Mechanical vs Tissue - need help deciding

[Unicusp]

Yep. There's a tremendous amount of unnecessary complexity in the multiple fragmented health insurance systems we have in the US. I would guess there is a lot of non value added admin cost as a result.

And there it is, ding ding we have a winner. I would venture to guess that we (the USA) spend at least as much, if not more on Administrative costs than on the actual healthcare. Think about it, for the majority of procedures, more time is spent on pre-approving, and approving, finding correct billing codes, billing insurance the obscene over inflated amounts, then agreeing to lower amounts, and then eventually sending out the bill to the patient for the balance. Then waiting.....then potential collections or negotiated settlement. It's ridiculous.
Years back my son was in a bad accident. Went to a local hospital that ran as many tests as they could think of, then told us they were unequipped to handle the necessary care and that he would need to be moved to another local hospital. The other hospital was about a 20 minute drive away. Yet, they forced us to use the helicopter service and said it was covered by insurance. So, instead of taking a 20 minute ambulance ride, it took them about 30 minutes to prep the helicopter and about 15 minutes to make the trip. Then about 2 months later the fun crazy billing procedure begins. My first bill for the "free" helicopter ride was close to $20k. Turns out that some of it is covered by insurance but if they bill $35k, and insurance pays $7k, they expect you to pay the balance. All for a 15 minute helicopter ride. Turns out that this is a standard practice at many hospitals where you have helicopter "profit centers" that are independent, and get the forced referrals. A friend of mine's son who only had a broken ankle was forced thru the same routine.
And as for the many tests they ran, none of them were transferable or usable at the next hospital, so they all had to be re-run. Who thinks that this is an efficient system? It is absolutely crazy. And this was not in the boondocks. It was in Philadelphia, PA.

 

[Superman]

Same. Billed $2,400 for an ambulance ride. Our son could have been driven by us from urgent care to ER. Insurance has an agreement with the ambulance company for an allowable amount of about $700 and we have a $150 copay. A cash customer would be stuck with the $2,400 and they’re subsidizing our coverage.

 

[carolinemc]

I'm not smart enough to figure this out but here is what I think anyway:

I retired early at age 56 by choice. Was not eligible for ACA due to means testing - fair enough. Bought $5000/pp deductible individual policies for my wife and myself from AARP/United Healthcare - thinking that I could manage premiums by self insuring for all but major illnesses or injuries which I correctly believed we might avoid. Badly miscalculated there. Over 12 years paid approx. $120,000 in premiums and, due to good overall health, never collected a $.01 in claims. Had monthly premium increased 19 times in 12 years - sometimes by $100/mo. Once called AARP/United Healthcare to complain about monthly increases despite $0 claims. They blew me off. My conclusion was that insurance companies know that individual policies are a gold mine that can be leveraged since the individuals have few options and all companies (at least in FL) play the same game.

I have nothing but good things to say about Medicare, although I chose to not use AARP/United Healthcare. Our annual out of pocket runs a few thousand $/year. Our out of pocket last year which included my OHS at CC and all preop and postop was $3600, not including travel costs to go to Cleveland.

My conclusion is that low income/net worth individuals have ACA (which has a decent approach to means testing included) or Medicaid. Employed individuals with decent employer sponsored coverage have that. Retired individuals have Medicare.

The gap is individuals who have not yet become eligible for Medicare and don't have a decent company sponsored plan but make a decent living. The insurance companies will take them to the cleaners on an individual policy, so some may decide to go without insurance.

Maybe the solution is to forget ACA and make everyone eligible to opt in to Medicare with appropriate levels of means testing and underwriting for those <65 years old. I would have gladly paid - say half of that $120,000 - to the government instead of AARP/United Healthcare. And since I had no claims to be paid, the government would be $ ahead on insuring us.

Of course the problem with any proposed solution is that our legislators are responsible for the laws that govern our healthcare. IMHO, therein is the real problem - we have no chance. None of our politicians from either major party have the willingness and the ability to craft a solution. They are too busy complaining and criticizing each other and working their self serving agendas.

You do know how Medicare works, first. It pays 80% of the medical cost from testing to surgery. Then you have to pay the 20% that Medicare does not cover. And then if you are disabled, or Retired, you can get Medicare. When you are very limited income cannot afford the extra stuff, it can be a rough time. My mother was on it when she has RA and she just did not pay the 20% that Medicare did not pay. And I may be heading that way myself soon enough. To get the extra stuff, you have to be rich enough to afford those premiums. I will see what I can do on the next set up. Hope to get one with Zero premium. I am still new kid, even though I have been on SSDI and Medicare for three years now. But Medicare does help with my testing supplies for Type 2 diabetes.
We all have out ways to get medical care paid for.

