I have 4 days to decide - help!

[river-wear]

Maybe I'm too cynical, but I think it's really interesting how every surgeon I have talked to personally (and many more found referenced in the forum), says they'd go with tissue and rely on TAVR when it fails. The interesting part is that (if I understand correctly), procedures like TAVR and their predecessors (stents) are placed by an interventioal cardiologist. Are they working themselves out of a job? Or should we be paranoid about the prospect of another surgery they can perform? I'm a little haunted by the story the first surgeon I talked to told me: the case he had that morning was the SEVENTH tissue valve for a woman in her 70s who had a body chemistry that made them calcify rapidly, but she refused to get a mechanical valve. His "silver lining" was that he said older patients generally experience much less pain from OHS than younger people. (Even at 46, I'd say it isn't that bad.)

It also reminds me of conversations I've had with my cardiologist when he'd tell me that the very best up-and-coming surgeons aren't going into heart surgery anymore. With all of the stents, statins, etc. available they don't have as much to do anymore. (Great for patients though!)

Sorry, no real point here, but I find the reliance on TAVR kind of odd. Maybe it's the new "holy grail" because the trials have been mostly successful and I think the selection criteria is loosening up beyond the most dire cases.

 

[deanmenta]

Once again some interesting insights.
I believe when they do TEVAR they do them in a combined catheter and OR

Check out this short doc from a year ago > http://youtu.be/m5DnlWun8oE

 

[pellicle]

Hi

Maybe I'm too cynical, but I think it's really interesting how every surgeon I have talked to personally (and many more found referenced in the forum), says they'd go with tissue and rely on TAVR when it fails.

I think perhaps I'm even more cynical than you and ask the question of "how many needed it" as I have found what people say they will do VS what they do when the chips are down varies.

I'm even more cynical because all this discussion of the leading edge technologies moving towards painless day in V in V artery delivered surgery being the way to go makes me think: ok, who suffers and who are the Guinea pigs in the middle. For there are inevitable mistakes and errors associated with learning. For myself (and I just had the choice 2 years ago) I wouldn't touch tissue with a barge pole.

When in 10 years its established sound best practice, when its the gold standard then I'll go for it.

People can (quite rightly) identify that when I had my first valvotomy (in about 1974) it was radical and new surgery. The difference is that then there was no other choices (except die slowly as the generations before had done).

When something is opaque the only way to attempt to understand it is by inference. My inference is this: in places like the USA where hospitals are profit centers (shudders) the customers are "given choices", yet to me they are steered towards tissue valve. Yet in places like Norway where the health system is socialised (meaning free) they have a preference for installing mechanical valve and don't really desire tissue without appropriate mitigating factors.

If you look at the major social and economic indicators the situation for people in Norway is excellent. Ultra low poverty, fantastic levels of social satisfaction and personal happiness, great services and very modern in delivery of all infrastructure.

Then there is the other money trail. I was having a chat over a coffee with my Pathologist mate who mentioned to me that a catheter surgeon said that the traditional thoracic surgeons were loosing patients to catheter surgery. His hospital does Catheter work (Queensland Public hospitals each specialises in a field within the capital city), while the hospital I went to specalises in thoracic surgery (I went to the private operated wing of that hospital for my surgery)

The thoracic surgeons are actually losing business to the catheter surgeons because the thoracic surgeons society made a deliberate choice to not include catheter based surgery in their field of specialisation (in the early days of its emergence). They stuck to the "we do open heart" line. Increasingly surgeries which were done by heart sugeons are being done by catheter. This is now seeming to include valve surgery.

Will Catheter intervention replace OHS? I suspect that the answer is probably yes. Over what time frame is unknown. Will it do so in a timeframe to be of benefit to me - well that answer is no.

Its not even clear that it will be the model of choice. History is littered with the "certanly: this is the future" that never happened.

Lastly, let me put up a bit of inference in my examination of that opaque box that I think makes a case on its own.

The table column says "Number" yet the bottom number is the addition of all the column and is labeled in $ ... its a little confusing if you ask me. Also, if you do the maths the numbers don't quite add up (507 out) and yet this was published in a "special report" of Aortic Valve and Ascending Aorta Guidelines for Management and Quality Measures (2013). I guess that wasn't an area where rigor was needed. Still even with a margin of error in the USA tissue valves are big sellers ... each one probably generating repeat business. Its clear to me that for every tissue you fit you'll fit another at least if the patient lives longer. That is largely not true with mechanical.

