interesting video here about valve choices

[ashadds]

This guy seems to hate a mechanical valve

 

[Todd]

Wow, I don't think I should have watched this ! I have a surgery coming up at the end of this month, my 3rd Aorta valve replacement and I am choosing to go mechanical . Watching this makes me second guess my decision .

 

[pellicle]

. Watching this makes me second guess my decision .

Don't.

This sort of thing has a bunch of assumptions in it and ignores data. Your choice is carefully thought out for your specific situation. You have additional data and criteria.

I didn't go through it but did it address Lp(a)?

What was it's assumption on anticoagulation?

May as well go listen to a valve makers sales pitch (hint, it will be what they have the biggest margin in).

 

[pellicle]

Wow

wow is how I usually feel when digging into the details ... most "pro one side" stuff was "pro bio-prosthesis" then became "pro-TAVR" ... its interesting how that goes when TAVR maximises profits and minimises hospital time so that insurance companies can green light it for "those who it was never intended for"

Lets look into this:

Aortic Valve and Ascending Aorta Guidelines for Management and Quality Measures
Lars G. Svensson MD PhD Chair Writing Committee; David H. Adams MD Vice-Chair Writing Committee; Robert O. Bonow MD Vice-Chair Writing Committee; Nicholas T. Kouchoukos MD Vice-Chair Writing Committee; D. Craig Miller MD Vice-Chair Writing Committee; Patrick T. O'Gara MD Vice-Chair Writing Committee; David M. Shahian MD Vice-Chair Writing Committee; Hartzell V. Schaff MD Vice-Chair Writing Committee; Cary W. Akins MD Writing Committee Member; Joseph E. Bavaria MD Writing Committee Member; Eugene H. Blackstone MD Writing Committee Member; Tirone E. David MD Writing Committee Member; Nimesh D. Desai MD PhD Writing Committee Member; Todd M. Dewey MD Writing Committee Member; Richard S. D'Agostino MD Writing Committee Member; Thomas G. Gleason MD Writing Committee Member; Katherine B. Harrington MD Writing Committee Member; Susheel Kodali MD Writing Committee Member; Samir Kapadia MD Writing Committee Member; Martin B. Leon MD Writing Committee Member; Brian Lima MD Writing Committee Member; Bruce W. Lytle MD Writing Committee Member; Michael J. Mack MD Writing Committee Member; Michael Reardon MD Writing Committee Member; T. Brett Reece MD Writing Committee Member; G. Russell Reiss MD Writing Committee Member; Eric E. Roselli MD Writing Committee Member; Craig R. Smith MD Writing Committee Member; Vinod H. Thourani MD Writing Committee Member; E. Murat Tuzcu MD Writing Committee Member; John Webb MD Writing Committee Member; Mathew R. Williams MD Writing Committee Member

ATS, 95 (2013) S1-S66. doi:10.1016/j.athoracsur.2013.01.083
(that doi can be searched on) if you do, you'll find this table:

So that's pretty sloppy stuff because All and Total just don't add up

Putting that data into a spreadsheet I get this:

Valve​	​	Number​
Mechanical​	​	​
​	all​	16,780​
Tissue​	​	​
​	ATS​	216​
​	Carbomedics​	5,290​
​	Edwards​	39,367​
​	Medtronic​	18,688​
​	St Jude​	11,666​
​	SUM​	75,227​
​	​	​
​	Mech + Tissue​	92,007​

The All in tissue does not fit in with the spreadsheet (so I've omitted it), despite formatting the All indented under Tissue is actually close to the Sum of the provided Tissue groups but not quite right. So when we look at the subsets of numbers added up we can reconstruct this table to be this

... very sloppy.

I'll come back to the Tissue valve costs: number

I see this again and again in medical stuff and it wouldn't fly in Engineering or any Science paper. You'd be ridiculed and hammered ... so far I'm the only one on the internet I can find taking issue with that.

Standing on the shoulders of Giants ... huh ... now, getting back to that look at the amount for Tissue valve costs $435,716,947.00 ... ho lee sheet ... that's $435Million which almost certainly doubles itself with repeat business. Follow the scent of money I say.

