The debate still On-x vs St Jude

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preciosa1974

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Hi all! I’m new and have asked a few questions. Here’s another one. (Surgery December 19). I was looking through old posts from like 2009! The on-x debate. Many on that thread said on-x and I’m wondering if people still feel the same over 19 years later?!? I am still waiting to discuss with my surgeon again. The more I read, it did seem the newer material made some difference but I would still not want a low INR. Anyways, just thought I’d see thoughts and if there’s anyone in here from that 2009 thread if you still feel the same!! 💜
 

nobog

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Your surgeon doesn't REALLY know the difference between the two valves - he may like one over the other because of a different cuff or he gets tickets to Disneyland or something from one but when it comes to the technical and functional difference, he/she would be hard pressed to give a solid reason. The material difference means diddly, how could one explain that carbon formula A vs carbon formula B supposedly makes a difference when we know both work - oh, and Delrin (plastic) works, stainless steel works, titanium works, etc. Pick one but know that leaflet function (flutter) on the SJM is superior.
 
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pellicle

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I was looking through old posts from like 2009! The on-x debate. Many on that thread said on-x and I’m wondering if people still feel the same over 19 years later
ok, well firstly I'll assume that was a typo because the maths makes it 13 years

Next its important to know that the primary site sponsor was On-X back in those days, there were no other ads. Hank started the site as an independent entity and had a St Jude himself. Ross was an important member before my time here and spent many a time doing (what is sadly missing here) the role of moderator when valve bashing got out of hand.

Accordingly its no surprise that On-x features strongly in these discussions.

When thinking about this topic you should adopt a stance that encompases:
  • how can you possibly inform yourself to know yourself if what you hear is correct or not correct (magic with no substance or a position supportable with hard arguable data)
  • the difference between marketing fluff and bio-engineering pragmatism
  • proper knowledge of the words used and what the differences are (like in vitro and in vivo)
  • knowledge that these are not consumer products (like washing machines or stereo units) and accordingly must pass entirely different standards to even be presented to "the market"
I already gave you a link in a previous topic which contained measurements and comparisons (in vivo) on the opening and closing and valve area of all valves, which also contained their marketing claims and their actual performance as measured. Did you read that? Did you understand that? Because if you did I'd wonder why you're even asking this question again.

Only one of us here to my knowledge has the actual experience in this to make a call and that poser will (intelligently) not tip his hand as to why for a number of reasons including non-disclosure binding contracts (meaning don't push them to disclose). That person does post small and subtle posts here from time to time and IMO when they speak you should choose to listen.

There is only one other topic which matters on the choice of a valve which you may not have picked up and that the pressures at tiny instants of time called "opening and closing jets". The computational fluid dynamic modelling of that shows that you can tune for better pressures on opening, but you get worse ones on closing (and vice versa).

Why is this important? Well triggering platelets to go into "aggregation mode". Why is that important? Well because that's what is the major cause of thrombosis formation as it passes through the valve. This aggregation will go up and into the blood from the aortic valve where it will be within inches from your brain .. which is probably the last place you want a clot to form right?

I can give you studies to read on this but can you follow them and how long have you got?

Lastly I'll ask you to look in the mirror and ask yourself "is this some sort of cunning trick of your unconscious to avoid thinking about what you need to think about or to avoid thinking about what you don't want to think about"? I mean that's ok, but now you should be seeking peace of mind and settling yourself in to commit to the ride and think about your family.

I have two blog posts which I think are of significance to you right now, this one was written in 2014 (which would be clear from the date if people looked at URL's)


in that what I think is important to you is right at the bottom, I'll paste it here:
Anyway, enough about you, think for a moment about your family.
My wife was distraught at the thought of my surgery (more so than me), she was beside me every step of the way. She said to me in recovery that some of the happiest moments of her life were in seeing me get better every day.
She put on a brave face, but the fact is that she was scared shitless that I would die and she would be left without me.
She was so pleased because she was so relieved. I would not want to put her through that again. If you are a reasonably healthy adult, and you choose a tissue valve you will for sure be putting your loved ones through it again.
Is that something you want to do to them?

