Aortic valve

[priley]

I'm not looking at TAVR, I was looking at what they are doing at WVU Dr Badwar. Apparently he has done 50 Aortic valve replacements with 100% success. I watched a video on it, he was being interviewed by Adam Pick on heartvalvesurgery.com
Looks good--Is it?

 

[pellicle]

Looks good--Is it?

well we don't know ... << that's the point

I *know* you aren't contemplating TAVR, but (assuming you're replying to my comments) but I furnished that another example of something new that was introduced to satisfy a specific need that's been taken up by the general public as being gold because it seems to involve less risk.

So my comments were a metaphor of something we are still gathering data on to this which is "something we have almost no data on"

Apparently he has done 50 Aortic valve replacements with 100% success.

this is a pretty meaningless stat (and that site you quoted if from is to me an unashamed shill) without knowing a lot more.

when I was 10 having OHS was new, but there were no alternatives other than known early death. Now we have a slew of good well known well tested methods and you seem to be fascinated by the one which has no history.

It might be better, it might even be "nearly as good" ... how do you feel about going to Vegas with everything you own.

 

[pellicle]

So wouldn’t higher all-cause mortality be expected? (Or do they somehow correct for this)? Just wondering?

taken alone perhaps, but when taken in comparing (for example) old people with old people it says something else

 

[Lucker]

What's here to win? Easier and faster recovery, probably lesser chance for surgical infection, probably easier future reoperation due to less scarring. What's to lose? Having a prompt open reoperation or worse if the robotic surgery fails.
The method appears to be good, but is also new and uncommon.

 

[pellicle]

Good analysis angle

What's here to win?
Easier and faster recovery

probably

, probably lesser chance for surgical infection

perhaps ... but that's low anyway right?

, probably easier future reoperation due to less scarring.

what's your basis for this? Scar tissue isn't just the stuff at the wound, its where the valve gets taken off and put back on again too ...

What's to lose? Having a prompt open reoperation or worse if the robotic surgery fails.

so basically the risk is you have two operations instead of one (and increased risk of infection on the second surgery) for the benefit of a faint possibility of an easier recovery.

This has to be dancing bears risk analysis.

 

[Lucker]

@pellicle
"perhaps ... but that's low anyway right?" - Differs from place to place, and if present can be very unpleasant, as you know, or deadly.

Also IMO scarring makes harder to access and distinguish the needed parts, not to cut them off. Since reoperations are likely more invasive procedures, having a "virgin" sternum and what's under should help.

 

[pellicle]

Also IMO scarring makes harder to access and distinguish the needed parts, not to cut them off. Since reoperations are likely more invasive procedures, having a "virgin"

Exactly

Like critical things such as the nerves on the heart that govern its beating. These are exactly where the incisions are placed for valve replacement.
The robot incisions will perhaps even scar more...j

 

[priley]

Do these numbers mean anything to anyone?
Aortic Valve bicuspid aortic valve with calcific sclerotic changes.
Aortic Stenosis peak velocity 5.59 m/s with gradient of 125.4 mmHg. Valve planimetry 0.58 cm2.
Aortic Regurgitation regurgitant jet with regurgitant fraction of 30%.

 

[Chuck C]

Do these numbers mean anything to anyone?
Aortic Valve bicuspid aortic valve with calcific sclerotic changes.
Aortic Stenosis peak velocity 5.59 m/s with gradient of 125.4 mmHg. Valve planimetry 0.58 cm2.
Aortic Regurgitation regurgitant jet with regurgitant fraction of 30%.

Aortic Stenosis peak velocity 5.59 m/s with gradient of 125.4 mmHg

5.59 m/s is high. A peak jet velocity across the aortic valve over 4 m/s is considered severe.

As far as gradient, they usually will specify peak and mean pressure gradient. Mean is the one used to grade severity. If the 125.4 mmHg is the mean, that is very high and severe, if not critical. But, without clarity on whether it is the peak or mean I can't say.

Valve planimetry 0.58 cm2.