In this day and age companies who make rugged and long lasting products are far less successful than those who make ones which need to be replaced frequently: its called the throw-away society.

Yet there are people (like me) who choose to buy rugged stuff because when I'm out skiing I don't want my fancy $300 skipole to break OR my bindings to jam forcing me to walk barefoot (well ok, in thick socks) back across the ice because I can't get my boot off (where we lit a fire to melt them off).

Durability is the key requirement for me in products. I seem to be in the minority and I accept that.

Singer used to make great and rugged sewing machines, we see plastic rubbish now and Singer is extinct. I'm still using Grandmas treddle Singer to repair my tents and backpacks... and I chose a mechanical valve in 2011 for the same reasons.

 

[river-wear]

Pellicle, it's too bad they didn't also include age curves for those valve numbers. You're correct about the guinea pigs, but at least in the early trials they were patients much like you in 1974: they had no other choice.

Dean, sorry if I caused your thread to become hijacked. You really need to do what you're comfortable with, regardless of what we're discussing. Monday is your big day and you should go into it with complete confidence. You have a very good surgeon with a lot of experience.

Finally, I need to make a small correction to my post just above - I did talk to a third surgeon (local follow up for my cross-country surgery) and he prefers mechanical valves in younger patients. Still, 2 out of 3 support tissue with an option for TAVR in the future.

 

[pellicle]

I also wish to reiterate to Dean that all of what I have said to you in this thread I still stand by.

I do not wish to seem duplicitous about this, and as I have said for you in your stated situation (physical and mental) I still feel that your choice is the best for you. Its just not what I would do (and I am not you). Indeed if you wish to discuss it via skype (you know, voice call) please PM me and I will make time at your convenience (irrespective of time zones), I understand its important and discussing things helps put one at ease.

Dean, sorry if I caused your thread to become hijacked. You really need to do what you're comfortable with, regardless of what we're discussing. Monday is your big day and you should go into it with complete confidence. You have a very good surgeon with a lot of experience.

Sincerely


Best Wishes

 

[deanmenta]

Thanks for your support and input you guys!

I very much appreciate it !

 

[pellicle]

Hey

I will be thinking of you in the coming days and hoping for a smooth procedure and an uneventful recovery.

You will be in good hands.

Don't forget to take something in with you to get the "downstairs" moving again after ICU. I recommend kimchi as the best natural stool softener and better yet, its actually good tasting food !

Steve has said:

Not only are softeners usually given, they are critical (my own opinion) to your safe recovery. You may also need something like Miralax to get things going again after the surgical meds and the oral pain meds they send home with you.

my own comment on that thread is here

Best Wishes

 

[neo]

I think this might be from the same talk. Very interesting article...

http://www.heart-valve-surgery.com/eBook-Advances-Aortic-Valve-Aneurysm-Surgery.pdf

I just re-listened to the recent Webinar conducted by Adam Pick and Dr. Allan Stewart conducted here last week.

During the Q&A section at the end there was a very interesting question posed and Dr. Stewart's answer really spoke to my situation in a very non-ambigiuos manner.

You can here the question and response here > https://www.youtube.com/watch?feature=player_detailpage&v=3RU9bIzBIM0#t=2929

That link should go to the time where the question occurs , but if it doesn't then skip to the time mark around 48:48.

Dr. Stewart states that he would choose a tissue valve for himself if he need AVR (he is 45 years old) and then rely on TAVR for future therapy when needed.

very interesting

 

[deanmenta]

Yes Neo , that's the one.

Here are the comments from Dr. Stewart that pertain to my situation :


Dr. Stewart's opinion on mechanical valves from webinar :

"I would say I’d be very careful if I needed a valve replacement to avoid mechanical valves. They’re rapidly approaching extinction, even in the youngest of patients, because of these new treatment options to rescue biological valves. I would say that if you’re over 50 years old, you certainly should undergo either a valve repair or a minimally invasive bio- prosthetic valve because I believe that as the future evolves and these currently available biological valves should give you about 15 to 20 years of good, quality function and by that point in time, our technology will have advanced even further that will allow valve-in- valve rescue after these valves deteriorate."

Dr. Stewart: "Again, I do what other people what I’d have done to me. I’m 45; I would have a tissue valve. I believe especially at 53, today’s tissue valves are specially sewn into a graft. The graft that I use, which is a Valsalva graft, I would typically use a stentless horse valve, an equine valve, which has excellent function and excellent longevity. If that gave me 20 years, I would believe that a transcatheter valve would get me through the next aspect of my life. I could live a robust age. I would not have a mechanical valve be- cause although research exists, there is no alternative to Coumadin at this point in time, and there’s no alternative to Coumadin that’s in the near future. I would assume that if I were 53, the Coumadin I would be taking tomorrow would be the Coumadin I’d be taking for the rest of my life."

