Tissue valve deterioration - signs, symptoms, etc.

[VegasBAV]

So I have this tissue aortic valve that is almost a year old. I know I will need to get it replaced perhaps 10-15 years from now.

Here is my question: how should I expect the deterioration of the tissue valve to go, and when will I know that it needs to be replaced? As the tissue valve deteriorates, does it regurgitate or does it become stenotic? Are there certain measurements or results on echocardiograms that I will want to play close attention to that "track" the deterioration?

Also, I have seen published criteria for when stenotic and regurgitating aortic valves should be replaced, but I haven't seen such written criteria explaining how doctors know when it's time to replace a deteriorating tissue valve. Are there published guidelines on this?

I plan to ask my cardiologist these questions when I see him at the the end of the month, but I was wondering if anyone here has any insight or experience with this. Thanks.

 

[pellicle]

Hi

I'm not a specialist, but ...

Here is my question: how should I expect the deterioration of the tissue valve to go,

my understanding is ... slow changes following something of a log curve in nature

so, with problems Y axis and time being the X

and when will I know that it needs to be replaced?

as I understand it, this is best determined by yearly monitoring and checks by professionals.

As the tissue valve deteriorates, does it regurgitate or does it become stenotic? Are there certain measurements or results on echocardiograms that I will want to play close attention to that "track" the deterioration?

yes, yes and yes. Close attention perhaps not, but yearly checks is prudent. Then they have a history of change (or no change) to observe.

I read that it is not uncommon for them to begin throwing clots in the last few years of their life. So warfarin therapy may be suggested at something like the 7 year mark.

Are there published guidelines on this?

well ... my thoughts on guidelines are well summed up in Pirates of the Caribbean...

I noted this in the American Heart Association...


click for larger image

of interest was the LHS side of the flow chart which says "LONG DURABILITY" as a criteria for Tissue Prosthesis ... like really?

I plan to ask my cardiologist these questions when I see him at the the end of the month, but I was wondering if anyone here has any insight or experience with this.

excellent plan ... hope this helped

 

[DebbyA]

My cardiologist answered the 'when' question with "Symptoms, symptoms, symptoms". The echo findings that she and the echo tech point out to me are gradients and whether there is enlargement of left ventricle.

I've had the same lack of success finding guidelines. Here's one: http://www.onlinejase.com/article/S0894-7317%2809%2900676-2/fulltext

 

[Rachel]

Nice charts and graphs Pellicle!

 

[neil]

cardio and surgeon both said tissue valves go the same way as your natural valve in most cases, so when you do start having problems there will keep a close eye on you, but that will be a long time down the line for you, pellicle dont know where you got the info on tissue valves throwing clots of and warfarin being mentioned at the 7 year mark ? never heard of that one and never been mentioned to me,

 

[Mike59]

Totally agree with your comments Neil

Pellicle - seriously think perhaps you are overly worrying sometimes

Life is for living not worrying about what might or might not happen in the distant future

 

[tom in MO]

Neil is on target. It will be similar to the original valve, but different since its a different valvae and you also change with time.

I was told by my surgeon that ~25% of tissue valvers are on warfarin, but these are generally elderly people and take it for non-valve reasons. My mother in law was on warfarin before her tissue valv, but for other ciculatory problems, not her valve.

 

[pellicle]

Hi

pellicle dont know where you got the info on tissue valves throwing clots of and warfarin being mentioned at the 7 year mark ? never heard of that one and never been mentioned to me,

I pulled seven years as some valves have started to fail as early as a year (read here) and others needed replacement at about 10 years but were observed degrading some years earlier. I've read in other places that as part of the degradation process some valves can do this.

I did not intend to imply that this is a normal process for I simply do not know what the regular process of failure is, but I do know that failure is regular. I was simply trying to be brief. Please pardon that.

I have read (for instance here) that people how were having stenosis and calcification of their valve had been placed on warfarin. I did not ask them why. I'm sorry that I have not been so through as to note the thread numbers. I also read it in that mayo presentation too.

Ok ... first find: http://circ.ahajournals.org/content/119/7/1034.full

Patients with prosthetic valves are at risk of thromboembolic complications, including systemic embolization, most commonly cerebral, and prosthetic thrombosis causing valve obstruction and/or regurgitation. The risk of thromboembolic events is higher with mechanical than with bioprosthetic valves, higher with mitral than with aortic prosthetic valves, and higher in the early (<3 months) versus late postoperative phase

this seems to not exclude tissue prosthesis, infact it specifically includes it. So while it would be obvious that its a lower risk in tissue, it is not that low as to be non-existent in the literature.

