NEWBIE: Needs advice

[W84Me]

My surgery was performed at Emory University Hospital in Atlanta. I’m not sure of the technical term, but they made a smaller incision in my chest, which made the healing process much easier and faster. They didn’t break open my chest as extensively as in a normal procedure. You definitely want to inquire about that.

It is called "Keyhole" surgery which is done more often in Europe. In the US, it is still pretty scarce. Will explore it on July 20 when I see the surgeon.

 

[V__]

I suspect the names of these types of surgery have changed over the years.

Could be. Could also be that there are two version of terminology in existence. (There is not "law" in English, or any other language, to use a consistent, unambiguous terminology ). My bias is to use what I see in medical literature, where OHS and "minimally invasive" terms are contrasted against each other, implying that they don't overlap.

When I had AVR I was initially told I was going to have "minimally invasive" open heart surgery

I ended up having a full sternotomy as the surgeon couldn’t access my aortic valve with the shorter “mini sternotomy”.

Sorry to hear that. It seems a few percent of "minimally invasive" cases result in a "conversion" to a full sternotomy. Which to me looks like a testament of how good the pre-surgery diagnostics is (that the fraction is so small). But these things happen. Hope the surgeon was proficient with the full sternotomy option.

 

[V__]

https://pubmed.ncbi.nlm.nih.gov/32961136/

Conclusions: Open CABG via sternotomy and MICS CABG approaches are associated with similar, excellent perioperative outcomes. However, MICS CABG was associated with fewer transfusions, shorter length of stay, and ∼$7000 lower hospital cost, a superior resource utilization profile that improves patient care and lowers cost.​

So are we doing it because it has better outcomes or enables cost savings?

There seems to be 2 different topics here. I’ll comment on them separately, to avoid long replies and confusion.

Not to be disagreeable, but I don’t see an evidence that the “minimally invasive” variant is more dangerous. Even in the paper you mentioned, the surgery duration parameters are listed as “also risk factors”, not the leading ones. In other words, it would seem reasonable to assume that both OHS and minimally invasive have their own sets of risk factors with different impacts. (Whether they are factored out and quantified in a given analysis, or not.) And that, if there were a real issue with either method, it would show up in the total risks (mortality or complications). But all the papers I looked at show them to be very similar. They all note that the duration tends to be longer for the minimally invasive (a disadvantage) and that the ICU and hospital stay is shorter (got to be a sign of advantage).

Here is one example, from a mitral valve meta-study :

Results: Ten studies involving 6792 patients (MICS: 3396 patients; Conventional: 3296 patients) met the eligibility criteria. In the pooled analysis, MICS significantly reduced the risk for blood transfusion (odds ratio [OR], 0.654; 95% confidence interval [CI] 0.462-0.928; P = .017) and readmission within 30 days after discharge (OR, 0.615; 95% 0.456-0.829; P = .001). MICS was associated with a significantly longer cross-clamp time (mean difference 14 minutes; 95% CI, 7.4-21 minutes; P < .001), CPB time (24 minutes; 95% CI, 14-35 minutes; P < .001), and total operative time (36; 95% CI, 15-56 minutes; P < .001), but a significantly shorter ICU stay (-8.5; 95% CI -15; -1.8; P = .013) and hospital stay (-1.3, 95% CI -2.1; -0.45; P = .003). This meta-analysis found no significant difference regarding the risk of in-hospital and long-term mortality, nor complications.

Conclusions: Despite longer operative times, MICS for MVRp reduces ICU and hospital stay, as well as readmission rates and the need for transfusion.

It’s also true that the risks are already so shockingly small, that reducing them further or comparing different methods is rather difficult, just because of the statistics required and of the different biases to account for in the data analysis.

 

[V__]

I often write that patient preference drives things but in the case of Minimally Invasive surgery its a 1 2 punch where the surgeon is second (perhaps pushed aside) to the ideas of patients (who clearly don't have a clue about any of this when its their first time and the real bosses, the bean counters.

If I read your post correctly, your are implying that the surgeons are forced to use a method that patients ask for?

