Interesting interview

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Pedestrian debate

Pedestrian debate

Let not mess around with these small change ideas. Let us take on a real philosophic discussion, that we all can get our teeth in to:


In a world of increasing healthcare cost, how do we justify to cost of repeat tissue valve surgeries when clearly it is a more efficient use of resources to implant a mechanical valve once and put people on ACT?

Assumptions;
1. Based on today?s technology
2. Consider all ages of pts.
3. What is best for society is the paramount goal

Debate note- whatever the position one takes, you may dispute the main premise, but
not the assumptions.
 
Andyrdj said:
I'm sorry, MarkU, but you're being a bit of a touchy over-defensive grumbler:mad:
Andy,

You continue to make unsubstantiated conclusions and generalizations in your posts to support your postions.

Show me some hard data from documented studies and then I'll give such comments due consideration.

As far as my post on the other thread, we all have one hard data point we can rely on - our own personal experiences.

I think it speaks volumes that you have to resort to personal attacks when someone calls you out or disagrees with your position.

Mark
 
Healthy Debate

Healthy Debate

It is fascinating to me how the topic of valve choice and preference always leads to a "heated" discussion.

This just shows how important and personal the subject matter is.

For instance... I can say some thing like...

"I have a machanical valve, coumadin therapy is no big deal for me and anyone who picks a tissue valve would be crazy..."

While this is a true statement, it could easily inflame others and lead to a forum meltdown.

The better statement would be something like....

"I have never regretted choosing a mechanical valve and coumadin therapy has not negatively effected my life in any way whatsoever...."

Anyway, my point is.. Always choose your words carefully and please make this debate a constructive one.

This topic is one of the main reasons that ValveReplacement.com was created.
 
MarkU, come down off your cross

MarkU, come down off your cross

I think it speaks volumes that you have to resort to personal attacks when someone calls you out or disagrees with your position.

And you haven't been doing this?

in your first response....

then I would suggest you keep such opinions to yourself. Doing otherwise is doing a disservice to other readers of this forum,

That is what is known in the trade as a "smarmy comment". It's a different kind of personal attack, and perhaps you didn't realise it was rude, but it was.

An attitude wounded innocence in that situation just doesn't wash, MarkU. Your belligerent attitude is implicit in your statements.

Take OldManEmu's response - when he showed me the reduced anticoagulation I happily extended the scope of the discussion and thanked him - because he knew how to do it in a friendly manner, rather than effectively telling me to "shut my trap" - which, effectively, is an attach on my character.

Similarly, I'm not railing at RCB''s post, although I will debate his points shortly.

Both of them possibly disagree with my position. Both weren't rude. Neither received cross comments. Notice the pattern?

For one thing, I'm still happy to debate the evidence - in my last post I postulated a situation where my original statement could have been wrong. Postulated, not concluded

Right from the start I put up an argument to be debated - proved, modified, or thrown out.. We're allowed to speculate - indeed, many of us will be basing our valve choices on a degree of speculation about the future.

Well, maybe I look like a grumpy, defensive git.:(

But Web discussion boards are full of examples when someone says something snide and then acts surprised when his character is criticised in response - "tease the dog and wonder why he bites back".

Occasionally, personal comments are justified - because when someone's being rude, they need telling.
 
To Hank

To Hank

Hank, I hope you will see that my original post was in the vein of a debating forum.

I invited people to break it down, like any other hypothesis.

I felt that surely this invitation to prove me wrong should be wording that is careful enough for anyone!
 
To RCB

To RCB

In a world of increasing healthcare cost, how do we justify to cost of repeat tissue valve surgeries when clearly it is a more efficient use of resources to implant a mechanical valve once and put people on ACT?

Assumptions;
1. Based on today’s technology
2. Consider all ages of pts.
3. What is best for society is the paramount goal

I see your point based on altruism and concern for society generally, RCB.
(I'd like to note an option I considered - going to Germany for my op. Cost is around £8900 sterling for a Valve replacement.)

