Why did my doc say that he would choose a tissue valve for me?

[Eva]

You're not alone, dorlone!

It took me a very long time until taking my warfarin pill became a structured routine and got somehow over my anxiety about not forgetting. I recently changed insurance, and I had a big anxiety as there was an issue with the delivery of my pills. Luckily, I had stocked on some before switching to Medicare!
At start, I bought special alarms for my warfarin bottle, yet, there were a couple of times I forgot to take the pill on time! I still wish sometimes I didn't have to take it, though I'm managing my INR very well on my own...pulling a tooth, putting an implant, other minor surgery were a bit tough on me to lower my INR to lowest range, though I was successful!

 

[jjhdc1]

I had an AVR this past June due to endocarditis. I had a BAV and knew some day I would need a valve. I had already done my research over the past several years and chose a tissue valve without hesitation when given the choice (48yo). I was told by the hospitalist cardiologist that I would likely be a 2 valve candidate regardless of valve choice, and being a very active outdoor person I wanted to avoid the thinners. My surgeon agreed and told me they are doing TAVR frequently and that I would be a good candidate for a TAVR when needed.

 

[pellicle]

Hi

No worries, Pellicle, I'm not offended at all.

thats good

I'm not convinced that intelligence is the core issue with self-management vs. personality type and coping skills, but whether a patient can self-manage is definitely a critical call for the doc, and for us as patients, which I feel a bit nervous about looking at this decision as I AM scatterbrained.

I'd agree with that assessment ... sometimes words are unclear, and when I call someone smart I'm not only referring to their IQ, but to their ability to be smart in actions. I work with people who have very high IQ's and in specific areas are far more capable than me ... yet they do dumb things all the time. I do too.

Its hard to express easily but you meet people who didn't finish school but at 40 aren't in debt and have decent stuff by working and being careful ... that's smart.

It took me a few months to get sorted out and change my lifestyle to create systems to remind myself. Phone's weren't always on, I wasn't always at home ... I needed to develop ways that would cause me to "trip over" the fact I'd missed a pill. In the main its worked well. On the road I've learned not only the truism that "missing a pill doesn't matter" but also exactly why it doesn't matter if you miss a pill here or there. I've tried to help others who were panicked (as I was at first) when they miss a pill to understand why its not a problem rather than just telling people it doesn't matter (some folks do need to know why).

Just saying that the capacity for medical dumbness lies in us all and "I can't be bothered to take a pill" is probably the least likely explanation behind forgetfulness, anxiety, stress, co-managing a lot of conditions, or just not being the sharpest tool in the shed through no fault of your own.

it could well be ... but if that causes you to have strokes then one can see a reason why a surgeon would steer them towards a tissue valve.

Myself I really don't know what I would have picked if I was 35 and just found out about stuff for the first time. I came to have a mechanical as an evolutionary process of having previous surgeries which were not a mechanical valve (repair and replacement with homograft). So as a result I have direct experience with not only the surgeries but the consequences.

I only offer my own experiences to others because there is more to making the decision than just reading data, there is actual experience. I've had 40 years of it, so I've had time to think and understand this stuff over a long run. A run where it went in and out of my mind many times (for years at a time).

My only goal is to assist people to know more of the truth than just one side and I try to be unbiased in my views. I try my best to dispel myths (aka total bullshit) and offer people a view outside the box.

I recognise that not everyone is even capable of making an informed decision and just want to be told. I can't help them.

Lastly I try to help people who wish to manage their AC therapy better (me being a Mecker) as I see that as a way to actually provide people with a benefit in their lives. I come here for free and put up with slanging and bullshit (not from you I might add) ... because I know I've helped a few and to me that's a worthy swap.

 

[Agian]

I would likely be a 2 valve candidate regardless of valve choice...

Why did he think that? Just curious.

 

[Protimenow]

Remaining off topic a bit, there a all kinds of noncompliance issues. It's not just about forgetting to take your daily dose of warfarin, or taking the right amount on the right day. Personally, I don't think I've had a problem taking my warfarin for the 25 years post-op. I may have missed a few doses, but certainly not many.

This brings me to a different issue....

I didn't do testing. I didn't have good (any?) medical coverage, and frequently spent a LONG TIME between doctor visits during the first 19 years post-op. A few cardiologists over those years told me how important it was to get blood draws every two weeks, or every month, but I didn't take them all that seriously. Fortunately, I was good about taking the warfarin, and somehow, I was always able to get a good supply.

