Trifecta Valve Concerns

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goffrey

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Not debating but wondering something, I have NEVER been offered a mechanical valve. Always either a homograph or animal tissue valve. My defect is right sided ( pulmonary valve to be exact and a tricuspid repair last surgery). Does anyone here have a mechanical valve on the right side? Specifically pulmonary? Is there a reason why surgeons would not want a mechanical valve on the right side? I know there is less pressure and pumping action so maybe blood clots more likely to form? Even on thinners? Just wondering out loud I guess. I was never really old enough to make any of those decisions until this last surgery and the only option I was given was tissue.
 

pellicle

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Does anyone here have a mechanical valve on the right side? Specifically pulmonary?
interesting question and I've only ever seen it on the Aortic or Mitral.

Interesting question.

Google suggests this:
However, when it comes to replacing a pulmonary valve in a patient without a condition favoring one type over the other, many surgeons (myself included) feel obliged to recommend against a mechanical valve. The accompanying study by Pragt and colleagues might prompt some of those surgeons to rebalance their bias.
...
So how do we interpret the findings in this study? As one who was biased against placing a mechanical valve in the pulmonary position, I was surprised that the incidence of valve thrombosis was only 1.7% per year. The authors acknowledge that this incidence is higher than what is reported for the aortic and mitral positions, but 1.7% is lower than I would have predicted. I was also impressed that when thrombosis was diagnosed, it was successfully treated with thrombolysis in the majority of cases. Both of these findings incline me toward considering a mechanical valve in an occasional “selected” case.

again I find what I usually consider disquieting; the short term view seems very significant

All types appear to function well for 5 years. Freedom from reintervention at 15 years, however, ranged from 41% to 75% in the 3 studies with the longest follow-up. An 81% freedom from reoperation at 15 years in the study by Pragt and colleagues places mechanical valve implantation in a comparably favorable position. However, reintervention in a patient with a bioprosthesis may be catheter based, whereas the reintervention for a mechanical valve must be a reoperation

underline mine ... why do these guys only consider the 5 year mark (yet apparently are unimpressed by 15 year reoperation figures? I mean its tantamount to saying "we're only expecting you to get 5 years".

the cited study by Pragt: Mechanical valves in the pulmonary position: An international retrospective analysis - PubMed
 
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goffrey

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Thanks for your input! One thing that gives me a bit of hope is the transcatheter valve replacement for pulmonary valves. I know several others with defects like mine that have underwent transcatheter placement with great results. I was not a candidate this last time due to the fact they had placed a homograph when I had my bout with fungal endocarditis at age 14 so it is not really compatible with transcatheter replacement. Due to my fungal infection it was the least likely tissue valve to become reinfected. I know sport a porcine valve with a bovine artery.
 

MdaPA

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Does anyone here have a mechanical valve on the right side? Specifically pulmonary?
During my wife's last OHS surgery, she got mechanical aortic and mitral valves, a tricuspid repair and a porcine valve in her pulmonary position (the porcine valve replaced a cadaver valve after a ROSS procedure about 20 years prior).

Is there a reason why surgeons would not want a mechanical valve on the right side?
When I asked the surgeon why not mechanical for the tricuspid and pulmonary positions, he said the tricuspid just needed to be tighten (annulus ring) and should be good for life and for the pulmonary, he said it could be addressed via catheter when/if any intervention is required. He did not directly answer my question but I knew going in he was more concerned with the left side of the heart than the right side.
 

Hokiesid

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I salute Pellicle and find his advice most helpful. I don’t think anyone is a tissue basher. In a perfect world Tissue valves would last as long as mech valves or mech valves need no warfarin. However, that is not the case. I had bicusp avr tissue replace at 43yo. I didn’t want to fool w blood draws and went right back to active lifestyle and poo poo’d my avr buddy’s advice to get the mech because “you’re too young” Lasted the 8 years that appears to be expected. Surgery last December. This time my surgeon said you picked the first one, I’m picking the second one. Mech Valve it is. Mentioned the TAVR and he thought there was a chance they would not last as long as the valves and put me in replacement territory in my 70’s. He said, I don’t want to pop the hood again. Surgery was much tougher. Had aneurysm repair, recovery more difficult. Would say 50% tougher this time. Warfarin not bad at all. Have had trouble getting in range but hopefully there now. I think as someone who has been thru both, I wish I had gone mech valve first and avoided this situation. You only have two low risk avr’s statistically and I wish I had not cashed the first one on tissue and saved it for if my mech has issue. Its a gamble so just study the odds to give best chance at survival and thrive.
 

nobog

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Mechanical valve leaflets may not function satisfactorily at such low pressure (tricuspid / pulmonary) conversely a tissue valve should last longer since the load is significantly reduced. A porcine valve works good for this as the leaflets react well and they seal good at these pressures.
 

