Tissue or Mechanical: Which Valve is Right for You?

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Marc Gillinov, MD:

Hello, I'm Marc Gillinov. I'm chair of the Department of Thoracic and Cardiovascular Surgery at the Cleveland Clinic. I'm a heart surgeon and my special area of interest is in heart valve disease, specifically performing heart valve repair and replacement when necessary. When a patient needs a valve replacement, the first question that comes to mind is always what type of valve replacement should I get? If I'm the patient, do I want a biological or bioprosthetic valve? Or do I want a mechanical valve? These are both good options, but they're different from one another, and it's important for a person to understand the differences and the advantages and disadvantages of each one. First, the biological or bioprosthetic valves, those are valves that come from pigs or cows, and they function extremely well.

The advantage of bioprosthetic valves, of pig and cow valves, their advantage is they do not require any anticoagulation, so meaning no blood thinners if you get a biological valve. In addition, they don't make any noise. You don't hear them, you don't know they're there. The disadvantage is that they can wear out. It turns out that the older you are, the longer your biological valve will last. And we don't completely understand why that is the case. But in general, if you receive a pig or a cow valve, you can think of that as a 10-year valve. We've seen as few as seven years, and we've seen people go 22 and 23 years. But on average, if you get a pig or a cow valve, you could say, that's probably going to last me about 10 years, and I will not need any blood thinners during that time. But it will wear out at some point, especially if you're young. If you get one in your forties or fifties, guaranteed it will wear out.

And then what? Then you'll need a new valve. Does that always mean heart surgery? If I had a pig valve 10 years ago and now it's worn out, do I need heart surgery? Not always anymore. There are many instances now in which we can take a new pig or cow valve, fold it like an umbrella, so it's very thin. Thread it up a vein in your leg or an artery in your leg and deploy it or place it in the heart, almost like opening the umbrella, and we can place that new valve in the housing of an old pig or cow valve. So those are the biological valves. Good news, no anticoagulants or blood thinners. Bad news, they can wear out. The other type of valve replacement is termed a mechanical valve. Some people call them metal valves, but actually they're made primarily out of a special form of carbon, so they're more carbon than metal.

The deal with the mechanical valves is that they virtually never wear out. Meaning if you get a mechanical valve, you should be thinking, I am very unlikely to ever need heart surgery again. There are some rare instances in which a person with a mechanical valve might come back to surgery, but usually not. Usually if you have a mechanical valve, that is a one and done proposition. However, if you have a mechanical valve, you need to take a blood thinner or anticoagulant because mechanical valves can cause blood to clot on the surface of the valve, and you don't want blood clots on your valve. If you have a mechanical valve, the anticoagulant that you must take is called Coumadin. It's also termed warfarin. Coumadin and warfarin are the same thing. That is the only anticoagulant that is currently approved and known to be effective in people with mechanical valves.

Well, what is the deal with anticoagulation? There are a couple of issues. First, if you're on Coumadin or warfarin, and God forbid you get into a situation that causes bleeding, like trauma or a bleeding ulcer, it becomes a bigger problem. If you're on a blood thinner, you're not going to cut yourself shaving and bleed to death or something like that. But if you do get into a real trauma situation and you're on a blood thinner anticoagulant, it can be a problem. The second issue with Coumadin is it requires monitoring. You have to get a blood test once a month, or you can do a finger stick like diabetic people do and check it at home. But regardless of the approach, if you're on Coumadin, you need to maintain your level, which we term INR. INR stands for international normalized ratio. That's the blood test for Coumadin. You need to maintain your Coumadin level or blood test in a certain range.

And then finally, mechanical valves make a slight clicking noise. People can sense that clicking noise. It's somewhat like if you lie down at night on your left side, you can feel your heart beating in many cases. It's a bit like that. A person with a mechanical valve will not walk into a room and have on an everybody suddenly stops and say, What's that noise? It's a very subtle noise, but you can sense it. That said, mechanical valves usually lasts forever, so how do you choose? Go with what fits you. It's like going to a shoe store. You want something that fits you. You want something that appeals to you. If your primary thinking, is I never want to have heart surgery or a cardiac procedure again and I'm willing to take an anticoagulant, then the mechanical valve with Coumadin might be your best choice.

On the other hand, if you say, I do not want to be on an anticoagulant, a biological valve is your best choice. And if you're over age 65, almost always over age 65, choose the biological valve because the odds are if you're 65 and you get a pig or cow valve, the odds are very, very good it will last your whole life. Most important though, talk to your doctor, talk to your surgeon, talk to your family, and then think about it and choose what you want. Because it is your decision which valve fits your lifestyle the best.

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