Valve Selection 2

[Lasker]

Hello,
This is my first posting. I'm grateful for this web site and hope you can help.I have severe aortic stenosis and need surgery without delay. The choice of valve is posing a major dilemma that I know is difficult for many.

No one welcomes a second surgery, which would be likely if I live beyond my actuarial life expectancy of 82 years; I am now 67.

But I am having an instinctive reaction to avoid Coumadin. I am hoping to spend my retirement winters in exotic places where laboratory facilities for monitoring won't be optimum.

However, if Exanta is approved in 2004 or 05 for valves, will I regret choosing a biological valve?


If I do go with a biologic valve, does anyone have a reference so that I could compare the Medtronics Hancock mosaic (porcine), chosen by Peter Easton according to his articulate account, to the Carpentier-Edwards Perimount pericardium (bovine), on which some long-term results are being published.

I welcome any help you can offer.

Lorraine Lasker

[hensylee]

Hi Lorraine = guess we will have to say Lasker as we already have a long time member Lorraine.

Welcome to VR - this is the place to be if you need info on valve choice. There will be many notes to you, but not from me as I didn't have a replacement - had quad bypass. But they will be along soon. God bless

[ccrawford]

Hi Lorraine - We have a member who will come along shortly and do her magic to provide you with a whole string of past posts that deal with valve selection. She may be a little busy being a gourmet cook for her husband at the moment, but bear patience and you will be rewarded. In the meantime, I'll start to lay the case for Coumadin not being the monster you may think it is. I happen to be a home tester, and I've read an awful lot about Coumadin and its various interactions with other drugs, herbs, and foods. I've had a few high INRs, a few lengthly nosebleeds, and my share of bruises. None of this, however, is about to slow me down much and I have a pretty active lifestyle. Coming up in November is a planned trip to Mexico for some scuba diving, I'm an active farmer, woodworker, and outdoorsman. Does this sound like Coumadin has created a Casper Milquetoast ? Draw your own conclusion. My only (sometimes) problem with a mechanical valve is that you have to learn to ignore it when you are sleeping - it can be a little more noisy. Hope this helps. Chris

[Nancy]

Hi Lorraine-

Welcome to the site. I guess you've been lurking and finally came out of the shadows, because you have already read one of the longest threads on this site, Peter Easton's "Making the Choice". If you're waded through that, then you know an awful lot already.

Can't help you with your specific valve question, but want to tell you that my husband has been on Coumadin 25 years and it's really not a problem. It's just another medication he has to be on, and although it does require that you get tested frequently, many folks on the site have their own testing machine and some even do their own dosing. If you should consider a mechanical valve, perhaps this is something that would work for you also.

As far as traveling to exotic places, anyone with any chronic illness would have to prepare thoroughly in order to travel like that, especially to countries with medical care which is not modernized. I'm sure you already give a considerable amount of thinking time about the "what ifs" of medical care in distant ports, should you need it.

Others will be along soon to address your valve question.

Hope to see you here often.

Note for Chris crawford--Joe has a sound machine that masks the noise of his valves. He listens to ocean waves each night. It works for him.

[ALCapshaw2]

Welcome Lorraine,

After age 65, the durability of the Bovine Pericardial Valve has been reported at 90% and counting. Some early recipients are approaching 20 years. The Bovine Valve was my first choice but for other reasons, my surgeon installed a St. Jude Mechanical.
While I have not had a lot of problems with Coumadin, it does
'complicate' one's life. There are times I still wish I had received the Bovine Valve I requested.

My recommondation would be to find a surgeon who has a LOT of expericnce with each valve and ask their opinion(s). I know that the Cleveland Clinic has a high regard for the Bovine Valves.

'AL'

[Lasker]

Dear Al, chris, Nancy and Hensylee,

I just realized I have no idea how to answer you, since I don't see a "reply" or "reply all" option as I would on my e-mail, but I'm trying this way.

It's heartening, pun intended, to hear from such responsive people so quickly, to know you are out there.

Chris, do you do self monitoring and dosing when you are in Mexico? How long a time will you spend there? And, no, I don't think people on Coumadin are Casper Milquetoasts; on the contrary, I think you are brave.

It seems to me that these decisions are like Rorchack Tests, and, if we are lucky we are tuned in to our own personalities. My need is for freedom. But, I am not brave; I'm fearful of a second surgery--I haven't had the first yet.

Is anyone in touch with Peter Easton? Perhaps he has some further valve advice; I would love to hear from him.

L.L.

[Lasker]

Dear Al,

Thanks for your bovine pericardium information. It was a paper from the Cleveland Clinic by Banbury et al. that peaked my interest in this valve because, indeed, they had evidence going out to 17 years, with 90% of those still living still having functioning valves.


