4 ms·

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

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!
  - StavrosK 8y ago
    > And at 55 he died because they can only do it twice. Fucking hell, that's brutal, why can they only do it twice?
    - robbiep 8y ago
      That’s not a hard rule, we treated a patient who was an IVDU who had 3 aortic valves in 3 years (IV drug users seed bacteria into their system which then form vegetations on heart valves, and there is an increased predisposition for the vegetations to form on foreign material such as replacement valves). But depending on the damage to the aortic root, that is going to be the primary determinant on if they are going to be able to undergo repeated procedures. I have heard of TAVIs being placed inside precious tissue replacements so that’s potentially the next route for a lot of people, which would mean basically x3, the third replacement being more streamlined than the previous two
      - StavrosK 8y ago
        That is very informative, thank you.
  - reallydude 8y ago
    I am on my 3rd - surgery ages 2, 9, 31 43yr old senior software dev
fernly 8y ago
Since you know a bit, can you clarify something not clear from the article? My aortic valve was replaced due to "ectasia", meaning the valve root stretched so the leaflets, which were otherwise fine, no longer met properly. Given the type of reconstruction to fit a porcine tissue replacement then, does this make TAVR more, or less, indicated for the replacement?
- alphaoverlord 8y ago
  Less, it’s not on label for aortic regurgitation, only aortic stenosis.
- rasmus1610 8y ago
  One problem with a TAVR in patients with aortic valve regurgitation is that they don’t have enough calcification on their valve in contrast to aortic valve stenosis patients. Some valves need the calcifications to stay in place. As far as I know there are some studies with TAVR in regurgitation patients but it’s not standard
lostlogin 8y ago
Do you have an idea of the financial cost of trans-catheter versus open surgery? I’ve heard it said that trans-catheter is more expensive, and a brief search agrees but it seems counterintuitive. https://www.ncbi.nlm.nih.gov/m/pubmed/29454487/ https://www.ncbi.nlm.nih.gov/m/pubmed/29454487/
- robbiep 8y ago
  I've heard that the procedure is quite similar in price (ie new tech, high $$), but when you compare a 4 hr open heart procedure, 3 days in CICU and another 3-4 days on the ward with 1 hour in the cath lab and observation overnight there is room for significant savings
reallydude 8y ago
> 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. The flow dynamics of newer metallic valves (like the Onyx) are superior in many ways. Not the least of which is consistency and durability, with a reduced risk of aortic dissection. Always go with a metallic. > can be a massive pain and cause other complications. The complications are not from the valve, of course. The complications are from the surgery which can disrupt electrical pathways (scarring of the chambers) with a worst-case pacemaker (additional risks and effects). _AVOIDING THAT RANDOM STRUCTURAL RISK IS THE BREAKTHROUGH_ The blood thinner is a cautionary medication for the newer valves by policy, until there are a few decades of field data. That being said, taking Sodium Warafin can cause common side effects like light sensitivity and chronic constipation. The excessive bleeding is overblown for a standard long cycle INR target of 2-3. When you get over 4 (due to triple doses or some other unusual circumstance), you will start to have bleeds that don't stop easily, in my experience.

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!
- StavrosK 8y ago
  > And at 55 he died because they can only do it twice. Fucking hell, that's brutal, why can they only do it twice?
  - robbiep 8y ago
    That’s not a hard rule, we treated a patient who was an IVDU who had 3 aortic valves in 3 years (IV drug users seed bacteria into their system which then form vegetations on heart valves, and there is an increased predisposition for the vegetations to form on foreign material such as replacement valves). But depending on the damage to the aortic root, that is going to be the primary determinant on if they are going to be able to undergo repeated procedures. I have heard of TAVIs being placed inside precious tissue replacements so that’s potentially the next route for a lot of people, which would mean basically x3, the third replacement being more streamlined than the previous two
    - StavrosK 8y ago
      That is very informative, thank you.
- reallydude 8y ago
  I am on my 3rd - surgery ages 2, 9, 31 43yr old senior software dev

fernly 8y ago

Since you know a bit, can you clarify something not clear from the article? My aortic valve was replaced due to "ectasia", meaning the valve root stretched so the leaflets, which were otherwise fine, no longer met properly. Given the type of reconstruction to fit a porcine tissue replacement then, does this make TAVR more, or less, indicated for the replacement?

alphaoverlord 8y ago
Less, it’s not on label for aortic regurgitation, only aortic stenosis.
rasmus1610 8y ago
One problem with a TAVR in patients with aortic valve regurgitation is that they don’t have enough calcification on their valve in contrast to aortic valve stenosis patients. Some valves need the calcifications to stay in place. As far as I know there are some studies with TAVR in regurgitation patients but it’s not standard

lostlogin 8y ago

Do you have an idea of the financial cost of trans-catheter versus open surgery? I’ve heard it said that trans-catheter is more expensive, and a brief search agrees but it seems counterintuitive. https://www.ncbi.nlm.nih.gov/m/pubmed/29454487/ https://www.ncbi.nlm.nih.gov/m/pubmed/29454487/

robbiep 8y ago
I've heard that the procedure is quite similar in price (ie new tech, high $$), but when you compare a 4 hr open heart procedure, 3 days in CICU and another 3-4 days on the ward with 1 hour in the cath lab and observation overnight there is room for significant savings

reallydude 8y ago

> 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. The flow dynamics of newer metallic valves (like the Onyx) are superior in many ways. Not the least of which is consistency and durability, with a reduced risk of aortic dissection. Always go with a metallic. > can be a massive pain and cause other complications. The complications are not from the valve, of course. The complications are from the surgery which can disrupt electrical pathways (scarring of the chambers) with a worst-case pacemaker (additional risks and effects). _AVOIDING THAT RANDOM STRUCTURAL RISK IS THE BREAKTHROUGH_ The blood thinner is a cautionary medication for the newer valves by policy, until there are a few decades of field data. That being said, taking Sodium Warafin can cause common side effects like light sensitivity and chronic constipation. The excessive bleeding is overblown for a standard long cycle INR target of 2-3. When you get over 4 (due to triple doses or some other unusual circumstance), you will start to have bleeds that don't stop easily, in my experience.