This is your aortic valve area. A normal valve area is 2.5 to 3.5cm2. Once it drops below 1.0cm2 it is considered severe aortic stenosis. Once the valve area drops below .70cm2 it is considered critical.

I expect that your surgeon is going to want to operate right away once he evaluates these numbers. When is your follow up consultation?

 

[Lucker]

And regurgitant fraction of 30% means moderate regurgitation.

 

[Timmay]

In my opinion, those numbers are bad. Get surgery sooner rather than later. Chuck pointed out everything above so I won't repeat ... except to say that 125 is super duper high. Not saying this to scare you ... but to increase urgency in your mind.

You're actually not too far from me (geographically). I had my aortic valve replacement done at Washington DC hospital, MedStar by Dr. Christian Shults. Dr. Shults did a good job (at least that's what my life is showing). That said, I cannot recommend that hospital. Although they have good success rates, I was more of a number there rather than a human being. My experience with that hospital was not a good one (and that was a little over 3 months ago).

 

[priley]

I'm trying to get a response from the cardiologist. I've been trying since the test. His nurse says it doesn't seem critical. I have been in touch with the Cleveland Clinic and am trying to get a cd of the ECHO from the cardiologist. They told me it would be $25 and 2 days to get it. Unbelievable but I paid them their much needed $25 up front as requested. Waiting on them to tell me the CD is ready. I have the one from the MRI. When I get everything together CC wants them. I have also contacted Dr Badwar's office at WVU. I have an appointment at the local valve specialist on the 21st but I don't see me getting them to do this. I think I've narrowed it to Dr Badwar at WVU or the Cleveland Clinic. I'm not waiting for anything except for Dr's to get back with me so I can get this thing behind me. Not looking forward to it but am not procrastinating either, Just want to make the right choice. I thought I was heathy as a Bull a few weeks ago. Timmay, You are right up the road from me, I just finished the new Northgate Fire Station in Frederick.

 

[priley]

My echo showed 4.0 MRI showed 5.59

 

[Timmay]

Timmay, You are right up the road from me, I just finished the new Northgate Fire Station in Frederick.

I’m literally just a few minutes from that station.

 

[priley]

Well I met with the 1st surgeon and he seemed to want to do a standard open surgery to replace my aortic valve. I am not sure I want to do that if other good options are available. He seemed very confident in his abilities and answered every question I had written down before I could ask it. However his options were Open or TAVI. So, I am off to Morgantown tomorrow to get a CT and visit with Dr Vinay Badhwar on Wed. I hope I feel more comfortable after this meeting. I sent Cleveland Clinic all the info they requested however I have not heard back from Dr Eric Roselli's office yet. I talked to them and they said he had the info and would review it and they would get back to me. As of yet I haven't heard anything. I was hoping to speak with them before my trip to Morgantown but Dr Badhwar seems to have a stellar reputation as well.
I'm still nervous though, Even when these Doctors have performed thousands of operations with good results. Only surgery so far in these 60 years is a tonsillectomy at 4 and I barely remember that. Wish me luck and I'll take all the prayers I can get.

 

[Timmay]

Going SAVR - so long as your body can handle it (and most do) - gives the surgeon full access to everything. It’s the tried and true way of having a new aortic valve “installed” easily and without complication. They have tons of room to work and get it right. Plus, they can see more of what’s going on and make judgement calls about what else might need to be done.

In my church there is a retired 70yr old who had full open heart surgery with full sternotomy 3 months prior to me. Same hospital and same surgeon. He recovered at the same pace as me … and I’m a fairly fit 50yr old. So SAVR at 70 is totally doable.

I, personally, would never even consider doing a TAVR at 60. No way. You’re gonna be right back in the hospital for a SAVR within 8 years or less.

I wish I could say something to help. But - what I can offer since your close to me is to sit down at a table for an early breakfast somewhere and let you ask as many questions as you want. Send me a PM if you’re interested.

 

[Beach77]

However his options were Open or TAVI...