There was even a nearly three year period when I was taking warfarin, but not testing. I know now how damned lucky I was that I didn't kill myself. There was a time when I had a 'growth' on my face. Something told me not to try a 'wart' remover on it - because it was on my face. I was actually PROUD of being able to go for so long without testing. It was a stupid sign or 'courage' or something. It could have killed me.

Once I learned that there were meters for testing, and blood draws (more expensive than machine testing), I finally figured a way to get a meter. I had a physician friend order the strips for me (apparently, this company wouldn't sell them without a prescription). With the help of this forum (and dosing calculators), I was able to get my INR into range. When I was back in range, my facial 'wart' disappeared -- I'm thinking that it was probably a clot, and may have stopped the clot from going into my brain. As I said earlier - I WAS DAMNED LUCKY.

This is one of the reasons that I got onto this forum -- I don't want anyone who needs warfarin to go without testing. I'd like to preach the gospel of weekly testing, and I'd like to see all those who are ABLE to self-test, to actually self-test. For those who can't self-test, or can't afford meters and supplies, ideally, a clinic, church, temple, or whatever, can offer free tests, with results called or mailed to a specialist who can evaluate INR, dosing, and make recommendations when necessary.

When I had my mechanical valve implanted, 25 years ago, at age 41, there was little choice other than mechanical. However, if my surgeon had been able to see clearly into the future, and saw that I would go long periods between tests, he may have thought more closely about a tissue valve. (Dead in ten might have been a better choice than a stroke in fifteen).

 

[neil]

good and honest post,

 

[jjhdc1]

Why did he think that? Just curious.

He said based on his 20 plus years and my age I would likely be a 2 valve candidate. I was going tissue valve regardless, I had decided that long before I actually had to choose. My surgeon telling me my next one will be a TAVR was bonus.

 

[Heartsong]

The doctor got back to me and it turned out that I did not understand exactly the point I was making. He said he was recommending a tissue valve only if I wanted more children, do certain sports, or don't want to be on blood-thinners. So that makes it mechanical for me. How did you go about choosing which mechanical or does the surgeon decide that?

 

[almost_hectic]

The doctor got back to me and it turned out that I did not understand exactly the point I was making. He said he was recommending a tissue valve only if I wanted more children, do certain sports, or don't want to be on blood-thinners. So that makes it mechanical for me. How did you go about choosing which mechanical or does the surgeon decide that?

Not positive but i think thats largely based on the surgeons experience or comfort level with different mechanical valves. If the choice is entirely yours, the OnX valves seems to be currently the most advanced. They are the only one FDA approved to require the lowest dose of coumadin with INR (how your coumadin levels are measured) ranges from 1.5 to 2.0 where most mechanical valves have INR range from 2.0 to 3.0 or even higher. Less blood-thinners would mean fewer potential problems from anti-coagulation. I wanted the OnX valve prior to meeting my surgeon, thankfully that was also his choice and recommendation for me.

 

[Protimenow]

The lower INR requirement for On-X valves is a great marketing point for them, but in practical terms, may actually be somewhat more dangerous than just marketing it as a good valve that MAY require a lower INR than others. The reasons for this have been pointed out by Pellicle and others in other threads, so I won't repeat much of it.

There's not much (if any) lifestyle difference between maintaining an INR close to 1.5 than there is with maintaining an INR closer to 2.5. If you shoot for an INR close to 1.5, there's a fair risk of having an INR somewhere below 1.5. Although the On-X is approved for INR of 1.5, there's no statement about the risk incurred if your INR is below 1.5. The On-X wasn't available 25 years ago when I had my St. Jude implanted into my chest. If it was, I'd still want to keep an INR (with that valve) around 2.0. The INR fluctuates in everyone - I just found this recently during my own testing, when my INR dropped from 2.8 to 1.4, without much apparent cause.

Given that INRs are not always stable, for a person with an On-X and an INR of 1.5 - this can possibly drop closer to 1.0 - and this could be dangerous. With an On-X, I'd shoot for 2.0, and maybe higher, just to be safe. Living with an INR of 2.0 doesn't take adjustment of routines - you may bruise slightly more than pre-surgery, but it wasn't much of an issue for me except when a 50 pound block of marble was dropped onto my foot.

If I had it to do over again, given my experience on warfarin, and what I've learned about anticoagulation over the years, I wouldn't let a slightly lower 'safe' INR be the deciding factor in choice of a valve.

(In my surgery, there was little choice NOT to go mechanical. I trusted my surgeon to decide, during surgery, which valve to use. This is probably still the case for most surgical teams).

 

[almost_hectic]

The lower INR requirement for On-X valves is a great marketing point for them, but in practical terms, may actually be somewhat more dangerous than just marketing it as a good valve that MAY require a lower INR than others. The reasons for this have been pointed out by Pellicle and others in other threads, so I won't repeat much of it.

