Surgery delay after pre-op testing?

[woulde]

has anyone else ever noticed that on many of these "discursive threads", the OP asks a question and somehow never posts again?

Somehow life gets in the way; wrapping up work matters and some personal matters does not always allow for time in front of the computer. I appreciate all of the feedback and support from the members of this forum. I've known for some time that with radiation damage AVR was inevitable so I have lurked here for some time now and learned a lot; time to ask some question as well as "give back" to this community and contribute, be it advice to newcomers or stimulate discussion.

Tissue versus mechanical really seems to provoke debate. I'd read through the many of the other threads on this topic, I think that no choice is wrong as long as it is an informed choice, a legitimate case can be made for either option. Every decision or choice made in life has a trade-off, the value I assign to each variable is going to be different from the value that any of you would assign to those same variables. For me; at this time I would prefer a tissue valve, activity level as well as extended periods of time with no access to medical care as factors.

McCbon: I agree, it is unlikely that I am put in queue and then in pre-operative workup told that maybe waiting would be the best course of action. Too much going serious stuff going on back there to queue up questionable cases.

ALLBETTERNOW: Yes, AVR is as inevitable as the changing of the seasons, just a matter of when. Probably a bit of denial on my part. I think the human body is an amazing organism with a profound ability to adapt and compensate, objectively though I have a sense that it is getting harder for my body to keep it between the rails but not overly so.

honeybunny: Thanks for your input, medically reasonable and no compelling reason to delay probably going to happen. Local cardiologist thought it may be time after stress echo in February of this year, peak jet and mean gradient were severe but area was still moderate. Had a coronary angiogram (thankfully no buildup in coronary arteries) and sent records to Dr. Gillinov who recommended waiting. Interestingly though, the coronary angiogram did not support the severity indicated by the echo findings. All this to say that from a financial standpoint AVR would be better this year as I am pushing up against the $6,000 out pocket limit. But obviously, only if it really is time.

Ske1973: Thanks for the input. I have not seen Pellicle's website but in keeping and open mind I will check it out. Good luck to you as well!

almost hectic: I was told that I would be getting a full sternotomy. If I understand correctly there is concern with radiation induced stenosis and possible damage or complications with adjacent tissues or structures. Best to open 'er wide up to get a clear view.

Per last echo peak jet velocity is 4.4 m/s (has been between 4.3 and 4.8 for the last 16 months), mean gradient is 45.8 mmHg (has been between 37.7 and 50.6 in the last 16 months) and AVA is again at .9 cm[SUP]2[/SUP] (has been between .9 and 1.2 in the last 16 months; .9 16 months ago, 1.2 eight month ago). Perhaps I am mistaken but I think the ejection fraction below 50% and the left ventricle mass are concerning enough that AVR is likely to proceed.

Thanks to all for your advice, experience and feedback. A healthy, vigorous debate helps ensure an informed choice.

 

[MethodAir]

For me; at this time I would prefer a tissue valve, activity level as well as extended periods of time with no access to medical care as factors.

Activity level? There is at least one elite level Crossfit athlete (in his 40s) who has a mechanical aortic valve. Day to day Warfarin management does not require medical personnel.

This woman climbed Everest with a mechanical valve (nuff said):

http://www.newsweek.com/my-turn-climbing-everest-bionic-heart-99749

So in 1997, at age 46, I underwent heart valve replacement surgery and received a mechanical heart valve. Five weeks later I was back climbing mountains with a new determination.

 

[ALLBETTERNOW!]

Yes the human body is amazing just found out I had a unicuspid valve (bascially no valve at all ) when they operated. Its extremely rare and my body adapted. i played 4 HS sports and college level soccer as a younger person. He was amazed I was asymptomatic before surgery but not surprised I had an aneurysm.

 

[pellicle]

Hi

Somehow life gets in the way; wrapping up work matters and some personal matters does not always allow for time in front of the computer. I appreciate all of the feedback and support from the members of this forum. \

thanks for taking the time to post back

Alllllll to often people such as myself give hours of time answering questions and instead of thanks, instead of even silence we just get negativity. Its always pleasing to have someone say thanks. A moment of thanks goes a long way to answering my self question of "why do I give a rats arse about these people when they couldn't even bother to be polite" ... missives are not needed (but equally not rejected),

best wishes

 

[woulde]

Activity level? There is at least one elite level Crossfit athlete (in his 40s) who has a mechanical aortic valve. Day to day Warfarin management does not require medical personnel.

