Tissue Valve and Future Percutaneous Replacement

[big_L]

I haven't met with the surgeon yet, but when I spoke with my cardiologist at KU Med Center, we spoke briefly about valve selection. I said - given my age, I suppose mechanical is the choice. He responds - not necessarily. One option to consider is tissue, with the advantage of no long term warfarin therapy, then when it needs replacement in maybe 16 years, we may be able to do that percutaneously. The percutaneous method is reserved at this time for those deemed to sick to have OHS.

Comments? Any one hearing similar talk from their Dr?

Thanks

 

[epstns]

I had the same discussion with my surgeon prior to my valve replacement. The difference for me was that I was 63 at the time, and they projected a relatively long life for a tissue valve due to my age. My surgeon stated that percutaneous replacement might be available when I next need a valve, but not to let that idea be the basis for my choice. Basically, he said that although they are working in the percutaneous process, there are no guarantees that it will be mainstream when I need it. It is, however, much more common in Europe than the US, so that may be a good indication of future acceptance.

 

[tom in MO]

My surgeon and cardiologist said the choice of valve was up to me. They both said that with a tissue valve at 54 yo (operation last year) I was to expect more surgery. They both said the path to the second sugery would have the same risks and sypmtoms as the BAV that brought me to the first surgery. With a mechanical valve, barring complications or later endocarditis, the path should be forward with no re-operation.

When I asked the surgeon about future advances, he indicated that I should not base my current choice on future possibilities. Even if the percutaneous replacement is accepted, it might not be indicated in my specific case. Plus he said, there will be many years of trial before use on "normal" valve replacements. If I chose a tissue valve, I should expect a similar repeat operation.

 

[Bracken]

big_L, I went into my initial consultation with the surgeon thinking he would recommend mechanical simply due to my age. He was quite open that the valve decision was mine and he had extensive experience with either option, but he also cautioned against making a decision based on possible future advancements. Meaning if I selected mechanical I should expect ACT for the rest of my life (and all that it entails) and if I selected tissue I should expect 2-3 more surgeries. It's up to you to decide which risks you're more willing to accept and live with and then go from there. I can certainly empathize with the decision you're making as I went through the same thing just a few months ago. Just find relief in knowing there is no wrong decision. Because there are benefits and risks with each option and the one that is right for you is really up to you. No one else.

 

[Bryan B]

I am a firm believer that transcatheter valve replacement will be routine, especially for the elderly, within the next 10 years. My surgeon is leading the clinical trials at Duke using the CoreValve. He recommended the CE Perimount bovine pericardial valve for me because he is positive (from running the trial) that this type of valve replacement will be the standard for older patients and patients that have already had multiple surgeries. If I get the "average life expectancy" out of my valve I will be in my mid 60's and I have already had 2 surgeries to date. When that day comes when it is time to replace it I will weigh my options and choose the best option that will last the rest of my life regardless of the type of valve that is, but I am hoping it will be the transcatheter method.

From one of my posts on another thread.

 

[Jkm7]

Like the others who posted above, my surgeon left valve choice to me.
I weighed all the given information that we all plow through when choosing which valve. When I told my surgeon I definitely wanted a tissue valve, he totally approved. We had the same percutaneous conversation as mentioned and seeing Mass General Hospital is active in the research and early use of that method, he felt very sure it would be very main stream in the foreseeable future. Clearly he would be knowledgeable about the studies/procedures that were being done in his hospital.

I am So grateful I made that choice. For me, it was without question the right valve.
There is no wrong choice. Whichever makes you the most comfortable is the right one for you and once you make that choice, don't look back. You will have chosen the right one.

 

[Rachel]

I selected a tissue valve and my surgeon happened to also recommended I go with tissue and I was 45. For me it was a very personal decision that I felt was right for me, I know and fully expect to have more surgeries in the future (if I live long enough) and I am fully prepared for the whole OHS experience again, understanding all the risks associated with this choice.

I agree with the others that you should not base your decision on future replacement options that may or may not be available.

