tissue vs. mechanical

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H.A. Olson

My wife (age 71) is scheduled to have both mitral and aortic valves replaced February 18. The surgeon sez:"How old are you? 71? If it were me, I'd go for the tissue valve." The cardiologist sez: "I'm not a big fan of tissue valves; the service life is still not very predictable, but it's your decision."
We decided to go with the tissue valve (thus SUPPOSEDLY avoiding the coumadin/"borderline hemophiliac for the rest of your life" spectre. But now we've discovered approximately 50% of patients go into atrial fibrillation due to traiuma of surgery which then requires at least short-term (several months?) coumadin regimen and possibly coumadin long-term/for life.

We realize nothing is certain or 100% predictable; we're dealing in overall probabilities here. But, our understanding was:

* mechanical valve = nearly 100% "guarantee" valve would
outlast the patient but downside is coumadin-for-life

* tissue valve=7-10 year valve life (depending on recipient age
and lifestyle) but supposedly coumadin-free post-op life.
Of course surgery will again be needed due to tissue valve
predictably failing 7-10 years (who knows?) hence.

Age 71 is sort of a "gray area" age on this "tissue vs. mechanical" question. But - - Have we made a perhaps flawed "pact with the devil"? If there's a high probability she will end up on coumadin anyway due to atrial fibrillation, the "advatages"of the tissue valve seem to be significantly reduced. It's getting awfully close to February 18. Is this concern of ours making any sense? Does anyone out there have any experience/information on this question. I don't see too many folks on this site talking about their experiences with tissue valves and/or resulting atrial fibrillation experiences. Any help would be appreciated. Will have enough to think about in days ahead without the extra burden of "did we make a dumb decision?" Many thanks for any input; this web site is great!
Herb in Houston
Hi Herb,

Welcome and you've come to the right place for support. People here have different experiences with a variety of valves. Everyone is very knowledgable in their own way. Just remember it comes from the horses mouth. Doctors only tell you so much!
I was 53 at the time of surgery and am 17 months post-op. I have a St. Jude's Mechanical and am on Coumadin. Once the Coumadin is stabilized it is no problem. There have been no side effects for me. You just have to take it once a day and make sure you have a doctor who knows how to regulate it. I personally have a Protime (Advertizement link is on this website) Home tester and do my testing at home, and I like it a lot. I don't go to labs anymore!
Many people will tell you that Coumadin is made out to be a bigger thing than it really is. There are people on this forum that have been on it for a quarter century or longer without any problems.
I had two AVR surgeries within eleven days because my Coumadin was not regulated properly by my cardiologists office, and I developed a blood clot. (Read my story in the personals) The first mechanical valve needed replacing with a new one. Was not fun to go through it again, but everything went well.
My surgeon chose the mechanical valve because they'll last the rest of your life, he told me! Well, things can happen as I told you before and no surgery is without risk. What he wanted to say, if nothing happens this valve will last the remainder of your life. And you don't want to do these surgeries too many times. I agreed! I was terrified as it was, and the thought of having to do this again scared me even more.
The choice of valve is very personal and is neither right nor wrong. She'll be feeling so much better in a few short weeks. It'll amaze you!

Best wishes to you and let us hear from you again.
For more info please contact me at: [email protected]

Aortic Stenosis
AVR's 8/7/00 & 8/18/00
St.Jude's Mechanical
"But now we've discovered approximately 50% of patients go into atrial fibrillation due to traiuma of surgery which then requires at least short-term (several months?) coumadin regimen and possibly coumadin long-term/for life."

Hi Herb

This is true. It feels like rolling the dice doesn't it? This is the most important decision you two will ever have to make. Hang in there.

The information I have gathered is that people in their 70's and older tend to bleed more readily on the anticoagulants. If I am not mistaken.... your clotting time naturally becomes longer as you age. Some older individuals are on a minimal amount of Coumadin to remain within the therapeutic range. For these reasons.... most surgeons like to see the older folks with the tissue valve. If your wife is already in a-fib....I would take the mechanical valve. Because, like you stated...she will have to use Coumadin regardless.

If I had not had valve replacement at age 30....and was your wife's age.... would go with the tissue valve and take my chances.
I went with the mechanical for longevity at my age. Coumadin is really not that big of a deal. There is a lot of information out there on that medication. I would suggest you do a little research before making up your mind.

