Hi everyone,
I'm waiting for aortic valve replacement and decided to go mechanical valve. I'm quite interested in the On-X valve, as it can have a lower INR. My surgeon uses CarboMedics. I found even surgeons' opinions about on-x valves are divided. Some think the difference between mechanical vales is trivial, Some recommended On-X.
So really want someone to share experience about either of the two valves. With On-X valves, can you keep your INR between 1.5~2.0 without any problem?
Regards
Hi Danbro666
Yes I had the On-X fitted in April 21. My INR range was initially 2-3 but then reduced to 1.5-2.5 after a few months.
When I go for my INR checks I'm generally around 1.8 now. It took a while to stabilise but seems to have done. I was so anti mechanical valve because of the Warfarin, but it's really not a problem.
If you aren't already in UK Aortic and Heart Defects Pre and Post surgery Facebook group then definitely consider it. Lots of support and advice.
Joanne 😊
Hi Joaane,
Thank you very much for sharing. Stay at 1.8 is impressive.
Did you choose on-x or did your surgeon recommend it to you? Did the surgeon explains the reason?
Regards
Dan
Hi
I thought I'd replied, but can't see it now.
My surgeon chose the valve because of the low INR range and my worry about Warfarin. I take 6mg a day at the mkment.
I go to Warfarin clinic every 2 months or so now, but the staff increase the frequency if my INR looks like it's becoming unstable
Joanne
Hi Joanne,
Which hospital and which surgeon did you have your operation?
and do you need to take aspirin together with warfarin permanently?
Best regards
Hi
I don't think that we are allowed to name our surgeons on here, but I was in Leeds General Infirmary.
I take an asparin as well as the Warfarin and also Lansoprazole (to protect my stomach from the Aspirin)
All those medications are for life, but I'm still on less than some others
Just as an aside I'm on Lansoprazol and low dose aspirin for life as well but I had a tissue valve so some experiences are common to both.
I have a Medtronic valve, and have a narrow range, which I'll come on to in a minute.
The INR ranges for mechanical valves by NICE's recommendation are in Table 1 at cks.nice.org.uk/topics/anti... where the range is target +/- 0.5. Most modern AVs are "low thrombogenicity" since they reduce the risk of clotting in their own way; my Medtronic is advertised as "open pivot" meaning the valve hinges are well open to the bloodstream and the crevices are minimal and get flushed, avoiding any static areas. So, 2.0 to 3.0.
I'm not familiar with the On-X valve, but range 1.5-2.0 sounds very low to me, though I see it has FDA and Canadian approval for that range. I'm not sure having a CE mark covers a particular INR range, though I may be wrong.
Whilst a low range is perhaps beneficial, I have to ask how much real-world benefit is there over 2.0 to 3.0, and as your question, can you keep it within 1.5 to 2.0? The risk of higher INR ranges is of bleeding when cut, which is visible and fixable by vitamin K infusion, but also if you bang your head badly (as I did once), A&Es will automatically CT your head for a brain bleed (I was ok, fortunately.) Conversely, the risk of going out-of-range on the low side is of clotting, especially if monitoring intervals are long (several weeks). For me, that's much the greater risk. I think it's said that 1 week with an INR of 1 will result in serious clotting on the valve, and consequent stroke risk.
In terms of staying in range, everyone will at some time go out of range. Some statistics suggest being in range only 70% of the time is fairly typical, I personally think that's way off and unacceptable. When I was first fitted, my range was 2.0 to 3.0, and I would sometimes get frustrated that when it was clear my INR was dropping towards and below 2.0, the clinic was quite unconcerned and only tweaked my dosage slightly, and surprise surprise my INR carried on downwards. It got to 1.7 more than once, possibly lower. At one point I wound up in A&E with chest pain which turned out to be a lung infection, but they were concerned it could have been a pulmonary embolism. With my clotting risk of AF as well, they were unimpressed by such excursions outside range, and revised my range to 2.5 to 3.0. This has at times definitely been hard to maintain, but if below 2.5 I'm not worried unless it gets near 2.0, and if above 3.0, it's only the bleed risk, which is manageable.
With a range of 1.5 to 2.0, from my own experience of a 0.5 range, it would be hard to stop it going below 1.5 at some time, and with a 1.5 minimum, the clotting risk below that probably gets quite significant. There are ways to help, such as frequent home testing by Coagucheck machine, and taking vitamin K to provide a more constant background level of vit K (though that has risks if you miss a tablet).
I can't personally see a huge benefit in 1.5 to 2.0, over 2.0 to 3.0, and NICE don't seem to recognise 1.5 to 2.0 as a separate class of valve, hence would the NHS agree to it? Maybe someone else has direct experience, I'd be interested to hear.
HTH
Hi Cliff_G,
Thanks for sharing your experience. It helps me to think about the true effect of the INR.
Do you take aspirin in addition to warfarin? One surgeon said he doesn't think On-X is different as it requires aspirin with warfarin, which means taking 2 blood thinners. I forgot to ask whether other valves require aspirin together with warfarin.