 

[carolinemc]

Same. Billed $2,400 for an ambulance ride. Our son could have been driven by us from urgent care to ER. Insurance has an agreement with the ambulance company for an allowable amount of about $700 and we have a $150 copay. A cash customer would be stuck with the $2,400 and they’re subsidizing our coverage.

I was able to skip the ambulance ride, when I fell on black ice quite a few years ago. Firefighters here also are EMTS, and they knew I was not made of money and told me, since I was not bleeding out, to ride the bus to the hospital. Loved it and scary at the same time. I was still working then.

 

[slipkid]

I was able to skip the ambulance ride, when I fell on black ice quite a few years ago. Firefighters here also are EMTS, and they knew I was not made of money and told me, since I was not bleeding out, to ride the bus to the hospital. Loved it and scary at the same time. I was still working then.

Yeah, when I had my heart attack the (5 minute) ambulance ride cost $2500 plus $65 gas.

And it is a total racket with "donating" to your local ambulance company & not getting charged. Unfortunately when 911 is called and an ambulance is dispatched by whatever district etc happens to be in the area/gets their first gets the prize (your money). Some townships here have deals with other townships so that if you've donated to one but serviced by another who has a deal with yours they are no supposed to charge you, but it is a total crapshoot as to who you get (so I stopped donating). Then there is the 5 fingered discount/wallet surgery some of them perform on you if you are unconscious or when left with your things even for just a few minutes (happened to me & even to Tony Soprano in an episode of the Sopranos!).

 

[carolinemc]

Yeah, when I had my heart attack the (5 minute) ambulance ride cost $2500 plus $65 gas.

And it is a total racket with "donating" to your local ambulance company & not getting charged. Unfortunately when 911 is called and an ambulance is dispatched by whatever district etc happens to be in the area/gets their first gets the prize (your money). Some townships here have deals with other townships so that if you've donated to one but serviced by another who has a deal with yours they are no supposed to charge you, but it is a total crapshoot as to who you get (so I stopped donating). Then there is the 5 fingered discount/wallet surgery some of them perform on you if you are unconscious or when left with your things even for just a few minutes (happened to me & even to Tony Soprano in an episode of the Sopranos!).

My local ambulance service was in the private sector quite a few years ago till the voters made it part of the fire Department. They used to do a membership driver every three months. So glad that is gone. But they can still bill you outrageously, no matter the insurance coverage. I was luck with my case, I was wide awake and aware of everything.

 

[pellicle]

Unfortunately when 911 is called and an ambulance is dispatched by whatever district etc happens to be in the area/gets their first gets the prize (your money)

Ever watch Mother Jugs and Speed?

 

[eftdan]

https://www.tctmd.com/news/more-deaths-bioprosthetic-mechanical-avr-young-patients

 

[Chuck C]

https://www.tctmd.com/news/more-deaths-bioprosthetic-mechanical-avr-young-patients

Thanks for sharing that meta-analysis. It may surprise folks how they define “young” The study defines it as under 70.

This type of meta-analysis should help people make an informed decision. Lots of pros and cons for each valve choice, as there is no perfect valve. But it is important that the choice be as informed as possible. For young patients this means that choosing tissue for fear of anti-coagulation medication means future interventions. The study you shared also suggests that this choice would also mean significantly lower life expectancy for young patients, which should not be a big surprise given the near certainty of future interventions and the risks that brings with it.

“The data suggest that physicians and patients might be making detrimental trade-offs with biological aortic valves: avoiding lifelong anticoagulation but increasing the risk of death and reinterventions.”

Most folks don’t look 5 years ahead. Asking them to think 10 to 20 years ahead is not likely to happen often.

Also, this type of data can never compete with:

“I heard the new tissue valves will last 30+ years, even for young patients”

 

[pellicle]

Thanks for sharing that meta-analysis. It may surprise folks how they define “young” The study defines it as under 70.

I'll just leave this here (again)

This type of meta-analysis should help people make an informed decision.

should is my favourite word ... and don't forget the warfarin problems

 

[slipkid]

Ever watch Mother Jugs and Speed?

Yes, but been so long ago the only thing I recall is that they named the wrong character "jugs".