The next post is this one, which was written just prior to surgery


You can see that at that time I knew very little about the current crop of mechanical valves and wrote what I did about the On-X ... I addressed that point like this:

The other choice that the surgeon seems to be considering will be the one from ATS Medical (also pyrolytic carbon). Since he (rather than me) has more experience in this matter (implanting valves) I'll be relying on him to make the final choice "when he's in there and sees what he finds".

so while I did a little reading on the valves (he did suggest the On-X as the other possibility) I knew far less then than I know now over 10 years later. Note that I genuinely felt that I would rely on him to make the better choice than me. He made the choice of valve based on exactly that criteria "ease of implanting" (which is not trivial because reducing time on the pump is critical). He also made it for another reason which related to management of INR.

What I know now is that I'm glad I got the ATS (having seen an On-X) ... simply because its huge compared to the dainty and delicate St Jude or ATS (I expect that comes from the Pannus Guard feature).

Lastly let me give you a metaphor, as it happens I know quite a lot about Stereo Gear from the technical perspective (and was involved in the HiFi industry for a short time). What I saw there was that utter twaddle that was un-supportable critically was marketed to people with "more money than sense" with "outright lies" often told. Ultimately people were to me deaf and relied on what salesman told them. Yet in the Audio Industry (PA, Concert, Studio Recording) there was less of that and brands that the consumers never knew existed were the mainstay of actual industry.

Basically you can't "go wrong" with either choice, and when its in (as I said before) what will matter in the long term is your INR management, not the valve.

Best Wishes
 
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Superman

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If you didn’t make to the end of pellicle’s dissertation above, this is the part that matters:
Basically you can't "go wrong" with either choice, and when its in (as I said before) what will matter in the long term is your INR management, not the valve.
😁

By the way, it’s probably worth pointing out that On-X has been out now as long as St. Jude was when I got mine back in 1990. They (St. Jude) quickly took over as the standard vs the ball and cage or tilting disc valves that were still seeing occasional use at that time. They (On-X) are not the new kid on the block and if your surgeon thinks it’s best for you and your anatomy, I wouldn’t be too quick to argue. I, personally, would argue for an INR range above 2.0 regardless though.
 
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tom in MO

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I asked my surgeon 10 years ago what valve I would get....St. Jude was the answer.

When I asked the surgeon why not On-X, he said he hasn't used it. When I asked why not, he said that the St. Jude is a proven performer, he has used it for many years and he saw no medical need to try On-X. He said they need to keep on stock valves for emergency procedures so what they have on hand is a St. Jude, but if I want an On-X, he'd get one. Since I am not an expert in heart valve technology I trusted my expert.

Since I've had a St. Jude, I've had two procedures and my cardiologist said my St. Jude is "robust" thus I didn't need to bridge for them. Due to many years of performance data, my valve INR recommended range has dropped from 2-3 to 2-2.5. However, just because a valve can go lower doesn't mean you have to.
 

Superman

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When I asked why not, he said that the St. Jude is a proven performer, he has used it for many years and he saw no medical need to try On-X.
Sadly, I fear this is why On-X has been trying so hard to medically differentiate themselves from the competition. Some might say dangerously so. If there isn’t a “medical need” to change, create one!
 

preciosa1974

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ok, well firstly I'll assume that was a typo because the maths makes it 13 years

Next its important to know that the primary site sponsor was On-X back in those days, there were no other ads. Hank started the site as an independent entity and had a St Jude himself. Ross was an important member before my time here and spent many a time doing (what is sadly missing here) the role of moderator when valve bashing got out of hand.

Accordingly its no surprise that On-x features strongly in these discussions.

When thinking about this topic you should adopt a stance that encompases:
  • how can you possibly inform yourself to know yourself if what you hear is correct or not correct (magic with no substance or a position supportable with hard arguable data)
  • the difference between marketing fluff and bio-engineering pragmatism
  • proper knowledge of the words used and what the differences are (like in vitro and in vivo)
  • knowledge that these are not consumer products (like washing machines or stereo units) and accordingly must pass entirely different standards to even be presented to "the market"
I already gave you a link in a previous topic which contained measurements and comparisons (in vivo) on the opening and closing and valve area of all valves, which also contained their marketing claims and their actual performance as measured. Did you read that? Did you understand that? Because if you did I'd wonder why you're even asking this question again.