Best of everything.....
Take care
Hi Herb-

My husband Joe's been on Coumadin for 25 years. It's really no "biggie". You go and get tested, you take what they tell you and go back for your next test when they say to and in the mean time, you go on with your life. Sort of like brushing your teeth, after a while.

Joe's 71 and has 2 valve replacements, both mechanical. He's had 3 valve surgeries, because he had to have a leak repaired this past year. I can tell you that going in for a second or third valve surgery when you can avoid it is something you should weigh very, very carefully. It just gets harder and harder with each surgery. There's scar tissue to contend with and you will be older and possibly sicker when the second or third time comes around. We've been there and done that. It's not that easy. Think about it even more carefully since your wife is going to have 2 valves replaced.

I wish you peace with your decision.
Sorry Herb....misinterpreted your post. Did not realize until reading Nancy's. Did not catch the dual replacements.

Chances are, if the mitral cannot be repaired she would automatically have a mechanical in that position. Good question for your surgeon.

If you have one mechanical....you might as well have them both. Even if a repair is successful, you may not get the longevity you hope for. With prosthetic valves,there is a more forceful flow than in our native valves. In turn this could stress the mitral valve. Potentially requiring mechanical mitral replacement after a repair. There have been individuals on the group that have had this situation.

If it were I, and I could not find someone to do a dual valve repair and or dual tissue replacement. Dual mechanical all the way.

It's a very personal decision. Talk to your surgeon.
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The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve replacements.

The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve replacements.


1: J Heart Valve Dis 2001 May;10(3):334-44; discussion 335

The homograft aortic valve: a 29-year, 99.3% follow up of 1,022 valve

O'Brien MF, Harrocks S, Stafford EG, Gardner MA, Pohlner PG, Tesar PJ, Stephens

The Prince Charles Hospital and the St Andrew's Hospital, Brisbane, Queensland,

BACKGROUND AND AIM OF THE STUDY: The study aim was to elucidate the advantages
and limitations of the homograft aortic valve for aortic valve replacement over
a 29-year period. METHODS: Between December 1969 and December 1998, 1,022
patients (males 65%; median age 49 years; range: 1-80 years) received either a
subcoronary (n = 635), an intraluminal cylinder (n = 35), or a full root
replacement (n = 352). There was a unique result of a 99.3% complete follow up
at the end of this 29-year experience. Between 1969 and 1975, homografts were
antibiotic-sterilized and 4 degrees C stored (124 grafts); thereafter, all
homografts were cryopreserved under a rigid protocol with only minor variations
over the subsequent 23 years. Concomitant surgery (25%) was primarily coronary
artery bypass grafting (CABG; n = 110) and mitral valve surgery (n = 55). The
most common risk factor was acute (active) endocarditis (n = 92; 9%), and
patients were in NYHA class II (n = 515), III (n = 256), IV (n = 112) or V (n =
7). RESULTS: The 30-day/hospital mortality was 3% overall, falling to 1.13 +/-
1.0% for the 352 homograft root replacements. Actuarial late survival at 25
years of the total cohort was 19 +/- 7%. Early endocarditis occurred in two of
the 1,022 patient cohort, and freedom from late infection (34 patients)
actuarially at 20 years was 89%. One-third of these patients were medically
cured of their endocarditis. Preservation methods (4 degrees C or
cryopreservation) and implantation techniques displayed no difference in the
overall actuarial 20-year incidence of late survival endocarditis,
thromboembolism or structural degeneration requiring operation. Thromboembolism
occurred in 55 patients (35 permanent, 20 transient) with an actuarial 15-year
freedom in the 861 patients having aortic valve replacement +/- CABG surgery of
92% and in the 105 patients having additional mitral valve surgery of 75% (p =
0.000). Freedom from reoperation from all causes was 50% at 20 years and was
independent of valve preservation. Freedom from reoperation for structural
deterioration was very patient age-dependent. For all cryopreserved valves, at
15 years, the freedom was 47% (0-20-year-old patients at operation), 85% (21-40
years), 81% (41-60 years) and 94% (>60 years). Root replacement versus
subcoronary implantation reduced the technical causes for reoperation and
re-replacement (p = 0.0098). CONCLUSION: This largest, longest and most complete
follow up demonstrates the excellent advantages of the homograft aortic valve
for the treatment of acute endocarditis and for use in the 20+ year-old patient.
However, young patients (< or = 20 years) experienced only a 47% freedom from
reoperation from structural degeneration at 10 years such that alternative valve
devices are indicated in this age group. The overall position of the homograft
in relationship to other devices is presented.

