Should I Have a Stent?

[rich01]

I don't think most cardiologists think that diet is not important. Clearly reducing various fatty components in the blood appear to be a good thing in statistically reducing the chance of plaque build up. Diet does help but may be inadequate and may not be followed by everyone. So drugs to reduce cholesterol are used and have been shown to be helpful in large prospective trials.
Angina is not necessary a requirement for a decision on dealing with coronary artery disease.
The first symptom can be death. One can look in the medical literature and cherry pick whatever you want to find. I am a physician but not a cardiologist but an 80% blockage sounds pretty worrisome. Stenting is generally done by interventional cardiologists bypass by cardiac surgeons.
There are various criteria to decide on stenting vs bypass. If the area can be stented that probably is easier and safer than bypass. The only issue with placing a stent and a valve is that for a mechanical valve you need to be on warfarin. For a stent you need to be on an anti platelet agent such as Plavix for at least a year. So one would be on both agents for a year if the valve and stent were done together. Why don't you bring in your literature that suggests that stenting is only required if you are symptomatic to a cardiologist to review with you. I have patients bring things to me which often are fourth rate in quality. Be careful of DR. GOOGLE. Also don't assume that every physician is stupid or a crook.

You didn't offer any proof that stents work. I said previously they have been shown to work in emergency situations, but I can't find any scientific studies that show they work better than medical therapy in non-emergency cases. Can you provide any references to scientific studies that show stents either prevent future heart attacks or prolong life?

 

[pellicle]

My cardiologist said about 15 years.

So suddenly you trust these guys?

Here is a graph of data from a study

so moderate Structural Valve Degredation by 8 years. Not bad if you're so frail that you're expecting to be dead by then.

Lets look at the cohort shall we?

Results A total of 241 patients (79.3 ± 7.5 years of age; 46% female) with paired post-procedure and late echocardiographic follow-up (median 5.8 years, range 5 to 10 years) were included. A total of 149 patients (64%) were treated with a self-expandable valve and 80 (34.7%) with a balloon-expandable valve. Peak aortic valve gradient at follow-up was lower than post-procedure (17.1 vs. 19.1 mm Hg; p = 0.002). More patients had none/trivial aortic regurgitation (AR) (47.5% vs. 33%), and fewer had mild AR (42.5% vs. 57%) at follow-up (p = 0.02). There was 1 case (0.4%) of severe SVD 5.3 years after implantation (new severe AR). There were 21 cases (8.7%) of moderate SVD (mean 6.1 years post-implantation; range 4.9 to 8.6 years). Twelve of these (57%) were due to new AR and 9 (43%) to restenosis.

so between 71 and 86 years old ... median follow up only 5.8 years but yet they feel comfortable at projecting it to 8.

If you think that data looks good enough to write this in the conclusions:

Conclusions Long-term transcatheter aortic valve function is excellent.

then you go for it
What am yet to see is how long these things last in active people in their 60's (who by definition would not be frail).

We need more lab rats to do Human Trials, we've had one here who was under 50 IIRC, but he hasn't shown back up (after leaning on everyone for tons of support) with any feedback to this community. Maybe that's an indicator he's super well (or not)

 

[pellicle]

I trust the surgeon to replace my valve. Since I hopefully will be in a trial, the valve is determined by the trial. If I have to have a stent, I will rely on the professionals to use the right kind of stent.

hmm ... if you're on a trial, you're a lab rat and they don't care about the outcome because that's what trials are to establish (if they are good or not)

if you go to a professional they'll choose something from the established stuff that has a long history of success.

but we need lab rats too

 

[pellicle]

You didn't offer any proof that stents work. ... Can you provide any references to scientific studies that show stents either prevent future heart attacks or prolong life?

its a fair question (if a bit roughly phrased), why don't YOU do due dilligence and do a through literature review? You know, of studies. They're published you know

 

[rich01]

hmm ... if you're on a trial, you're a lab rat and they don't care about the outcome because that's what trials are to establish (if they are good or not)

if you go to a professional they'll choose something from the established stuff that has a long history of success.

but we need lab rats too

Actually it's just the opposite. Medtronics is funding the study, so they want it to be as successful as possible. The trial has already completed the TAVR vs SAVR phase and results were favorable. Now they are just collecting info on TAVR, so if accepted I get TAVR with a Medtronics valve.

 

[rich01]

its a fair question (if a bit roughly phrased), why don't YOU do due dilligence and do a through literature review? You know, of studies. They're published you know

Why assume I haven't done due diligence? I posted info on studies that show stents did not reduce risk of heart attack or increase lifespan beyond what medical intervention did, and said I haven't been able to find any studies that show stents are superior to medical intervention in non-critical cases.

If your only point of responding was to criticize, why bother?

 

[pellicle]

Why assume I haven't done due dilligence?