 

[user 15848]

https://www.tctmd.com/news/more-deaths-bioprosthetic-mechanical-avr-young-patients

Good article, simple facts. I always say, i wish i was born with a normal 3 cuspid valve heart, no luck, i wish don't have to plan
go back to a hospital for surgery, i wish didnt have to take any pill what so ever, but between taking a pill and going back
to hospital to become a source of recurrent revenue for big pharma, nope, i stick to old and proven mech as my 2 doctor sisters
said, my 8 first cousins also doctors, and my little mathematical engineering brain told me, but, that is just " my " opinion, we
are not in Com China were all have to love Mao or else

 

[pellicle]

Good morning fellas.

Firstly this is a thorny issue and I've been targeted in the past by quite vile attacks on my character (apparently with the full approval of the then administration) for speaking on this topic, so it is with a little reticence I offer my thoughts here.

I had my AVR at 45, tissue valve. Both my cardiologist and surgeon, while they were keep saying, "it's your decision, we're not trying to influence you", were obviously pushing for tissue valve.

the point Dan raises is pretty common, with surgeons occasionally confronting a patient in the hospital on the ward, moments before surgery and saying "you should have a tissue".

That is not respecting patient "informed choice" and is outright intimidation.

The problem is that the vast majority of patients are well over 50 and this skews the thinking of the industry. Worse they seem to willingly ignore the known issues of selection bias against warfarin therapy and cite data from disparate (and unrelated to valve surgery) sources on the issues with INR management. As I understand it the USA is prime here at forcing people into clinics which have at best "no better" and frequently worse track records of management of patients.

This is an old presentation, but the facts of the matter remain unchanged.



interestingly almost every single point that Dr Schaff made in that has proven correct (except new drugs), in particular the advances in INR self testing and self management (all blocked by "the system" {mostly in the USA} who makes money out of you). I expect that I'll get accused of USA bashing again but that's ok.

... The whole industry is pushing for tissue valve, "this is where the future is", they'll tell you... While the future might be there, we live in the present, I'm 53 now and I can feel that soon, few more years maybe, I would have to go again through the same ordeal... and I kind of regret the decision I made back then.

Dan I feel for you and the way I look at it "you didn't make a decision" you were taken advantage of. Anyone with any humanity would know you were in a sensitive psychological situation and instead of caring support you got "opinion's forced upon you"

The actual purpose of this site is was and should be to provide support for patients trying to make sense of this conundrum and seeking help from the people who are already well along the path. Instead we have a tribalism here which frequently espouses "just trust your doctor" backed up with "nobody here is a doctor".

Ironically I know we have some doctors here and so its just a false claim. Pathetic when you have to make false assumptions to validate your fact free flaccid arguments.

This is a pair of logical fallacies; Ad populum/Bandwagon Appeal and Ad hominem. It frequently said by those who I strongly suspect feel the need to have "company" in their decision: ergo actually feel insecure in it. To drag someone down like this to make themselves feel good is just repugnant.

Anyone regularly reading here should become familiar with this list:
https://owl.purdue.edu/owl/general_...logic_in_argumentative_writing/fallacies.html

Eating well, going to gym, keeping yourself in shape, sure, it's important, but this won't save you from future surgeries, especially if you are 'relatively' young.

exactly and there have been many evaluations of SVD here by me and others, but (to be frank) some people are either so imbibed in their thinking that they find the idea unpalatable (and thus reject it) or are so uneducated and dunning kruger as to be unable to process and comprehend it (sometimes both).

It all depends from individual to individual, of course, but as a basic rule of thumb, one younger that 55 should go with mechanical, 55 to 65, SAVR tissue and over 65, SAVR or TAVR tissue.

yes and this WAS and still is the surgical guidelines, now being undermined by some groups.

Evidence like this is emerging...

https://www.tctmd.com/news/more-deaths-bioprosthetic-mechanical-avr-young-patients

but then many in medicine and the flying monkeys they enlist don't like evidence, its messy and subject to interpretational difficulties.

I quoted Chuck here because this is exactly a point I've made here since 2012

Most folks don’t look 5 years ahead. Asking them to think 10 to 20 years ahead is not likely to happen often.

Also, this type of data can never compete with:
“I heard the new tissue valves will last 30+ years, even for young patients”

which essentially is an appeal to emotions, begs the claim and is a circular argument.

Now I'll no doubt get pushback (fortunately I've got most of those Richard Craniums on my ignore list) and accused again of being a pro mech tissue hater (which is in itself both an Ad hominem attack and a moral equivalence failure of logic), which is NOT borne out by evidence of my posts here.

I often say to these "just follow your doctor" - "there is no wrong decision" - "nobody here is a doctor" Dunning Krugers this: "will you be there to help the person through your bad advice"?

