Advances in Aortic Valve & Aneurysm Surgery

[AZ Don]

The subject is the title of a webinar that was recently hosted by http://www.heart-valve-surgery.com/, with the presenter being Dr. Allen Stewart from the Mount Sinai Hospital (10th ranked for Cardiology and Heart Surgery by US News). I actually missed the webinar but the host graciously documented a transcript of the webinar here: http://www.heart-valve-surgery.com/eBook-Advances-Aortic-Valve-Aneurysm-Surgery.pdf.

There was some good information on valve repair, valve sparing root replacement (he does both with a minimally invasive procedure) TAVR, and an interesting perspective on valve selection. The info was better than I expected and I learned a few things. I found the Dr's perspective on valve choice interesting, as well as his comments on hospital choice. Separately I've seen that it's recommended to have valve repair at a top hospital. It seems he would make that recommendation for most heart surgeries.

FWIW, I'm not intending to start another debate on valve choice, just passing along info from an expert that is very optimistic about the future of TAVR and obviously biased in favor of tissue valves. There are certainly other experts with different opinions.

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 bioprosthetic
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-invalve
rescue after these valves deteriorate.

In response to a question from a 53 year old scheduled to have an aneurysm repair and valve replacement (mechanical).

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 because
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.
I would not have a mechanical valve because as time goes on, other things crop up; a fall
with a broken hip, colon cancer, gallbladder remove. All these things complicate having
a mechanical valve. If I were 53 years old, man or a woman, I would have a tissue valve.
With a bicuspid, you want to make sure that your valve’s not repairable, so I would get
another opinion.

Adam Pick: Next question, “Is it better to travel to find a surgeon in another state who
may have more skill, or stay close to home? How should we evaluate the different types
of valves?” Ed Ebner.
Dr. Stewart: I would say that you only have one heart. About 15% of the patients I operate
on come from outside the United States. Really, it’s a five-day hospital stay and now with
Facetime and with iPhones, I can do a lot of the follow-up remotely. I can look at people’s
incisions and look at their echocardiograms real-time, or the surgeons or doctors in other
countries can send me what a postoperative incision looks like, or an echocardiogram,
and I can look at it and talk to patients with Facetime, which I do quite frequently. I believe
that it’s – that I would not look at geography as a reason. Many of Adam’s patients
who have contacted me have gotten on a plane to come to New York or driven several
hours. I think for a very brief hospital stay, it is not a problematic experience. In places
like ours in New York City or Cleveland at Mayo Clinic, there are clinic where there are affordable
hotels around and the ability to easily travel into an airport should allow patients
to all get the best healthcare available.

 

[river-wear]

Thanks, Don. I didn't have an aneurysm, but I found the presentation interesting too. I hadn't read the Q&A section, so I appreciate you highlighting some of it here. I can certainly support the view that traveling for surgery is worth considering, if you can afford it and insurance allows. It wasn't cheap, but I have a deeper understanding of how valuable health is compared with anything else!

 

[AZ Don]

FYI, I just found that the webinar was recorded. The video of it is here: http://www.heart-valve-surgery.com/videos/webinar-aneurysm-aortic-valve
... for those that want to see the video's referenced in the text document.

 

[Roberta]

FYI, I just found that the webinar was recorded. The video of it is here: http://www.heart-valve-surgery.com/videos/webinar-aneurysm-aortic-valve
... for those that want to see the video's referenced in the text document.

Thanks for sharing and an interesting and informative webinar, AZ Don! I wonder if he ruffled any feathers amongst his peers being so 'pro' tissue in the under 60 category. I found his statement pretty provocative in that he believes mechanical valves will be extinct. However, he has way more knowledge and expertise in this area than I will ever have. In my case, I hope he is right regarding TAVR as being the way of the future seeing that I am a tissue valver in the 'under 50' category. Only time will tell...

 

[river-wear]

Roberta, pushing tissue at all ages doesn't seem at all controversial anymore. Only one (of three) surgeons I talked to didn't think it was the best choice for someone under 50. He was a fellow (the stage after residency before being able to practice independently) under my surgeon and has been on his own for a year. If I understood correctly, medical school and then all of the training that follows to become a cardiothoracic surgeon, took 20 years!