Quarry1

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for what it is worth....... Had a trifecta put in on 5/ 2/2017... I was 73 at the time and all went well with the operation but spent an extra three weeks in the hospital with sepsis caused by a sloppy nursing staff. l now have a moderate leakage and will soon have an echo to start with. Not sure if sepsis had anything to do with this but am hoping this does not become serious. Also starting to get a lot of PVC's. Over health is good for now.
 

goffrey

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Hi

Endo at 14, very inconvenient, sorry to hear that.



Seems strange to me because I understood that a mechanical is usually the goto with infective endocarditis.

Best Wishes
I think you are right about mechanical being the go to for endocarditis but because of my defect being right sided I don't think there are any medical centers currently doing right sided mechanical valves. I could be wrong but I know Mayo Clinic and Cleveland Clinic do not. Fungal endocarditis is very tricky to treat. I had a 10% chance of survival and have to be on life long antifunguals where as with bacterial endocarditis I think the survival rate is higher and once you are done with the antibiotics you are done?
 

goffrey

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Thanks for clearing that up. I had suspected that too however @goffrey suspected correctly :)

It really sucks since with right sided valves replacement it ends up being a lifetime of surgeries if you are very young when the pulmonary valve has to be replaced. I am "hoping" to get at least 15 years out of this one since I am finished growing it should hopefully last a bit longer!
 

pellicle

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I think you are right about mechanical being the go to for endocarditis but because of my defect being right sided I don't think there are any medical centers currently doing right sided mechanical valves.
probably because of the evidence point that @nobog raised...

I know Mayo Clinic and Cleveland Clinic do not. Fungal endocarditis is very tricky to treat. I had a 10% chance of survival and have to be on life long antifunguals

thats harsh.

where as with bacterial endocarditis I think the survival rate is higher and once you are done with the antibiotics you are done?

yes, but if it makes you feel any better if you get a surgical infection around the outside of the prosthesis or in that area (as I did) then you're also on antibiotics for life (as I appear to be)...

It really sucks since with right sided valves replacement it ends up being a lifetime of surgeries if you are very young when the pulmonary valve has to be replaced.

that does indeed suck and I'm sorry that is the case for you. I guess you must (like me) wince a little at some of the threads around here.

I am "hoping" to get at least 15 years out of this one since I am finished growing it should hopefully last a bit longer!

Fingers crossed this end that you do just that, how old are you now?
 

sharky7

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Hi

firstly I'm in no way negative about your choice. Its your choice and more than that its in there now, so you're on for the ride. Further I believe that for you that choice was quite reasonable and sensible.

This response address only this:



and I write not so much for you but for the many lurkers.

Well there are indeed only two to choose from and so it must boil down to one of those.

If you don't care about what valve you pick then its simple: don't ask and just pick it.

Nobody here (especially me) will tell anyone to change their mind about a choice, and most of the worst arguments come down to tribal views people hold strongly. The most common seem to be:
  • my surgeon told me a tissue valve will last my lifetime, but if it doesn't then I can have a TAVR : depending on your age the first part is true, the second is not a given
  • I can't pick a mechanical because I can't eat greens if I'm on warfarin : patently untrue but somehow people still argue this (usually only those who aren't on warfarin
  • sure the old tissue valves don't last more than 15 years, but the new ones will : this is sadly only a hope and not backed by any actual evidence or reasons other than "new and improved" on the box
I suspect that part of the problem is that people don't actually read the posts and are dismayed by it. Further most people are inexperienced with science, inexperienced with discussions and its been a long time since they went to school and thus are not good at differentiating evidence from falsehood.

This table addresses some interesting points about discussion and what is probably 100% misunderstood by many people: that an argumentative writing style is bad and being emotional appealing is good.

View attachment 888490

So, for instance, when someone says "you can eat greens" if the person saying you can't doesn't address the facts presented but moves on to just other points against (say) a mechanical then you know that their point is weak.

Lots of words so far, because sadly just like conspiracy theory, its easy to say lies and often harder to contradict them in 5 words, not least because its time consuming to put forwards the evidence as to why a line of reasoning is valid.

Next its well known in the research community around heart valves that age is the primary indicator for choice - meaning as you age a tissue prosthesis is less likely to fail before you do

View attachment 888491
So at around the age you are at there is quite an overlap of which is clearly more well suited to the role. Clearly at a younger age (say between 25 and 50) a mechanical valve will be the only choice that enables you to minimise surgeries.

People often don't think past 10 years but only think in points about pre and short term post surgery. This is something I've seen here many times, and that people think that a one or even 5 year "valvaversary" is a big thing indicates that is perhaps true. As you know I've had greater than 20 years between my surgeries and come to expect that. So many of the points that long term mechanical valvers (like Dick or Superman or I) bring up relate to those questions.

Lastly (and it should be obvious but often isn't) we do not have any cure for valvular heart disease, we instead exchange valvular heart disease for "prosthetic valve disease". One is managed surgically by monitoring and reoperation (as a certainty from the start) and nothing can be done to change that. The other is managed by the valve recipient and his immediate medical team to ensure their AntiCoagulation Therapy is well managed. Generally speaking no other intervention will be required.