Only one of us here to my knowledge has the actual experience in this to make a call and that poser will (intelligently) not tip his hand as to why for a number of reasons including non-disclosure binding contracts (meaning don't push them to disclose). That person does post small and subtle posts here from time to time and IMO when they speak you should choose to listen.

There is only one other topic which matters on the choice of a valve which you may not have picked up and that the pressures at tiny instants of time called "opening and closing jets". The computational fluid dynamic modelling of that shows that you can tune for better pressures on opening, but you get worse ones on closing (and vice versa).

Why is this important? Well triggering platelets to go into "aggregation mode". Why is that important? Well because that's what is the major cause of thrombosis formation as it passes through the valve. This aggregation will go up and into the blood from the aortic valve where it will be within inches from your brain .. which is probably the last place you want a clot to form right?

I can give you studies to read on this but can you follow them and how long have you got?

Lastly I'll ask you to look in the mirror and ask yourself "is this some sort of cunning trick of your unconscious to avoid thinking about what you need to think about or to avoid thinking about what you don't want to think about"? I mean that's ok, but now you should be seeking peace of mind and settling yourself in to commit to the ride and think about your family.

I have two blog posts which I think are of significance to you right now, this one was written in 2014 (which would be clear from the date if people looked at URL's)


in that what I think is important to you is right at the bottom, I'll paste it here:
Anyway, enough about you, think for a moment about your family.
My wife was distraught at the thought of my surgery (more so than me), she was beside me every step of the way. She said to me in recovery that some of the happiest moments of her life were in seeing me get better every day.
She put on a brave face, but the fact is that she was scared shitless that I would die and she would be left without me.
She was so pleased because she was so relieved. I would not want to put her through that again. If you are a reasonably healthy adult, and you choose a tissue valve you will for sure be putting your loved ones through it again.
Is that something you want to do to them?

The next post is this one, which was written just prior to surgery


You can see that at that time I knew very little about the current crop of mechanical valves and wrote what I did about the On-X ... I addressed that point like this:

The other choice that the surgeon seems to be considering will be the one from ATS Medical (also pyrolytic carbon). Since he (rather than me) has more experience in this matter (implanting valves) I'll be relying on him to make the final choice "when he's in there and sees what he finds".

so while I did a little reading on the valves (he did suggest the On-X as the other possibility) I knew far less then than I know now over 10 years later. Note that I genuinely felt that I would rely on him to make the better choice than me. He made the choice of valve based on exactly that criteria "ease of implanting" (which is not trivial because reducing time on the pump is critical). He also made it for another reason which related to management of INR.

What I know now is that I'm glad I got the ATS (having seen an On-X) ... simply because its huge compared to the dainty and delicate St Jude or ATS (I expect that comes from the Pannus Guard feature).

Lastly let me give you a metaphor, as it happens I know quite a lot about Stereo Gear from the technical perspective (and was involved in the HiFi industry for a short time). What I saw there was that utter twaddle that was un-supportable critically was marketed to people with "more money than sense" with "outright lies" often told. Ultimately people were to me deaf and relied on what salesman told them. Yet in the Audio Industry (PA, Concert, Studio Recording) there was less of that and brands that the consumers never knew existed were the mainstay of actual industry.

Basically you can't "go wrong" with either choice, and when its in (as I said before) what will matter in the long term is your INR management, not the valve.

Best Wishes
Thanks for your response. Sometimes it’s hard to “read” tones in a post. I did read what you sent. Did I completely understand it? No I did not. Which is why I continue looking through the forum and trying to learn as much as I can. I’m assuming this is the place to post questions even if you feel they might be repeats? I guess I didn’t see it that way.

Of course I know I’m doing this for my family and for myself. No doubt. I like to try and be informed as possible in most decisions I make and this is a big one. Also it was all thrown at me rather quickly so I went from Never even hearing of this to needing surgery in a month’s time.
I just want ti be informed when I talk with the surgeon again as I know he is open to either one and I definitely trust if he needed to choose one over the other that would be fine.
And oops! Sorry about the typo regarding years.
 