There's not much (if any) lifestyle difference between maintaining an INR close to 1.5 than there is with maintaining an INR closer to 2.5. If you shoot for an INR close to 1.5, there's a fair risk of having an INR somewhere below 1.5. Although the On-X is approved for INR of 1.5, there's no statement about the risk incurred if your INR is below 1.5. The On-X wasn't available 25 years ago when I had my St. Jude implanted into my chest. If it was, I'd still want to keep an INR (with that valve) around 2.0. The INR fluctuates in everyone - I just found this recently during my own testing, when my INR dropped from 2.8 to 1.4, without much apparent cause.

Given that INRs are not always stable, for a person with an On-X and an INR of 1.5 - this can possibly drop closer to 1.0 - and this could be dangerous. With an On-X, I'd shoot for 2.0, and maybe higher, just to be safe. Living with an INR of 2.0 doesn't take adjustment of routines - you may bruise slightly more than pre-surgery, but it wasn't much of an issue for me except when a 50 pound block of marble was dropped onto my foot.

If I had it to do over again, given my experience on warfarin, and what I've learned about anticoagulation over the years, I wouldn't let a slightly lower 'safe' INR be the deciding factor in choice of a valve.

(In my surgery, there was little choice NOT to go mechanical. I trusted my surgeon to decide, during surgery, which valve to use. This is probably still the case for most surgical teams).

Well of course. Why would anyone body aim for a 1.5 level, that would be foolish? I aim for 2.0 and sometimes I'm a 1.7 other time 2.1 and it's all good either way. I'm no medical researcher like some on here like to be, just stating that to me the OnX appears to be the most advanced design. Lower INR levels being a benefit of that. I hadn't mentioned all the other design advantages unique to OnX like the longer design to prevent pannus ingrowth and the pivot design for improved flow dynamics. I'm not here to sell, I think everyone should do some of their own research. Just offering my two cents. I wouldn't choose less tech in this situation.

 

[JulienDu]

...............

 

[JulienDu]

and being a very active outdoor person I wanted to avoid the thinners. My surgeon agreed and told me they are doing TAVR frequently and that I would be a good candidate for a TAVR when needed.

My whole life is outdoor wether for work, fishing, hunting or hobby and I have a Mec valve now around 6 months post op. Just spent 4 weeks in a remote place in the arctic, fixing hunting camp, packing moose, shooting waterfowl birds and boating in the freezing fall arctic on the mighty mackenzie and building log raft. I am not a picture guy but when I was still trying to make a choice as to what valve to chose, I enjoyed seeing pictures from other valvers. Don't see how a Mec valve limit me though I am not yet back to 100 percent of my shape.

 

[Protimenow]

Well of course. Why would anyone body aim for a 1.5 level, that would be foolish? I aim for 2.0 and sometimes I'm a 1.7 other time 2.1 and it's all good either way. I'm no medical researcher like some on here like to be, just stating that to me the OnX appears to be the most advanced design. Lower INR levels being a benefit of that. I hadn't mentioned all the other design advantages unique to OnX like the longer design to prevent pannus ingrowth and the pivot design for improved flow dynamics. I'm not here to sell, I think everyone should do some of their own research. Just offering my two cents. I wouldn't choose less tech in this situation.

It's 'of course' to you, but I would be surprised if there aren't others (and even medical professionals) who AIM for 1.5, rather than looking it as a slightly better margin of error, if you consider 2-2.5 or 2-3 as being the desired range.

 

[Mahoskic]

I am reading all of these replies and still have not decided tissue or mechanical and my surgery is tomorrow morning. I was really siding with mechanical ON-X but now have concerns over future procedures that may have complications due to blood thinners. But I don't want to go through this in 12 or 15 years from now, although technology may be more advanced and a TVAR over a tissue valve may be an option for another 10 to 15 years.
At 58 I would be 70 when the next swap will happen and what will my health be and where will healthcare in the US be.

 

[Protimenow]

I appreciate your concern about warfarin and the whole anticoagulation thing. I've had to stop taking warfarin a few days before some minor diagnostic procedures (or even dental extractions), and had to bridge a few times. It's not much fun, but it's not that terrible, either.

If you get an On-X valve, you'll probably have it for the rest of your life. For many procedures, you're supposed to be safe to have the procedure with an INR below 1.5 (for a few days). Your concern about anticoagulation may not be as significant than it is for people like me who have older valves that require higher INRs.

Some medical professionals - and I assume most competent surgeons - know how to quickly bring an INR down (with IV Vitamin K or something similar) in case emergency surgery is required.

