1 time a week (mostly those that home test), and some in the UK are on 6 week testing schedules. Testing 2 times a week is only going to make the INR swing because of dosage changes in order to keep tightly in range. I was 4.2 today, last week I was 3.6, the week before I was 4.0. I have made no changes to my dose. I home test, so I test weekly, but more out of habit. I've been thinking of going to every 2 weeks. Chances are, someone requiring me to test 2 times a week would have been changing my doses for the 4's.
I will also comment that it appears Cleveland used primarily mechanicals at the time when ACT management was hard. (There are a handful of us here who had our mech valves when ProTime was the standard). The INR wasn't widely used, testing wasn't as developed and it was more of a guessing game. Now with INR and improved testing, they are giving up on mechanicals when ACT has never been more easy to manage. I can't help but think that some of this is based on bias generated by old information and my thoughts were supported a bit by Petterson's remark on testing 1-2 times a week.
I will agree with him when he says that risk of anticoagulation is patient and medical system related. And I would emphasis the "medical system". That is where the education needs to come from and if they are giving the wrong info (like 1 -2 times a week
) that's not good.
ACT management has become easier, and bioprosthetci valves have improved in longevity. However, younger adults still go through tissue valves faster, requiring reops. And even though the skinny on reops vs. ACT management is pretty much a wash, this doesn't often take into consideration any diminishing abilities due to repeat surgeries where the heart can be weakened or arrhythmia may become more prevalent. I've always been of the opinion that if bleeding and stroke is going to be discussed as a risk for mechanical (which it should be), the possibility of diminished heart function and over-all physical health should also be discussed when referring to risk of reoperation. While I know you are taking that into consideration, the younger patients may not. (That whole invicible youth thing.) Most articles just address mortality, nor do they mention that bioprosthesis rarely just all of a sudden fail one day. There is the road of degenerating valve that's traveled before the reoperation.
I have always said that if I have to get my St. Jude replaced, depending on my age and developement of valves, I may go tissue. Petterson mentions that some reoperations for replacing bio valves involve putting in a mechanical. I would think that the older you are, the more you would want tissue because of bleeding issues that elderly have. But I suppose some of that depends on age, and may be referring to women who went bio first in order to have babies and then went mechanical for the redo. (guess I'm thinking out loud.)
Well, my laundry's done drying, so I'm done writing. Interesting article. I'd like to question him on some of his comments (and set him straight on INR testing
), but over-all an intersting read.