ATHENS1964

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346
I have written it in another post, my surgeon told me that they have all the companies and all the sizes available before the surgery. he told me he will decide which one to put during the surgery according to the anatomy.
Surgeons are paid well for their work judged by how many successes they have with a score he won't put anything in if he doesn't have to just to get a small commission from some company.
You decide if you want mechanical or tissue and let the surgeon do what he knows.
 

preciosa1974

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If you didn’t make to the end of pellicle’s dissertation above, this is the part that matters:

😁

By the way, it’s probably worth pointing out that On-X has been out now as long as St. Jude was when I got mine back in 1990. They (St. Jude) quickly took over as the standard vs the ball and cage or tilting disc valves that were still seeing occasional use at that time. They (On-X) are not the new kid on the block and if your surgeon thinks it’s best for you and your anatomy, I wouldn’t be too quick to argue. I, personally, would argue for an INR range above 2.0 regardless though.
Yes, this is where I’m at regarding the INR. I have never even known what that means but now I’m understanding that a lot better and would not be at all comfortable with 1.5! Which is what the nurse said they recommend for on-x
 

preciosa1974

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If you didn’t make to the end of pellicle’s dissertation above, this is the part that matters:

😁

By the way, it’s probably worth pointing out that On-X has been out now as long as St. Jude was when I got mine back in 1990. They (St. Jude) quickly took over as the standard vs the ball and cage or tilting disc valves that were still seeing occasional use at that time. They (On-X) are not the new kid on the block and if your surgeon thinks it’s best for you and your anatomy, I wouldn’t be too quick to argue. I, personally, would argue for an INR range above 2.0 regardless though.
Gosh, maybe I sounded like I was arguing with my surgeon but I’m not at all. He had suggested the st. Jude and I brought up the on-x bc my cardiologist mentioned it and I wanted his opinion. His main reason was the lower INR. And now that I’ve learned more about that, I don’t want that to be the only reason for it. Thus I’m waiting for us to have a chat about it.
 

Superman

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Gosh, maybe I sounded like I was arguing with my surgeon but I’m not at all. He had suggested the st. Jude and I brought up the on-x bc my cardiologist mentioned it and I wanted his opinion. His main reason was the lower INR. And now that I’ve learned more about that, I don’t want that to be the only reason for it. Thus I’m waiting for us to have a chat about it.
Sorry. I use “argue” very loosely. How about an informed discussion. 😁
 

tommyboy14

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Hello,

There is actually a recent randomised control trial to answer the On-X vs St Jude question.


It concludes: 'The On-X valve and St Jude Medical valve performed equally well in the study with no differences found.'.

Now this was only over a 5-year time period. Only the St Jude has studies with 35+ years, since it has been around since 1980.

I hope that this helps.
 

preciosa1974

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Hello,

There is actually a recent randomised control trial to answer the On-X vs St Jude question.


It concludes: 'The On-X valve and St Jude Medical valve performed equally well in the study with no differences found.'.

Now this was only over a 5-year time period. Only the St Jude has studies with 35+ years, since it has been around since 1980.

I hope that this helps.
Yes! I’ve read this and now being a little more informed I just saw this part.

The target anticoagulation level for both prostheses was: for aortic position prostheses international normalized ratio (INR) between 2.2 and 2.8,

That is nowhere near the 1.5 the nurse was saying. This is a great point to make if I do get the on-x regarding INR.

Thanks for sharing!
 

