20 ms·

Transcatheter aortic valve replacement effective in younger, healthier patients

137 points by matt4077 8y ago

loopycode 8y ago
Cool
ignoramous 8y ago
/offtopic This article reminds me of Steve Yegge's dad and his experience with heart failure and having to go through a bypass surgery, post which, unfortunately, his femoral artery [0] burst, compounding more hardships on what had been an already tough ordeal. He wrote a letter to the hospital staff once he was back living his normal life: https://sites.google.com/site/steveyegge2/really-no-big-deal https://sites.google.com/site/steveyegge2/really-no-big-deal -- [0] https://en.wikipedia.org/wiki/Femoral_artery#Clinical_significance https://en.wikipedia.org/wiki/Femoral_artery#Clinical_signif...
- snazz 8y ago
  That letter’s wonderful. It was the first time I’d read it and I’m really glad I did. It’s funny, slightly sad, and really well-written.
sverige 8y ago
I had open heart surgery for repair of an aortic aneurysm. I also inherited the same wanky bicuspid aortic valve that has contributed to the death of at least one person (and usually more) in each of the last four generations of my family. For some reason, the heart surgeon decided not to replace it when he had me opened up. Maybe I'll have the joy of undergoing another $160k operation to fix the valve using this technique. By the way, in case you're wondering, open heart surgery kind of sucks. I wouldn't recommend it unless you absolutely need it.
- tehlike 8y ago
  Not sure what kind of insurance you have, but it might make sense to go to european countries for surgery.
  - Waterluvian 8y ago
    How does this work if you're not a citizen or resident? Do you just pay cash?
    - Brakenshire 8y ago
      I don’t know, but it may well make sense. Private treatment often is quite reasonable because the alternative is free. You can get a private self-referral MRI for instance for £200-400 in the UK. I haven’t heard of people coming from the US for treatment though, only about people from the UK going to Poland for dentistry, which apparently is cheap and good quality.
      - sverige 8y ago
        I ended up paying $8k out of pocket after my pretty good insurance paid out. I'm still astonished at the overall cost, though.
        randerson 8y ago
        $160K sounds cheap to me if you're in the US. I had a heart ablation a few years back for an irregular heart beat. Like the procedure in the article its minimally invasive where they go in through the groin to zap some electricity at a few cells in the heart. I was conscious throughout and was back at work the next day. They billed $400K for that, and insurance negotiated it down to around ~$120K. For something as complex as what you've mentioned I'd have expected 7 figures.
        tehlike 8y ago
        what did you end up paying?
- jedberg 8y ago
  > I wouldn't recommend it unless you absolutely need it. Ask your doctor if open heart surgery is right for you! (If your local cardiologist advertised on TV)
  - carbocation 8y ago
    There was an ad for Impella (a form of mechanical circulatory support - basically advanced life support) during the Super Bowl 1-2 years back [1]. Which is basically even more absurd than advertising aortic valve replacement... 1 = https://www.ispot.tv/ad/ArZf/protected-pci-impella-25 https://www.ispot.tv/ad/ArZf/protected-pci-impella-25
  - sverige 8y ago
    Well, I would say if you are given a choice of a procedure like the one described in the article or open heart surgery, choose the less invasive one. Although in my experience, they don't really consult with you about what you'd prefer so much as tell you what they are going to do.
- robbiep 8y ago
  Aortic valve disease is bi (Tri- for unileaflet but that usually presents at about 5-10 years) modal; trileaflets around 70-80, bileaflets at 40-50. There are quite good reasons to not replace, not least of which is that replacement valves are nowhere as good as your native, particularly if it’s still functioning. Ie if metallic, you need to be on anticoagulants for life which can be a massive pain and cause other complications. Metallic last for around 30 years. If porcine/bovine or possibly human, then they degrade much faster, 10-15 Years is the average. So, depending on your age, and depending on the repair your aorta needed, the surgeon likely decided that since you will have to undergo the knife at some point again anyway (either for graft replacement for the Dacron that now makes up the proximal part of your aorta) or eventually due to the valve, you might as well minimise the complexity by only doing one thing at a time. Plus, since we first started doing TAVIs (transcutaneous aortic valve repairs) they are getting better and better - see article - so possibly you wouldn’t need the on-pump surgery. Interesting that it costs you $160k; in the Australian public health system a valve is about $30k. Source: I did my honours thesis on cardiothoracic surgery (actually on mitral valve repair, but spent a lot of time in cardiothoracic theatres dealing with aortic valve-disease)
  - sverige 8y ago
    Thank you for the very informative reply. Frankly I didn't have the energy to really quiz my very excellent surgeon on all the details. I was pretty low energy at the time. I was relatively young for the surgery, mid-50s, so I don't doubt that that was a factor. I'm not sure a valve will cost $160k. That was the cost of open heart surgery with a double bypass and aortic aneurysm repair. I ended up paying about $8k of that after the insurance did its part. I would definitely prefer a less invasive procedure. Recovery would probably take less than five months, for example.