Many of us - especially those of us on this forum - are on warfarin, and it hasn't had that big an impact on our lives. Having a mechanical valve usually means that you won't have to get it replaced. This can be said - yet - for tissue valves, although there ARE significant advancements being made with TAVR and other less invasive valve repair techniques.

I won't advise you of what choice to make. Whatever you choose will probably be right for you. For me, at 41 years old, my only realistic choice was a mechanical valve and a lifetime of anticoagulation therapy. Today, if I was older when I had to make the choice between tissue and mechanical, and with the possibility that technology to repair failing tissue valves (or waiting a few years when they may even be able to fix my valve), the decision would probably be much harder to make. It's sort of like choosing between what might be in contrast to what is currently available and already well understood.

Good luck with your surgery. I hope that the choice for you is easy to make.

 

[pellicle]

Hi Maho

...but now have concerns over future procedures that may have complications due to blood thinners.

its a good question. I would say that the answer depends on what future procedures you are talking about (or are you just conjectureing?)

Generally speaking if its just surgical procedures the management is realtively clear cut these days (after many decades of experience):

1. you go off warfarin, which restores normal clotting,
2. you have the procedure
3. at a time after the procedure where things are satisfactory (often 2 or so days) you resume AC therapy. Such resumption may be to give you a fast acting AC agent like Heparin (commonly called Lovenox in the USA) and at the same time resume your warfarin dose. Warfarin slows clotting, but once tissues are mending then coagulation plays no further role

The perhaps more difficult issue is the management of other drugs you may be on. That will "depend" on the drugs you're on.

If you don't have any expectation on being on drugs which will conflict with (make management of warfarin difficult) then it's not a problem. Even still, with modern trends in self testing and the availability of low cost self testing machines (similar to that sort of things diabetics now use) managment of drug interactions can be handled by you

If you can provide a little more informational background I can give a more detailed answer.

Best Wishes

 

[nagyg]

I had an AVR this past June due to endocarditis. I had a BAV and knew some day I would need a valve. I had already done my research over the past several years and chose a tissue valve without hesitation when given the choice (48yo). I was told by the hospitalist cardiologist that I would likely be a 2 valve candidate regardless of valve choice, and being a very active outdoor person I wanted to avoid the thinners. My surgeon agreed and told me they are doing TAVR frequently and that I would be a good candidate for a TAVR when needed.

yours is is very similar to my situation: endocarditis, AVR this june (edwards 3300tfx bovine), but 61 years old. I am also betting on TAVR when I need it replaced. TAVR is not science-fiction, but it is already deployed in hospitals around the world, from what I have read especially in Germany. The surgeon told me that he had put in a large valve ( 27 mm) so the next valve could just be "popped in".

 

[Superman]

Procedures I've had since being on Warfarin for the last 26 years:

Colonoscopy
Broken arm
Broken thumb
Stitches
2nd open heart surgery
Vasectomy
Gall bladder removed
Appendix removed

I suppose broken bones could be a big deal on ACT, but I don't recall it being an issue. Anything invasive, I went off Warfarin until I was below 2.0 INR, bridged with Lovenox, then restarted Warfarin right away.

The only issue I recall, was with the Gallbladder / Appendix (I did a 2 for 1, because we've had a lot of appendicitis in the family and I didn't want it to come up later. The gallbladder had to go.) The Dr. was requiring that I receive donor plasma as part of the procedure. I refused. First I'd heard of it, but he was acting like it was standard operating procedure. Something to do with aiding in clotting before restarting Warfarin. We had a stalemate until about half hour prior to the procedure. Figure I'd put my foot down then, and they couldn't rebook the room. I won. No donated blood products.

I'm sure donated blood products are great in an emergency, but I won't take them voluntarily. I know they are more tested then every, but they can only test for things that they already know about. Have you seen some of the people at the donate plasma for cash clinics?

I'm sure I'll have many more procedures to come. Hoping for another 40 years or more out of this ticker.

 

[Superman]

Such resumption may be to give you a fast acting AC agent like Heparin (commonly called Lovenox in the USA)

My understanding is Heparin and Lovenox are different drugs.

From: http://www.wisegeek.com/what-is-the-difference-between-heparin-and-lovenox.htm

"Lovenox® is derived from heparin. The difference is that it has been altered in such a way that is has a lower molecular weight than heparin. This change in structure allows Lovenox® to last much longer than heparin, as much as 24 hours, making it much more effective in some situations."

Heparin is typically given in a continuous IV drip in the hospital. Lovenox is a once/day injectable administered at home.