 

[deanmenta]

I hope I'm not giving the impression that I (and that most cardio doctors these days) think that mechanical valves are obsolete, have more inherent risk or inferior to bio valves. I'm just gathering information that will help me to make a choice for my specific situation. My mechanical valve has served me well for a long time and if I choose to keep it I'm sure it will continue to do so into the future. Thanks for all of your input and opinions guys it's really helpful.

dean

 

[Jkm7]

Hi



I think perhaps I'm even more cynical than you and ask the question of "how many needed it" as I have found what people say they will do VS what they do when the chips are down varies.

I'm even more cynical because all this discussion of the leading edge technologies moving towards painless day in V in V artery delivered surgery being the way to go makes me think: ok, who suffers and who are the Guinea pigs in the middle. For there are inevitable mistakes and errors associated with learning. For myself (and I just had the choice 2 years ago) I wouldn't touch tissue with a barge pole.

When in 10 years its established sound best practice, when its the gold standard then I'll go for it.

People can (quite rightly) identify that when I had my first valvotomy (in about 1974) it was radical and new surgery. The difference is that then there was no other choices (except die slowly as the generations before had done).

When something is opaque the only way to attempt to understand it is by inference. My inference is this: in places like the USA where hospitals are profit centers (shudders) the customers are "given choices", yet to me they are steered towards tissue valve. Yet in places like Norway where the health system is socialised (meaning free) they have a preference for installing mechanical valve and don't really desire tissue without appropriate mitigating factors.

If you look at the major social and economic indicators the situation for people in Norway is excellent. Ultra low poverty, fantastic levels of social satisfaction and personal happiness, great services and very modern in delivery of all infrastructure.

Then there is the other money trail. I was having a chat over a coffee with my Pathologist mate who mentioned to me that a catheter surgeon said that the traditional thoracic surgeons were loosing patients to catheter surgery. His hospital does Catheter work (Queensland Public hospitals each specialises in a field within the capital city), while the hospital I went to specalises in thoracic surgery (I went to the private operated wing of that hospital for my surgery)

The thoracic surgeons are actually losing business to the catheter surgeons because the thoracic surgeons society made a deliberate choice to not include catheter based surgery in their field of specialisation (in the early days of its emergence). They stuck to the "we do open heart" line. Increasingly surgeries which were done by heart sugeons are being done by catheter. This is now seeming to include valve surgery.

Will Catheter intervention replace OHS? I suspect that the answer is probably yes. Over what time frame is unknown. Will it do so in a timeframe to be of benefit to me - well that answer is no.

Its not even clear that it will be the model of choice. History is littered with the "certanly: this is the future" that never happened.

Lastly, let me put up a bit of inference in my examination of that opaque box that I think makes a case on its own.

The table column says "Number" yet the bottom number is the addition of all the column and is labeled in $ ... its a little confusing if you ask me. Also, if you do the maths the numbers don't quite add up (507 out) and yet this was published in a "special report" of Aortic Valve and Ascending Aorta Guidelines for Management and Quality Measures (2013). I guess that wasn't an area where rigor was needed. Still even with a margin of error in the USA tissue valves are big sellers ... each one probably generating repeat business. Its clear to me that for every tissue you fit you'll fit another at least if the patient lives longer. That is largely not true with mechanical.

In this day and age companies who make rugged and long lasting products are far less successful than those who make ones which need to be replaced frequently: its called the throw-away society.

Yet there are people (like me) who choose to buy rugged stuff because when I'm out skiing I don't want my fancy $300 skipole to break OR my bindings to jam forcing me to walk barefoot (well ok, in thick socks) back across the ice because I can't get my boot off (where we lit a fire to melt them off).

Durability is the key requirement for me in products. I seem to be in the minority and I accept that.

Singer used to make great and rugged sewing machines, we see plastic rubbish now and Singer is extinct. I'm still using Grandmas treddle Singer to repair my tents and backpacks... and I chose a mechanical valve in 2011 for the same reasons.

(my bold)

There is No free medical care.
You either pay for it through insurance premiums and/or individual payment at the time of receiving care or you pay for it in taxes.
Either way, someone is always paying for the medical care.
The government is the people and the government's primary source of revenue is taxes.