    - Gibbon1 8y ago
      > I was relatively young for the surgery, mid-50s, so I don't doubt that that was a factor. Ex-gf's ex husband needed a valve replaced at 25 due to damage from an infection. That lasted 15 years. So at 40 he had to have it replaced again. And at 55 he died because they can only do it twice. So yes I suspect your surgeon wanted to push that as far into the future as possible. And every decade that passes is an opportunity for better treatment. > I would definitely prefer a less invasive procedure. Cross fingers. My friends brother is a young[1] cardiac surgeon that does really whack less invasive valve replacements. So this stuff is becoming available. [1] Gosh he's like in his only his late thirty's!
- ludicast 8y ago
  I'm not a doctor, but I have had valve-sparing aortic root replacement surgery done myself. think the reason the valve wasn't done was maybe 1) it's a big decision that the surgeon might not have felt comfortable making 2) there are safer valve replacements coming out (neither metal nor animal) that the FDA (in America) should eventually be approving. This caused one surgeon I'd spoken to to wisely delay the decision. Perhaps this article is describing the specific valve but it seemed to be metal. 3) I dont know how bad the regurgitation is on the valve, it might not have been time My 0.02 - see the absolute best surgeon you can get for this (in NYC his name is Takayama, don't know where you are). And depending on your root/valve dance, get a "gated ct-scan" rather then a run of the mill that most doctors recommend.
- rscho 8y ago
  From personal experience, I would say that one should generally be most thankful if the surgeon decided to not do something. Surgeons are the kind of people you generally need to restrain, not encourage. That said, I wish you the best.
et2o 8y ago
TAVR is a remarkable advance. Interventional cardiologists are taking away lots of cardiotoxic surgery volume, and it's great for patients because it's much less invasive.
fernly 8y ago
I had an "aortic root reconstruction" by open heart surgery about 18 years ago, and my animal-tissue valve will no doubt need replacement sometime reasonably soon. At that time, I made the optimistic prediction that by the time I needed a replacement, they will be able to grow me a new valve from my stem cells, and install it laparoscopically. Well, 50% ain't bad, I guess.
- justinjlynn 8y ago
  Progress seems to always be extremely slow, and then it just happens remarkably fast. The scary part is you never know when the punctuated equilibrium will flip. Take CRISPR for example... sheesh. You never know when they'll figure out scaffolding, could be sooner than you think. Could be later. Hopefully sooner.
- deleted 8y ago
  [deleted]
superbaconman 8y ago
I found out a few years back I've been living with ebstein's. I was surprised at the time to learn just how limited we are when it comes to heart surgery... It all seems to last 10-15 years and that about it. I'm glad to hear things are progressing for younger patients, but there's so much more work to be done.
dmead 8y ago
I'm 'young' and getting my second open heart surgery soon. Headlines like this are slightly misleading in that you have to have a pathology that will support tavr. In my case, I have a dilation of the annulus that apparently makes it less likley that a tavr valve can find a basis to stay in place. It has to be sown in.
tuukkah 8y ago
Note that 'younger' in the title refers to people in their 70s as opposed to 80s, so perhaps confusing on Hacker News. From the article: > Aortic valve replacements have been performed for decades, and surgeons know the valves placed during surgery last at least 10 to 15 years. It remains to be seen if TAVR valves will fare as well. The question is especially important for younger patients. The average age of subjects in the current studies was the low to mid 70s, younger by a decade or more than most patients getting TAVR now. If anyone here needs a new aortic valve, you might also want to read about the latest results on the less-known Ross procedure and whether it might be suitable in your situation. It's been a thing since the 1960s especially for young patients (children) but I hadn't even heard of it until last year: https://en.m.wikipedia.org/wiki/Ross_procedure https://en.m.wikipedia.org/wiki/Ross_procedure Ouzounian, Maral et al. 2017. The Ross procedure is the best operation to treat aortic stenosis in young and middle-aged adults. The Journal of Thoracic and Cardiovascular Surgery https://www.jtcvs.org/article/S0022-5223(17)31124-8/fulltext https://www.jtcvs.org/article/S0022-5223(17)31124-8/fulltext
Tharkun 8y ago
> “Open-heart surgery, particularly in low-risk patients, is very profitable,” Dr. Herrmann said. Sheesh. For-profit hospitals are a foreign concept to me. Seems incredibly cynical to crack open someone's chest, leaving them with a very slow and painful recovery, to then think about profit instead of patient welfare.
- yostrovs 8y ago
  Do you think the same about farmers who optimize profits on something that sustains life itself? Doctors just make you feel better and extend life a few years at best. Farmers, though, they make you tick every day.
fellowniusmonk 8y ago
Due to congenital defect I have a bicuspid valve that will have to be replaced before I'm 55, likely in the next 10-15 years, innovation can't come soon enough.

