Will TAVR ever be a better choice than OHS for BAV?

[nate99]

Hello all,

I'm trying to be more proactive in understanding everything. To be upfront, OHS sounds intimidating to me, so i've been researching trying to find anyway that TAVR will somewhere down the line be a better option than OHS. In researching, I just don't see the possibility there, at least not in the current landscape. As intimidating as OHS sounds, I should probably try to get used to the idea that it will happen one day. Reasons:

First, for younger age Bicuspids like myself, it seems like there are just too many other issues (aortopathy, shape, etc.) that keep it from even being in trials to collect data.

Second, even if TAVR did work out for BAV, the biological valves will wear out and it is too early to tell if the TAVR valves will last even as long as the SAVR bio valves. Is there any possible way of doing TAVR with a mechanical valve? Doesn't sound like anyone is trying to do that. So given the limits of valve in valve procedures with diminishing returns, OHS and a mechanical valve seems to be an inevitability if you are having this done between 40 and 50.

There are a few stories that give me hope lately. There was a UW Medicine story recently (called "Saved by a fall - and a first anywhere procedure") in which Danny Dvir used a catheter to surgically cut a bicuspid valve into a tricuspid and then used TAVR to put in a biological valve. Sounds awesome, but again, after a certain amount of time that valve will need to be replaced. The ImaValve Project sounds cool, a bio valve that can repair itself, but again no mention of how long it would last. I read that in November, China did a retrievable TAVR.

All of these innovations sound awesome and I hope that somewhere down the line, more minimally invasive stuff that is safe and effective is available, but it doesn't seem like right now is that time.

I was encouraged by the quote by Dr. Deeb at Michigan Medicine: In 10 years, "We'll have a TAVR valve for patients with aortic insufficiency as well as those with a bicuspid valve. For patients with an aneurysm in the aorta, we might have TAVR endovascular stenting." In 20 years, he predicts the majority of aortic disease will be treated with TAVR.

Well, checking to see if what I have learned is correct and if anyone has anything else to add.

Thanks

Nate

 

[dick0236]

There will always be advances that "are on the horizon" or "just around the corner". If, or when, your time comes you will have access to the latest cutting age repair or replacement. My valve and the surgical procedure itself would be considered pre-historic today........but, guess what, I've lived with it successfully for over 5 decades. Stay "tuned in" to your condition and when the time comes get it fixed. By the time you may need surgery there is no telling what solutions might be available to you.

 

[pellicle]

Hi

to answer the question in the subject, it already is: IF you are (for instance) an 80 year old with a condition too frail to take surgery. It can also be so for someone (who I know) who was very ill from multiple cancer treatments and who had the option of death soon if you don't.

Everyone else its not ... may never be really ...

I'm trying to be more proactive in understanding everything. To be upfront, OHS sounds intimidating to me,

its hard for me to not say something unhelpful (very hard). As one who has had three OHS in my life, I know its tough. but if you sit there "worrrying" about it the it will simply become more of an imagined obstacle.

So my advice is to whipe the "emotional stuff" off your consideration table and just look at the outcomes. TAVR has inferior outcomes and higher risks for anyone under 70. A new breed of "don't care about you" Interventional Cardiologists are taking this procedure (intended for the weak and frail to give them a bit more life) and marketing it to the emotionally weak and frail for the purpose of gathering more evidence, more human trials and taking business off Cardiac Surgeons.

The other group who love this are the bean counters in insruance companies. They love it because its cheaper and if you stop taking the big picture (meaning, will it lead to more surgeries) then that alone makes it encouraging.

Reading your post (while I reply) I see you've found the same reasons I see:

All of these innovations sound awesome and I hope that somewhere down the line, more minimally invasive stuff that is safe and effective is available, but it doesn't seem like right now is that time.

I recently posted some comparisons on minimally invasive ... again its a marketing ploy and just as many who were promised it wake up to find "we needed better access" so you got normal.

Are you mechanically inclined? Have you ever worked on cars? If so you'll know that sometimes its just better, faster and less hassle to pull the thing out and work on it properly. If you have no experience with simple machines then you will have a struggle to really (fully) understand what I'm saying.

I was encouraged by the quote by Dr. Deeb at Michigan Medicine: In 10 years, "We'll have a TAVR valve for patients with aortic insufficiency as well as those with a bicuspid valve. For patients with an aneurysm in the aorta, we might have TAVR endovascular stenting." In 20 years, he predicts the majority of aortic disease will be treated with TAVR.

do a search and see how many years ago the same things were said ... more than ten.