Unicusp

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In a very brief summary (I can't write like Pellicle, ha). Assume that the two valves are very similar. Assume that you will maintain the same INR with either one. Choose a great surgeon with extensive experience with installing both valves. Let him/her make the final choice during surgery that fits your anatomy best. This is what I did, and it worked out well. Funny story, but after basic research I chose the On-X, after further research I chose the SJ. Upon consultation with my surgeon, he recommended the SJ. During surgery he chose the On-X because he said it was best for my specific anatomy. Done deal. Good luck!
 

sangfroid

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Hi all! I’m new and have asked a few questions. Here’s another one. (Surgery December 19). I was looking through old posts from like 2009! The on-x debate. Many on that thread said on-x and I’m wondering if people still feel the same over 19 years later?!? I am still waiting to discuss with my surgeon again. The more I read, it did seem the newer material made some difference but I would still not want a low INR. Anyways, just thought I’d see thoughts and if there’s anyone in here from that 2009 thread if you still feel the same!! 💜
I have a St Jude from 1999 and as of today, still going strong.
 

pellicle

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Hi

Thanks for your response. Sometimes it’s hard to “read” tones in a post.

agreed, and complicated by cross cultural norms (I'm Australian), (style of) sense of humour, and perhaps a tincture of cross "generational" too

I did read what you sent. ... I’m assuming this is the place to post questions even if you feel they might be repeats? I guess I didn’t see it that way.

I needed to ask because (I'm in education) I find that 90% of the time people don't read carefully (especially students, which to me on this you are), I need to ask because I don't like to assume. I've found that when someone doesn't ask anything about what you said it was either clear and simple (which this subject isn't) or its because they glanced at it and didn't get it and moved on.

If a student (in my experience) asks a question, gets an answer then asks the same question it often indicates that they didn't understand the answers given (which would usually be indicated by a specific question about the answer). That didn't happen which left me in the dark, which is why I asked.

This is a complex subject and you've got a short time to cram it in so I'm doing what I can to try to steer you towards what I've come to see as the key points to answer your specific questions.

That these questions are asked before is normal, that I've "said something previously" simply means that. It wasn't intended to chide you (note I've assumed something from "your tone" here and that may be wrong).

Lastly I don't know what your expectations are or how to communicate. As you may guess (even by this) I'm actually making an effort to try to help you to grapple with and understand the question you've asked and the answers you've got and who may be answering the questions. We've got hundreds of active members here and so far there is about 16 posts on this thread. So of those who are here I'm making an effort to try to guide you on your path to informing your "informed choice".

Sorry if that's not helpful
 
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pellicle

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Now this was only over a 5-year time period. Only the St Jude has studies with 35+ years, since it has been around since 1980.
I know the article you cited says 5 years, but its actually a bit worse than that, its 3.8 years according to the original PROACT study data



Results: A total of 375 aortic valve replacement patients were randomized into control (n = 190) and test (n = 185) groups from September 2006 to December 2009. The mean age ± standard deviation was 55.2 ± 12.5 years; 79% were men; and 93% were in sinus rhythm preoperatively. Calcific degeneration was present in 67%; active endocarditis was excluded. Concomitant procedures included coronary artery bypass grafting (27%), aortic aneurysm repair (14%), and other (25%). The follow-up duration averaged 3.82 years (755.7 patient-years [pt-yrs] for control; 675.2 pt-yrs for test). The mean INR was 2.50 ± 0.63 for the control and 1.89 ± 0.49 for the test groups (P < .0001). The test group experienced significantly lower major (1.48% vs 3.26%/pt-yr; P = .047) and minor (1.32% vs 3.41%/pt-yr; P = .021) bleeding rates. The incidence of stroke, transient ischemic attack, total neurologic events, and all-cause mortality were similar between the 2 groups.​

This is significant because the evidence from another study of some thousand


Methods We evaluated all patients visiting the Leiden Anticoagulation Clinic with mechanical heart valve prostheses, atrial fibrillation, or myocardial infarction from 1994 to 1998..... We enrolled 4202 patients for a total of 7788 patient-years.​

showed this graph in summary

1670528915948.png


which as I understand it means that an event is statistically probably in 3.75 years for any valve at that INR range.

Meaning there is nothing to differentiate the PROACT trial findings from earlier existing bileaflet trial findings.

In their results they observe: The optimal intensity of anticoagulation for patients with mechanical heart valve prostheses was an international normalized ratio (INR) of 2.5 to 2.9;

Which is interesting because that's pretty close to the range that my surgeon suggested to me to follow in 2011 when we had our first 3 month post surgical follow-up. Interestingly the lab thought differently and didn't want to abide by his guidelines (while I personally do)
 
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