137 points by matt4077 8y ago

Cool

/offtopic This article reminds me of Steve Yegge's dad and his experience with heart failure and having to go through a bypass surgery, post which, unfortunately, his femoral artery [0] burst, compounding more hardships on what had been an already tough ordeal. He wrote a letter to the hospital staff once he was back living his normal life: https://sites.google.com/site/steveyegge2/really-no-big-deal https://sites.google.com/site/steveyegge2/really-no-big-deal -- [0] https://en.wikipedia.org/wiki/Femoral_artery#Clinical_significance https://en.wikipedia.org/wiki/Femoral_artery#Clinical_signif...

snazz 8y ago
That letter’s wonderful. It was the first time I’d read it and I’m really glad I did. It’s funny, slightly sad, and really well-written.

sverige 8y ago

I had open heart surgery for repair of an aortic aneurysm. I also inherited the same wanky bicuspid aortic valve that has contributed to the death of at least one person (and usually more) in each of the last four generations of my family. For some reason, the heart surgeon decided not to replace it when he had me opened up. Maybe I'll have the joy of undergoing another $160k operation to fix the valve using this technique. By the way, in case you're wondering, open heart surgery kind of sucks. I wouldn't recommend it unless you absolutely need it.

tehlike 8y ago
Not sure what kind of insurance you have, but it might make sense to go to european countries for surgery.
- Waterluvian 8y ago
  How does this work if you're not a citizen or resident? Do you just pay cash?
  - Brakenshire 8y ago
    I don’t know, but it may well make sense. Private treatment often is quite reasonable because the alternative is free. You can get a private self-referral MRI for instance for £200-400 in the UK. I haven’t heard of people coming from the US for treatment though, only about people from the UK going to Poland for dentistry, which apparently is cheap and good quality.
    - sverige 8y ago
      I ended up paying $8k out of pocket after my pretty good insurance paid out. I'm still astonished at the overall cost, though.
      - randerson 8y ago
        $160K sounds cheap to me if you're in the US. I had a heart ablation a few years back for an irregular heart beat. Like the procedure in the article its minimally invasive where they go in through the groin to zap some electricity at a few cells in the heart. I was conscious throughout and was back at work the next day. They billed $400K for that, and insurance negotiated it down to around ~$120K. For something as complex as what you've mentioned I'd have expected 7 figures.
        tehlike 8y ago
        what did you end up paying?
jedberg 8y ago
> I wouldn't recommend it unless you absolutely need it. Ask your doctor if open heart surgery is right for you! (If your local cardiologist advertised on TV)
- carbocation 8y ago
  There was an ad for Impella (a form of mechanical circulatory support - basically advanced life support) during the Super Bowl 1-2 years back [1]. Which is basically even more absurd than advertising aortic valve replacement... 1 = https://www.ispot.tv/ad/ArZf/protected-pci-impella-25 https://www.ispot.tv/ad/ArZf/protected-pci-impella-25
- sverige 8y ago
  Well, I would say if you are given a choice of a procedure like the one described in the article or open heart surgery, choose the less invasive one. Although in my experience, they don't really consult with you about what you'd prefer so much as tell you what they are going to do.
robbiep 8y ago
