What ever decision you make, I think the best thing is listen to your gut. This isn't something you want to second guessing yourself afterwards if you didn't feel it was the right choice for YOU going into surgery. Knowledge is good, just make sure it is what YOU want and not what some online stranger thinks you should get, even if they mean well
Valve selection
- Thread starter dsaf2001
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What ever decision you make, I think the best thing is listen to your gut. This isn't something you want to second guessing yourself afterwards if you didn't feel it was the right choice for YOU going into surgery. Knowledge is good, just make sure it is what YOU want and not what some online stranger thinks you should get, even if they mean well
Superman
Well-known member
My first procedure at 17 was mechanical all the way. My second at 36, my surgeon was an advocate of tissue. My guess is because that is what he installs most of the time. He put a tissue valve in the 38 year old husband of one of my co-workers.
Just to be clear, my second surgery had nothing to do with the effectiveness of my first valve. Were it not for an ascending aortic aneurysm - I'd still have my first valve.
I still went mechanical. After going through open heart surgery twice - anything I can do to minimize the likelyhood of a repeat is my best option. I've lived on warfarin longer than I lived without it (over 21 years on warfarin now). It has not been an issue at all. Post op it does take some time to regulate and find a dose that works for you. What people need to remember is that your body has been through so much, it takes a long time get back to the way you felt pre-op. It probably took a good six months to a year to get back to my presurgery dosing. I was on the same dose forever, however post op it just seemed like it was all over the place. It was getting frusterating but now it's back like clockwork and exactly at my same dose as before my second operation. That's in reference to the experience of Jkm7, who indicated that after three months, he knew ATC wouldn't be right for him. Not discounting that individuals experience, but just offering hope that if it seems difficult after a couple months - it could just be your body still going through recovery.
The cynic in me says surgeons tend to push tissue because they make money in re-ops. Keeps the pipe line going. But that is a pretty cynical view.
Just to be clear, my second surgery had nothing to do with the effectiveness of my first valve. Were it not for an ascending aortic aneurysm - I'd still have my first valve.
I still went mechanical. After going through open heart surgery twice - anything I can do to minimize the likelyhood of a repeat is my best option. I've lived on warfarin longer than I lived without it (over 21 years on warfarin now). It has not been an issue at all. Post op it does take some time to regulate and find a dose that works for you. What people need to remember is that your body has been through so much, it takes a long time get back to the way you felt pre-op. It probably took a good six months to a year to get back to my presurgery dosing. I was on the same dose forever, however post op it just seemed like it was all over the place. It was getting frusterating but now it's back like clockwork and exactly at my same dose as before my second operation. That's in reference to the experience of Jkm7, who indicated that after three months, he knew ATC wouldn't be right for him. Not discounting that individuals experience, but just offering hope that if it seems difficult after a couple months - it could just be your body still going through recovery.
The cynic in me says surgeons tend to push tissue because they make money in re-ops. Keeps the pipe line going. But that is a pretty cynical view.
Not sure these surgeons are in it for the money as the hours and care they give transcends the money rewards the two surgeons I meet where driven by saving and helping people. The one surgeon is my neighbor and I know his wife and kids who are my kids age. The first time I meet the doctor was after living 3 house down from him was eight years after he operated on my dad. His friends and family call him the friendly ghost as he is never home
That dedication is unheard of. So I don't think they look at the dollars
I
That dedication is unheard of. So I don't think they look at the dollars
I
I tend to agree with you, especially Heart surgeons who give up pretty much their 20s and 30s training to save peoples lives, while others in their age group are already making money growing their families. Then of course the best centers and busiest sugeons hardly have enough time to operate on everyone that needs surgery right now, which is why the waiting list can be so long. Not to mention valve surgeries are such a small part of their workload, I think for most heart surgeons, it is more than a little insulting to suggest they care more about what another 5 thousand dollars? in 15-20 years for a REDO than what is best in their opinion for their patients..
There ARE risks to coumadin, especially as you get older or have other comorbidities, many people do fine and the first problem is life altering, if they survive. Then of course there are the other effects to the body from taking Vitamen k antagonist.