I've written about that in this lengthy post:
https://cjeastwd.blogspot.com/2014/01/heart-valve-information-for-choices.html

Best Wishes

 

[-andrew-]

I haven't watched all of the video yet, but from what I've seen so far it's not one I'd personally be recommending for people preparing to go through valve surgery. It appears that the presentation had a clear objective of highlighting the disadvantages of mechanical values and so selected statistics and examples to demonstrate the point. Whether the motivation is financial or just the professional opinion of one surgeon / researcher / facility, I don't know but it certainly didn't seem to be putting forward a well structured and balanced argument to me. I started to watch it because I'll be needing to make a decision about whether to go for another bioprosthetic option or a mechanical for my 4th surgery and my gut instinct and preference is still to avoid mechanical. So being honest I was looking for some info to back me up! But I wouldn't let anything in the first part of that video influence me much - far to reliant on specific, pre-selected examples - to support that decision. It also looked to focus on relatively short term stats - 10/15 years and so likely didn't fully capture the risk associated with repeat surgeries.

It's also a presentation that is given by a surgeon to what appears to be a group of other surgeons / medical professionals and so the language and terminology used is not always suitable for patients. That's not something that bothers me, but I suspect it would cause unnecessary worry to others.

I'll be watching the rest of it later, but my initial reaction was strong enough to pop this comment on here.

 

[dornole]

It was actually kind of reassuring to me how strongly my surgeon recommended a mech valve for me because it makes it much less likely I will ever see him again. Not that I think he has ANY trouble getting enough patients to operate on. : )

 

[Chuck C]

I have several issues with that video. Here is just one which jumps out at me.

He makes the argument that a young patient needing a mitral valve should consider a biological valve, because only about 20% of those patients will ever need a redo. When he explains why, it is sad- many have died before needing valve replacement. The same study which he uses to make this case shows that for these young patients, the bio valves had about a 50% higher rate of mortality after 10 years. He glosses over this, but take that in for a moment to see how warped his advice is.
Essentially he is saying that the signifcantly higher rate of mortality with this valve means that you will not likely need a redo operation, because you will die before it is needed. So, choose that valve. That is bonkers. Why wouldn't the patient and his team choose the valve which gives the significantly higher survival rate after 10 years?

What about personalized medicine? Sure, if a person has a 10 year life expectancy, due to age or comorbidities, then tissue makes sense. But for a young patient who might have a life expectancy of 30 to 50 years, the high probability of that patient will need a reop done should be taken into account in valve choice. He uses generalized data for life expectancy after valve surgery, to make his argument to choose bio valves. The patient's individual life expectancy should always be taken into account in this decision.

 

[tommyboy14]

@ashadds @Todd @ @-andrew-

Hi Team,

I think it is a bit funny that he doesnt cite a study from his own hospital (Mount Sinai):

https://www.sciencedirect.com/science/article/abs/pii/S0003497507006674

That study says mechanical valve patients with Biscupid valve disease have normal life expectancy following a Bentall operation.

I just think it is a bit weird that they do not cite research from their own hospital... They must have been aware of it. Are they not citing evidence because it doesnt fit with their beliefs?

 

[pellicle]

I think it is a bit funny that he doesnt cite a study from his own hospital (Mount Sinai):

https://www.sciencedirect.com/science/article/abs/pii/S0003497507006674

That study says mechanical valve patients with Biscupid valve disease have normal life expectancy following a Bentall operation.

interesting, that makes him like a woke-agenda infiltrator into your company (and next thing you've got DEI) and you're organisation is shedding high experience staff, short term profit seeking is on the rise and the reputation of the organisation is changing (not for the better).

 

[MdaPA]

FWIW...
My wife went to this hospital for a consultation for her 3rd OHS. The surgeon, the man who introduced the speaker in the beginning of the video, recommended replacing her stenotic mitral bovine tissue valve (implanted in 2nd OHS) with another tissue valve (i.e. thereby guaranteeing yet another surgery/procedure down the road). He said that she was too young (at 50) to be on anti-coagulation therapy. Needless to say, for that reason and a few others I will not discuss here, she had her mitral valve replaced with a St Jude mechanical valve elsewhere.

 

[kentuckyed]

If you calculate the tissue valve cost from this data ($435,716,947 / 75,734) you get $5,753.25 per valve. Doesn't sound like an outrageous price to me.

 

[vitdoc]

Surgeons don't do TAVR valves, interventional cardiologists do, so there should not be any motivation to push TAVR by a surgeon, just the opposite. Surgeons do like to do surgery so one can, if you have a conspiracy type mindset think that they like tissue over mechanical because it will allow them to do more surgery replacing the tissue valves. I personally don't think this is a motivation.

The clicking and warfarin issues appear to be way over emphasized and again don't reflect the vast majority of patient's experiences. Yes there are some who are affected but I suspect the number is very modest. Self checking for the INR levels has been a marked improvement on controlling my own INR and I suspect many others. I detested the lab experience and I must admit even as a physician I didn't test often for months. I used my bleeding hemorrhoids as a marker. Not very smart. Can't say much about the clicking. I can hear my valve mostly in bed when I listen for it otherwise I don't notice it. Maybe after 43 yrs of having a mechanical it has become sort of reassuring.

