transcatheter aortic valve implantation
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Thanks for the link
M
Mary
Will interventional cardiologists perform the implants rather than a cardiothoracic surgeon?
If so, I can't imagine the surgeons pushing for them.
If so, I can't imagine the surgeons pushing for them.
yes the Inv cards do them.(just like stents now instead of cutting and patching) actually a whole session on the aats webcast was the surgeons discussing this and how they have to work more as a team ect, because they have to be back up.
B
Bridgette
"The numbers are relatively small: 105 patients were enrolled in REVIVE II and 55 in REVIVAL II. Inclusion criteria for patients treated by transfemoral valve placement in these two studies were severe, symptomatic aortic stenosis, age >70 years, high surgical risk..."
"Patients entered into both registries all had high-risk conditions: prior cardiac surgery (29%), previous cerebrovascular accident or transient ischemic attack (16%), chronic obstructive pulmonary disease (27%), renal dysfunction (22%), diabetes (26%), porcelain aorta (6%), chest wall radiation (7%), and chest deformity (4%). Eighty percent of patients had a predicted operative risk of >20% (Euroscore)"
These 2 paragraphs illustrate to me why we can't get too excited about this procedure just yet.
If you are young, asymptomatic, and with no co-morbidities, don't be thinking this will be an option for you in the NEAR future.
Yes, things do look promising but as with anything medical it'll take a long time before it is approved for the masses, if at all?
Oh, and this procedure has been performed in NZ (in both the public and private sector) and the patients fitted the above criteria.
"Patients entered into both registries all had high-risk conditions: prior cardiac surgery (29%), previous cerebrovascular accident or transient ischemic attack (16%), chronic obstructive pulmonary disease (27%), renal dysfunction (22%), diabetes (26%), porcelain aorta (6%), chest wall radiation (7%), and chest deformity (4%). Eighty percent of patients had a predicted operative risk of >20% (Euroscore)"
These 2 paragraphs illustrate to me why we can't get too excited about this procedure just yet.
If you are young, asymptomatic, and with no co-morbidities, don't be thinking this will be an option for you in the NEAR future.
Yes, things do look promising but as with anything medical it'll take a long time before it is approved for the masses, if at all?
Oh, and this procedure has been performed in NZ (in both the public and private sector) and the patients fitted the above criteria.
Usually in clinical trials to replace something like a valve replacement that the stats are already good for, They have to start with high risk patients who aren't candidates for surgery.
B
Bridgette
Yes, I'm sure, but the author of the article did say that it will be a steep learning curve.
Remember that there were adverse events post procedure in some of the patients from the study.
He made it sound like there would have to be a lot of fine tuning of the technique.
Do YOU think that it's going to be available for the general population anytime soon, and if so, what makes you believe that? I am genuinely curious.
I'm not trying to dampen anyone's enthusiasm, and it IS an exciting development. I just think people need to be cautious, that's all.
Remember that there were adverse events post procedure in some of the patients from the study.
He made it sound like there would have to be a lot of fine tuning of the technique.
Do YOU think that it's going to be available for the general population anytime soon, and if so, what makes you believe that? I am genuinely curious.
I'm not trying to dampen anyone's enthusiasm, and it IS an exciting development. I just think people need to be cautious, that's all.
I think it will be available to patients in 5-10 years. Honestly I thought it would be 10 or more until I spent a couple days listening to all the surgeons presentations in the 2008 AATS webcasts and hearing them talk like it would be sooner than later. I was surprised to hear the Edwards valve will be available commercially in probably 2011, because I thought it would be a few years after that. One of the speakers was from Europe or UK (i'll have to check) and he showed graphs with the results from their first set of patients and the next set after they learned alot from the first set. The stats for the next group were much better, so the newer doctors learn from their experience and won't make the same mistakes, since they tweaked a few things. Also since the patients in the trial were the high risk patients with alot of medical problems, I don't know how much that played into the adverse events and how they would have lived with out any intervention.
I know the pulm ones were the first and they have been doing them in Europe for 10 years now and the stats are pretty good. (they even have already replaced a percutaneous valve the same way)In the clinical trials for the pulm replacements (Melody)right now in the US they don't have the same criteria about only on high risk patients, I think (but don't know for a fact) that was because one of the criteria was the patient had to already have a conduit and they are doing them on kids and adults older than 5 who generally, except for their heart, are pretty healthy. But most have already had a couple surgeries if their issue is their pulm valve because PVRs tend to be needed in congenital patients not aquired later in life, (not always just the majority)
I do know things can move fast IF people (doctors) are pushing for it. It reminds me alot of when Justin was 10. His original surgeon and ped card left CHOP to work in Switzerland for a few years and help start a center there (and yes they sent us postcards incase we wanted to zip over to Switzerland for Justin's check up, they even mentioned it overlooked the beautiful lake Geneva) When they came back to the US they started the CHD center in Delaware so we transferred Justin's care there. Anyway his first appt he needed a cath, and after the cath his card told us a section of his conduit was blocked and he needed surgery to cut that section out and patch it up. His cardiologist told us if we were in Switz he could just use this new stent he was working with, but it wasn't approved yet in the US so Justin needed surgery. 2 years later the new section of conduit was blocked but this time the stent was available so Justin was able to get the stent in the cath lab and avoid yet another surgery. To US it was worth trying, if it failed they would need to operate, but if it worked.. great. Because of the stent and the way they could balloon it more open as he grew he was able to put off surgery until he was 17 and the stent couldn't get any bigger.