Regards
Dan
I initially took aspirin, but I had a stent as well and I think it was to do with that. The cardiologist took me off the aspirin about a year after my op. as he said it was no longer needed plus an extra bleed risk. Also a gastric risk of course. I'm only on warfarin. I've never heard of an AV needing aspirin as well. Maybe that's just an On-X thing
Thank you to confirm on warfarin only. I looked at other posts and it seems on-x valve indeed needs aspirin if the INR is kept at 1.5 ~ 2. As you have pointed out, it was concern if the INR drops below 1.5. Well, more reading ...
So be sure to talk to the surgeon and cardiologist about what medication you need to be on. I've got the on-x and was advised that to have lower inr you have to take aspirin with warfarin. Ultimately advised to just take warfarin and have my inr at 2.5. I thought it was going to be an issue as I'm pretty active. It wasn't I still climb, bike, run, swim and get up mountains no problem.I've had some issues which means I need to keep my inr a little higher at 3 but still not had any issues. Biggest issue with warfarin no matter what your inr is everything that interacts with it.
Good luck with your decision and which ever one you make it will be the right one for you.
hi. 18 months ago I had Endocarditis which destroyed my Mitral valve so I required open heart surgery. The decision is very tricky as you get little help with the decision. I plumped for a mechanical valve as at 58 I couldn’t face the thought of replacing a natural valve every 10/14 years. The warfarin is the issue with me as I’ve still not really stabilised yet . My level is 3.5 and my body just reacts differently to the norm I guess . Cheese booze and vitamin K veg are the things for me . Not a lot of data etc about on this as it’s so individual. I couldn’t face the thought of 2/3 more surgeries to replace a natural valve as i was in hospital for 6 weeks . It will depend on your age I guess and if you are willing to curb and adjust your life style . The other thing with my valve is it’s like a clock ticking . You really only notice it at night . Research the warfarin it can be an issue also bruising and bleeding is an issue so certain physical activities might need to be given up . Motorcycling in my case had to go 🤦♂️. Good luck with it . Rob
Hi after having endocarditis twice in 2 years aortic valve replacement ( mechanical) pacemaker fitted, it’s taken over 2 years for my inr to settle my range 2.5 -3.5 I personally now self test once a week any problems contact your surgeries I had all but given up on ever coming in to range & suddenly I did I’ve now been in range for 3 months. I would rather be a little bit higher on the inr O would rather bleed than have a stroke
Unfortunately I still ride my motorcycle for them not for me
Please everyone be patient, at least with the mechanical valve you have the comfort of hearing it
hi, i have a bicarbon fitline mechanical valve, had it fitted last year. I take 8mg warfarin and no aspirin. I self test at home and send readings to the hospital for them to dose me, but i seem to be settled at the moment. Good luck making your choice.
hi there. I had a mechanical valve just over 2 years ago now but want given the choice which (nor was I interested really as you can see from my bio, I’ve had 5 valve replacements now). My INR is between 3 - 4 and I have no issues with warfarin at all. My doseage is generally 4mg a day. No need for aspirin. I also have a coagucheck machine so that I can test my own INR at home so only go to my GP probably once a year. Can strongly recommend getting one and my GP will give me the strips and lancets on prescription now so only the initial outlay of circa £300. No help with the valve, I know, but, thought you might be interested in the machine
Thanks for the advice. I'll definitely get a home test machine in due course.
Hi, I did the usual googling when I needed my aortic valve replacing, I saw the On-X valve and suggested that to the surgeon, based upon the fact that I think it gave me more wiggle room on the higher end. At the time, he said they didn't use that one, so I said no problem, I'd rather go with whichever they normally use. (I'd rather get thru the operation than worry about the valve). After the OP, I was surprised to see on the documentation that I'd been given the On-X valve and was pleased. Like others, my range was 2-2.5 and then lowered to 1.5-2. At my first review with the cardiologist, he questioned why I was also on Aspirin and there was a back & forth between him and the surgeon. Either 1.5-2 with aspirin, 2-2.5 without. But basically it was left for me to decide my preference, which I wasn't totally happy with (I'd rather be told what is best). It seems that the On-X valve is becoming more widely used here and I can't believe they could be used without first being approved. (Otherwise there would be some serious lawsuits). But I recognise the other comment about the lower INR range being a clotting risk and it certainly has crossed my mind. This was prompted by the fact that last winter I was ill over Xmas/New Year, over it in a few days and thought nothing of it. I didn't have my INR check until near the end of Jan as my INR was pretty stable but found my INR had shot up (high 2's). This started a rollercoaster, as my dosage was cut (by their computer system) and (as I had suspected) - the INR came down into range and then out of the bottom. It remained at 1.3 - 1.4 for a few weeks whilst the dosage slowly came up. I will admit, I was worried. I'd also been a little worried about the high reading too. So if I'd have been asked at the time about the On-X valve, I may have been less convinced. But......It's just a case of putting it to the back of your mind and getting on with life. After a short time I was back in the range and things stabilised. When I first had the OP I have one of those machines to test your INR at home and initially I used that a lot.. And that can be scary if you see you are out of range on a Friday and don't fancy waiting 8 hours in A&E... but now I don't bother... (& the strips are expensive!). We all have to put our faith in the technology (& skills of the health professionals) that keep us ticking.. I always have the option of having a higher INR range with the On-X valve, it was my choice, which I like. I choose the lower range with Aspirin as I like going to the Pub once a week and not overly scared of getting a little merry on a rare occasion. If I ever get stomach issues from the Aspirin, I'll go for the higher range instead. Life is for living, you just need to decide which is best for you and remember that there is no wrong choice.