This woman climbed Everest with a mechanical valve (nuff said):

http://www.newsweek.com/my-turn-climbing-everest-bionic-heart-99749

So in 1997, at age 46, I underwent heart valve replacement surgery and received a mechanical heart valve. Five weeks later I was back climbing mountains with a new determination.

Activity level… and activity type. I am an enthusiastic mountain biker; I enjoy fast, sometimes technical descents. Sometimes there are consequences not matter how proficient one may be. I realize Warfarin does not require continual medical personnel and care but extended periods of time playing in the woods sometimes has consequences as well. I read an abstract of a study published in JAMA in October of 2014 covering survival outcomes of patients 50 - 69 following tissue versus mechanical valve replacement, results indicated that the 15 year cumulative incidence of major bleeding was much higher in mechanical valves. Conclusion was that those with tissue valve are more likely to require re-operation but there is a lower likelihood of major bleeding. Finding suggest that bioprosthetic valves may be a reasonable choice for that age group. For me bleeding, both internal and external is a concern with the activities I enjoy. Perhaps I don't fully understand that aspect or am over-weighting that concern.

http://www.ncbi.nlm.nih.gov/pubmed/25268439

 

[pellicle]

Hi

Activity level… and activity type. I am an enthusiastic mountain biker; I enjoy fast, sometimes technical descents.

good ... I doubt that warfarin will make any difference to that, but a mechanical may mean you do not require a reop which may result in an outcome that will. It may be that the activity and youth contributes to that being as soon as 10 years, maybe sooner.

I read an abstract of a study published in JAMA in October of 2014 covering survival outcomes of patients 50 - 6

well I hope you don't mind me throwing my opinions into an evaluation of that study. When I was doing my masters (which was a masters by research not coursework) we did a seminar subject as part of our training in a literature review on critical thinking. Its essential to apply critical analysis to all articles you read. Do not be passive, be an active reader.

Ok ... so their research question seems to be

The choice between bioprosthetic and mechanical aortic valve replacement in younger patients is controversial because long-term survival and major morbidity are poorly characterized.

Firstly, seriously ... do you think 11 years (or even 16 years) is long term? If you are 60 maybe, but if you are 30, if you've just had kids, really?

Also, myself, I don't think they've done a significant job in contributing anything towards better characterising them.

Survival and long-term outcomes following bioprosthetic vs mechanical aortic valve replacement in patients aged 50 to 69 years.

so, younger is not "younger" in my mind. If they'd chosen 27 year olds that would be younger. So younger means "younger subset of older people". I mean ask a 30 year old if they think 50 is younger ... sure a 60 year old will have a different perspective, but is a 60 year old young? I know there is a modern tendency in our aging population towards denial of age, but to me 50 is not young. 20 is young. I had my firsts surgery at nine, my second at 28 ... both of those are young.

OBJECTIVE:
To quantify survival and major morbidity in patients aged 50 to 69 years undergoing aortic valve replacement.

Note it was not to quantify the ongoing effects of other considerations like
"oh, now you need a pacemaker"
or
"oh, now you have atrial fib"
or
"oh, now you have a permanent infection in your chest"

morbidity means "you died" ... nothing more, nothing less

...Median follow-up time was 10.8 years (range, 0 to 16.9 years);

so mostly they only followed up 11 years with a few outliers ...

the last follow-up date for mortality was November 30, 2013. Propensity matching yielded 1001 patient pairs.

so really its a study of 2002 people

MAIN OUTCOMES AND MEASURES:
Primary outcome was all-cause mortality; secondary outcomes were stroke, reoperation, and major bleeding.

ok ... nothing else in there ... like what happens after you have a reoperation for instance or how long your valve lasted you which is a valid question for a 40 year old ... but then its not really addressing younger people is it.

RESULTS:
No differences in survival or stroke rates were observed in patients with bioprosthetic compared with mechanical valves.

ok ... so no difference there

Actuarial 15-year survival was
60.6% (95% CI, 56.3%-64.9%) in the bioprosthesis group compared with
62.1% (95% CI, 58.2%-66.0%) in the mechanical prosthesis group (hazard ratio, 0.97 [95% CI, 0.83-1.14])

as they later observe no significant difference there either ... but its only 10 years right?