Aortic valve disease is bi (Tri- for unileaflet but that usually presents at about 5-10 years) modal; trileaflets around 70-80, bileaflets at 40-50. There are quite good reasons to not replace, not least of which is that replacement valves are nowhere as good as your native, particularly if it’s still functioning. Ie if metallic, you need to be on anticoagulants for life which can be a massive pain and cause other complications. Metallic last for around 30 years. If porcine/bovine or possibly human, then they degrade much faster, 10-15 Years is the average. So, depending on your age, and depending on the repair your aorta needed, the surgeon likely decided that since you will have to undergo the knife at some point again anyway (either for graft replacement for the Dacron that now makes up the proximal part of your aorta) or eventually due to the valve, you might as well minimise the complexity by only doing one thing at a time. Plus, since we first started doing TAVIs (transcutaneous aortic valve repairs) they are getting better and better - see article - so possibly you wouldn’t need the on-pump surgery. Interesting that it costs you $160k; in the Australian public health system a valve is about $30k. Source: I did my honours thesis on cardiothoracic surgery (actually on mitral valve repair, but spent a lot of time in cardiothoracic theatres dealing with aortic valve-disease)
- sverige 8y ago
  Thank you for the very informative reply. Frankly I didn't have the energy to really quiz my very excellent surgeon on all the details. I was pretty low energy at the time. I was relatively young for the surgery, mid-50s, so I don't doubt that that was a factor. I'm not sure a valve will cost $160k. That was the cost of open heart surgery with a double bypass and aortic aneurysm repair. I ended up paying about $8k of that after the insurance did its part. I would definitely prefer a less invasive procedure. Recovery would probably take less than five months, for example.
  - Gibbon1 8y ago
    > I was relatively young for the surgery, mid-50s, so I don't doubt that that was a factor. Ex-gf's ex husband needed a valve replaced at 25 due to damage from an infection. That lasted 15 years. So at 40 he had to have it replaced again. And at 55 he died because they can only do it twice. So yes I suspect your surgeon wanted to push that as far into the future as possible. And every decade that passes is an opportunity for better treatment. > I would definitely prefer a less invasive procedure. Cross fingers. My friends brother is a young[1] cardiac surgeon that does really whack less invasive valve replacements. So this stuff is becoming available. [1] Gosh he's like in his only his late thirty's!
ludicast 8y ago
I'm not a doctor, but I have had valve-sparing aortic root replacement surgery done myself. think the reason the valve wasn't done was maybe 1) it's a big decision that the surgeon might not have felt comfortable making 2) there are safer valve replacements coming out (neither metal nor animal) that the FDA (in America) should eventually be approving. This caused one surgeon I'd spoken to to wisely delay the decision. Perhaps this article is describing the specific valve but it seemed to be metal. 3) I dont know how bad the regurgitation is on the valve, it might not have been time My 0.02 - see the absolute best surgeon you can get for this (in NYC his name is Takayama, don't know where you are). And depending on your root/valve dance, get a "gated ct-scan" rather then a run of the mill that most doctors recommend.
rscho 8y ago
From personal experience, I would say that one should generally be most thankful if the surgeon decided to not do something. Surgeons are the kind of people you generally need to restrain, not encourage. That said, I wish you the best.