Generally, Interesting points would be:

Purely Financial

1. Lifetime cost of warfarin - $10 a month for 60 years comes to $7200 (that's half the cost of a heart op in Germany!)

2. Cost of anticoagulation care - how many people need it? Regular blood draws? How often are these, how much hospital time does it involve?

3. Cost of internal bleeding complications due to prolonged ACT - since the survival rates are the same long term, there must be other complications to the anticoagulated patient causing mortality.

4. Cost of bridging therapy and extra care required for non-heart related operations - is the patient in hospital for longer?

Feasibility
Now, there are some for whom warfarin is contraindicated, or would interfere with things like having a baby (I read of one woman having to be on (Lovenox?) throughout pregnancy, getting a clot on the mech valve, and having an extra operation anyway, which was riskier!

So, clearly, we cannot abandon the tissue valve path entirely, and indeed would wish to see it continue to be developed by companies.

For the other patients? I understand warfarin precludes someone from being a pilot. Certainly if your career was down the pan, it might seem ery unreasonable to be denied an alternative.

Survival
This post http://www.valvereplacement.com/forums/showthread.php?t=16301 has suggested that anticoagulated patients are prone to poorer physical fitness, although BobH suggested that this might be due to overcautious care providers.

But, is it also possible that the "overcautious" care is responsible for the leelling of survival times - unless being more unfit is a higher factor? And also, to balance things, BobH also suggested that the stroke rates may have been due to an age bias (even within this study) pushing the average of Bio recipients up. We really could do with some properly controlled stats here!

Society
OK, now for a personal point: the "What is best for society is the paramount goal" must be interpreted carefully - because society overall would no doubt seem better off to many if we were all to die at a young age!

For another - if resources are skant, population reduction through birth control seems a much better option to me. I have no children, do not wish to have any, so I trust my ecological footprint will be vastly smaller than a mech valver with 4 children.

Thirdly, it also seems to me that no society is being run well if the individual members within that society are not happy. Having a heart problem, especially at a young age, means you've already been dealt a bum hand, so getting you as well as possible and happy with yourself is of much merit, methinks - certainly beats sacrificing yourself for those healthier than you!

And it's very odd- I can intellectually look at you mech valvers and understand that you are happy with your choice, but I cannot empathise with it at all. The idea of me going down that route is not one I wish to contemplate, indeed it caused me to dread my annual appointments before I found out about alternatives, even though I had received lifestyle information from a mech valver.

Even now, if I pass a glance over the anticoagulation section, with all the assurance and support I feel people receive from site, I am fully convinced that it is no life I would wish to lead - although, of course, you might consider the reverse idea - not having the mech and being forced to undergo multiple operations - equally scary.

Lastly, (ok RCB, I know it's partly beyond today's technology, but at least it stands alone at the end of the debate, and it beggars belief to assume that technology won't improve)

I strongly believe that this will all be academic within 25 years,
due to:
1. tissue engineering and a valve that truly belongs to your body. (Trials currently in place in Germany)
or
2. Mature percutaneous implant technology. Note that this year an ageing prosthetic tissue valve was replaced percutaneously (see www.corevalve.com). A fair bet, then, that if you implant a tissue valve today, in 20-25 years when it wears out the replacement cost will be minimal.

We don't need a leap in technology for this, just good follow up on the current cutting edge.

RCB, if you're being really strict about "today's technology" then that would mean we can't consider 3rd generation valves - only 2nd generation with 20 year follow up. Now that would be very cautious indeed, and I think to be that strict would be to deny people hope for a better future.

Cost wise, as I mentioned before, you'd all do better having several operations in Germany (£8900 sterling for a VR). Wonderfully clean and efficient, by all reports.

Some of you have had expensive surgeons in the $100,000 region, I recall- perhaps there's a less restrictive way of saving resources.

Anyway, RCB, I trust I've had a jolly good throw at debunking the proposition a bit. I look forward to the response.
 
Andyrdj said:
And you haven't been doing this?

in your first response....