If this is the case, this would indeed look quite dangerous, in the sense of “managing risks”:

• The methods are significantly different, in terms of tools and techniques used. The process is obviously complex, with few hundred micro-manipulations involved.
• Valvular surgeries are considered a sub-specialty – a different class, compared to, say, the bypass (CABG). Which is more of “bread and butter” type, since it occurs so often.
• Then there is a need for constant practice and initial learning. From https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.112.001402 “The typical number of operations to overcome the learning curve was between 75 and 125”

So asking a surgeon who is not practicing the minimally invasive method to do such surgery is asking for higher risk. Seems dangerous.

However, if the surgeon is used to minimally-invasive method, I would not ask them to do OHS either, for the same reason of needing skills and constant practice to maintain them.

So, I’d think that choosing the method is not so applicable for many people, unless one has time and means to choose different surgeons. It’s probably the best to choose the best surgeon and center, if there is choice at all.

Finally, I “only” had 1 surgery, and you could consider me biased. Didn’t ask for the minimally-invasive method, but my surgeon just happened to practice it, since his general surgery days. So, after asking him about the experience, volume of surgeries, and outcomes, I was more than happy to go for it. At that time my primary objective was the long-term outcome. However, I came to appreciate the shorter recovery time, since it mean less burden on my family and shorter work absence. And, I’d imagine that for people with other health issues, or “just out of shape” this could be even more important. So my impression is that, in an ideal world, the minimally-invasive method has its own time and place even if it has exact same long-term outcome as OHS.

 

[pellicle]

Hi

Not to be disagreeable, but I don’t see an evidence that the “minimally invasive” variant is more dangerous.

firstly, I don't think what you've written is "disagreeable" but just a discussion. However I think you've distorted what I said somewhat. I did not say "more dangerous" I just suggested of no significant benefit.

Further, if you dig into it, there are a number of occasions (yes, even reported here) when they say we can do minimal invasive only to find "when in there" that they can't and end up needing a better view and doing full sternotomy.

The point I am making is that its a nothing which people seem to get worked up about as if it was crucial.

 

[pellicle]

and to get on to the next part:

Finally, I “only” had 1 surgery, and you could consider me biased.

no, I'd consider you may not have had a lot of experience and I'd say there was a possibility that after having had this most of my life (like at 10yo, 28 and then 48) as well as over 10 years of discussions here I've probably had a lot more experience in thinking about this, reading about this, conversations with surgeons and personal recovery experience.

If I read your post correctly, your are implying that the surgeons are forced to use a method that patients ask for?

"forced" again is a strong word, but lets just say that in some countries its all about making money and attracting clients. In some countries they allow predatory advertising and "inform" people directly based on the manufacturers desire for sales (Edwards is quite prolific at this). Such direct to patient advertising is not the norm in every country (it is for instance illegal in some), after all the patients usually know less than nothing about the topic.

So one the patient has recovered from the shock they set about reading on google what is the way to (in their minds) minimize this whole horror show. Any little thing is blown out of proportion frequently in the pre-surgical minds of people.

I've even seen <40yo's wanting to pay CASH (yes, in the USA) to get a someone to do TAVR on them (even though that wasn't approved).

So people will go somewhere else (shop around) if they feel that doing a bioprosthetic minimally invasive (robot surgery was widely discussed a few years back) at that age of 30 because they are "traumatised" by the idea of surgery.

So what I'm saying is don't under estimate the emotional reactions to things.

Hope that clarifies my position a bit.

If I may ask, what field are you a "scientist" in?

Best Wishes

 

[carolinemc]

did you not start the warfarin for 3 years?

I have been on warfarin for more than three years. I made an error, I was 36 when I had me valve replaced, but you made up 3 years. My surgery was in 2001, been on warfarin since 2001, not three years. You need to read the comments a little better. Now I am corrected how old I was in 2001. And started on the blood thinner at that time. Had not problems before to take it before surgery. Have a nice day and read the comment a bit better.

 

[V__]

firstly, I don't think what you've written is "disagreeable" but just a discussion.

Happy to hear that this is your view

However I think you've distorted what I said somewhat. I did not say "more dangerous" I just suggested of no significant benefit.

Sorry for that, it wasn't intentional. And thanks for the correction.

Further, if you dig into it, there are a number of occasions (yes, even reported here) when they say we can do minimal invasive only to find "when in there" that they can't and end up needing a better view and doing full sternotomy.

TEE is done during the surgery to provide more "view". From my memory of the papers I've read, the rate of conversion to full sternotomy is a few percent. Seems to be the case of "we found another problem to take care of" (*), rather than "we want to look at something else". To me, this seems to be a low rate, underscoring the highly definitive pre-surgery assessment of the problem(s).