I didn't make that assumption, you did ... I just encouraged you to do it ... I made no assumptions that you had or had not.

as always my posts are to encourage. You did not present any of the results of your research so its hard to actually discuss that

 

[pellicle]

Actually it's just the opposite. Medtronics is funding the study, so they want it to be as successful as possible. The trial has already completed the TAVR vs SAVR phase and results were favorable.

so you're not on a trial then?

 

[rich01]

so you're not on a trial then?

Since I am still asymptomatic, I am a candidate for the trial, but can't be approved until symptoms develop (I already posted this). They are in the 2nd phase of the trial now which is TAVR only.

 

[rich01]

I didn't make that assumption, you did ... I just encouraged you to do it ... I made no assumptions that you had or had not.

as always my posts are to encourage. You did not present any of the results of your research so its hard to actually discuss that

If your posts are to encourage, you had me fooled.

I posted links to the studies in the 1st post of this thread.

 

[pellicle]

I posted links to the studies in the 1st post of this thread.

when I did my masters research we were expected to provide more than that, indeed I usually provide more than that in supporting a proposition here. When choosing something as important as this its critical to examine both positives and negatives (as both do exist in the studies) and not just pick the studies which support the view you had before beginning. Now note please I'm not saying that's what you did, but just expressing a general concept and you can decide for yourself if you have done that.

 

[carolinemc]

Please note the term "interventional" prefacing cardiologist in what I wrote

https://en.m.wikipedia.org/wiki/Interventional_cardiology

Also
https://www.acc.org/latest-in-cardiology/articles/2015/09/09/08/44/cardiac-surgery-and-the-futureFood for thought

Thanks for giving more information, I stand by my comments also. Hugs for today.

 

[carolinemc]

I always wonder why so many people are still having open heart surgery for aortic valve replacement when TAVR appears to be as safe or safer. Mick Jagger was out on tour about 4 weeks after having his aortic valve replaced by TAVR.

Because the aortic valve is in the middle of the heart, the heart has to come out for the repair or replace. Hence the cracking of the chest, hence the heart and lung machine used. There is no simple way to get to the aortic valve but to take the heart out to get to it. You can't do that with a TAVR. Mic Jaggar had a repair, not a replacement.

 

[Suckyvalvegurl]

You absolutely can replace the valve without cracking the chest or TAVR. I just had it in February. There just are not a lot of surgeons skilled at it so word is not getting out. They do the bypass through the groin. I have a 2 inch incision on my right upper chest.

 

[rich01]

Because the aortic valve is in the middle of the heart, the heart has to come out for the repair or replace. Hence the cracking of the chest, hence the heart and lung machine used. There is no simple way to get to the aortic valve but to take the heart out to get to it. You can't do that with a TAVR. Mic Jaggar had a repair, not a replacement.

Caroline, TAVR is much like getting a stent or a cardiac catheterization. They go in through the groin or arm and run a catheter into the heart. Then they insert a new valve inside the old valve and that's it. Done.

You are usually released from hospital next day and driving in a week.

 

[rich01]

when I did my masters research we were expected to provide more than that, indeed I usually provide more than that in supporting a proposition here. When choosing something as important as this its critical to examine both positives and negatives (as both do exist in the studies) and not just pick the studies which support the view you had before beginning. Now note please I'm not saying that's what you did, but just expressing a general concept and you can decide for yourself if you have done that.

Boy, this is a strict forum. I didn't know I would be graded on my posts.

However, the way I posted a snippet and a url is the proper way to create a reference for a web posting

 

[vitdoc]

What type of valve was placed?

 

[Paleowoman]

The problem with TAVR is that the valve is not as strong as the conventional tissue valve given with open heart surgery so will not last as long - the leaflets on the TAVR valve are more flimsy/thin so that the whole thing is smaller so they can get it threaded through the artery. So, if a regular tissue valve has an average lifespan of 10 years (maybe more for the newer Inspiris Resilia valve) how much less long will an average TAVR valve last ? The problem with giving TAVR to someone who is not so elderly is that when it fails another TAVR cannot be done and so the person will then have to have conventional open heart surgery. In the example of Mick Jagger, who is 75 and apparently very fit and healthy, this may mean that by the time he is less than 85 his TAVR valve may fail and then he will have to have open heart surgery which, him being that much older is more risky - whereas if he had had conventional open heart surgery now with a regular valve with average life ten years, or longer, he could then have TAVR within that valve - a valve within valve procedure which can be done within a regular replacement valve (as long as it is 23mm or more) but not within a TAVR valve.

 

[rich01]

Current valves used in TAVR are expected to last about as long as those used in SAVR which is 10-15 years.

 

[Paleowoman]

Current valves used in TAVR are expected to last about as long as those used in SAVR which is 10-15 years.

Well if that's true, what will a person who, like Mick Jagger, has TAVR, do when their TAVR valve fails ? If Jagger's valve fails in 10 to 15 years time he will be 85 or 90 and not such a good age for SAVR but he won't be able to have TAVR again.