Thanks for your reply.
It does feel a bit perplexing that you got an on-x valve that your surgeon initially said he didn't use. A good thing nevertheless.
What's your current target INR now? Do you choose to stay above 2.0 without aspirin, or below 2.0 with aspirin?
Hi, I had a very skilled heart surgeon, but he wouldn't have won any prizes for his interpersonal skills. lol. But I'd rather have it that way around than the other! I treat getting the valve I wanted as a bonus. Anyway, my range is 1.5-2.0 with Aspirin. I just went for a 6 week check today and it came in at 2.0 (was 1.8 & 1.7 on the previous two). This is pretty much exactly where I would like it to be. (I'll put this down to the Guiness I had on Wednesday). This gives me a fair bit to drop before I'd worry and also as long as I'm not having any issues being on Aspirin (touch wood) I will stay on that and keep it as close to 2.0 as I can. But it is a personal thing. Also... I've noticed that my INR has risen after being ill (flu/cold etc) twice now, even when there has also been a bit of a gap between the illness & testing, so it is quite possible that my INR has been higher than 2 and just not measured (Or it had nothing to do with it! lol) . But compared to the other ranges people quote, even if it had been higher, it doesn't worry me that much. (I was on a target of 2.0 -> 2.5 with Aspirin for 3 months after the OP and then was moved to 1.5/2). Of course people are different, it is just a case of getting the right balance for you, both physically and mentally.
Dan, I don't know anything about on-x valves but I have probably more experience with Warfarin than most others on the site. I have not heard of an aspirin/warfarin combination before. I take only Warfarin, and my target INR is 2.0-3.5. I very rarely go out of range, can only remember two readings over 3.5 and I am sure one of those was through taking a health supplement which I did not realise would affect the readings. When my INR is stable I can go 8-10 weeks between tests. I have had a number of dental extractions over the years (I won't do root canal treatment as this sounds too painful) with no complications. Admittedly I rarely drink alcohol, partly because my car is never far away but I find alcohol free lager actually tastes better! I also have half a grapefruit every day. I have never had uncontrollable bleeding on the rare occasions I cut myself by accident. My mechanical valve celebrated its 35th birthday earlier this year so I think it is safe to say that long term use of Warfarin is quite possible with no side effects. I was told at my Cardiac Rehab course that if I stopped taking Warfarin it would probably be a week or two before I entered dangerous territory with a serious risk of thrombosis. Hope this offers reassurance to yourself, and to anyone else reading this who has concerns about long term effects of Warfarin.. And while I am not a fitness fanatic, I certainly don't sit around the house all day and my last job required me to pass a safety critical medical
Thank you for your sharing Classof1988. That's really encouraging. Warfarin feels daunting for people who are not familiar with it. It's a bit relief to hear your story. Thanks.
This is an excellent forum for discussions of all heart valve topics including valve selection and anticoagulant management...
One of the experts is Pellicle.
Thanks for the information.
Hi Dan
I'm 41 and had an On-X valve fitted in February. I confess I did no research on the valves themselves (beyond tissue vs. mechanical) and trusted my surgeon's decision.
My target INR is 1.5 to 2.0 and I'm on daily aspirin and Lansoprazole like others have mentioned. Its taken a long time for me to stabilise my INR; you establish the things you are sensitive to which affect your levels (alcohol and paracetamol for me). One thing I will add is that if my INR drops below 1.5 I have to self-inject anti-coagulant (Inhixa) until my INR is back in range. This was instructed by the consultant on discharge and I need to comply every time it drops below 1.5 (I have clarified it many times with the specialist nursing team as injecting is not nice and the bruising awful).
Wishing you all the best for your operation and the future.
Hi Football-Mum, thanks for your story. How often did your INR drop below 1.5?
It feels a bit insecure that you have to inject Inhixa in that situation. Do you worry about if you keep between 1.5~2. As the other post suggested, dropping below 1.5 is dangerous.
Hi again Dan
Its taken me a long time to establish my correct warfarin dose; for 8 months I was being tested weekly as I wasn't consistently in range to move out to less frequent testing. In that time I reckon I've had 6 separate weeks of injecting but most of those were in the aftermath of my op. Put it this way I was discharged with a warfain dose of 5mg/day and the dose I'm on now (and stable) is 4x8mg and 3x7mg/week! Now I'm established on this dose (and on 3-weekly testing) my INR has been within range. The other thing to consider on the aspirin therapy is the 1.5-2.0 INR window is only a 0.5 window where as warfarin only window is normally 2.0 - 3.0 so with the latter there's more room for manoeuvre!
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