(*) There are limitations to the minimally-invasive approach, e.g. doing CABG at the same time as valve operation is better with the full sternotomy.

 

[V__]

lets just say that in some countries its all about making money and attracting clients. In some countries they allow predatory advertising and "inform" people directly based on the manufacturers desire for sales (Edwards is quite prolific at this).

The hint is well taken, and I see how it could lead (and did lead) to abuse of drugs. Would hope that surgeons, who have to care for their reputations and statistics, are not easily swayed by unusual suggestions.

So what I'm saying is don't under estimate the emotional reactions to things.

Why would I?

Had enough trouble calming down friends and family, who clearly had an idea that the cardiac surgery is dangerous. (The risk used to be much higher in the past, and maybe this old notion lives on.) And they were not perceptive to the notion that 1% risk is "small". Even though I think people rarely worry about such risks in other scenarios (or identify them).

Could think of 2 examples:
- The acute peritonitis also has 1% risk, but it got to be a much simpler surgery.
- A past PCP mentioned that acid reflux has 5-10% chance of causing an esophagus cancer. Which has no symptoms until a very late stage, when it's hard to cure. And I don't think people like to worry about the acid reflux.

But I hope that, in spite of the anecdotal evidence of the frightened patients looking for unreasonable treatments, the medical establishment can do their job.

If I may ask, what field are you a "scientist" in?

I'm not sure if this is relevant at all. But it's not biology or medicine.

 

[pellicle]

Hi

But I hope that, in spite of the anecdotal evidence of the frightened patients looking for unreasonable treatments, the medical establishment can do their job

Understand

I'm not sure if this is relevant at all. But it's not biology or medicine.

It isn't actually, but it was all there was in your bio.

I actually have less and believe it's the strength of the arguments that matters, not the qualifications. Sometime the education is an indicator, frequently it's not.

Best regards

 

[Mister_James]

This is not true.

Mechanical valves do have a reported life span, typically 20-30 years. Although rare, they also may need to be replaced sooner due to structural dysfunction, endocarditis, and various other reasons. In fact, I personally know someone who recently just had both their AV and MV St Jude valves replaced with tissue valves due to pannus in both valves (Dr. said pannus was due to under anti-coagulation).

Structural dysfunction, endocarditis, pannus are not restricted to mechanical valves. They are related to all valve surgery.
Mechanical valves have no wear and tear that requires replacement.
The point is bioprosthetics wear out and calcify over time and these other valve risks are in addition.
Mechanical IS forever.

 

[W84Me]

I was reading a research paper relating to biological and mechanical valves. It has put me in a state of dilemma now. According to the paper’s schematics, I should get a tissue valve not mechanical valve. It highlights some freaky things about mechanical valve. I am attaching three graphs here but I would suggest everyone to read the paper which is not very long.

Any input is highly welcome. As my appointment date is approaching (on July 20) with the surgeon, I am feeling progressively more informed. Many thanks to you all for enriching me.

 

[jeffp]

Just for grins and giggles I put my personal situation into the algorithm chart: 50 y/o at time of surgery, MVR, no other health issues. It’s missing important branches of the decision tree. The options for not at risk of TE are either life expectancy “very short” or “<10-15 yrs”. I’m already 18 years out and still clicking. There’s no branch on the decision tree for me.

I have to disagree with the “research” (now 13 years old). His methodology seems to be based on mostly extrapolated actuarial data on Medicare (>65 y/o) patients and post-mortem cause of death data. There’s a fairly obvious bias lean throughout the paper against chronic oral anticoagulant therapy.

My favorite was figure 2. He’s got an 8 year MVR survival rate of 45% for St. Jude’s type valve and 55% for Starr-Edwards (come on, what is this, 1960? Ball and cage valve as the comparison? And as the better performer at that? In the mitral position?).

Just because it got published, doesn’t make it relevant or reliable.

My vote is not to use this in your decision making. (Unless you’re very old and have one foot in the grave health wise already. Nah… not even then.)

 

[W84Me]

Good points.

pellicle:

Here is my Lp(a) level. The way I see it, the number should be equal to or less than 29 whereas mine is slightly elevated at 31. Some websites say that the normal is up to 30. Please share your thoughts.

 

[V__]

it was all there was in your bio.