My honest advice is just stop thinking about getting the "short cut" and ask yourself the important questions:

• how healthy are you
• how can you get healthier
• when things get closer nag them about "what is the likelihood of aneurysm" (for this is about the biggest driver of an unscheduled OHS - well except the tissue valve failing earlier)

I see people here say it again and again, there are no certainties. This is not true. If you are younger and have a bioprosthetic or a TAVR then it is a certainty: you will certainly need another operation (unless you die).
If you get a mechanical its not a certainty that it will last for your life, but at least you have some chance of that.

But again, I stress talk seriously about the chances of aneurysm ... if you're bicuspid valve then its higher.

Best Wishes

 

[pellicle]

in ten years we'll all be driving electric cars too ... (or so "they" say)

 

[Agian]

I personally think it's inevitable. TAVI, or something resembling it, that doesn't involve OHS.
The question is one of when (?)

 

[uncanni]

Interesting discussion. I'm six weeks out from OHS on my BAV. My thoughts: OHS may be effective, but it's a barbaric procedure in so many ways. Sometimes I think that for where we are technologically, we certainly lag behind in the field of medicine. Not that I'm not grateful to live during a time when the SAVR was available to me, but when I read about the high rates of afib after this surgery, I wondered why they haven't worked that out yet. OHS is incredibly traumatizing to the body... But I'd go through it again in a heartbeat...

 

[nate99]

uncanni's thoughts are pretty much how i feel about it. There's got to be a better way to achieve this in the future.

I have only been researching this stuff for a few weeks, so I'm unfamiliar with the dynamics of trying to take business from cardiac surgeons that pellicle mentioned. But i would think it reasonable that if it is possible that this life saving procedure could be done without stopping your heart for an hour and breaking your sternum, everyone involved would want that.

Yes, we are not there yet. I hope we will be one day, but i doubt it will be within my timeframe. Advancements take awhile, and it seems like they have OHS down pretty good. Greater than 99% success at Cleveland Clinic is no small feat.

Unless they can either find a way to TAVR a mechanical valve for everyone or TAVR indefinitely (without extreme cost to the patients), then i don't see how it can match a OHS/mechanical. Also, as pellicle pointed out, there is the additional concern of aortic aneurysm, which i don't think any TAVR addresses now

 

[Superman]

In my opinion (and that’s all it is), it all comes down to materials. Once there is a breakthrough in materials that allows someone to make a tissue or tissue like valve that can, in theory, outlast a native valve - TAVR will be the norm. Until then, business as usual.

I dont see it happening with bovine or porcine. It will have to be a tissue like man-made material or something grown from stem cells.

The above is a very uneducated guess of where things need to go.

 

[dick0236]

.........Unless they can either find a way to TAVR a mechanical valve for everyone or TAVR indefinitely (without extreme cost to the patients), then i don't see how it can match a OHS/mechanical.

You are asking and answering your own question. However, the current technology of TAVR makes it a very attractive possibility for the patient in their 70s+ who are not likely to need more than one TAVR redo.

 

[pellicle]

In my opinion (and that’s all it is), it all comes down to materials. Once there is a breakthrough in materials that allows someone to make a tissue or tissue like valve that can, in theory, outlast a native valve - TAVR will be the norm. Until then, business as usual.

agreed. I'd add to this the following "opinion"

The less you know about the underlying stuff the easier it is to weave a fictional narrative to explain why it should be like star trek.

The more you now about the underlying stuff the easier it is to see the pattern of people exploiting the ignorance of others for their own gain.

 

[pellicle]

uncanni's thoughts are pretty much how i feel about it. There's got to be a better way to achieve this in the future.

what if for the next 30 years there isn't?

and if you want to see trauma go watch orthapedic surgery

The biggest problem is that modern people are such total whimps. Have such distance from the actual world, force people (financially) to do the **** jobs (like slaughter house workers) but want their beef at a discount. Generally speaking I'm disgusted by modern western society.

.... But i would think it reasonable that if it is possible that this life saving procedure could be done without stopping your heart for an hour and breaking your sternum, everyone involved would want that.

well its cut and not broken, but if you understood the body and the immune system you may find that the 'obtuse solution" has less risk than the "apparently elegant one" (google the issues they have with catching debris when doing a TAVR from dislodged calcium just for a starter)

but yes, one day we'll probably have a medical system like on Star Treck, but that may be after you're dead, so my avice is to research the best practice that exists and when (if) you need a surgery then just go with that ...