This is a very personal decision and I wish you much luck with it

Rachel

 

[Tirone]

Keep in mind that TIVA is only possible in calcified valves at the moment. The anchors can't grab healthy tissue. It might be possible to overcome this issue in the next years, it might be possible that this procedure becomes routine till then and it might also be possible that biological valves will improve till then. The only thing we know for sure is that you will need another surgery if you go with a tissue valve and that you will have to take Warfarin with a mechanical valve.
I'm also presurgery and both options don't sound very appealing to me. To be honest, I'd rather have none of them. So I turned it around and asked myself whether I'd rather have NO warfarin or NO second surgery. For me this made the decision easier.

 

[big_L]

Thanks for the comments. Prior to the meeting with the cardio a few days ago, I had about four weeks to do research on Warfarin and start making the mental adjustment. I had reached the point that it didn't feel like as horrible an option, as I previously imagined. It certainly was more appealing than a future surgery. My spouse was a med tech in her earlier life and has had quite a bit of experience interacting with warfarin patients. Most of her experience is not positive. This was nearly 30 years ago, likely before home testing. Even so, I still felt that the warfarin was better than facing the surgery again.

I'm still not decided, but after a few days playing with the idea of tissue, I'm moving back toward mechanical. I'll meet with the surgeon in a few weeks, we'll see what he has to say.

 

[pellicle]

Hi
I've had 3 OHS, spaced by about 20 years each. First was when I was 9 or so.

#1 was a valve reconstruction
#2 was a human living tissue implant
#3 is a ATS pyrolytic carbon mechanical

I had about four weeks to do research on Warfarin and start making the mental adjustment. I had reached the point that it didn't feel like as horrible an option, as I previously imagined

its funny isn't it, how its made out to be the boogey man in "common knowledge" but when you actually dig into it its actaully not that bad.

I too was given the impression all my life that "well at least you're not on WARFARIN" by medical people. All I can put this down to is a combination of ignorance and a slanted perspective.

Discussion yesterday with a pharmacist mate of mine (I am an ex-biochemist) was interesting. We discussed a fellow who was on one of the warfarin alternatives (Pradaxa). He fell down stairs and broke his nose. Not horrible, but it wouldn't stop bleeding. They had to give him dialysis for some days to clear his blood. Had he been on warfarin the this could be cleared almost immediately with a simple injection of vitamin K.

That's one of the reasons why I like simple solutions to problems.

My spouse was a med tech in her earlier life and has had quite a bit of experience interacting with warfarin patients. Most of her experience is not positive.

its a bit like asking an Ambulance driver or a Policeman questions about what they see every day ... its usually only the worst of everything. By definition they just don't see the people who have no problems.

This has to give you a slanted perspective on stuff (just as having no experience does).

This was nearly 30 years ago, likely before home testing. Even so, I still felt that the warfarin was better than facing the surgery again.

which is exactly my usual point. I'm expect that your partners view is different now to what it was then...

I feel that the worst side effect of warfarin is that it will make it more likely that you don't need re-operation and will get old and die of old age just like everyone else.

It is true that there are a number of reasons for re-operation that even a theoretical perfect valve made of something that didn't need warfarin and never wore out would not prevent.
- further complications of the heart (say the need for bypass or an aneurysm)
- complications from the surgery
- pannus growth
- ...

so a mechanical valve isn't a ticket to "freedom", but it is far far less likely that the mechanical valve will need to be replaced due to structural failure than a tissue valve (which may be 20 years or so).

I'm still not decided, but after a few days playing with the idea of tissue, I'm moving back toward mechanical. I'll meet with the surgeon in a few weeks, we'll see what he has to say.

Only you can make the decision, however I can only attest to the following personal experiences and how I view them:
- avoid re-operation if you can (check my post here for my reasons)

- self testing (as you mention) is both available and is much more likely to keep you within your therapeutic range. I have a Coagucheck XS and having it enables me the freedom to travel as I wish, while keeping a check on my INR so as to not go out of range (either direction)

- selft testing and monitoring enables you to be "empowered" and take an active hand in your health. This has flow on effects into other areas. You may become more aware of things related to your health and cease taking it for granted (ok in your youth, dangerous in your later years) and manage it yourself.

I wish you wisdom in making your choice and peace in living with it after that point.