Should say I'm not quite sure what you refer to as a "bio". I did put a few bits in the profile (assuming it's a brief reference), and posted an intro. Happy to do something else or adjust them, if it helps.

 

[V__]

I was reading a research paper relating to biological and mechanical valves. It has put me in a state of dilemma now. According to the paper’s schematics, I should get a tissue valve not mechanical valve. It highlights some freaky things about mechanical valve. I am attaching three graphs here but I would suggest everyone to read the paper which is not very long.

Any input is highly welcome. As my appointment date is approaching (on July 20) with the surgeon, I am feeling progressively more informed. Many thanks to you all for enriching me.

Figure 2 is hard to understand. I briefly looked up the paper. The figure is taken from another publication, where re-operation risk and bleeding risk are factored out:

As you can see, the reoperation risk very much favors the mechanical valve, at any age. I still don't understand why the MV lifetime bleeding risk rises with age, but I'm not an expert here.

However, as jeffp said, the publication quality varies. (Which is why they do "meta-studies" in medicine, to figure out the conclusions from publications that vary in quality.)

For example, here is another publication, where, from the point of view of mortality and reoperation the choice may look very differently:

(Yes, "mortality and reoperation" are different factors, compared to "reoperation and bleeding". I guess you'd have to choose what's important to you. And maybe find other/recent meta-studies.)

 

[pellicle]

Hi

I was reading a research paper relating to

Well I suspect you may not have much experience reading this sort of material. So let me put in a few pointers if I may.

Firstly its important to remember what journal you are reading from, this indicates its target audience. Then its important to understand what is being written about, this author isn't writing up research outcomes they are writing up their opinion of research outcomes in a Journal of Cardiology; importantly not a journal of Thoracic Surgery.

In this update, a few issues are re-emphasized; however, the major thrust is on newer​

findings that have had an impact on the choice of PHV.​

The author apparently loves to put in "conclusions" on every section, suggesting that each section is unrelated to the others. Strange that there are 8 "conclusion" sections.

Conclusions. When comparing outcomes with different PHVs, it is important to: 1) ensure that the baseline characteristics of the patients and their comorbid conditions are the same, or are at least very similar, which can be best determined by a good prospective randomized trial (14); and 2) determine cause of death when comparing survival after PHV replacement.​

that seems more like simply good advice to anyone who doesn't have a clue about research and trying to determine validity ... I wonder if he's talking about himself?

Conclusions. Mechanical PHVs that are approved by the Food and Drug Administration (FDA) and have good and comparable outcomes at >=15 to 20 years of follow-up will likely have good outcomes on very long-term follow-up.​

really ... wow ... and pray tell which valves in replacement are used which are not approved by the FDA? Further which studies are actually available showing 15 to 20 year follow up? Please show me a few. Because all the ones I've seen that claim that have in the detail something like "mean paitient follow up ~7.5 years" or something like that

Conclusions. In 2000, Ross advised the terminology “Ross procedure” should not be used because what surgeons are doing is not what he described; instead, it should be called the “Ross Principle”​

not much of a conclusion, but I agree with this (and I'm as it happens no fan of the Ross and believe its got highly specific criteria where its successfull ... ask Arnie)

Conclusions. At present, the choice of PHV in most clinical situations is between a mechanical PHV and a stented bioprosthesis. An important determining factor in the choice between these 2 PHVs is which of the 2 complications, anticoagulation therapy or SVD, one wants to avoid.​

I'm just going to FacePalm this one ... I think anyone who's read anything at all knows this. Its like PHV 101

Conclusions. Anticoagulants are essential with the use of mechanical valves, and can be instituted and maintained in many patients with low risk. The disadvantages include lifetime needs of therapy and tests, difficulties in initiating and maintaining an adequate INR in many patients, and major risks of bleeding​

more PHV101, its like word salad and if anyone didn't know all of the above, then they should not be practicing.

Frankly so far I'd have just dumped this as word salad with a bunch of pretty pictures which are largely meaningless. So I'm not going to go citing and criticising his poor writing.

Some worthy mentions of weird is his use of combined metrics

What an outstandingly strange metric: the risk or reoperation and major bleed all rolled into one metric (which should use OR not AND).

It's like the risk of car engine failure and flat tyre in a car.

