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.