IF anyone thinks that about their surgeon they should look for a new one.
agree with lyn on this, dont be swayed to much by a stranger on here however well meant it may be, go with your gut and the cardio and surgeons opinions after all they are the experts and see thousands of cases ,respect peoples opinions but thats all there are,it can be a hard choice tissue means re op, which most people do fine with,or anti goacs and the possible problems with it,but again most people do ok,good luck with what you pick and you will be just fine and dandy
Jkm7
Well-known member
I think you have over simplified my Coumadin ACT experience but that's okay.
By the way, I'm a she not a he.
Here's a couple of reports on the Tissue vs Mechanical and Coumadin/Warfarin issues:
http://www.onxlti.com/2011/08/clinical-update-thirty-six/
http://www.onxlti.com/2011/12/clinical-update-38/
Interesting reading
http://www.onxlti.com/2011/08/clinical-update-thirty-six/
http://www.onxlti.com/2011/12/clinical-update-38/
Interesting reading
Superman
Well-known member
I did say that was a very cynical view. I should have clarified further that it's not one I've chosen to embrace.
In trying to figure out why a surgeon would lien tissue on a 36 year old (me, in that case) who was extremely comfortable with the mechanical I already had I thought of quite a few ideas in the whirlwind leading up to surgery.
In talking to him further I learned that the majority of his patients were over 60 and as a result the vast majority of his replacements were tissue. I suppose it was what he was most comfortable with.
Jkm7, sorry for coming off that way (and for guessing the wrong gender). Wasn't trying to oversimplify your experience so much as reassure those that may be reading this and struggling to find a decent dose post op that it can take some time. Try not to get too frustrated. I wasn't enjoying my post op dosing mess either - but it did eventually come around.
OP - bottom line on much of this is that there is not wrong answer. You do whatever you're most comfortable with.
In trying to figure out why a surgeon would lien tissue on a 36 year old (me, in that case) who was extremely comfortable with the mechanical I already had I thought of quite a few ideas in the whirlwind leading up to surgery.
In talking to him further I learned that the majority of his patients were over 60 and as a result the vast majority of his replacements were tissue. I suppose it was what he was most comfortable with.
Jkm7, sorry for coming off that way (and for guessing the wrong gender
). Wasn't trying to oversimplify your experience so much as reassure those that may be reading this and struggling to find a decent dose post op that it can take some time. Try not to get too frustrated. I wasn't enjoying my post op dosing mess either - but it did eventually come around.OP - bottom line on much of this is that there is not wrong answer. You do whatever you're most comfortable with.
Jkm7
Well-known member
<snip>
Jkm7, sorry for coming off that way (and for guessing the wrong gender
OP - bottom line on much of this is that there is not wrong answer. You do whatever you're most comfortable with.
No problem.
Bob in Colorado
Well-known member
I've had them both
I've had them both
I had a tissue valve - homograft - at age 48 at the Cleveland Clinic and I was happy with the choice initially for the reasons that others have stated. However there were signs of valve failure within 6 years and a reoperation at 9 years. It was NOT any more fun the second time! I was very active and in good condition and as you know each case is different. The mechanical valve - On X is performing very nicely now two years later and I actually feel better than I did after the tissue valve surgery. I can hear it in a quiet room. Warfarin is easy to manage and it is worth noting that some people (including a friend of mine) have tissue valves and still must take warfarin as quite a few people do in their older age.
As others have said so well, this is your choice and there is no bad one. I do know that for me I wish I had chosen a mechanical valve the first time. Reoperations are not just a matter of the surgery and recover again, they are generally more complicated and can be highly technical.
I wish you the best. It sounds like you are comfortable with your decision and that is the best way of going into this. Best to you.
Bob
I've had them both
I had a tissue valve - homograft - at age 48 at the Cleveland Clinic and I was happy with the choice initially for the reasons that others have stated. However there were signs of valve failure within 6 years and a reoperation at 9 years. It was NOT any more fun the second time! I was very active and in good condition and as you know each case is different. The mechanical valve - On X is performing very nicely now two years later and I actually feel better than I did after the tissue valve surgery. I can hear it in a quiet room. Warfarin is easy to manage and it is worth noting that some people (including a friend of mine) have tissue valves and still must take warfarin as quite a few people do in their older age.