Totally different and unrelated events. When you see something like that it's a red flag for either incompetency or a other agenda. I find it interesting how few cardiologists are actually interested in the nitty gritty of INR management. None I've met have ever even been involved with it, yet all are clear that Time in Therapeutic Range (TTR) is critical for good outcomes. The above seems to accept that there will not be adequate TTR and the ignored elephant in the room is "how can we improve TTR" ... Did I refer you to this presentation by a Dr Schaff from the Mayo?


if I didn't please grab a coffee and go through it. However the absolute minimum Too Long Didn't Read it is this bit:



So there you have a premier Thoracic Surgeon saying TTR is crucial for success in mech valves. Its so simple its ludicrus.

I'm going to point you at what we try to instil in our University undergraduates (in the USA there is this strange idea of calling Universities by two names, University (eg UCLA) a Colleges (can't think of a University that calls itself a College). In Australia we just call them Universities.

Critical thinking isn't just "Deny and rebuke everything" it is "Read, undertake a moments reflection and consider". Monash Uni has a great page (I didn't go to Monash, I've done degrees from other universities here in Queensland) on Critical Thinking

https://www.monash.edu/learnhq/enhance-your-thinking/critical-thinking/what-is-critical-thinking

What is critical thinking?​

Critical thinking is not about being negative. The term critical comes from the Greek word kritikos meaning discerning. So critical thinking is a deeper kind of thinking in which we do not take things for granted but question, analyse and evaluate what we read, hear, say, or write. It is a general term used to identify essential mindsets and skills that contribute to effective decision making. While there are many definitions for critical thinking, here is one that covers its essential aspects:​

In summary my opinion is that that paper was not even toilet worthy.

Lastly (since I mentioned the Ross) let me link you to an "critical analysis" I wrote up some years back to demonstrate the method of reading articles meant for scientific publication (link).

I hope this helps.

 

[pellicle]

I'm not quite sure what you refer to as a "bio".

sorry, using old terminology ... I'm calling the "About" section, your personal information, your Biography (and abbreviating that to bio).

Its actually a very useful part of your participation here because

• when someone asks a question others can refer to it to see the persons basic releveant "medical history" to answer a question Eg because you have a Mitral V repair not a MV replacement I can infer that you may not be on warfarin and may not have the usual recommended INR Target of INR = 3
• when someone is answering a question, a reader can refer to that to see what the person may know and may have experience in or what may in general be related to their perspective on an answer.

It can be accessed conveniently from the thread this way

HTH

 

[Gkeraney]

sorry, using old terminology ... I'm calling the "About" section, your personal information, your Biography (and abbreviating that to bio).

View attachment 889338

Its actually a very useful part of your participation here because

• when someone asks a question others can refer to it to see the persons basic releveant "medical history" to answer a question Eg because you have a Mitral V repair not a MV replacement I can infer that you may not be on warfarin and may not have the usual recommended INR Target of INR = 3
• when someone is answering a question, a reader can refer to that to see what the person may know and may have experience in or what may in general be related to their perspective on an answer.

It can be accessed conveniently from the thread this way
View attachment 889339

HTH

is it possible the rising trend of bleeding risk is simply the number compounding over time? And I also wonder about elderly getting just a little more sloppy with their meds, and or that sloppiness being more likely to lead to events. Perhaps its just the vessels becoming stiffer or humans start having more trouble dealing w blood that is 3x thinner.

 

[pellicle]

Hi

is it possible the rising trend of bleeding risk is simply the number compounding over time?

it is, but this set of points is as I see it

• as my father (in particular but everyone I know) ages you become more prone to bleeds. Dad is my control on this because he wasn't ever on anticoagulants
• there is no evidence to show that well controlled ACT increases bleeds in age corrected general population (and this "survey opinion piece" makes no real mention of well controlled ACT leaving me to ask why not)
• the chances of reoperation in any valve fall of dramatically as you age because not only will there be less influence from SVD but if you have a PHV at 68 then the present average US male life expectance is 77.2 years meaning the valve only has to last 9 years: meaning that if you die of other causes before the valve fails then the bioprosthesis will be weighted higher in not having failed. So while the mechanical didn't fail either we would expect to see a raise in the index due to bleeds and inadequate ACT monitoring (low TTR)

That's as I see it.

I observe that it always takes more words to say why "it isn't aliens" than to just say "the pyramids were built by aliens". Such a practice is usually also employed by "used car salesmen".