percutaneous speculation...

[Karen]

I had occasion to visit with a cardiac surgeon last week. Among other things, we talked about his predictions concerning percutaneous valve replacement in the "near" future. I won't even try to do justice to his explanation as to why, but he does not believe that this will be an option for stenotic aortic valves. He's not really optimistic that even aortic valves that just have regurgitation will be replaced by this procedure in the very near future. But in his opinion, there are too many obstacles in dealing with stenotic aortic valves that would make it practical or prudent. It is also his belief that it will take many years to prove (IF it is proven) that patients will have a better long term prognosis with percutaneous valve replacement than they do with the standard surgeries.

Just one more speculative opinion that I thought may be of interest to some of you...

Karen

 

[AlonnolA]

I had a congenitally stenotic aortic valve, and it was repaired with a balloon, which reduced the stenosis in exchange for regurgitation which, 22 years later, resulted in the need for a valve replacement.

So it makes sense that percutaneous valve replacement wouldn't address stenosis - you would need to expand the valve first, then insert the new valve, no? Why not expand the valve, then wait and see if that solves the problem, at least for a while, maybe forever? Does that make sense?

 

[starfish11040]

Seems that some people are choosing a tissue valve in the hope that, when the valve needs to be replaced, the percutaneous procedure will be in common use.

This may or may not be a reasonable expectation. But there seems to be another question to consider: Is the percutaneous procedure meant to replace (or be inserted into) only a native valve? My cardiologist told me that he thinks it's not meant for a sewn-in valve. That's not what I wanted to hear.

The question is important for me because I will most likely need AVR at some point in the future and this info will influence my decision of mech vs. tissue. Can anyone shed more light on this?

 

[Karen]

In the opinions of two of the three cardiologists I have talked to, that is also their belief. One surgeon and one interventional cardiologist said that it would only be an option for a native valve replacement.

The surgeon believes that it will not be an option even then for a STENOTIC aortic valve. (And is skeptical that it will be proven superior to traditional surgeries for the long haul).

The other cardiologist, my new adult congentital heart disease expert, just doesn't believe the quirks are going to be worked out to replace any of the valves percutaneously in the very near future. He definitely wouldn't recommend making choices, assuming this procedure would be available when it would be time for reoperation...

'Definitely things to consider.

Karen

 

[BackDoc]

And the experts said the Wright brothers would never fly. The experts also claim that the bumble bee shouldn't be able to fly. It seems no one has told that to the bumble bee. Keep this in mind: every ten year period see's us expand our scientific knowledge base double over the entire period of history before this most recent 10 year period.
Heart valves are now being developed from stem cells. The cadio's at the Cleveland Clinic told me that no one can predict what valve replacement surgery would be like in 20 years.

The present choice of valve should be based upon your own lifestyle decisions, not upon what you hope may be in 20 years time.

Right now perc valve replacement is showing promise for stenotic aortic valves.
http://www.clevelandclinic.org/heartcenter/pub/history/future/default.asp?firstCat=56&secondCat=57
Who knows what the future will hold for regurg?

 

[DeWayne]

A month ago when I went to see my family physician he told me his best friend had been hired at Emory in Atlanta. His friend is a specialist in the field of percutaneous surgery. I feel that it will be the future. Everything points to it. The fact is they are already using it in extreme cases. What has to happen to make it main stream for valve surgery is a better valve. When that happens things will change in a big big way. Imagine outpatient surgery for heart valve replacement. that is the hope

 

[Andyrdj]

have said this before, but....

have said this before, but....

Corevalve (www.corevalve.com) have replaced an ailing bioprosthetic valve using this method, as well as a number of diseased valves.

It takes a bit of finding, need to look though all of their news articles, but it's worth reading. I find it somewhat surprising the number of surgeons who have said "it can't be done" when it already has, in some cases

 

[BackDoc]

isn't that the truth. any surgeon who says it can't be done when it already has is sadly not keeping up with the scientific literature.

 

[Karen]

isn't that the truth. any surgeon who says it can't be done when it already has is sadly not keeping up with the scientific literature.