As others have said so well, this is your choice and there is no bad one. I do know that for me I wish I had chosen a mechanical valve the first time. Reoperations are not just a matter of the surgery and recover again, they are generally more complicated and can be highly technical.
I wish you the best. It sounds like you are comfortable with your decision and that is the best way of going into this. Best to you.
Bob
Waiting is tough because for nearly all of us this procedure is a trip into the great unknown. But everything I learned about it by reading, seeing other's experiences, and having it done told me that this is an overwhelmingly successful procedure, and considering what happens to your body during it, it has for most people a surprisingly benign recovery phase. So, all I can do is tell you not to worry and focus your attention elsewhere. You say your surgeon and cardiologist STRONGLY favor tissue and you have faith in them and trust their judgment. That trust is very important. I wouldn't want to question that. My surgeon had a strong preference too, and ultimately I went along with it, but I didn't decide that until 8PM the night before the surgery. And a lot of my decision was about faith in him. Actually that struggle kept my mind off worrying about what was about to happen. I was very calm going into the OR, but the fact that the pre-op prep guy was a truly gifted conversationalist helped that a lot. I don't remember even a bit of the OR (most don't) and before I knew what hit me, I was awake in the ICU feeling nothing worse than an extremely dry mouth. That was over 2 years ago. Soon enough you will be writing a message like this to another AVR newbie.
JeffF
Well-known member
This was by far the hardest decision for me. I naturally leaned toward tissue valve (not wanting to be on an ACT regimen), but at age 32 the idea of having multiple re-ops didn't really appeal either. My surgeon at Johns Hopkins recommended a mechanical valve, but I still wanted another opinion. So I decided to drive up to Cleveland Clinic to see what they would recommend. The surgeon I met with at CC would not give a recommendation one way or the other. He told me the pros and cons of both (which was frustrating since I drove 7 hours to hear something I already knew). In our conversation he did say if I was at the Mayo Clinic they would almost always put in a mechanical valve unless I kicked and screamed.
The Top 3 Heart Hospitals in the country they would recommend :#1 CC non committal, #2 Mayo Clinic Mechanical, #3 Johns Hopkins Mechanical. So thats how I made my decision, but any choice you make will be better than what you currently have.
So on December 16th I received my On-X valve from Dr. John Conte @ Johns Hopkins. The recovery has been so much better than I had ever imagined. The Warafin has not really been an issue, I am still playing with the dosage, but my INR is in range.
Good Luck with your surgery and valve choice, it will all be fine.
Jeff
The Top 3 Heart Hospitals in the country they would recommend :#1 CC non committal, #2 Mayo Clinic Mechanical, #3 Johns Hopkins Mechanical. So thats how I made my decision, but any choice you make will be better than what you currently have.
So on December 16th I received my On-X valve from Dr. John Conte @ Johns Hopkins. The recovery has been so much better than I had ever imagined. The Warafin has not really been an issue, I am still playing with the dosage, but my INR is in range.
Good Luck with your surgery and valve choice, it will all be fine.
Jeff
2003miata
Member
I had AVR in early November and at age 59, I chose a mechanical valve over a tissue valve primarily because I did not want to face OHS in my seventies. I don't have enough experience with warfarin yet to have a well informed opinion, but so far, it hasn't been an issue.
Last week, when discussing my decision to get a mechanical with my primary care physician, he brought up a point I have not seen discussed in any of the threads on valve selection. His view (granted he is not a cardiologist) is that in 10-15 years, I will not be on warfarin. He was pretty adamant that with all the research into anti-coagulation therapy, other drugs (more easily managed) will be available. I don't necessarily have the insight into what he says, but it does make sense to me that there is at least as good a chance that medical science will find an easier to manage replacement for warfarin than they will develop a trans-catheter replacement for a failing tissue valve.