..there is the additional concern of aortic aneurysm, which i don't think any TAVR addresses now

correct, that still requires OHS ... so while they have the covers off, why not replace the lot ... that's what they did for me on my third (although some USA hospital would probably have repaired the anuerysm and set me up for a certainty of a 4th operation (cos that'd be interesting to work on).

 

[nate99]

pellicle

I pretty much agree with everything you are saying. In the end what it comes down to is fear. We, obviously myself included are just scared of OHS. It's being taken apart and put back together. It's natural to want to find an alternative to a surgery that, despite the statistics, we instinctively feel we won't survive. I'm not proud of myself for being afraid. And maybe I'm in the bargaining phase that will eventually lead to acceptance.

I agree with what you say about society. I think we are trained to avoid unpleasant truths. To avoid thinking about death. Probably a lot of it is religion, which is the ultimate way to avoid believing in death. a lot of us never think about it until tragedy strikes. Even then there can be a disconnect to actually thinking that I myself will actually die. So now when I research OHS, it's like are you serious???? That will kill me!!! Something like TAVR seems safer instinctively even if it is actually not.

 

[mrfox]

One could spend a lot of time wishing surgeries were just a little better or that magical breakthrough which basically means the problem just goes away comes through in time. Hey, maybe it will happen for you, but what you're really doing is just wishing the problem away, something nobody could blame you for by the way.

Here's the thing: most people survive OHS. People in their 70s survive it, and go on to have years more life. It's not perfect but let's take a minute to be grateful for that and to believe we could easily be those survivors as well.

Nobody would choose to have one, but eventually it will become the best option for you and then you'll take i. And if by then TAVR is your best option you'll take that instead - and I guarantee you it'll come with its own set of issues and compromises!

 

[pellicle]

Hi

I'm not proud of myself for being afraid.

Equally not should you be ashamed. If we didn't experience fear bravery would have no meaning. We'd be automatons.

And maybe I'm in the bargaining phase that will eventually lead to acceptance.

I think that's spot on ...

Probably a lot of it is religion, which is the ultimate way to avoid believing in death.

That's a topic I best avoid, because my views on that don't sit well with all the prayer callers here... You can Google my views expressed here if you want.

I think your progress on the path to making peace with a decision is pretty good. So don't feel like I'm slamming you, so much as attempting to guide you through what I've already done.

See what the future brings when it becomes the present.

Best Wishes

 

[nate99]

Thanks, pellicle. I'm trying to come to terms with the future. Some days are better than others.

mrfox, thanks for chiming in, particular given your recent surgery. I'm very happy for you that you made it through without issues. You are an excellent example of handling a sudden surgery diagnosis bravely

 

[cldlhd]

in ten years we'll all be driving electric cars too ... (or so "they" say)

I don't think it'll happen in 10 years but I do think eventually most cars will be electric. I've also wondered if TAVR is going to be pushed by the insurance companies as it's surely cheaper.
I agree, sometimes when working on a car or the house I resist pulling a lit of stuff out even though it's almost always easier.

 

[nate99]

So aortic aneurysm is a major issue as it can lead to dissection which is a most painful and potentially fatal thing to deal with (do i have this correct?). Aneurysms can also develop independent of when valves go bad, correct? TAVR also does not currently have any way to deal with aneurysms. There is that quote I posted from that michigan doctor that speculated there would one day be endovascular stenting with TAVR for aneurysms in the future.

My question is what then happens currently if someone is elderly and considered really high risk for OHS and they start to develop an aneurysm? Is the risk of surgery just weighed against the risk of non surgery and that is it? I'm glad I gave up early in undergrad about being a doctor. I wouldn't be able to handle it. A person's life is mathematically determined and we are limited by whatever the current tech can do.

I have read repeatedly that this is a fast moving time for innovations in cardiac treatments. Can someone enlighten me on this?