I don't think there is any financial advantage for doing a tissue over a mechanical other than the possibility of more surgery in the future. I would hope that this is in no way a motivation. I think the guy really believes what he is saying and is in no way financially motivated.

I saw some of this video and my reaction was clearly this guy had an anti warfarin mentality with cherry picking studies that often were old and interpreting them to enhance the predetermined message. If this was felt by the majority of cardiac surgeons no one would be using mechanical valves. Since the tissue valves are slowly improving from generation to generation and since TAVR exists to allow for rescuing failed valves in some instances the percentage of tissue valves placed has increased gradually. But, as has been noted multiple times every procedure has it risks. Stroke, AV block occur just with TAVR. Some of the statements in this video seem to go in the face of what many here have experienced.

I detest open heart surgery which I have had to go through three times. Once for the initial tissue valve placement, once to replace the failed tissue valve and once for an ascending aortic aneurysm. If I had continued tissue valves I would have had several more procedures to get to my age with possibly more to come. When I had my last surgery at age 58 my surgeon who had done around 3,000 aortas said "you don't want someone in your chest a fourth time".

I almost went to Mt. Sinai for my fourth open heart when my mitral valve markedly decompensated about 10 years after my aortic surgery. The guy in charge was noted for his expertise in mitral surgery. At the last minute he called and said I should have a clip instead which I did a few days later. The clip has worked flawlessly for over eight yrs.. I was told that the guy at Mt. Sinai had a huge ego and for him to turn down my surgery suggested that I would have negatively affected his statistics. The guy who gave the lecture was trained by my almost surgeon. So I hope that no one will base any decision that have to make just on this one video. They should get several other opinions if need be to make a well thought out decision.

 

[pellicle]

When I had my last surgery at age 58 my surgeon who had done around 3,000 aortas said "you don't want someone in your chest a fourth time".

Similar words from my guy.

 

[dornole]

Too young for anticoagulation? Odd.

It seems like older adults actually have the greatest risks from warfarin, statistically speaking. Combined with better tissue valve longevity it seems to be a good reason why tissue is a better fit for them. That’s actually the one factor I thought of as a downside of choosing mech - I will (I hope!) be old someday and more prone to bleeds and possibly to goofing up taking my warfarin correctly due to age and confusion. It’s a risk I’m willing to accept to avoid multiple OHS procedures but it’s still a risk.

 

[pellicle]

Too young for anticoagulation? Odd.

yeah, but in some ways I get it. I recall my surgeon saying to me at OHS#2 planning time the words "we don't want to see you on warfarin just yet"; I was about 28 then and the year was 1992. Back then there was no self testing and he'd have been aware of all the issues (regular vein puncutures, the requirement of a clinic, the "chains of location" which that implies on someone younger (who within 10 years would be living in Tokyo not in Brisbane) who may wish to be more "mobile" than a 60yo.

Personally I'm glad that I had that time (particularly in light of the deficits of technology at that time) to have the freedom I had. I truly appreciate just how lucky I am to not be wearing a pacemaker or have multiple on-going (and developing) issues (like arrhythmia) as complications from my 3 OHS's (and glad the infection seems to be in remission too, also a gift of multiple OHS).

As you may know, I assist (behind the scenes) a number of people with ACT and some of them are young. I've found that the younger they are the less likely they are to be diligent, detailed, thorough and reliable. Indeed their ability to communicate is less developed. There is so much that comes with having lived for 40 years as an adult (hopefully) that we may fail to see just isn't present in youth.

So from that perspective alone I can see why some person maybe "too young" to be on ACT.

All that experience of mine is part of why I try to help and mentor them. That I know what happens from Kicking the Can (not that I feel I did that) just amplifies that desire.

Best Wishes

 

[dick0236]

If you calculate the tissue valve cost from this data ($435,716,947 / 75,734) you get $5,753.25 per valve. Doesn't sound like an outrageous price to me.

I suspect that this $5800 is for the valve itself and not the overall hospital/surgeon charges. I used to have copies of my total billing for my valve that was implanted in 1967. My total billing, including 14 days in the hospital and the cost of the mechanical valve was about $5700. I doubt that ANY valve, mechanical or tissue, could be done today for what it cost in 1967.......and my costs included 14 days of hospital services.

 

[pellicle]

I suspect that this $5800 is for the valve itself and not the overall hospital/surgeon charges.

agreed ... I've heard of US$200K as the full bill ...