(I don't know if there is a way I could have responded directly to you by clicking a site directly on your message.)

L.L.

[Lasker]

Dear Nancy,

We experienced the health care system in an emergency in Bali as soon as we arrived. My husband slipped on the wet polished concrete floor and dislocated his shoulder. Fortunately, we had a private car and driver standing by, because we spent half a day going from hospital to hospital before we could locate one with x-ray facilities on a Saturday. And, the murky x-ray was difficult to read. I can't imaging monitoring my prothrombin time there. It is a wonderful place, though, and there must be other wonderful places I haven't experienced yet.

L.L.

[ccrawford]

LL - If you want to send a private message, click on the PM button, otherwise, you're doing just fine. I'll be in Mexico for a week. I normally test once a month, so I feel no need to take my testing equipment with me. If I was having problems, i.e. I was taking a new medication that was causing my INR to fluctuate, then I would most certainly take the equipment with me. Its fairly compact, and the battery holds a charge for more than a month. When I first started Coumadin, I was nervous about all this stuff too, but as you learn more, the comfort level improves. I forgot to mention, there is a web site that lists Coumadin clinics around the world in the event you are not a home tester. I don't remember the address.Hope this helps. Chris

[sylviayasgur]

hi L.L.(lorraine, lasker, whatever...)
where in ny do you live? have you met with surgeons yet? where would you plan on having the surgery done?
i think that there are surgeons who have preferred valves that they use... something to discuss with him/her.
also, if you do a search (at top of page) for "valve selection" you will surely come up with numerous threads that discuss this subject. peter easton's "making the choice" thread is one of the best, however, there have been other great ones as well. have a look.
please let us know how things go.
be well, sylvia

[Lasker]

Dear Sylvia,

I have just become aware that you did not receive my response to you since it’s not posted anywhere. And I was so eager to hear from you because you are in New York.

I live in Westchester and also have an apartment on Roosevelt Is. I had a cath at WCMC in July. I saw Dr. Richard Moggio, head of cardiothoracic surgery, and like him a lot. I didn’t know enough at the time to ask about specific biologic valves, which is my preference after a lot of waffling. Now I would ask if I am a candidate for the Carpentier-Edwards bovine pericardium valve, on which there are some good outcome studies.

Dr. Moggio felt the word was still out on sternum minimal invasive incision. We are trying to get more information on this procedure, but could only get one abstract on the internet, and not the full papers. The group at NYU medical publishes in this area, and Dr. S. Colvin has been recommended by one cardiologist.

Your husband’s doctor was recommended to me by my GYN, as a great surgeon. I tried looking him up on the web but couldn’t find anything, so I was so interested to hear from you. I didn’t do more diligent followup because I heard negative things about nursing care at Beth Israel, but I don’t doubt that CICU would be different from the general hospital.
What was your experience at Beth Israel?

Is your husband’s cardiologist also associated with Beth Israel? I need a new one since mine’s practice relocated to CN, and though this could be independent, I was trying to zero in on a hospital for my surgery.

Risk adjusted mortality rates are posted for bypass, not valve surgery, on the NYS DOH website and I did look up Drs. Moggio, Colvin and Stelzer, as well as others in this area. I also just checked healthgrades for the first time; the only hospitals listed as outstanding in this area re valve replacement mortality are P&S, St. Francis and Vasser Bros.

Did you consider anyone at St Francis or at P&S?

The Ross procedure is more complex than I would have but I’d still like the best surgeon and hospital. Please advise.

Lorraine

[MelissaM]

Hi Lorraine,

Welcome to the site!

Dr. Moggio felt the word was still out on sternum minimal invasive incision

Different doctors seem to have different opinions about this. I had a minimally invasive incision done at the Cleveland Clinic about nine weeks ago, and believe it made a significant difference in my recovery. Having said that, the doctors at CCF do about 80% of their valve surgeries using partial sternotomies and are HIGHLY SKILLED at doing them. Not every surgeon will have the same comfort level in performing what amounts to laproscopic heart surgery. Neither of the surgeons I spoke with here in Colorado were comfortable with the minimally invasive technique. If you can find a surgeon who is comfortable with the procedure, I would HIGHLY recommend it.

Melissa

[Lasker]

Hi Melissa,

OK, I will give MI another go-round, thank you.

In NY, NYU does all their mitral valves by minimal incision. For aortric valves, about 60% of those planning MI actually are effected. The mortality statistics may bear out that this procedure is slightly more risky, but perhaps not at CC.