Last week, when discussing my decision to get a mechanical with my primary care physician, he brought up a point I have not seen discussed in any of the threads on valve selection. His view (granted he is not a cardiologist) is that in 10-15 years, I will not be on warfarin. He was pretty adamant that with all the research into anti-coagulation therapy, other drugs (more easily managed) will be available. I don't necessarily have the insight into what he says, but it does make sense to me that there is at least as good a chance that medical science will find an easier to manage replacement for warfarin than they will develop a trans-catheter replacement for a failing tissue valve.
ElectLive
Well-known member
Direct quote of the second key point (which they put in bold) from the first report:
"With the innovative new drugs [Pradaxa, bivalirudin, argatroban, Xarelto, apixaban] on the horizon, it now appears unlikely that mechanical heart valve patients will be maintained with warfarin for more than a few years."
A few years, seriously? Marketing is one thing, blatantly misleading information is quite another. Shame on On-X.
dwhist
Well-known member
Good luck on your surgery. I am sure it will go well.
I thought I would throw my 2 cents in. At 52 and needing a new AVR, my cardioligist wanted mech and my surgeon said pig. Cardiologist said he felt new drugs would be coming on the market and in 3 to 5 years I would be on a safer anti-coagulant. I bike alot and it seemed those who exercise by doing marathones ect were the people getting the mech valves. My dad had a valve replaced 15 years ago when he was 63 and had a mech put in. He has done fine on warifin and I figured I should be fine on it. At 12 weeks I have had no problems getting settled in at the 3.0 to 3.5 INR level they want me at. But I know everybody is different. I have not had any isssues with bleeding and know I will have to be careful when I get riding again. But I figure I have done 40,000 miles on bike in last 15 years with no wipeouts or injuries.
I thought I would throw my 2 cents in. At 52 and needing a new AVR, my cardioligist wanted mech and my surgeon said pig. Cardiologist said he felt new drugs would be coming on the market and in 3 to 5 years I would be on a safer anti-coagulant. I bike alot and it seemed those who exercise by doing marathones ect were the people getting the mech valves. My dad had a valve replaced 15 years ago when he was 63 and had a mech put in. He has done fine on warifin and I figured I should be fine on it. At 12 weeks I have had no problems getting settled in at the 3.0 to 3.5 INR level they want me at. But I know everybody is different. I have not had any isssues with bleeding and know I will have to be careful when I get riding again. But I figure I have done 40,000 miles on bike in last 15 years with no wipeouts or injuries.
bradvo
Well-known member
My surgeon convinced me to go mechanical at my age , said he had patients as early as 6 years back in after tissue failure.
Enuff said for me.
Brad
Enuff said for me.
Brad
normofthenorth
Well-known member
All the best for your surgery tomorrow, dsaf!
Despite the explosive and emotional issues and choices involved in this thread, I think it contains an amazing amount of "gold" and embodies a lot of what's best about this VR.org community. If the rest of the world (e.g., the US congress) could discuss and possibly resolve serious and divisive issues as maturely and civilly as this discussion is proceeding, the world would be a WAY better place, IMHO.
One issue that's lying a bit below the surface but "jumped off the screen" at me, is the conflict between two facts: (a) most of us consider this a very personal and values-based decision, properly made by the patient after considering all the angles and conflicting opinions (including those from Internet-based strangers! Some of my best advice has been received, and given, that way! ;-) ), but (b) many of our health professionals (Cardiologists, Heart Surgeons, GPs, etc.) have formed very strong preferences -- some might say biases -- in one direction or another. (In fact, in other threads about valve selection, people have suggested that the patient first choose a valve, then choose a surgeon who's comfortable using it.)