 

[Jkm7]

Unless, of course, you are like me.
There was no way for me to know in advance the very large dose of coumadin I would require to get near my range.

My surgeon wanted me on warfarin for 3 months post op my tissue valve until my own tissue grew over it and smoothed the edges thus minimizing clot risk. I had a very competent ACT manager and I was a compliant patient yet despite appropriate raises incrementally in my dosage I never got comfortably into my 2.0 - 3.0 range.

When my surgeon heard the high dosage I was taking, he told me to stop at 2 1/2 months.
Had I gotten a mechanical valve and had to take warfarin the rest of my life, it could/would have been a real problem anytime I would have any procedure which might produce bleeding.

I was extremely anxious being on very high dose and yes, I get it.........
the right dose for anyone is the dose that keeps you in your proper range but no one would think it insignificant to be on a deal more than 100 mg /week. I am relieved I made the choice I did.

 

[pellicle]

Unless, of course, you are like me.
There was no way for me to know in advance the very large dose of coumadin I would require to get near my range.

...

When my surgeon heard the high dosage I was taking, he told me to stop at 2 1/2 months.
Had I gotten a mechanical valve and had to take warfarin the rest of my life, it could/would have been a real problem anytime I would have any procedure which might produce bleeding.

This is an interesting point. I wonder why I never hear of anyone being trialed on warfarin before their surgery to see how they would do? After all there would be no harm in a 3 month or so trial to see if there were any incompatibilities for the patient.

Seems a logical and prudent step in light of your experience. As you say after surgery is a bad time to find that out. Just because many have no problems does not mean some won't.

 

[sood]

I had the same dilemma and conversation with my surgeon. The truth of the matter is that there is just not much data yet on tavi. And there is absolutely no data on them stacking these valves on top of one another and how they will perform as a result.

Meanwhile there is a ton of data on mechanical replacement with OHS.

There is also no guarantee you will not be on warfarin with a tissue. After just going through this op 9 days ago I'm very happy that I chose the route that might not lead me to another operation.

I have no doubt tavi will be common and effective in the future. I think they will need to tinker with and find a solution to how they get these valves to work by stacking them together everytime you need a new tissue.

I am far more excited about possible stem cell usage to create a new tissue valve for yourself then tavi.

 

[catwoman]

I haven't seen any mention of the stroke risks with any procedure that requires cardiac catheterization.
Catheterization can dislodge aortic plaques. A friend had a stroke right after a heart cath. Her husband was driving the car around to the hospital's entrance after the heart cath, came in to the cath lab recovery and discovered that she had had a stroke. She was admitted to the hospital.

This is an interesting point. I wonder why I never hear of anyone being trialed on warfarin before their surgery to see how they would do? After all there would be no harm in a 3 month or so trial to see if there were any incompatibilities for the patient.

Seems a logical and prudent step in light of your experience. As you say after surgery is a bad time to find that out. Just because many have no problems does not mean some won't.

I have several iPhone apps for warfarin management or initiation of warfarin.
iWarfarin -- designed to be used in initiation of warfarin therapy -- uses an IWPC algorithm. You key in the patient's age, weight, height and known genetic factors.
I keyed in my age, weight and height. I didn't know my genetic factor, so I chose UNK. The app said my dosage should be 36mg/week. I am taking 36.5mg/week; I tested this morning and my INR was 3.2 -- my range is 2.5-3.5.
However, this app doesn't figure in what the range should be.
I use the WarfarinGuide app, which is for maintenance of management. For initiation, it mentions using either 5.0 or 10.0mg daily, citing the AFP (I assume it's the American Family Physician journal) 2005 article, but also mentions the ACCP (Anticoagulation Care Provider) and warfarin initiation based on pharmacogenetic testing.