The 15-year cumulative incidence of stroke was
7.7% (95% CI, 5.7%-9.7%) in the bioprosthesis group and
8.6% (95% CI, 6.2%-11.0%) in the mechanical prosthesis group (hazard ratio, 1.04 [95% CI, 0.75-1.43).

more or less no difference worth mentioning there ... but one asks why so many had strokes? The stroke level in the general community is MUCH lower (and btw its hard to get a figure on that)

The 15-year cumulative incidence of reoperation was higher in the bioprosthesis group
12.1% [95% CI, 8.8%-15.4%] vs
6.9% [95% CI, 4.2%-9.6%];

ok, so nearly double the reoperation rate

The 15-year cumulative incidence of major bleeding was higher in the mechanical prosthesis group
13.0% [95% CI, 9.9%-16.1%] vs
6.6% [95% CI, 4.8%-8.4%];

Ok, firstly why is bleeding so high in the tissue prosthesis group? I expect that to be above background. But its well known that as you age you are more likely to have a little bleed here and there.

Since this study is over 11 years it means that the 69 year olds are now 81 year olds ... and the 56 year olds are now 67 year olds ... does this have an influence?

Next without digging into the text its difficult to know about the quality and efficacy of anticoagulation monitoring. For instance were mech valve cohort properly anticoagulated (meaning in range) or were they typically US Clinic standards (meaning abysmal) of anticoagulation monitoring?

The accepted situation is that modern AC therapy (like European nations are moving towards) where the patient is in charge of dosing and measuring halves the rate of bleed events which have been accepted in the US literature for the previous decades. Technology (point of care monitoring) is indeed having as much benefical effect there as technology has had in internal combustion engines. It really makes a difference.

CONCLUSIONS AND RELEVANCE:
Among propensity-matched patients aged 50 to 69 years who underwent aortic valve replacement with bioprosthetic compared with mechanical valves, there was no significant difference in 15-year survival or stroke. Patients in the bioprosthetic valve group had a greater likelihood of reoperation but a lower likelihood of major bleeding. These findings suggest that bioprosthetic valves may be a reasonable choice in patients aged 50 to 69 years

note the wording of that last sentence:
These findings suggest that bioprosthetic valves may be a reasonable choice in patients aged 50 to 69 years

it seems to be phrased from the point of view of "we think bioprosthetic is not a reasonable choice in 50 to 60 year olds and we've found that it may"

this implies that mechanical valve certainly is a reasonable choice.

So without going too far into the actual methods the abstract reads to me like its trying to sell up something which needs marketing to sell ...

I did read the whole article and I did not see anything discussing the anticoagulation monitoring of the mechanical cohort. But I did see this:

The absence of a significant survival benefit associated with one prosthesis type over another focuses decision making on lifestyle considerations, including the burden of anticoagulation medication and monitoring

oh, the burden .. 5 minutes a week, perhaps less if you are not as anal as me. Taking a pill every day seems to be a burden, unless its a vitamin pill ... strange isn't it.

Strange too that a reop isn't a lifestyle consideration ...

 

[pellicle]

Firstly I want t make perfectly clear: I do not care what choice anybody makes. It will not effect my life in the slightest. I post this in the interests of informed decision. People seem poor at informing themselevs, something which marketing and sales usually takes full advantage of.

So, with my motives clear: A few portions of my blog post: http://cjeastwd.blogspot.com/2014/01...r-choices.html

This is interesting because it fits in with a presentation and criticism of an earlier version of these guidelines by the Mayo Clinic (presented in 2010 URL ) also discussed this exact topic and the presenter took issue with the 2006 guidelines which said:
"On the basis of these considerations, most patients over 65 years of age receive a bioprosthesis. There are no data involving narge numbers of patients that clearly show one type of or fo any individual prosthesis over another."

His opinion on this was:
"when you see something like this in a guideline then you know there was a very strong persuasive personality in the room... Because this was put in there with no supporting data ... and that person seemed to hold the day or at least last longer in the guidelines session than anybody else."
He goes on to provide analysis of study after study which presented quite similar graphs to the one above.

I guess that the "strong personality" (perhaps it was a corporate personality?) was again in the room for the 2013 guidelines. The difference is that this time some data was supplied at least in the form of graphs.

So lets go back to the latest guidelines and see the other graphs.



This graph (obviously) looks at patients who had operations at between 50 and 70 years of age, and once again we see that after 10 years survival of the mechanical valve cohort moving higher than the others after 10 years. Allograft did well, as well as mechanical but Porcine and Pericardial were (again) at the bottom of the chart.