That is what is known in the trade as a "smarmy comment". It's a different kind of personal attack, and perhaps you didn't realise it was rude, but it was.

An attitude wounded innocence in that situation just doesn't wash, MarkU. Your belligerent attitude is implicit in your statements.

Take OldManEmu's response - when he showed me the reduced anticoagulation I happily extended the scope of the discussion and thanked him - because he knew how to do it in a friendly manner, rather than effectively telling me to "shut my trap" - which, effectively, is an attach on my character.

Similarly, I'm not railing at RCB''s post, although I will debate his points shortly.

Both of them possibly disagree with my position. Both weren't rude. Neither received cross comments. Notice the pattern?

For one thing, I'm still happy to debate the evidence - in my last post I postulated a situation where my original statement could have been wrong. Postulated, not concluded

Right from the start I put up an argument to be debated - proved, modified, or thrown out.. We're allowed to speculate - indeed, many of us will be basing our valve choices on a degree of speculation about the future.

Well, maybe I look like a grumpy, defensive git.:(

But Web discussion boards are full of examples when someone says something snide and then acts surprised when his character is criticised in response - "tease the dog and wonder why he bites back".

Occasionally, personal comments are justified - because when someone's being rude, they need telling.

You made a definitive statement and asked for criticism. You got some, along with some personal opinions.

I could go along with a statement something like:

"Your long term survival chances will probably be higher with a third generation tissue valve, or the ON-X mech valve, than with other mech valves"

Nothing about valve replacement is definitive or black & white. Every individual case is different and every outcome will be unique. I personally have a mech, because I believed it was the best solution for me. I also firmly agree that tissue valves are the best solution for some others. The most reliable decisions will always be ones based on facts and hard data; the statistical law of large numbers applies here. Do you want to speculate that medical science will advance in the future - sure, I'll agree that's a pretty good bet. Do you want to gamble your future health and survival based on hopes and speculation that medical science will advance by X date? Not such a good bet, IMHO. If you're having AVR tomorrow, you need to make a decision based on what's going to be available tomorrow. If you're not having it for ten more years, then all bets are off - speculate away.
 
Hmm

Hmm

Nicer tone Mark - just to show I'm not always cross, thanks. A small point, though
"Your long term survival chances will probably be higher with a third generation tissue valve, or the ON-X mech valve, than with other mech valves"

I suppose I considered ,since a chance is always a statistical thing , including "chances" and "probably" both would be a bit tautalogical. A bit like "everyone agreed unanimously".

But anyway, the "gamble" bit. Will poss need AVR soon.I am taking a measured gamble by pushing for the C/E Magna as opposed to the older C/E Perimount. The Perimount is proven (would prob give me 15-20 years), the magna is a natural progression from the previous and has good simulated results in sheep, better orifice area and excellent short term results in humans.

So I'm going for a measured gamble here, rather than use 20 year old technology. Not the same as going for a larger gamble, suchcutting edge tissue engineered valve which is highly experimental but has the potential to be a valve for life.

I pretty much know i'll have to have another AVR in around 20 years, maybe longer. At worst, I'd pick one of the mech options around today such as the ON-X, but I think it pretty likely that by then something far better will be around.

But I am willing to undergo an extra op in exchange for 20 or more years freedom from ACT, to enjoy my 30s and 40s without too many daily cares.

Choosing the "safer" option would drive me barmy!
 
Andyrdj said:
Nicer tone Mark - just to show I'm not always cross, thanks. A small point, though


I suppose I considered ,since a chance is always a statistical thing , including "chances" and "probably" both would be a bit tautalogical. A bit like "everyone agreed unanimously".

But anyway, the "gamble" bit. Will poss need AVR soon.I am taking a measured gamble by pushing for the C/E Magna as opposed to the older C/E Perimount. The Perimount is proven (would prob give me 15-20 years), the magna is a natural progression from the previous and has good simulated results in sheep, better orifice area and excellent short term results in humans.

So I'm going for a measured gamble here, rather than use 20 year old technology. Not the same as going for a larger gamble, suchcutting edge tissue engineered valve which is highly experimental but has the potential to be a valve for life.