It's been just shy of 3 years since I learned that my coarctation surgery 40 years ago was not the fix-all that we thought it was for my particular heart issues. In the context of a lot of other things going on in my life, it has been important to me to get a sense of what might lie ahead for ME.

I have regularly read these forums since happening onto vr.com only last year, and I have been grateful to be directed to many articles and studies that have been posted concerning what is happening now and what is projected for the future. I don't believe that any of the cardios that I have personally talked to, including the surgeon that I referred to in these posts, are predicting what will be possible "in 20 years." But even my first cardio (who has been meeting with cardios in Brazil who HAVE done percutaneous valve replacements) said that, although he believes this procedure will be somewhat commonplace in 3-5 years, I would not want to be a cardio's first percutaneous valve replacement patient... (And I think I probably wouldn't want to be his 10th or 20th either).

In discussing these developments with my new cardio and with the surgeon that I referred to, I have come to these conclusions:

1. For ME, I finally feel that I have a cardio who really "gets it" as far as the bicuspid valve, aorta stuff is concerned. I have a confidence in his experience and expertise in monitoring MY situation and also in his ability to provide follow-up care AFTER surgery for ME, when that time comes that is very reassuring. If, somewhere in the world, cardios are doing things that are very frontier-ish, that's great. But it has been a huge peace of mind thing for me to believe that I have cardios in MY world, studying these issues that can help sort it all out with me.

2. For ME, I've discovered that I have less enthusiasm to speculate on those unknowns than I probably had a few months ago. If and when I have to make a decision regarding valve replacement (assuming that that would be within the next 5-10 years), I don't think I would make a choice that would depend on options in the future that are not yet proven. I appreciate the caution given to me that it will take years of careful follow-through to really know which procedures will be proven the most effective for the long term. That's the case even if percutaneous replacements started on a large scale tomorrow. I've found myself willing to be patient and to go with the known -- for ME.

I rather suspected this post would prompt responses similar to the ones that have been posted. I only offered it because, like Starfish suggested, some of us might be well served NOT to assume that just because a certain procedure (or even a new valve) might show promise, that we don't need to ask the hard questions and decide for US, personally, if it really is the way to go, even IF given the option today. Some brave patients and cardios ARE going to be the "first." I have learned that I don't want to be, and it's great to have confidence that TODAY medicine is able to give me some pretty great, proven, options for a long and healthy future...

Karen

 

[BackDoc]

read these interesting comments by Cardiothoracic surgeons and residents regarding the future of percutanious valve replacement;

http://forums.ctsnet.org/ctsnet/thread.jspa?threadID=827&tstart=0

 

[bvdr]

A very interesting read....thank-you. I believe that cardiac surgery has just barely begun the transformation to take place in the next several years and valve patients will benefit from some of them.

 

[think]

not very encouraging but seems to be quite realistic evaluation

not very encouraging but seems to be quite realistic evaluation

Off-pump aortic valve replacement with catheter-mounted valved stents.
Is the future already here?


In conclusion, however enthusiastic the current mood may be, in my opinion, which may not be read as a condemnation, this technology is still far from the stage of mass application and it probably will never replace conventional valve replacement surgery. Obviously, after this initial enthusiasm, which is not necessarily unhealthy, and auto-proclaimed good results [25], the time has been reached to implement well planned and appropriately conducted comparative studies to determine the potential advantages of these technologies. Study candidates should consist of symptomatic patients in whom medium and long-term survival is anticipated to be severely compromised and the results of conventional surgical valve replacement rigorously calculated to be well above acceptable values. These studies would allow the collection of mid-term device durability data while providing much needed clinically relevant safety and effectiveness data. But this may be hampered by the continuous evolution of the devices.


For the full text http://ejcts.ctsnetjournals.org/cgi/content/full/31/1/1

 

[Keithf]

Cribier-Edwards Percutaneous Aortic Heart Valve implanted in 92 year old lady.

Cribier-Edwards Percutaneous Aortic Heart Valve implanted in 92 year old lady.