In my case they will make a decision on the mitral valve at the time of surgery for the aortic valve. Perhaps this has a bearing on whether or not MI is feasible, i.e.,is a wide open chest more desirable when more than one valve may need intervention.

In any case, I certainly can appreciate that healing would be faster with MI and will find out more.

Lorraine

[Lasker]

Hi,

Does anyone have any experience with or good references on the Hancock Mosaic valve.?

I have found a number of references with outcome studies on the C-E Perimount but no long term studies on the Hancock Mosaic. I was growing comfortable with the idea of the C-E Perimount bovine pericardium valve, but I understand that the choice between the two may depend on aortic root size.

While the choice may not be mine, I would appreciate learning as much as possible.

I anticipate avr either the week prior to Thanksgiving, or the second week of December.

Thanks,

Lorraine

[Bob Bates]

Lorraine;

Did you ever come across any good information on the Hancock Medtronics Mosaic valve? Or can you just comment on what, if anything, you may have found out/ your opinion, etc.?

My first choice in a valve is still the CE pericardial bovine valve. I like the durabilty statistics on it. I am thinking about my "backup plan" for a second valve choice however, and the Hancock Mosaic looks pretty good, based upon some limited information I've found so far.

Regards,

Bob Bates
AVR scheduled for 11/3/03

[Lasker]

Dear Bob,

I am disappointed in the lack of publication I could find on the Hancock II Mosaic, including those on the Medtronics website. I did not receive a response from anyone on this forum.

Did you read Peter Easton's thread on valve selection? I believe he was leaning towards the C-E Perimount bovine pericardium valve. However, his surgeon recommended the Hancock II Mosaic. He gives some data by from a paper (I believe the first author is Jamieson) which indicates this valve performed somewhat better than a C-E porcine valve (the SAV in this paper may stand for Swine Aortic Valve), so this comparison is, as I understand it, not with the C-E Perimount bovine pericardium valve. This valve certainly could be considered as a backup--but I am wishing for more data to make it first choice, if there is a choice.

From one early paper, I believe this porcine valve is washed with a calcification retardant, but I could not find additional reports on how this is working out over time.

Since I eventually wanted to speak to my surgeon about this valve because I know it is one of the biologic valves he uses,
I telephone him this afternoon to see what I could learn prior to your surgery. I'm expecting a call back tomorrow and will let you know what I learn.

All things being equal, I would still go with the C-E bovine pericardium valve.

Lorraine

[Nancy]

Hi Lorraine-

Maybe you already tried Google for a search, but when I used the term, "Medtronic Mosaic" I got 144 hits. I left out the other words and got much more info.

Hope this helps.

[Lasker]

Thanks Nancy,

Your suggestion worked, and I have been reading until my eyelids are drooping, about the Medtronic Mosaic, which actually is a third generation porcine valve.

Bob,

Because this valve was only approved in 2000, there isn't clinical data on long term outcome, but the early hemodynamic information is promising (best as I could appreciate, it seemed approx equal to the C-E Perimount in hemodynamic performance. )This valve is washed in alpha amino oleic acid (found in olive oil) to prevent calcification. It is supposed to incorporate improvements based on I and II. The goal is 25 years' durability, but that's only a goal. Trials to compare this valve to the C-E Perimount are in progress, but the results are a long way down the road, of course. This is my summary of what I've read.

I'll let you know if I learn anything further,

Lorraine

[Bob Bates]

Lorraine;

Thanks for the info. I intend to do my own research, and I've only got a few days before my surgery (11/3/03). So the die will be cast pretty soon.

But if you do have any more thoughts in the next day or two about the choice between the CE Perimount Bovine, and the Metronic Mosaic valves, I'd love to hear what you have to say!

Regards,

Bob Bates

[Lasker]

Dear Bob,

OK, I just finished talking to my surgeon. Dr. Richard Moggio is chief of cardiac and thoracic surgery at the Westchester Medical Center. I will have my aortic valve replaced, and possible bypass surgery, in December; I am waiting to hear again on the exact date.

Because of your November 3 surgery, I hastened to the computer. The bottom line in my discussion on the valve selection is this: Dr. Moggio uses the C-E Perimount and the Medtronic Mosaic as his two biologic valves of choice currently. The first consideration is valve placement vis-a-vis aortic root size. For a somewhat smaller size, is choice would be the C-E Perimount; for a larger size the Medtronics Mosaic. All things being equal, he stated it was a toss-up, but I detected a slight preference for the MM, now a third generation valve. He said there was no reason to believe the new washed valves would be worse than prior valves; they might be better, but it is too soon for data, as we know.

Though I am very comfortable with the C-E data, I am also comfortable now with going along with the surgeon's choice, and I will not be surprised to wake up with the Medtronics valve.