It really does come down to just the above in the majority of circumstances.

An anecdote: people here often worry about managing their INR, bringing up what if after what if. So one of the people I assisted managing their INR had had cancer which required extensive chemo. When she was in remission with no statistical likelihood of return of the cancer she told me her doctors said to her it was a good thing she had a mechanical valve because the chemo would have destroyed her tissue and she'd be facing another re-operation. Nobody wants cancer and as icing on the cake another OHS to top it off.

So ... just an anecdote, because cancer is rare.




it is exactly all good :)

Best Wishes
FIRST I would say, to me this happened, and now that I know more, i should have, back then, been given much more detailed data and info, about what i was about to go thru.
I will try to make this short, but it may not be possible,
My heart doctor down here in South Florida informed me that I would need to have surgery after my mitral valve started to go down hill, and fast at that point/1998 or so. He had worked and was close to a Dr. Cosgrove in Cleveland OH. And at that time almost nothing was brought to my attention, cept that I needed to repair my mitral valve, and nothing about an animal or mech heart valve replacement, NOTHING AT ALL, and I think now that, that was a disservice to me at every level! but that is the past, so in 2012 or so my MITRAL VALVE again began to get bad, not as bad but my heart started to enlarge, and get weaker, so in 2015/JUNE, I became the proud owner of a SAINT JUDE MITRAL VALVE, but again i wasnt given the REAL CHOICE of which valve that I wanted.....so before i knew what was going on this happened! I never was given the chance to meet with my doctor before the day of the surgery, nor even on that day of the surgery! I was in contact with the doctor/office at that time/2015 and they all knew that I "THOUGHT" that I had decided to go with the on-X i think it is called, and NOT the saint jude! what i didnt know at that time, my heart doc/surgeon was doing only the SAINT JUDE for some reason, and today I still do not know......so that is what i have now till my life comes to an end!
I instructed my wife also on the DAY of the surgery to anyone that would listen, that I decided on the ON-X, ya sure, that helped like zero amount, and after the surgery the doctor/surgeon would not even meet with me to discus what and why what happened, happened. I had one appointment in his office, post surgery, and it was with the head nurse????i think??? it sure wasnt the DOCTOR!
SO?? You may ask, am I past the anger and confusion as to why this all happened, and twice it seemed, that I didnt really get nor have the chance for a real and informed chance to decide on my OWN what I wanted, and when I wanted it, NO, will i ever get past that, who knows, is it happening to any others? YES, i think it is and I am here now with what happened to me in my attempt to inform others of the chance of this happening to them, or loved ones!
I now own my MACHINE, and HOME TEST, and it is awesome, i say do whatever you need to do, and start home testing, PLEASE!!! With what i now know this is the way to go and along with anything else or how ever your testing, FOR ME it is, home testing/VA hosp, I AM USAF, and instead of the small amount of $500 for the NEW machine, i now know and feel if that same machine would have cost me twice that, $1000 it would have been worth it, and it also by now would have more then paid for itself by now, i been testing now for almost 2-3years or so.......IT IS AWESOME. is it easy, not much if anything is easy if it is that important but i will say this.....AND i dont say this lightly...>>>>>>>>if i can figure it out and do it, ANYONE CAN!
USING MACHINE>>>place strip into machine, wait for the number of strip to come up, mine is 483 right now/push left button and wait until machine warms up strip for testing/when it shows the countdown [about 160 seconds or so], prick finger for blood, place blood onto strip and hold finger to strip until it shows that it got the blood/wait for results! {{{today my INR was 3.0.....YAAAAAAAA!!!!!! range is 2.5-3.5}}}
my best wishes for all, and i do mean everyone, we can do this, if i can......anyone can!!!
 
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Superman

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Interesting info and thanks for sharing. I seem to recall some years ago St Jude had a recall on a certain set of their valves as well. This is the kind of info that makes this forum a valued resource.

St Jude started using a silizone (elemental silver) coating on the sewing ring in the late 1990’s on certain mechanical valves. There was increased paravalvular leakage in those valves.

I wasn’t here when that happened so I don’t know if any forum members were affected by the recall.
 

AZATADINE

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Interesting info and thanks for sharing. I seem to recall some years ago St Jude had a recall on a certain set of their valves as well. This is the kind of info that makes this forum a valued resource.

St Jude started using a silizone (elemental silver) coating on the sewing ring in the late 1990’s on certain mechanical valves. There was increased paravalvular leakage in those valves.

I wasn’t here when that happened so I don’t know if any forum members were affected by the recall.

Aha! That must be what my surgeon was referring to when I was pushing for Inspiris Resilia! He thinks the Inspiris Resiilia may well turn out to be a great choice for people in the future BUT he wasn't comfortable using it on me at 52 as there's not enough data yet. He mentioned that exact example that you've referenced there I think. He mentioned silver coating on the ring and that, if I recall correctly, the tissue didn't form correctly around the ring leading to serious issues obviously. This was his reasoning for using the Magna Ease which has years and years of safety data.
 

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