I pretty much know i'll have to have another AVR in around 20 years, maybe longer. At worst, I'd pick one of the mech options around today such as the ON-X, but I think it pretty likely that by then something far better will be around.

But I am willing to undergo an extra op in exchange for 20 or more years freedom from ACT, to enjoy my 30s and 40s without too many daily cares.

Choosing the "safer" option would drive me barmy!

Like I said, everyone's situation is different. In my case, I choose to live with ACT, rather than face the prospect of repeat surgeries down the road, most probably preceded by deteriorating cardiac function and corresponding quality of life. The most difficult aspect of living with ACT for me has been dealing with ignorance and misinformation that surrounds it.
One AVR was enough for me at age 47. The prospect of going through it again at 67 would not be something I would look forward to. Again, I realize that my mechanical valve does not guarantee no future surgeries, it just reduces the risk/probability. At the same time, a tissue valve is no guarantee of no ACT, it just reduces the probability based on historical data. I'm still just trying to play the numbers game in my favor.
I would never criticize another person's choice of valve; once that decision is made I feel it is our duty and responsibility to be supportive of that decision and of the individual. I would only hope that they make an informed decision based on objective information. I still am of the opinion that too much speculation is a dangerous thing in such matters. My $0.02.
 
MarkU said:
Like I said, everyone's situation is different. In my case, I choose to live with ACT, rather than face the prospect of repeat surgeries down the road, most probably preceded by deteriorating cardiac function and corresponding quality of life. The most difficult aspect of living with ACT for me has been dealing with ignorance and misinformation that surrounds it.
One AVR was enough for me at age 47. The prospect of going through it again at 67 would not be something I would look forward to. Again, I realize that my mechanical valve does not guarantee no future surgeries, it just reduces the risk/probability. At the same time, a tissue valve is no guarantee of no ACT, it just reduces the probability based on historical data. I'm still just trying to play the numbers game in my favor.
I would never criticize another person's choice of valve; once that decision is made I feel it is our duty and responsibility to be supportive of that decision and of the individual. I would only hope that they make an informed decision based on objective information. I still am of the opinion that too much speculation is a dangerous thing in such matters. My $0.02.
BINGO! Everything I'd like to say, but can't.
 
RCB said:
In a world of increasing healthcare cost, how do we justify to cost of repeat tissue valve surgeries when clearly it is a more efficient use of resources to implant a mechanical valve once and put people on ACT?

Assumptions;
1. Based on today?s technology
2. Consider all ages of pts.
3. What is best for society is the paramount goal

I "justify" repeat tissue valve heart surgeries for those who opt for them because: "In a world of increasing health care costs," the distended mass of foetid rot devoted to the art of paper-pushing alone in the health care in-duh-stry probably dwarfs the cost of a second, third, fifth valve job.

as for this assumtion three: ask N people about what is best for society and you'll get N different answers. what does it mean to you? for me, what is best for society is freedom of choice, period. based on my take of this assumption, members of a society must be able individually determine which valve to get.
 
If we all had a crystal ball and could look into the future, the choice of which valve to choose would be a no brainer.

However, those who must choose are faced with the impossible. No one knows what lies ahead, yet they are forced to make a decision which will impact their future in a BIG way, no matter which way they choose to go.

Thus, we end up with the emotionality of personal choices based on an end result which no one can predict with any certainty. There are only statistics to go on, and they are not a constant thing, since each new valve design changes the statistics.

I think that is why it becomes like a discussion about religion or poilitics.

Maybe we should include valve choices in the list of public discussion no-nos. :D

It always ends up in an emotional debate, and always will.

Just my observation.

There will never be a right or wrong side of the debate.

I say, choose your weapon and don't look back or second guess.:p
 
I think a fair debate is a good thing.

I think a fair debate is a good thing.

I think Andyrdj's comments are appropriate, civil & helpful. And I say this as one who had my own disagreements with Andyrdj, but we worked them out just fine in a couple of private messages.