et2o 8y ago

TAVR is a remarkable advance. Interventional cardiologists are taking away lots of cardiotoxic surgery volume, and it's great for patients because it's much less invasive.

fernly 8y ago

I had an "aortic root reconstruction" by open heart surgery about 18 years ago, and my animal-tissue valve will no doubt need replacement sometime reasonably soon. At that time, I made the optimistic prediction that by the time I needed a replacement, they will be able to grow me a new valve from my stem cells, and install it laparoscopically. Well, 50% ain't bad, I guess.

justinjlynn 8y ago
Progress seems to always be extremely slow, and then it just happens remarkably fast. The scary part is you never know when the punctuated equilibrium will flip. Take CRISPR for example... sheesh. You never know when they'll figure out scaffolding, could be sooner than you think. Could be later. Hopefully sooner.
deleted 8y ago
[deleted]

superbaconman 8y ago

I found out a few years back I've been living with ebstein's. I was surprised at the time to learn just how limited we are when it comes to heart surgery... It all seems to last 10-15 years and that about it. I'm glad to hear things are progressing for younger patients, but there's so much more work to be done.

dmead 8y ago

I'm 'young' and getting my second open heart surgery soon. Headlines like this are slightly misleading in that you have to have a pathology that will support tavr. In my case, I have a dilation of the annulus that apparently makes it less likley that a tavr valve can find a basis to stay in place. It has to be sown in.

tuukkah 8y ago

Note that 'younger' in the title refers to people in their 70s as opposed to 80s, so perhaps confusing on Hacker News. From the article: > Aortic valve replacements have been performed for decades, and surgeons know the valves placed during surgery last at least 10 to 15 years. It remains to be seen if TAVR valves will fare as well. The question is especially important for younger patients. The average age of subjects in the current studies was the low to mid 70s, younger by a decade or more than most patients getting TAVR now. If anyone here needs a new aortic valve, you might also want to read about the latest results on the less-known Ross procedure and whether it might be suitable in your situation. It's been a thing since the 1960s especially for young patients (children) but I hadn't even heard of it until last year: https://en.m.wikipedia.org/wiki/Ross_procedure https://en.m.wikipedia.org/wiki/Ross_procedure Ouzounian, Maral et al. 2017. The Ross procedure is the best operation to treat aortic stenosis in young and middle-aged adults. The Journal of Thoracic and Cardiovascular Surgery https://www.jtcvs.org/article/S0022-5223(17)31124-8/fulltext https://www.jtcvs.org/article/S0022-5223(17)31124-8/fulltext

Tharkun 8y ago

> “Open-heart surgery, particularly in low-risk patients, is very profitable,” Dr. Herrmann said. Sheesh. For-profit hospitals are a foreign concept to me. Seems incredibly cynical to crack open someone's chest, leaving them with a very slow and painful recovery, to then think about profit instead of patient welfare.

yostrovs 8y ago
Do you think the same about farmers who optimize profits on something that sustains life itself? Doctors just make you feel better and extend life a few years at best. Farmers, though, they make you tick every day.

fellowniusmonk 8y ago

Due to congenital defect I have a bicuspid valve that will have to be replaced before I'm 55, likely in the next 10-15 years, innovation can't come soon enough.