PMID: 11380096 [PubMed - indexed for MEDLINE]
Primary aortic valve replacement with allografts over twenty-five years: valve-relate

Primary aortic valve replacement with allografts over twenty-five years: valve-relate


1: J Thorac Cardiovasc Surg 1999 Jan;117(1):77-90; discussion 90-1

Primary aortic valve replacement with allografts over twenty-five years:
valve-related and procedure-related determinants of outcome.

Lund O, Chandrasekaran V, Grocott-Mason R, Elwidaa H, Mazhar R, Khaghani A,
Mitchell A, Ilsley C, Yacoub MH.

Academic Department of Cardiac Surgery, Harefield Hospital, Middlesex, United

OBJECTIVES: Allografts offer many advantages over prosthetic valves, but
allograft durability varies considerably. METHODS: From 1969 through 1993, 618
patients aged 15 to 84 years underwent their first aortic valve replacement with
an aortic allograft. Concomitant surgery included aortic root tailoring (n =
58), replacement or tailoring of the ascending aorta (n = 56), and coronary
artery bypass grafting (n = 87). Allograft implantation was done by means of a
"freehand" subcoronary technique (n = 551) or total root replacement (n = 67).
The allografts were antibiotic sterilized (n = 479), cryopreserved (n = 12), or
viable (unprocessed, harvested from brain-dead multiorgan donors or heart
transplant recipients, n = 127). Maximum follow-up was 27.1 years. RESULTS:
Thirty-day mortality was 5.0%, and crude survival was 67% and 35% at 10 and 20
years. Ten- and 20-year rates of freedom from complications were as follows:
endocarditis, 93% and 89%; primary tissue failure, 62% and 18%; and redo aortic
valve replacement, 81% and 35%. Multivariable Cox analyses identified several
valve- and procedure-related determinants: rising allograft donor age and
antibiotic-sterilized allograft for mortality; donor more than 10 years older
than patient for endocarditis; rising donor age minus patient age, rising
implantation time (from harvest to aortic valve replacement), and donor age more
than 65 years for tissue failure; and rising donor age minus patient age, young
patient age, rising implantation time, and subcoronary implantation preceded by
aortic root tailoring for redo aortic valve replacement. Estimated 10- and
20-year rates of freedom from tissue failure for a 70-year-old patient with a
viable valve from a 30-year-old donor and no other risk factors were 91% and
64%; the figures were 71% and 20% if the donor age was 65 years. The rates of
freedom from tissue failure for a 30-year-old patient with a 30-year-old donor
were 82% and 39%; the figures were 49% and 3% with a 65-year-old donor.
Beneficial influences of a viable valve were largely covered by short harvest
time (no delay for allografts from brain dead organ donors or heart transplant
recipients) and short implantation time. CONCLUSIONS: Primary allograft aortic
valve replacement can give acceptable results for up to 25 years. The late
results can be improved by the use of a viable allograft, by matching patient
and donor age, and by more liberal use of free root replacement with
re-implantation of the coronary arteries rather than tailoring the root to
accommodate a subcoronary implantation.

PMID: 9869760 [PubMed - indexed for MEDLINE]
bio vs. mechanical?

bio vs. mechanical?

Personal experience- I was 72 when I had mitral valve replacement with a mechanical St. Jude. It really gave me a second chance and I feel 50 again now at 75. Ticking? Can't even hear it any more. Coumadin?, easy to handle with the Coaguchek.
I feel safer with this valve and have no interest in going back for another mitral valve at age 80 or 82. There is a lot of evidence going that tissue valves are getting better but why are so many cardiologists and surgeons leery of them? Also your point about
post op fibrillation being common is important. An older friend about my age went for the tissue valve and two years later is still fibrillating and on Coumadin.
hi herb!
welcome! this is a wonderful place to get support, information and just some good old hand holding. glad to have you among us.

as others have said, i hear that coumadin is a big nothing for those who take it daily. it is those of us, who (whose so's) do not take coumadin, who find it intimidating.

my husband joey had a ross procedure and as is very common post vr surgery, went into afib. he was on coumadin for a few months and is currently taking an antiarrhythmic drug (amiodarone) on a short term basis. so , you're right, often times patients end up in afib anyway due to the manipulation that goes on with the heart during the surgery (as per our surgeon and the cicu nurses)_ very common.