I think that those of us who have already had our surgery and made our valve choice can easily forget what an all encompassing issue this is until it is resolved. Knowing that I would have to make a valve choice is what brought me to the forum in the first place. And while I was making that choice nothing else on the forum was of much interest to me. Now that I have made that choice, my interests have branched out to other parts of the board.

So, I hope the board always invites these discussions, and I hope we don't strain relations any more than necessary while we have them.

Now for my 2 cents worth. I have not posted much on this topic as I have often been concerned about adding to the level of apprehension for those facing surgery. If you don't want to hear from a guy who thought the whole deal was very painful, you should quit reading now. For everybody else, here goes: I had my surgeru under close to ideal conditions. I planned ahead, picked a good Dr. & a good hospital. I was a trial attorney for 25 years, and I prepared for this surgery like it was the biggest trial of my life. Despite exercise restrictions, I managed to drop 25 pounds in the 4 months before surgery. I went into the hospital fitter than I had been for 10 years. I was out of surgery hours before expected, apparently everything went "just right". I had all the family/friends support that anyone could ask for. I was out of the hospital after six days. And, despite all of this, the 20 days following surgery were the most painful and difficult days of my life. I can't describe waking up with a tube down my throat, unable to talk, swallow or breathe (it seemed). On the heart ward of my hospital it seemed to me most every patient was feeling the kind of pain I am trying to describe. I know this can be different for every individual, but I can't escape the feelling that stories of people who found the surgery to be no big deal may be way over-represented on our board. It would be much easier for me to write about how I skipped out of the hospital and walked 5 miles 10 days after surgery, but that was not my experience.

I got a mechanical valve, and the one consolation as healing took place was that I shouldn't expect to have to go through that surgery again. As far as ACT is concerned, I guess that has also been more difficult for me than what I often see described on the board. Again, I have been much more fortunate than many. I have a home test unit. My wife is a great help in monitoring my INR. Al and others on this forum have been so helpful that I have never felt like I am in this alone, or need to wait several days to hear back from my busy doctor.

But: I never took any medication before my surgery. Now I have to take pills every day. I find taking the pills, testing my levels, and dealing with coming back into range very unappealing. But I would take them 5 times a day rather than have that surgery again.

As to financial cost- I think there are going to be a whole different set of issues depending on whether you have national health care or a private pay system. I can only speak to the US system of fee for services. As for the US: the soaring cost of health care and health coverage is the “elephant in the room” that nobody wants to discuss when making valve choices. When I had my AVR in August of 2005, my surgery was $100.00 out of pocket. I don’t believe anybody should expect to have open-heart surgery 20 years from now without being required to pay a MUCH larger sum. The premium for my insurance (for all policy holders) went up 300% in three years. At one point I had studied this in substantial detail. There is simply not much question that premiums will continue to soar, and policies will require very high deductibles to be affordable.

So: I don’t think the issue of cost of a second surgery is an abstract, philosophical issue for those of us in the US. I think it is going to become personal, and fairly expensive. If you don’t see this as a major issue, I would urge you to do the briefest research on what is happening to the cost of medical procedures and insurance premiums. I assure you the best minds addressing this topic are predicting substantial increases.

Finally: Is there going to be some major medical advance that makes this surgery cheap and/or easy? Maybe, and I sure hope so. I tried to research this as well when I made my valve choice. I don't see the basis for expecting this. But: In the words of Paul Simon "Everybody loves the sound of a train in the distance...Everybody thinks it's true.
 
Dennis S said:
Finally: Is there going to be some major medical advance that makes this surgery cheap and/or easy? Maybe, and I sure hope so. I tried to research this as well when I made my valve choice. I don't see the basis for expecting this. But: In the words of Paul Simon "Everybody loves the sound of a train in the distance...Everybody thinks it's true.
Not everyone, at least not me! I too had horror stories for surgery and yes, it upsets me when people go in, do the deed, get out in 4 or 5 days then start wanting to go golfing or something else. Pretty hard for me to accept when I spent 2 months in CSISU. Many people here are tired of hearing it from me, so I stopped posting it.
 
