Thrombosis in bioprosthetics

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pellicle

Professional Dingbat, Guru and Merkintologist
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Hi

One of the reasons I come here is to learn things. With such a diverse group there is always something of interest (if perhaps trivial). Recently I discovered that a failing bioprosthetic valve (in fully expectable and predictable onset of SVD) has caused liver failure in a patient. I was stunned. I wonder how many deaths occur in "all cause mortality" on the greater than ten year scale with bioprosthesis (thanks for this thought, you know who you are).

There are few good resources out there showing that one should perhaps pick a mechanical valve; with everyone just accepting that the modern way is a bioprosthesis ... I mean it's obvious isn't it?

This brings me to this more recent discussion than the Dr Schaff video that I often point people to and its by the same group, the Mayo; indeed they even mention his work. Let me quote:

If you do not know a problem exists, you will not find it. You know what they say: "The eyes will not see what the mind doesn't know." The first troubling issues came with the realization that many patients who had bioprosthetic valves implanted came back for redo surgery early on. Dr Hartzell Schaff, our lead surgeon for many years now, published his experience with aortic BPVT spanning almost 12 years.​

So if you are in the valve choice period, and you are actually interested in informing yourself, I recommend listening to it. Click the image to take you there.

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or just click the link: https://www.medscape.com/viewarticle/838221


I feel uncomfortable with the term "conventional wisdom" because of mostly the same reasons I feel uncomfortable with the term "common sense", so let me instead use the phrase "its generally said". Its generally said that the choice of valves comes down to I don't want the ticking or I don't want to be on blood thinners. Either way we think we know that with a bioprosthesis we trade off durability for the ticking and the blood thinners. This is something that I frequently say is incorrect, not least because as one ages one often finds that some other issue (be it DVT, or having a Stroke, or arrhythmia develop ...) sees us prescribed blood thinners.

I've always thought that such an eventuality must be a cruel blow to those who made the decision to choose (usually without actually knowing much at all about what they are signing up for) a re-operation in the future to kick that can down the road (with a rosy eyed hope for a TAVI).

So with this in mind I'll leave you with some key points from the discussion

LaPrincess C Brewer, MD: I'm Dr LaPrincess Brewer, an advanced cardiology fellow at Mayo Clinic. During today's Mayo Clinic talks, we will be discussing bioprosthetic-valve thrombosis (BPVT). I am joined by Dr Sorin Pislaru, consultant and associate professor of medicine, who specializes in valvular heart disease.
"Misconceptions, diagnostic challenges, and treatment opportunities in bioprosthetic valve thrombosis: Lessons from a case series," published in the European Journal of Cardiothoracic Surgery in May 2014.[1]
They did more than 4000 prosthetic aortic-valve implantations; and of those, about 3000 were porcine valves. The incidence of BPVT was actually quite low, just about 0.18%. At the same time, we do not know how many patients had valve thrombosis and were never diagnosed or were outside the 2-year window that was predefined for the search that they performed.
A more troubling signal came from a very systematic review from Denmark published in JAMA.[3] This study encompasses every aortic-valve replacement that has been performed in Denmark. They have a registry that every hospital in the country subscribes to, and they also have data on every medication that these patients have taken. The troublesome finding was that if patients discontinued warfarin within the first 6 months after aortic-valve replacement, they were more likely to die, have a stroke, or have a thromboembolic complication. It is hard to not associate this finding with the possibility of aortic-valve thrombosis being a common reason for all these events. With that in mind, we thought we should look at our own experience with BPTV, and this is what we plan to talk about today.
In our series, 17 patients were treated with either thrombolytics or surgery and about 15 patients were treated with just warfarin, a vitamin-K antagonist. They did equally well. So 13 of 15 patients treated with warfarin had improvement in their gradients and resolution of their symptoms. We suggested that vitamin-K antagonists should be considered for first-line therapy whenever the patient is stable enough for longer treatment.

So if I were in the shoes of deciding between A or B now I'd want to make double sure that I wasn't making a choice based on an incorrect idea and based on ignorance (so much for informing) or based on an imaginary pride topic of "I don't want to be on medicine for life". I've never really got that argument.

There is no perfect valve and so its up to us as patients to understand what we are choosing, so that then with that set straight, we can decide which is best for us.


Best Wishes
 
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I had a bio-prosthetic as my first valve. During the eight years, I had two neurological incidents (where I never had any previously). 2nd year after AVR woke up with half of my face numb. Went to hospital. Nothing detected, but I can tell you my face felt very strange for a while. They diaganosed it as Bell palsy and moved on. Then in 2021, two weeks after my second Astra Zeneca Vaccine, I woke up from a nap with a numbing feeling on the top of my left hand. Docs figured some sort of sudden nerve damage, but didnt blame it on the valve. It took two years, but this numbing feeling is gone.

Now I dont know if we should blame these incidents on the valve. But I think that these are really uncommon in a person in the late 30s. and I never had any such issues before...

Again, it is hard to blame on the valve direclty, but hard to rule out completely as well...
 
Morning

sorry to read all of that and glad it wasn't permanent

Now I dont know if we should blame these incidents on the valve. But I think that these are really uncommon in a person in the late 30s. and I never had any such issues before...

Again, it is hard to blame on the valve direclty, but hard to rule out completely as well...
a wise reaction to limited data.
 
I had a bio-prosthetic as my first valve. During the eight years, I had two neurological incidents (where I never had any previously). 2nd year after AVR woke up with half of my face numb. Went to hospital. Nothing detected, but I can tell you my face felt very strange for a while. They diaganosed it as Bell palsy and moved on. Then in 2021, two weeks after my second Astra Zeneca Vaccine, I woke up from a nap with a numbing feeling on the top of my left hand. Docs figured some sort of sudden nerve damage, but didnt blame it on the valve. It took two years, but this numbing feeling is gone.

Now I dont know if we should blame these incidents on the valve. But I think that these are really uncommon in a person in the late 30s. and I never had any such issues before...

Again, it is hard to blame on the valve direclty, but hard to rule out completely as well...
From my experience, I've had similar problems but unrelated to my valve. My face went numb because of either Bell's palsy or a herpes infection of the nerve. It went away. My valve was not a problem at the time, it was just BAV and monitored every 5 years with an echo. Various parts of my right hand and arm have gone numb (comes and goes over the years) due to a pinched nerve in my neck caused by arthritic stenosis of the spine.
 
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