The dosage that you need to get into and stay in range is what is right for YOU. It may be high for someone else, and it may be too low for someone else.
My range is 2.5-3.5. My husband was on warfarin for about 7 months due to a-fib after his MV repair in 2007 and was given a range of 2.0-3.0. His INR tests were run on a CoaguChek at our family doctor's practice and because our own doctor was off when John had his INR's, another doctor called the shots on adjusting the dosage.
Whatever adjustments he made weren't enough to get him into range, so I voice my concerns to the doctor's office and suggested different adjustments. They knew I have my own monitor and adjust my own dosage. They deferred to my suggestions and I got him into range. John brought home a copy of the practice's algorithm chart and it was too conservative in dosage adjustments. These were competent people, but they were using an algorithm charts that just weren't working, at least not for my husband.
In order to stay in range at 2.0-3.0, John had to take more warfarin than I did to stay at 2.5-3.5. He's 4.5 years older than me and was taking only terazosin, which does not interact with warfarin.

 

[Jkm7]

This is an interesting point. I wonder why I never hear of anyone being trialed on warfarin before their surgery to see how they would do? After all there would be no harm in a 3 month or so trial to see if there were any incompatibilities for the patient.

Seems a logical and prudent step in light of your experience. As you say after surgery is a bad time to find that out. Just because many have no problems does not mean some won't.

That is ONE of the reasons I have remained posting here, year after year, to share this story with people now making their decisions as to valve type. It is something people may wish to take into consideration. If they have never heard of anyone having difficulty, they don't know it happens.

 

[Oilman]

Back in April of 2010, I suffered a TIA, I experienced vertigo for a couple months after as my symptom, luckily everything was back to normal after that. At that time I had an echo and CT & MRI and lots of blood cultures, trying to get answers, and find out why this occurred, never found a answer, lots of theories. At that point they decided that warfarin would be a plan of prevention until my valve went from moderate to severe.

So I had almost three years of warfarin experience until the valve was replaced. It was the first time I required any medication in my life. I had no problem at all with the drug, my biggest deal was remembering to take it, I purchased my CoaguChek and that made things real easy, I became very stable faster before surgery than I did this time, just getting back to my old dose 5.5 months after surgury now, at 70 mg per week. My understanding is that each body metabolizes medication different, therefore the different doses, I'm hoping that us higher dosing people have the same risk or long term, as anyone on Warfarin trying to maintain a 3.0 INR. Time will tell, thankfully I have more of that now.

Anyways, this experience I acquired pre surgery with warfarin made my valve decision at age 49 a lot easier, along with the members with 20+ yrs of experience with warfarin. This is a surgical experience, god willing, I only have to have once due to a mechanical implanted. I agree, if possible a trail run with warfarin would be beneficial for people with valve choice.

 

[pellicle]

warfarin does calculators

warfarin does calculators

I have several iPhone apps for warfarin management or initiation of warfarin.
iWarfarin -- designed to be used in initiation of warfarin therapy -- uses an IWPC algorithm. You key in the patient's age, weight, height and known genetic factors.
I keyed in my age, weight and height. I didn't know my genetic factor, so I chose UNK. The app said my dosage should be 36mg/week. I am taking 36.5mg/week; I tested this morning and my INR was 3.2 -- my range is 2.5-3.5.
However, this app doesn't figure in what the range should be.

for those interested there is an excel spreadsheet here:
http://www.pharmgkb.org/download.action?filename=IWPC_dose_calculator_6-19-09.xls

I keyed in my factors and it did a remarkable job of predicting my current dose.

 

[Gail in Ca]

Just curious, how much warfarin were you up to JKM7 before the doc took you off of it? How many mgs per week?
My medical people tell me I must have a good liver because I used to take 72.5mg/week to stay in 2-3.0 range, but closer to 3.0.
Now, with my new valve inside graft, I'm taking 57.5mg/week to stay in 2-2.5 range.

 

[Liam]

My surgeon convinced me to go with a tissue valve, although he would gladly put in an on-x valve if I requested. He is convinced that even in 10 years if I need work done on the valve it will be done via a cathater.

 

[Heather Anne]

I'm 48, and I'll be having a tissue valve implanted in August. I expected my cardiologist to suggest mechanical because of my age, too, but he said he fully expected the catheter approach to be safe and commonplace by the time I need it replaced. Even if it weren't, he said that people in their 60s (as I would likely be) tolerate re-ops very well, in his experience.

I met with the surgeon a couple of weeks later and he said the same thing. So I'm very comfortable with my decision, but of course everyone makes their own choice based on what's best for them. Good luck to you, Liam!