At age 64, I was told I needed surgery to replace the bicuspid valve, my first thought was TAVR, but after speaking to a couple of surgeons and cardioligists, the decsion was left to me. It was a tough choice! I choose the On-X. It's been 22 months since my surgery and everything is going great! Warfarin took a little time but now it's no problem. Good luck deciding! It's tough!

 

[Chuck C]

https://www.heart-valve-surgery.com/surgeons/dr-Vinay-Badhwar-Morgantown-West Virginia.phpActually he does AVR robotically, see video. That's rare.

Very interesting interview. I'm glad that I watched it.

From the video

-They have been doing robotic aortic valve replacement since the beginning of the pandemic, so, a little more than 2 years.
- They have done about 50 of them, as of the time of the video.
-100% of the patients survived short term. Of course, having only been performed for a few years no long term data.
-He calls it ultra-minimally invasive, with even a smaller incision than the other minimally invasive options, offering quicker wound recovery time
-As a side note, he does mention that the 5 year outcome data has proven to be worse for TAVR than SAVR for younger low risk patients, making the point that TAVR is probably not a good choice for said low risk patients, in terms of low term mortality. I totally agree with this.

It will be really interesting to see if this robotic procedure becomes more popular.

I'll take a shot at what would seem to be the pros and cons:

Pros:
-Quick wound recovery time.
-So far 50 out of 50 survivors, but it is still early

Cons:
-About 2.5 years of experience and patient outcome data.
-Limited access in the event that a more involved procedure is called for. Personally, I'm glad that I did not have this procedure, because once my surgeon got his eyes on my aorta, he made a judegment call to replace it, as it appeared to be the tissue type that would potentially have an aneurysm later down the road. I'm glad that he made this call and it could not have happened in an operation such as this.

Although I would not choose this operation myself, I can certainly see the appeal. It will probably be a few years before the risks of operation are known and how that compares to OHS SAVR. Ultimately, one would expect that the outcomes would be similar long term, as you end up with the same piece of equipment attached to your heart. The long term issues should be the same- either reoperation or warfarin management. Once a few thousand have been performed there should be a better idea of how surgical outcomes compare to standard SAVR with OHS in the short term and eventually we will have long term data.

As has been the case with TAVR, regardless of limited data, I predict that they will have no shortage of volunteers given the appeal of a quicker surgical recovery.

@priley please share with us the outcome of your consult with Dr. Badhwar. This is very interesting.

 

[Chuck C]

Just wondering, if I understand this correctly, seems like the samples are from pre-2019 and would have to be at least 5 years older. Seems like back then TAVR was pretty much only used on older folks. So wouldn’t higher all-cause mortality be expected? (Or do they somehow correct for this)? Just wondering?

When it is a randomized contolled trial, RCT, this is accounted for, as the patients are of similar age and randomly assigned to TAVR or SAVR.

Take a look at this publication linked below if interested, on low risk patients randomly assigned to either SAVR or TAVR.

"In fact, these concerns are underscored by a PARTNER-2 landmark analysis showing a higher rate of death and disabling stroke with TAVR (hazard ratio, 1.27 [95% CI, 1.06–1.53]) from 2 to 5 years."

https://www.ahajournals.org/doi/10....ith a mean,occurs earlier in younger patients

 

[priley]

Thanks for all the response's and information. When I talked to the first surgeon he explained the the TAVR procedure could be performed up to three times, after that they would have to go in and remove them and "It's a bear of a job" he said. Considering my age and the supposed life of the valve It just doesn't seem like a good way to go. Maybe do TAVR when the replacement valve starts to fail. At this point I want to talk the Dr Badhwar. I don't think when I talked to his PA that they were thinking about total robotic surgery but I will know after our meeting. I believe they are thinking about some sort of minimally invasive technique. I will know more after our meeting. I wish Dr Roselli from CC would have got back to me before this meeting though but regardless I think WVU is working on a World Class heart center so there is some comfort there. Thanks to everyone and Thanks for the offer Timmay. I've been obsessing about this for a bit now and know more about it than I thought I'd ever need to know.