 

[tom in MO]

I had my surgery at 55 two years ago. I got a different take on "new" procedures from my health care providers. My surgeon is involved in the trials and I was counseled by him and my cardio not to bet on future technology. It may or may not be approved, I may or may not be a good candidate in the future when a tissue valve needs replacement. I was told that if I chose tissue, to plan on some type of open heart surgery, because it works in all cases, except where the health of the patient is compromised for other reasons.

 

[Mike59]

So did you choose. Tissue or mechanical.

I had my surgery at 55 two years ago. I got a different take on "new" procedures from my health care providers. My surgeon is involved in the trials and I was counseled by him and my cardio not to bet on future technology. It may or may not be approved, I may or may not be a good candidate in the future when a tissue valve needs replacement. I was told that if I chose tissue, to plan on some type of open heart surgery, because it works in all cases, except where the health of the patient is compromised for other reasons.

 

[pellicle]

Hi

There is No free medical care.
You either pay for it through insurance premiums and/or individual payment at the time of receiving care or you pay for it in taxes.

you are absolutely correct. I'm sorry to have caused confusion with my words 'free' ... there is no free lunch.

Taxation is an interesting point, I recommend that you look at the data on this page:
http://en.wikipedia.org/wiki/List_of_countries_by_tax_rates

and at the list try sorting it by individual tax, payroll tax and then corporate tax and see where the USA falls. The USA is a high taxing country yet somehow manages to provide lower service levels to its constituents than say Germany, Norway, Sweden ... I feel that when most Americans compare their country in order to come out on top they pick South American ones or African ones, or Asian ones. Naturally you win those comparisons.

None the less, the point I was making is that with a universal health care there is an institutional bias to provide what is best for the patient while attempting to minimize their exposure to the health system. Over servicing detracts from somebody else.

This is in contrast to a user pays system, where the more you can service the client the more you make. Often it seems to me that the user then can't afford the prices so user chooses {and I use that word choose loosley as many just get what comes from their employer} from a health plan on offer which then tells them what they can and can't have (I have seen many sad stories already even only here on vr.org).

Of course this eats at the heart of a very fundamental question: social contract VS free market

Which is of course an economics debate ...

 

[pellicle]

Hi

I hope I'm not giving the impression that I (and that most cardio doctors these days) think that mechanical valves are obsolete

everything has its useby date. I believe that mechanical valves are far from perfect and would love to see them replaced by a better valve system. This is of course the problem, we have no perfect system yet.

My surgeon once said to me (as a littlun) that only God made the perfect valve and even He made a few which weren't perfect.

Thanks for all of your input and opinions guys it's really helpful.

glad to have a chat, glad it made you feel better ... I guess discussions with most of our personal friends are more "blank looks" because no body else really gets it

 

[deanmenta]

I had a sit-down meeting with Starne's assistant, Bob Sachs, and went over all the questions once again.

I decided that my preference would be to replace the mechanical with a tissue valve withe the caveat of letting Starnes make the final call as to what would give me the best outcome.

The valve that they recommend is the Carpentier-Edwards PERIMOUNT Magna Ease Aortic Heart Valve
http://www.edwards.com/products/heartvalves/pages/magnaease.aspx

Which allows for valve-in-vavle replace via TAVR when (if) necessary.

Wish me luck folks and thanks again for your comments!

Dean

 

[pellicle]

Wish me luck folks

best wishes for a smooth event and recovery

:thumbup:

 

[deanmenta]

Thank you!

 

[river-wear]

Good luck, Dean! You'll do great.

Hi

The USA is a high taxing country yet somehow manages to provide lower service levels to its constituents than say Germany, Norway, Sweden ...

Unfortunately we also have the highest expenditures for healthcare, while our life expectancy isn't any better (or even worse in some cases). The variability within the country is staggering too.

 

[pellicle]

Hi

Unfortunately we also have the highest expenditures for healthcare, while our life expectancy isn't any better (or even worse in some cases).

yes, I've noticed that too. I'm going to go with my gut here and suggest its related to (in no specific order)
* billing and over servicing (people don't pay, systems pay, people only pay the system which removes most of the benefits of a 'free market')
* modern diet in the US significantly contributes to obesity and diabetes and other health problems
* treatments keeping people alive longer when 60 years ago we (and I'm one of those) would have died earlier

I have no data on this, but recall being (at first) horrified with various stories of friends living in the USA for their hospital treatments. Even the breakdowns of specific things (like delivering a paracetamol to my friend) were just outrageous.

Its an interesting subject and one I'd like to actually learn more about