my dad, however, is 68 and has had his st. judes valve for almost 3 yrs and takes coumadin very easily. he's very active and it doesn't interfere with his lifestyle one bit.

so, either way, your wife's life will be renewed. she may just have to make a few adjustments, that's all. nothing anyone can't get used to.
as gina said though, if they do replace the mitral with a mechanical ( is that the only choice for a mitral replacement?), then it would seem reasonable to have the av replaced with a mechanical as well, no?

good luck in your decision. we are here for you to bounce things off of. as you will find, many others will come forward with other info and suggestions.
hope all goes well and please keep us posted as to what you decide and what happens.
all the best,
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I had a porcine aortic valve done in '89 at age 34. I had no problems at all for 11 years when it began to fail. I exercised very regularly then as now to try to prolong the longevity of the valve.
I took coumadin only for 3 months after surgery and then went off of it and really felt myself again for 11 years.
I know it's a hard decision to make. My surgeon decided to give me the porcine and I'm glad I had those years without the coumadin.
tissue vs. mechanical

thanx for your reply, Gail. Follow-up question: What happened after your porcine aortic started to fail in 2000 (after 11 years)?
Are you still functioning on that valve (albeit with reduced efficiency) or have you had another valve replacement (possibly with a mechanical)? Not trying to be personally prying but - - as you can probably appreciate - - I'm scrambling for any scrap of information/experience I might factor into this very important decision. I'm not overly computer literate, so I tend to stumble and bumble my way around the web site and it takes me longer than necessary to figure out how to communicate efficiently. I can
be reached at: [email protected]
Hi, difficult decission to make. I had a avr on 12-15-2000 and choose a homograph. I was 49 at the time of surgery. Had no problems either during surgery or after. Always had low blood pressure, so that only went up a little. Also no rythem problems.Glad I made the decission I did. Only need to take baby asperin once a day. It's important that the surgeon you choose is comfortable, and skilled, in doing the kind of valve you decide on. Good luck, please keep us posted what every way you decide to go.
Age and Health

Age and Health

Age and health play a big role in this decision.
Over the age of 70, tissue valves tend to have a far longer life than they typically do in younger people. The older we get, the less we tend to calcify tissue valves and that is one of the more common reasons for re-op. Tissue valves actually a long time in older patients. Sometimes up to 20 years or more. The 7-10 year figure sounds to me like that of a younger person receiving a stented tissue valve.

Several papers on the subject advocate the use of the tissue valves due to the increased risks (the degree of risk varies and many here say they do not feel there is one) present in long term coumadin use as we age.

I'm simplifying this based on my limited knowledge, but if there are no other complicating health concerns to worry about, the decision really doesn't sway too far in either direction towards one alternative versus the other. If your wife were 80, then it's likely they would push you harder towards the tissue valve.

Despite the decision you come to, I agree with Gina when she mentioned that if they have to do a mechanical replacement for one, you would be better off having two mechanicals. This reduces the risk of reoperation later on a potential calcified tissue valve.
havnt been on for a long time thought id pop in and see whats new, regarding this age old question i had tissue 14 yrs ago age 51, still no problems other than a small leak which cardio not worried about, its a personnel choice which is gonna save your life whichever you choose, good luck
havnt been on for a long time thought id pop in and see whats new, regarding this age old question i had tissue 14 yrs ago age 51, still no problems other than a small leak which cardio not worried about, its a personnel choice which is gonna save your life whichever you choose, good luck
Nice to see you here again @neil ! And good advice too.
Hi Herb (and welcome)

well I'm not sure if it'll help, but here are thoughts I put together some years back. Its biased towards younger healthy patients but there are parts for older people too

a segment which perhaps relates to you:

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.

Lastly I suggest you sit down with a coffee (or tea) and listen to this, and make your own call

Best Wishes

Your point on "warfarin for life" is well taken but if your wife was to suffer a small stroke she may well be that anyway
havnt been on for a long time thought id pop in and see whats new, regarding this age old question i had tissue 14 yrs ago age 51, still no problems other than a small leak which cardio not worried about, its a personnel choice which is gonna save your life whichever you choose, good luck
Hi Neil,

Just checking in to see how you are doing and how the valve is holding up ?

And Happy New Year to you!