This is from the Edwards Lifesciences 2005 annual report.
They have a picture of this valve. It looks like they can just run it up your groin and inflate it into place.

http://www.edwards.com/investorrelations/annualreports.htm
http://media.corporate-ir.net/media...nnualReport05/investorDownloads/EW_2005AR.pdf

Valerie R. has been healthy all of her life;
diagnosed with a heart murmur in 1988, she
had enjoyed an active life until last March, when
a series of unexpected fainting episodes were
linked to a faulty aortic heart valve and the need
for percutaneous heart valve replacement. Today, at
age 92, Valerie enjoys working out twice weekly
at the gym and is looking forward to welcoming
guests to her new home this summer. ?I am so
grateful to everyone, the doctors and the Edwards
employees, for this wonderful valve,? she says.
Cribier-Edwards Percutaneous Aortic Heart Valve
This experimental, proprietary technology is
designed to treat patients with severe aortic heart
valve stenosis by threading a replacement heart
valve via a catheter through the patient?s circulatory
system. Percutaneous heart valve replacement
and repair represent important therapeutic
options for patients, and Edwards leads the
field with the most advanced and comprehensive
platform of technologies in development. These
new therapies offer the promise of less-invasive
treatments, shorter hospital stays and
faster recovery times for patients.

 

[tobagotwo]

The concern with stenotic valves might be more in terms of controlling bits of apatite from flaking off and running to the heart, lungs and brain during the procedure. It happens occasionally during or shortly after a catheterization. There are several, catheter-delivered "strainers" out there now on an experimental basis to try to limit or remove that risk.

They've already improved since the first one was placed, and there are five or six manufacturers who have prototypes out there.

They will work the bugs out. There's money there.

Best wishes.

 

[Karen]

Even if solutions are found for "apatite flaking off" and the more difficult maneuverability for the surgeon in the case of a stenotic valve, there is one more consideration that I struggle with, concerning percutaneous replacement. It seems there is a huge potential advantage for the surgeon to be able evaluate the aorta when doing a traditional sternotomy. For those of us with bicuspid valves and concern about enlarged aortas, I don't see how a percutaneous approach is going to serve very well in answering questions about the aorta.

By the way, after being told that my aorta "looked just fine," the report of the cardiac MR that I had done in October indicates "mild ascending aortic enlargement." The measurement is only 3.6 cm. But all the other measurements of my aorta ranged from 1.6 to 1.8 cm with 25% stenosis at the coarctation repair site. With such varied values from past echos, a two-sided heart cath, and now this MRI, I would think it would be very reassuring to have the aorta examined at the time of a valve replacement... That couldn't happen with a percutaneous procedure.

 

[Andyrdj]

However

However

It seems there is a huge potential advantage for the surgeon to be able evaluate the aorta when doing a traditional sternotomy.

I did see a series of fascinating and detailed pictures of vaious enbryonic animals in the womb, taken with some very high resolution ultrasound scanners.

These scanners could very well provide the surgeon with a 3d video of the valve before the operation, with the heart in its untampered state (ie. not cut open) and could mean that the "cut open to have a clear look" argument no longer applies.

I hope this does come about - I'm sure this is one situation where you'd love to be proved wrong, Karen!

 

[Karen]

I did see a series of fascinating and detailed pictures of vaious enbryonic animals in the womb, taken with some very high resolution ultrasound scanners.

These scanners could very well provide the surgeon with a 3d video of the valve before the operation, with the heart in its untampered state (ie. not cut open) and could mean that the "cut open to have a clear look" argument no longer applies.

I hope this does come about - I'm sure this is one situation where you'd love to be proved wrong, Karen!

As a matter of fact, I would. Given the residual effects of the coarctation surgery I had 40 years ago (and that wasn't even a sternotomy), it would be very, very good news if I didn't have to have my sternum cracked open. 'Hopefully my situation will stay stable for 10 years and then we'll see what magic has been "proven" to satisfy even my qualms AND the cautions of those advising my health care.

Karen