Still willing to chant the mantra of "there is no difference at all between valve type and survival".

Ok, so lets go onto the data for the group who (according to conventional views) should have the least to gain from a mechanical, that is those who were 75 years of age and older at surgery.


yet it would seem looking at the data that they gained more. We see that after 10 years the mechanical valve recipients kick up substantially higher in survival rate. Sadly the Pericardial group drops to zero. Which I expect means that they died. Mechanical still has survivors at 15 years.

...

Which of course brings us to the importance of Structural Valve Degradation. Under the "Cons" section in Tissue prosthetic valves is this:

Lastly:

Studies have shown that Patient Self Testing reduced the bleed complications from 11% to 4.5% and Thromboembolic events from 3.6% to 0.9%.

Yet Tissue prosthetic valves are not free from Thromboemolic events nor are the patients free from bleed complications. The article suggests that:

Thromboembolic rates with biologic valves in the aortic position are approximately 0.6% to 2.3% .

So the risk of Thromboembolic rates for Tissue prosthesis is greater than that for well managed INR and Mechanical valves.

 

[ALLBETTERNOW!]

Pell, you are smart and with it so managing it is not hard. I'll never forget sitting waiting to have my INR checked and an elderly man came out and the nurse told him something like , skip a day, take 1/2 a pill on Tuesday and go back to 7.5 the rest of the week and half pills over the weekend and come back Monday for a retest. The guy was bewildered, she wrote it down for him. I went in, got my finger stuck came out and guy and his elderly wife were sitting there, she was crying and they had I think, their daughter or son on the phone trying to explain it all and to speak with the nurse.

unfortunately I think this more common place than you allow for. it can certainly be managed better but for many this is their reality and why doctors rightly or wrongly try to steer clear of it. I know somedays I was confused on my dose for the day....

 

[pellicle]

Pell, you are smart and with it so managing it is not hard. I'll never forget sitting waiting to have my INR checked and an elderly man came out and the nurse told him , skip a day, take 1/2 a pill on Tuesday and go back to 7.5 the rest of the week and come back Monday for a retest. The guy was bewildered, she wrote it down for him.

agreed ... but then I've never suggested it for the elderly and I've always made the point that if you are not competent to manage it don't. But when I see younger mentally competent people arguing then I know thats not a point of issue.

 

[Zoltania]

morbidity means "you died" ... nothing more, nothing less

In medical usage, "morbidity" means complications, side effects, etc. "Mortality" means "you died."

 

[pellicle]

Hi

In medical usage, "morbidity" means complications, side effects, etc. "Mortality" means "you died."

that's a good point. It can mean a few things, such as the rate which something (disease) occurs in the population, however one would expect it to be defined. Since it is not defined I'm left wondering what they mean by that if not death? They can't mean valve disease as that was already 100% ... if they are only meaning the portions of the study cited (reoperation, bleed events, then the term has no particular significance ... my degrees are not in medicine, but in Biochem, IT and Environmental Science so its entirely likely I've misunderstood that term.

From that article :

because long-term survival and major morbidity are poorly characterized.

and

[h=4][/h] MAIN OUTCOMES AND MEASURESrimary outcome was all-cause mortality; secondary outcomes were stroke, reoperation, and major bleeding.

which inclines me to believe that its just death and those factors.

did you have any other feedback on my analysis? Criticism of my evaluation is always welcome.

 

[ALLBETTERNOW!]

agreed ... but then I've never suggested it for the elderly and I've always made the point that if you are not competent to manage it don't. But when I see younger mentally competent people arguing then I know thats not a point of issue.

Fair enough, as usual you are spot on.

 

[McCbon]

Well,Pellicle, but, even if we get a mech valve in 30s, 40s, 50s, (presumably not yet old) since survivablity is pretty good, someday most of those mech valvers on Warfarin will be old. Even if the valve was placed when they were young. That would presnent all the challenges "for th elderly" or those folks you don't suggest it for??
That gave me pause. McCbon

 

[MethodAir]

Activity level… and activity type. I am an enthusiastic mountain biker; I enjoy fast, sometimes technical descents.

http://www.ncbi.nlm.nih.gov/pubmed/25268439

Are you suggesting your activity level exceeds that of an elite Crossfit athlete?? I think it's reasonable to conclude it does not. Elite Crossfit will place some of the highest demands on the aortic valve, and from what I understand, the On-X valve (to name but one) handles that task quite adequately. If you undertake any high risk activity, in many cases, the probability of suffering debilitating joint and/or spinal injuries is far greater than the risk of 'bleeding' associated with well managed Warfarin use.