It seems like OHS is still the best options for the vast majority of patients, and while refined it still stops the heart and is majorly invasive. Mechanical valves to me at least still seem like the best option. All things being equal I would take no more OHS over dealing with ticking noises and warfarin. Are there advancements with the mechanicals themselves I don't know about? I guess there is TAVR, but as pointed out that seems like it is only geared towards high risk without much consideration of how this can really benefit younger patients and BAV patients. I guess there are more biological valve choices? It just seems to me when I was a teen, the best option would have been OHS with a mechanical, and now that I'm middle aged the best option is still the same.

What are the innovations? Or maybe I'm just not seeing them as they don't apply to me?

 

[pellicle]

Hi

So aortic aneurysm is a major issue as it can lead to dissection which is a most painful and potentially fatal thing to deal with (do i have this correct?).

I'd phrase it as "Aortic aneurysm is a possible complication which if you don't bother to check up will sneak up on your by surprise as it has no symptoms"

car accidents are probably a more painful cause of death. Probably more likely in the general population. Cancer treatments (which my friend is undergoing now) are certainly a more painful treatment ... try looking at the glass seven eights full than the one eighth empty.

Aneurysms can also develop independent of when valves go bad, correct?

aneurysms grow at their own pace, which may slow. There is some evidence that the scar tissue of a surgery can slow them.

but they don't spring like a tiger from the bushes...

TAVR also does not currently have any way to deal with aneurysms.

nor does a regular valve replacement surgery ...

There is that quote I posted from that michigan doctor that speculated there would one day be endovascular stenting with TAVR for aneurysms in the future.

Science Fiction fan?

My question is what then happens currently if someone is elderly and considered really high risk for OHS and they start to develop an aneurysm?

man you put on a jetpack for going down that rabbit hole didn't you ... have you considered buying an old motorbike cheap and working on it?

Then they deal with that rare occurence on a case by case situatio. Myself I've not heard of an aneurysm develoing in an elderly person.

also by definition elderly people die ... its what happens after you are born, mature, age ... death (well, and taxes along the way)

Is the risk of surgery just weighed against the risk of non surgery and that is it?

of course it is ... risk analysis is one of the primary tools of surgery.

A person's life is mathematically determined and we are limited by whatever the current tech can do.

yes, its all stats ... read this and think about it:

http://cjeastwd.blogspot.com/2015/09/denial-or-delusion.html

I have read repeatedly that this is a fast moving time for innovations in cardiac treatments. Can someone enlighten me on this?

marketing jism ...

It seems like OHS is still the best options for the vast majority of patients

agreed

Mechanical valves to me at least still seem like the best option. All things being equal I would take no more OHS over dealing with ticking noises and warfarin.

agreed, although there have been leaps and bounds in management of warfarin (self testing) making it more appealing again:

Are there advancements with the mechanicals themselves I don't know about?

as that guy says (8 years ago now) "I don't see why any valve maker is going to invest millions to improve what we already have"

... I guess there are more biological valve choices?

unsure what you mean here ... I had a cryo preserved living tissue valve from a tissue typed donor ... got me 20 years ... less than a mechanical, but hey, in that time warfarin management improved (and so too did my brain).

It just seems to me when I was a teen, the best option would have been OHS with a mechanical, and now that I'm middle aged the best option is still the same.

saws axes are still a better option for cutting wood than your hands.

What are the innovations? Or maybe I'm just not seeing them as they don't apply to me?

what the hell do you want? We've had innovations out the wazzo for decades now ... there has to be a plateau eventually. From when I was born to right now its been amazing, were you born in your parents time you'd already be dead.

Its easy for kids to grow up accepting that "right now is as it always has been" but in my grandparents generation there was no "reticulated water" in many places (still isn't on a global scale) and electricity wasn't common (or cheap). Kiddies all think that its been like now forever (and history is just some weird place in books).

We live like Gods, we live better now than Kings and Emperors of just 100 years ago.

 

[nate99]

Thanks for your responses, pellicle.

Innovations I'm specifically referring to are related to heart valve treatments. As you have said though, it is mostly marketing talk. However, it does seem that there are innovations with types of tissue valves. I don't think it would be enough to make me not choose mechanical if i had to make the choice soon. Of course there are tons of advancements in technology for general society, the internet being one of them.

You are indeed correct that I have been going down the rabbit hole. It is not really healthy but there is a degree of compulsion there. But maybe you are right, i need more hobbies to get my mind off of things. Such changes aren't made instantly though, but I appreciate your desire for me to have a healthier life.

I was assuming that there were some advances made in open heart surgery in the last 20 years, but I guess they have just refined the technique so well.