Hope this helps. Let's hear from you after. Best of luck,

Lorraine

[Bob Bates]

Dear Lorraine;

Thanks for the speedy reply. In my research today I came across something about the Medtronic Mosaic which gave me pause. It was not dated, so it could be very old data.

It was on :www.mdiconsultants.com/section_NI/FDA_Recalls/recallarchiev6.htm

It referenced a product recall for the Medronic Mosaic Porcine Bioprosthesis, for Aortic Valves, model numbers 30519,30521,30523,30535,30527. recall #Z-867/868-0.

Reason: " A misinterpretation in measurement of coaptation depth by a technician resulted in the release of out of specification devices."

I am guessing this issue has long been resolved, but its the first I heard about this, and thought it worth passing on.

Regards,

Bob

[Granbonny]

I think I am one of only a handful of women valvers in their 60's..I am age 63..I had my Valve replaced at age 61 due to an aneurysm.........Lucky me they found it...:) My surgeon told me (laying on bed after Cath. of heart) that he would be putting in a mech. valve....that at my age...he would not want to see me go through another open-heart surgery....Yes, I am on coumadin...I think Chris has covered all the home-testing (Protime)..which I have. My INR IS always in range.:) ..I travel, eat most anything, take care of an age 11 year old and half his friends.:D :D (Grandson)...And the Surgeon was correct. I would never want to go through another surgery. I did great..just that it takes a year..to get back to where you were..before Vr. surgery....I am so lucky that I had a great hubby ( 37 years) that watched after me..Driving, cooking, housework, ect...and..yes, these are things you will not feel like doing for a long time. There will be many doctor appointments to go to..after surgery..plus driving to drugstore, ect....... I am so glad that I have a mech. valve...NO surgery to dread in the future. Just take a pill a day...:) Also, at our age..I'm sure your doctors will want to see you every 6 months...(Even with a tissue).....I am happy that in 15 years..I will not be a burden to my family again...and I plan to live way beyond age 82..:D :D ..If you live in New York and planning surgery in the winter..be sure and have an inside place you can go for walking...Malls, ect. Will need that for several months. And watch the icy sidewalks.:eek: Am lucky I live in the South..and had VR. in March..Was able to walk my streets, ect. in warm weather.Takes a good 3 months..to get back into light exercise, ect....Good Luck..Bonnie

[EVELYN]

Hi Lorraine

Welcome to another New Yawker!!! We're from Long Island (east end) and my husband, Tyce, had an AVR at St. Francis in June 2002. His surgeon was Dr. James Taylor and we couldn't have been happier with him. We were also extremely pleased with the hospital....well run, clean, unbelievably efficient....can't say enough good things about them. If you're interested, I'd be happy to tell you more, just send me a pm......I can tell you, though, that Dr. Taylor was recommended to us by a very dear friend who does medical mal practice for self insured hospitals....needless to say, she knows who NOT to go to. Her opinion on his group was "absolutely outstanding!"

Welcome aboard!!!

Evelyn

[Lasker]

Dear Bob,

I looked at the mdiconsultants website that you noted; there are hundreds of recalls for all kinds of medical devices from many companies. Medtronics is a very large company that makes many devices, and I do not know of a reason to think they have a worse safety record than other companies. It is scary to read that a technician mismeasured something so important, but compliance in devicemanufacture and in drug development is a very difficult subject and fraught with problems. I have some experience in the research compliance field. What I read would not make me uncomfortable about choice of their valve.

Lorraine

[Lasker]

Dear Bonnie,

It's good to hear from another person who is more than 50. Most of those on this forum are so young, even though it's the over 60 group who are having most of the valve replacements. Probably a function of who is using the computer to communicate.

I waffled for a bit over the type of valve, but do seem to have an extreme need for freedom, even though I do not do the type of sports or motorbiking that some have written about. And, as others have noted, there is a change in calcium metabolism as one ages that favors durability of the animal valve. I have also looked at the statistics on reoperation in making my decision. While riskier than the first surgery, most people by far survive and do well afterwards, even though advanced age, characteristic of this group, is an independent risk factor. I am comfortable with my decision to select a biologic valve.

I am wondering though, why more of the younger people are not considering the Ross procedure, which is what I probably would have opted for at their age.

I am seeking the best way to take your advice on walking. Last winter was brutal here, and icy driveways frighten me. I've already asked my surgeon if he thought I could fly somewher warmer; of course he couldn't say anything definite until after surgery when he sees how I am doing, but I'm encouraged that he didn't rule it out. It doesn't have to be swimming weather, just a temperate place with good places to walk and some things to see. Any ideas for an extended stay in February?

Best,

Lorraine