I find that our societies (esp. US & Canada, which I know best) are still pretty confused about how "God-like" a doctor is, and how unquestionably correct a doctor's opinion is. I am very fond of all my present doctors, and have high respect for all of them. They are all gifted and bright and committed professionals. But I wouldn't substitute my reasoned opinion, decision, or informed consent for theirs on a choice like this. Not today, not ever, not on a bet. All humans -- even doctors -- form and defend our opinions through complicated pathways, as much emotional as rational, and psychologists are only starting to understand those pathways. E.g., it's perfectly reasonable for human "confirmation bias" to prompt a surgeon who implants a lot of valve-type "A" to recommend it over valve-type "B", even for patients whose clinical expectations (based on the best evidence) would be better with valve-type "B". It doesn't take an evil person, or a blind one, or a greedy one; just a human one. It's us -- you the patient -- who's going to have to live with the decision, whether things go smoothly or the other way, so I'd say don't defer to anybody. Take it all in, and make the decision that YOU are happy (or at least "less unhappy") with.
One other thing: There are some cardiac surgeons who actually (co-)author scholarly statistical studies on relevant topics, like valve longevity, complications, total post-HVR life expectancy, etc. But most don't, and I bet a lot of them don't even read half of them. It's a big complicated field, these folks are VERY busy (some would even say over-worked), and some of them are even trying to have a personal life, too -- no shame there. Again, that doesn't mean that they're lazy or incompetent, it just means that they're humans. Half of us patients were in the bottom half of our class at school, and half of us are probably in the bottom half at work, too. Don't assume that every doctor was in the top 10% at Med School, 'cause it ain't so. Also like us, they all have strengths and weaknesses. A surgeon can have "beautiful hands" and still not be able to interpret the statistics in a randomized trial. . .
Despite the explosive and emotional issues and choices involved in this thread, I think it contains an amazing amount of "gold" and embodies a lot of what's best about this VR.org community. If the rest of the world (e.g., the US congress) could discuss and possibly resolve serious and divisive issues as maturely and civilly as this discussion is proceeding, the world would be a WAY better place, IMHO.
One issue that's lying a bit below the surface but "jumped off the screen" at me, is the conflict between two facts: (a) most of us consider this a very personal and values-based decision, properly made by the patient after considering all the angles and conflicting opinions (including those from Internet-based strangers! Some of my best advice has been received, and given, that way! ;-) ), but (b) many of our health professionals (Cardiologists, Heart Surgeons, GPs, etc.) have formed very strong preferences -- some might say biases -- in one direction or another. (In fact, in other threads about valve selection, people have suggested that the patient first choose a valve, then choose a surgeon who's comfortable using it.)
I find that our societies (esp. US & Canada, which I know best) are still pretty confused about how "God-like" a doctor is, and how unquestionably correct a doctor's opinion is. I am very fond of all my present doctors, and have high respect for all of them. They are all gifted and bright and committed professionals. But I wouldn't substitute my reasoned opinion, decision, or informed consent for theirs on a choice like this. Not today, not ever, not on a bet. All humans -- even doctors -- form and defend our opinions through complicated pathways, as much emotional as rational, and psychologists are only starting to understand those pathways. E.g., it's perfectly reasonable for human "confirmation bias" to prompt a surgeon who implants a lot of valve-type "A" to recommend it over valve-type "B", even for patients whose clinical expectations (based on the best evidence) would be better with valve-type "B". It doesn't take an evil person, or a blind one, or a greedy one; just a human one. It's us -- you the patient -- who's going to have to live with the decision, whether things go smoothly or the other way, so I'd say don't defer to anybody. Take it all in, and make the decision that YOU are happy (or at least "less unhappy") with.
One other thing: There are some cardiac surgeons who actually (co-)author scholarly statistical studies on relevant topics, like valve longevity, complications, total post-HVR life expectancy, etc. But most don't, and I bet a lot of them don't even read half of them. It's a big complicated field, these folks are VERY busy (some would even say over-worked), and some of them are even trying to have a personal life, too -- no shame there. Again, that doesn't mean that they're lazy or incompetent, it just means that they're humans. Half of us patients were in the bottom half of our class at school, and half of us are probably in the bottom half at work, too. Don't assume that every doctor was in the top 10% at Med School, 'cause it ain't so. Also like us, they all have strengths and weaknesses. A surgeon can have "beautiful hands" and still not be able to interpret the statistics in a randomized trial. . .