Next link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1861363/

Thrombosis of a bioprosthetic valve4 is a rare occurrence when compared to mechanical prostheses. Bioprosthetic PVT is usually diagnosed in the early postoperative period, when endothelialisation of the suture zone is not yet complete. Hence, this has led to the recommendation of anticoagulating patients with bioprostheses for the first three months postoperatively....

Lastly from the mayo presentation (my notes of his speech)

77 yo patient had severe heart failure. It could be said that this was
'Gods hand' for 77 year olds. Its not true that tissue valves don't
thrombose, they do. If not identified it can be confused with heart
failure. Patient is now anticoagulated.
This patient would have died for lack of diagnosis of thromboembolism.

 

[pellicle]

Pellicle - seriously think perhaps you are overly worrying sometimes

I'm uncertain what this means. If you feel that I worry, well then don't because I don't worry. If you feel that I cause worry ... well I was only answering a question. I didn't go stirring up worry by posting this as a start to a thread.

If you meant something else, please let me know

 

[Jkm7]

I think it might mean you sometimes exhibit a bias.
For example, where in your above discussion did you mention those tissue valves that last 20+ years?

 

[kfay]

My cardiologist told me that they will know (from echo's and exercise stress test) long before I will be able to tell, that my valve is starting to fail. She then showed me on my tests the numbers that were important to watch. The valves can either become more stenotic, or more regrug.

I was like you at one year out, somewhat anxious and wanting to know everything I could about how this whole thing worked and what I could expect. At 5 years out, I hardly give it a second thought other than the week of my yearly appt. and so far, so good.

 

[epstns]

Vegas - I would not set a reminder in your calendar at 15 years to shop for a new valve. I would simply live life and keep up with your periodic cardio monitoring. Your docs will know when or if your valve begins to deteriorate. You may or may not know before they do. In either case, 15 years is simply the average - which means that half the tissue valves last less than 15 years and half last more. You won't know which half you are in until you know.

Whenever somebody asks me how long my tissue valve will last, I always answer "Until it wears out." We cannot know our fate until that time. The manufacturers state that the current third generation tissue valves are projected to last longer than the second generation valves. Those second generation valves are the ones for which they have long-term lifespan data (that 15 year average) - NOT our third generation valves. We will not know the average lifespan of the third generation valves until they have actual data for more years since implantation.

As for tissue valvers taking warfarin for valve-specific reasons (not for afib, etc.), I have not heard of any in my years here on vr.org. That is not to say it doesn't happen, just that it is not common practice and does not seem to be headed that way.

 

[pellicle]

Hi

I think it might mean you sometimes exhibit a bias.

could be. Perhaps I do ... I do attempt to present what I know and what I learn in an unbiased fashion. Clearly that's not fully possible, but I do try. Personally I have no (and I mean totally zero) concern if person X chooses tissue or mechanical. I mean I really don't care.

What I do care about is clearing up misinformation.

For example, where in your above discussion did you mention those tissue valves that last 20+ years?

Well no, but that's because I wasn't answering the question of "how long will they last" (and given that the OP actually started with the statement:

I know I will need to get it replaced perhaps 10-15 years from now

it clearly wasn't asked ... so rather than answer something which wasn't asked, I thought I'd just answer what was.

But on the topic, can you provide some data on this? For instance what percentage of tissue valve recipients are still free from reoperation at 20+ years.

That would be valuable input.

what I read is this:

http://circ.ahajournals.org/content/116/11_suppl/I-294.full

Twenty-year follow-up data were available on 1512 patients, of whom 567 were adults <60 years of age at the time of their initial left-heart valve replacement.

Within AVR patients, the 20-year actuarial freedom from valve reoperation was 11.4±3.5% in those initially implanted with a tissue prosthesis, versus 73.0±4.9% in those who received a mechanical aortic valve

so about 12% as I see it

From St Jude, with patients who were older than 65
http://investors.sjm.com/phoenix.zhtml?c=73836&p=irol-newsArticle&ID=1245247&highlight=
At 20 years, the data show that 92 percent of patients more than 65 years old, whose aortic valves were replaced with the Biocor Stented Tissue Valve, remain free from reoperation due to structural valve deterioration.


So it matters how old you are when you get it if you want to get 20+ years out of it

or am I being biased again?