 

[pellicle]

Hi

Well,Pellicle, but, even if we get a mech valve in 30s, 40s, 50s, (presumably not yet old) since survivablity is pretty good, someday most of those mech valvers on Warfarin will be old. Even if the valve was placed when they were young. That would presnent all the challenges "for th elderly" or those folks you don't suggest it for??

I had assumed that the main problem was in elderly learning something new. If after having done your own dosing for 30 years you became unable to do it (one would hope you were used to it by then, but lets say you became mentally incompetent due to senility) it is likely that someone else could assist you. I would hope by then that warfarin testing dosing practices had modernised to be at least equivalent to todays best practice. We don't all get doddery. Research in medicine has shown that the only reason elderly perform at lower levels of comprehension with respect to medical issues is because "its all new to them and they have no frame of reference".

​Perhaps dick0236 could offer how much trouble he is having in managing his dose? He is late 70's IIRC and has been doing warfarin for 30 years (on the same valve too) now.

On algorithms and the future, I am hoping to devote next year to development of computer (well phone) base app which will make dosing and prediction more straight forward. I am very happy with the results from the last 2 years of testing and development. I have contacted Roche about it, but they have said that right now they are not increasing development. I'm intending to target low end android devices because I want to see uptake in poorer countries.

 

[cldlhd]

Well old age is relative, my son thinks the 90's were the old days, I have 60+ guys I work with who think I'm young and 30 yr olds who think I'm old (er) - I'm 46. Its impossible to know the future . If someone in my age range was on warfarin and they had an accident with significant bleeding ,internal or external, and the anti coagulation turned out to be the difference between surviving and bleeding out ( assuming you could make that conclusion) well then yes you would be able to say that person would have been better with a tissue but PERSONALLY when I was debating the issue weighing the possibilities of something like that happening vs the certainty of at least one reop , which was a certainty unless something else killed me, I concluded mechanical would be my backup.

 

[ALLBETTERNOW!]

Are you suggesting your activity level exceeds that of an elite Crossfit athlete?? I think it's reasonable to conclude it does not. Elite Crossfit will place some of the highest demands on the aortic valve, and from what I understand, the On-X valve (to name but one) handles that task quite adequately. If you undertake any high risk activity, in many cases, the probability of suffering debilitating joint and/or spinal injuries is far greater than the risk of 'bleeding' associated with well managed Warfarin use.

I presume flying downhill on a mountain bike carries a high risk of crashing, breaking something or getting a bruise or cut. I am not sure cardiovascular valve wearing out is. Major risk here. The risk may be a crash or Coumadin bleeding risk? Life is risky I guess.

 

[ALLBETTERNOW!]

Well old age is relative, my son thinks the 90's were the old days, I have 60+ guys I work with who think I'm young and 30 yr olds who think I'm old (er) - I'm 46. Its impossible to know the future . If someone in my age range was on warfarin and they had an accident with significant bleeding ,internal or external, and the anti coagulation turned out to be the difference between surviving and bleeding out ( assuming you could make that conclusion) well then yes you would be able to say that person would have been better with a tissue but PERSONALLY when I was debating the issue weighing the possibilities of something like that happening vs the certainty of at least one reop , which was a certainty unless something else killed me, I concluded mechanical would be my backup.

Seems like a well thought out and reasonable plan!

 

[cldlhd]

Seems like a well thought out and reasonable plan!

Thanks , ultimately my valve was repaired so the big decision turned out to be a moot point. I can't speak for others and I know hobbies are important but for me if my main reason for leaning towards a tissue valve as a youngish person was a hobby I'd think about getting new ones. Again it's a personal decision but I wonder how many people go that route because this diagnosis is life changing enough -at least mentally- and there's a desire to try to keep things as normal as possible. I also wonder how many regret it when the 2nd operation rolls around.

 

[ALLBETTERNOW!]

Thanks , ultimately my valve was repaired so the big decision turned out to be a moot point. I can't speak for others and I know hobbies are important but for me if my main reason for leaning towards a tissue valve as a youngish person was a hobby I'd think about getting new ones. Again it's a personal decision but I wonder how many people go that route because this diagnosis is life changing enough -at least mentally- and there's a desire to try to keep things as normal as possible. I also wonder how many regret it when the 2nd operation rolls around.

I bet 100% regret it for #2!