The answer is no. Their responses are usually stony silence or "hand wringing"

Will I be here to help people with management of their INR ... the answer there is found in my posts.

So I'm sorry Dan and I'm sorry that sections of this community and the medical system have let you down.

Best Wishes.

 

[Gator Chief]

Good morning fellas.

Firstly this is a thorny issue and I've been targeted in the past by quite vile attacks on my character (apparently with the full approval of the then administration) for speaking on this topic, so it is with a little reticence I offer my thoughts here.



the point Dan raises is pretty common, with surgeons occasionally confronting a patient in the hospital on the ward, moments before surgery and saying "you should have a tissue".

That is not respecting patient "informed choice" and is outright intimidation.

The problem is that the vast majority of patients are well over 50 and this skews the thinking of the industry. Worse they seem to willingly ignore the known issues of selection bias against warfarin therapy and cite data from disparate (and unrelated to valve surgery) sources on the issues with INR management. As I understand it the USA is prime here at forcing people into clinics which have at best "no better" and frequently worse track records of management of patients.

This is an old presentation, but the facts of the matter remain unchanged.



interestingly almost every single point that Dr Schaff made in that has proven correct (except new drugs), in particular the advances in INR self testing and self management (all blocked by "the system" {mostly in the USA} who makes money out of you). I expect that I'll get accused of USA bashing again but that's ok.



Dan I feel for you and the way I look at it "you didn't make a decision" you were taken advantage of. Anyone with any humanity would know you were in a sensitive psychological situation and instead of caring support you got "opinion's forced upon you"

The actual purpose of this site is was and should be to provide support for patients trying to make sense of this conundrum and seeking help from the people who are already well along the path. Instead we have a tribalism here which frequently espouses "just trust your doctor" backed up with "nobody here is a doctor".

Ironically I know we have some doctors here and so its just a false claim. Pathetic when you have to make false assumptions to validate your fact free flaccid arguments.

This is a pair of logical fallacies; Ad populum/Bandwagon Appeal and Ad hominem. It frequently said by those who I strongly suspect feel the need to have "company" in their decision: ergo actually feel insecure in it. To drag someone down like this to make themselves feel good is just repugnant.

Anyone regularly reading here should become familiar with this list:
https://owl.purdue.edu/owl/general_...logic_in_argumentative_writing/fallacies.html



exactly and there have been many evaluations of SVD here by me and others, but (to be frank) some people are either so imbibed in their thinking that they find the idea unpalatable (and thus reject it) or are so uneducated and dunning kruger as to be unable to process and comprehend it (sometimes both).




yes and this WAS and still is the surgical guidelines, now being undermined by some groups.

Evidence like this is emerging...



but then many in medicine and the flying monkeys they enlist don't like evidence, its messy and subject to interpretational difficulties.

I quoted Chuck here because this is exactly a point I've made here since 2012


which essentially is an appeal to emotions, begs the claim and is a circular argument.

Now I'll no doubt get pushback (fortunately I've got most of those Richard Craniums on my ignore list) and accused again of being a pro mech tissue hater (which is in itself both an Ad hominem attack and a moral equivalence failure of logic), which is NOT borne out by evidence of my posts here.

I often say to these "just follow your doctor" - "there is no wrong decision" - "nobody here is a doctor" Dunning Krugers this: "will you be there to help the person through your bad advice"?

The answer is no. Their responses are usually stony silence or "hand wringing"

Will I be here to help people with management of their INR ... the answer there is found in my posts.

So I'm sorry Dan and I'm sorry that sections of this community and the medical system have let you down.

Best Wishes.

Interesting your still here trying to help people with the choice. I remember you when I was making my choice in April 2012. At 62, I choose the On-X mechanical valve replacement. My cardiologist and surgeon both said that baring no issues during the surgery, that I should research the valves and make an informed decision for me and my lifestyle. It’s almost the 10 year milestone for me and I decided to come back to the site that influenced me the most in my journey.
4/20/2012 AVR On-X 23mm mechanical
7/10/2012 Alere home monitoring INR
Surgeries after valve replacement:
10/2015 shoulder surgery for massive rotator cuff repair. ( no bridging )

1/2019 surgery for cervical spinal fusion c4 c5 ( no bridging )

11/2020 surgery for total knee replacement bridging with heparin and had a bleeding event in hospital. Stopped heparin and started Coumadin bleeding controlled.
I have managed my Coumadin for almost ten years now with only one significant event. I did however take advice from this site for my INR target range. Opting to keep my target at 2.5 to 3.0 instead of 1.5 to 2.0. I will say that at 72, it’s more practical to medicate for more clotting risks. My life is fairly normal since the surgery and hopefully I will never need AVR for the rest of my life. Hang in there. Like my surgeon said at my first follow up visit, “ go live your life”