 

[epstns]

"So it matters how old you are when you get it if you want to get 20+ years out of it"

No visible bias in that comment - I think that was one of the points I was trying to make. Patient age is one of the critical decision factors. The confusing added fact is that the "cutoff point" at which they recommend tissue over mechanical valves is moving lower, based upon projected service lives of the newest valves. We will not have this data for some time yet, so there is still a major element of faith in the projection needed from younger patients selecting the tissue valves. I know that if I had been much younger at time of implant (I was 63), I would have opted for a mechanical. I had that very discussion with my cardio when we were discussing his recommendations for surgeons. He wanted to be sure I was prepared to discuss the choice fully with the surgeons, rather than to just agree to whatever the surgeons wanted to suggest.

 

[Mike59]

Hi Pellicle

Clearly you have posted many useful comments

But you do have and portray a bias towards mechanical valves, which is disappointing as both options have significant benefits but carry different drawbacks

I ask you this question genuinely - if one valve was significantly better than the other why are both used in great numbers

Why are both authorised by the MHRA in the UK or the FDA in the States

Please give advice objectively based on both are life saving options and improve quality of life

Otherwise your commentary will not be valued by many readers of your posts which is a shame for someone who has been to date a significant. Contributor to this invaluable site

Please take this as constructive criticism

I wish you all the very best

 

[Gail in Ca]

Uh oh, people are attacking mechanical valvers opinions, again.
I have gone thru the tissue valve deterioration, so I'll tell you what happened to me. My porcine valve was watched yearly after implantation. My doctor knew the averages and always mentioned how close to the average I was getting. He also was adamant that I exercise so I would know if I felt different, like SOB during exercise. I did all that was asked of me. At 3 yrs beyond the average at that time, he said I would need replacement in about 6 mos, according to my echo. I had no symptoms, but he could see my valve was calcifying and all that goes with it I suppose. All I know was I was devastated and began to cry! Fast forward 5 months, and I was getting a cardiac cath in preparation for seeing my surgeon. During the procedure, I was given a fluid overload, went into congestive heart failure, spent a night in the hospital and then sent home. Three days later I experienced sob while climbing stairs at a dance recital. That same night, I felt feelings of dread and major back pain at about 1am. I went to er and my bp was 90/19, I was in bad shape, sent by ambulance to Stanford hospital and had OHS a couple of days later, when my chosen surgeon could do it. He said I was a very sick woman, and couldn't even address my leaky mitral valve at that time, as he would have if I hadn't presented as urgent. That's my story.

 

[Guyswell]

Vegas,

I received my aortic tissue valve and conduit at age 41 at Cleveland too. Here's my experience with a failing tissue valve...

I received a bovine pericardial valve at age 41 and hoped I would be the lucky one to get longer-than-average use of the valve. After seven and a half years (sooner than average), my first symptom was shortness of breath when climbing multiple flights of stairs or cycling up hills. The echo showed moderate calcification and mild-to-moderate stenosis so we scheduled a six-month follow-up echo. Five months later, my symptoms were notably worse and included shortness of breath and angina with moderate exertion so I went in early for my follow-up echo. It showed extensive calcification, moderate-to-severe stenosis and high pressure gradients. I contacted my favorite surgeon for a re-do and waited about 2 months for a surgery date because of his busy schedule. In the final weeks before my surgery, I had several espisodes of SVT that didn't resolve on their own and resulted in trips to the ER for cardioversion. In the final week before my surgery, when I was at the hospital for pre-surgical testing, my pressure gradients had reached the critical level (the valve was almost completely calcified shut) and I was having symptoms walking down the hallway. I clearly waited too long but I was being stubborn about not wanting to change my plans once the surgery was scheduled. I now have a mechanical valve and take warfarin. My advice... go in for yearly echo studies, exercise with gusto so you can recognize symptoms early and don't wait as long as I did to proceed with your re-do surgery.

 

[Rachel]

THANK-YOU Gail and Guyswell!!!!! That's some pretty useful information and I appreciate that

 

[Duffey]

I've had my bovine since June of 2005 and according to the cardiologist, the valve is functioning fine. I've never heard of clots being thrown by a tissue valve that's wearing out much less at seven years.
My advice is to not worry about how you'll know when your valve is wearing out. As Guyswell and Gail have stated, you'll notice something's wrong so live your life without the burden of needless worry.

 

[Agian]

Within AVR patients, the 20-year actuarial freedom from valve reoperation was 11.4±3.5% in those initially implanted with a tissue prosthesis, versus 73.0±4.9% in those who received a mechanical aortic valve

So 25% of mechanical AVR patients need a re-operation by 20 years. Did they break down the reasons for this? Valve failure? Pannus? Clot?