My broken record bit

My broken record bit

So: I don?t think the issue of cost of a second surgery is an abstract, philosophical issue for those of us in the US. I think it is going to become personal, and fairly expensive.

There was a report in a UK newspaper on the health tourism industry. AVR was, as I said, about £8900 (perhaps $16000 dollars) in Germany, and maybe around £4500 in India.

Plus after care expenses, of course, but perhaps worth considering? Perhaps once you know you're going to need it, you'd be better off putting in a trust fund for yourself since the insurance companies will hjack up the premiums more than enough to compensate.

I've seen costs on this baord ranging from sub $10,000 to over $150,000 within the US. Perhaps getting in a car and driving over the state boundary is another good tip.
 
My point:

My point:

Andyrdj said:
There was a report in a UK newspaper on the health tourism industry. AVR was, as I said, about £8900 (perhaps $16000 dollars) in Germany, and maybe around £4500 in India.

Plus after care expenses, of course, but perhaps worth considering? Perhaps once you know you're going to need it, you'd be better off putting in a trust fund for yourself since the insurance companies will hjack up the premiums more than enough to compensate.

I've seen costs on this baord ranging from sub $10,000 to over $150,000 within the US. Perhaps getting in a car and driving over the state boundary is another good tip.

My point is that having these surgeries may get more difficult/expensive. If/when it does, maybe we will go to India or Germany. (My Dr. is from India, and I loved him!) But I consider having my surgery performed in India or Germany (while filled with educational possibilities) to be considerably more difficult than having it done near my home. You may well have suggested the best solution to a difficult situation, but I think the point still stands-going to India may be more affordable, but certainly sounds difficult to a family man whose wife, kids & friends wanted to be with him.
 
Repeat surgeries = Big Bucks

Repeat surgeries = Big Bucks

Andyrdj said:
There was a report in a UK newspaper on the health tourism industry. AVR was, as I said, about £8900 (perhaps $16000 dollars) in Germany, and maybe around £4500 in India.

Plus after care expenses, of course, but perhaps worth considering? Perhaps once you know you're going to need it, you'd be better off putting in a trust fund for yourself since the insurance companies will hjack up the premiums more than enough to compensate.

I've seen costs on this baord ranging from sub $10,000 to over $150,000 within the US. Perhaps getting in a car and driving over the state boundary is another good tip.

For the lucky members who are reop. customers, most would agree that cost
and complexity goes up with more surgeries. Most good surgeons can do a young virgin chest, but if you have a few miles on you since your last surgery(ies) you better have one of the best. My last surgery was $180,000.00(Medicare was charged- meaning private insurance would have been much higher!), as it would have been in any state over here. I bet some of the young kids here who had a much more difficult surgeries, were higher then mine.
 
RCB-
That is the most incendiary, mean-spirited, an inappropriate post I have ever read on VR.com. You should be permanently removed from this site. Thanks for showing me that I can skip over anything you ever write again.
 
What's up?

What's up?

I am sorry Andy for some of the treatment of you that I have seen on this thread. I don't think it is indicative of who we are. P.S. I console my self by being pretty sure you won't lose a moments sleep over it. I mentioned I was a lawyer for about 25 years. Sometimes these discussion remind me too much of negotiating child custody agreements! People need to read while we discuss the pros & cons of different choices. Let's try to act in ways that are helpful to them.
 
Dennis S said:
I am sorry Andy for some of the treatment of you that I have seen on this thread. I don't think it is indicative of who we are. P.S. I console my self by being pretty sure you won't lose a moments sleep over it. I mentioned I was a lawyer for about 25 years. Sometimes these discussion remind me too much of negotiating child custody agreements! People need to read while we discuss the pros & cons of different choices. Let's try to act in ways that are helpful to them.

word. keep it up andy, i've learned a lot on VR.KOM from your posts and feel like i'm making more informed decisions because of it. don't let some whack sarcasm get you down.
 
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