 

[Unicusp]

Interesting your still here trying to help people with the choice. I remember you when I was making my choice in April 2012. At 62, I choose the On-X mechanical valve replacement. My cardiologist and surgeon both said that baring no issues during the surgery, that I should research the valves and make an informed decision for me and my lifestyle. It’s almost the 10 year milestone for me and I decided to come back to the site that influenced me the most in my journey.
4/20/2012 AVR On-X 23mm mechanical

Opting to keep my target at 2.5 to 3.0 instead of 1.5 to 2.0. I will say that at 72, it’s more practical to medicate for more clotting risks. My life is fairly normal since the surgery and hopefully I will never need AVR for the rest of my life. Hang in there. Like my surgeon said at my first follow up visit, “ go live your life”

Great to hear. I made the same decision and had the same valve (and size) installed Feb 2021 right before turning 60. No regrets.

INR range. Same here. I also target 2.5 to 3.0 and declined participation in the Eliquis study. Take care!

 

[Chuck C]

eah, when I had my heart attack the (5 minute) ambulance ride cost $2500 plus $65 gas.

You'd think that at the rate of $2,500 that they could comp you the gas. Way overpriced and super tacky.

 

[pellicle]

Hi

Thanks for your kind words

Interesting your still here trying to help people with the choice.

I'm glad everything is working out and hope it continues to do so

Opting to keep my target at 2.5 to 3.0 instead of 1.5 to 2.0. I will say that at 72, it’s more practical to medicate for more clotting risks.

I would agree entirely.

Best Wishes

 

[Chuck C]

Interesting your still here trying to help people with the choice. I remember you when I was making my choice in April 2012. At 62, I choose the On-X mechanical valve replacement. My cardiologist and surgeon both said that baring no issues during the surgery, that I should research the valves and make an informed decision for me and my lifestyle. It’s almost the 10 year milestone for me and I decided to come back to the site that influenced me the most in my journey.
4/20/2012 AVR On-X 23mm mechanical
7/10/2012 Alere home monitoring INR
Surgeries after valve replacement:
10/2015 shoulder surgery for massive rotator cuff repair. ( no bridging )

1/2019 surgery for cervical spinal fusion c4 c5 ( no bridging )

11/2020 surgery for total knee replacement bridging with heparin and had a bleeding event in hospital. Stopped heparin and started Coumadin bleeding controlled.
I have managed my Coumadin for almost ten years now with only one significant event. I did however take advice from this site for my INR target range. Opting to keep my target at 2.5 to 3.0 instead of 1.5 to 2.0. I will say that at 72, it’s more practical to medicate for more clotting risks. My life is fairly normal since the surgery and hopefully I will never need AVR for the rest of my life. Hang in there. Like my surgeon said at my first follow up visit, “ go live your life”

Welcome back! Thank you for taking the time to share your experience.

I went with a St Jude mechanical valve 10 months ago and also self manage my INR and use the same target range as you do.

I find it interesting that two of your significant surgeries did not involve bridging. Did you bring your INR down prior to surgery?

I have an upcoming minor procedure in my thyroid to ablate a benign nodule. There is not typically too much bleeding with this procedure, but some. The surgeon, based on his experience, indicated that he does not believe that bridging is necessary, as long as I bring my INR under 1.5 for this particular procedure. I am not concerned about bringing it that low for a day or two.

My cardiologist would rather that I bridge, so I've got a decision to make. Given that there is some risk of a bleed with bridging, as you experienced, I think I'd rather bring my INR down briefly for such a minor procedure than to bridge.

 

[pellicle]

Yes, but been so long ago the only thing I recall is that they named the wrong character "jugs".

I used to reflect on this, but if they'd named Bill Cosby "mother" it may have been too close to the bone.

 

[pellicle]

Morning

My cardiologist would rather that I bridge, so I've got a decision to make.

https://www.nps.org.au/australian-p...e-perioperative-management-of-anticoagulation
From that:

The authors argue that for every 10 000 patients with mechanical heart valves who are given perioperative intravenous heparin, three thromboembolic events are prevented at the cost of 300 major postoperative bleeding episodes. (ref Kearon C, Hirsh J. Management of anticoagulation before and after elective surgery. N Engl J Med 1997;336:1506-11.)​

seems to be supported by various other evidence too
PS: I just fixed the ref from the NPS.ORG reference to point to the right place