IMO Probably when they first get approved they will only do them in a few centers, and it will take awhile for lots centers to be able to do them, for the doctors to be trained and to have the hybrid labs they should have to do them. So they will probably be available, but you may have to travel in the beginning. I hate to keep going back to CHD but that is my experience. When Justin was a baby (in 88) his surgeon Norwood, was the one that first started doing the Fontan in 3 stages that made it possible for babies with HLHS to live. There were very few (5-10?) centers in the US that were doing them at the time but it was available to anyone that wanted to travel and knew about it. Which not alot of doctors told the parents since it was so new alot of the babies didn't survive and long term wasn't known. Before that the choices were to get on a list for transplant (even tho transplants were pretty new and baby heart are pretty rare)or go home to be loved for a short time. Then more and more centers were doing them as residents went thru the origonal centers then went off to start their own practice and older surgeons got trained on the new surgery, and now there are hospitals all over the world that do it.
I don't think it will take that long (decade) for the percutaneous valves to be available widespread once approval is given since many interventional cards do stents and they are already doing trials in about 20 centers all over the US. Am I counting on it 100%? ...NO!Whose to say in the next year or so all the original valves from 5 years ago won't start failing and they will have to go back to the drawing board. but so far it looks good
I know the pulm ones were the first and they have been doing them in Europe for 10 years now and the stats are pretty good. (they even have already replaced a percutaneous valve the same way)In the clinical trials for the pulm replacements (Melody)right now in the US they don't have the same criteria about only on high risk patients, I think (but don't know for a fact) that was because one of the criteria was the patient had to already have a conduit and they are doing them on kids and adults older than 5 who generally, except for their heart, are pretty healthy. But most have already had a couple surgeries if their issue is their pulm valve because PVRs tend to be needed in congenital patients not aquired later in life, (not always just the majority)
I do know things can move fast IF people (doctors) are pushing for it. It reminds me alot of when Justin was 10. His original surgeon and ped card left CHOP to work in Switzerland for a few years and help start a center there (and yes they sent us postcards incase we wanted to zip over to Switzerland for Justin's check up, they even mentioned it overlooked the beautiful lake Geneva) When they came back to the US they started the CHD center in Delaware so we transferred Justin's care there. Anyway his first appt he needed a cath, and after the cath his card told us a section of his conduit was blocked and he needed surgery to cut that section out and patch it up. His cardiologist told us if we were in Switz he could just use this new stent he was working with, but it wasn't approved yet in the US so Justin needed surgery. 2 years later the new section of conduit was blocked but this time the stent was available so Justin was able to get the stent in the cath lab and avoid yet another surgery. To US it was worth trying, if it failed they would need to operate, but if it worked.. great. Because of the stent and the way they could balloon it more open as he grew he was able to put off surgery until he was 17 and the stent couldn't get any bigger.
IMO Probably when they first get approved they will only do them in a few centers, and it will take awhile for lots centers to be able to do them, for the doctors to be trained and to have the hybrid labs they should have to do them. So they will probably be available, but you may have to travel in the beginning. I hate to keep going back to CHD but that is my experience. When Justin was a baby (in 88) his surgeon Norwood, was the one that first started doing the Fontan in 3 stages that made it possible for babies with HLHS to live. There were very few (5-10?) centers in the US that were doing them at the time but it was available to anyone that wanted to travel and knew about it. Which not alot of doctors told the parents since it was so new alot of the babies didn't survive and long term wasn't known. Before that the choices were to get on a list for transplant (even tho transplants were pretty new and baby heart are pretty rare)or go home to be loved for a short time. Then more and more centers were doing them as residents went thru the origonal centers then went off to start their own practice and older surgeons got trained on the new surgery, and now there are hospitals all over the world that do it.
I don't think it will take that long (decade) for the percutaneous valves to be available widespread once approval is given since many interventional cards do stents and they are already doing trials in about 20 centers all over the US. Am I counting on it 100%? ...NO!Whose to say in the next year or so all the original valves from 5 years ago won't start failing and they will have to go back to the drawing board. but so far it looks good
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WOW sorry that got so long Anyway here is an interesting chapter from Interventional cardiologist org yearbook about the different percutaneous valve therapies with some pictures ect http://www.sis.org/docs/2007Yearbook_Ch11.pdf
Ross
Well-known member
I would be great if it can be rolled out to everyone, but I'm not betting the farm on it. Way too early to even determine if it works properly in those patients that have received it.
B
Bridgette
Yeah, that was exactly the message that the author of the article was trying to get across.
The doctors in NZ who have performed the procedure say that traditional OHS will remain the gold standard for a long time to come.
The doctors in NZ who have performed the procedure say that traditional OHS will remain the gold standard for a long time to come.
BigOwl
Well-known member
I'm not a candidate for it (not old enough, and probably not sick enough), but I do wonder if the promise of an alternative to later surgery, even if it's several years away, might not affect the choices we make now: i.e. tissue vs. mechanical.
I'm 61 and, having had one OHS already (CABG) I'm not looking forward to the possibility of another surgery (if I live long enough to need one) so I'm fairly resigned to becoming the Bionic Old Bat. I'm going to be talking to my cardio this afternoon about setting up my AVR, so you can bet I'm going to bring this up. I'll let y'all know what he says (he's an interventional cardiologist at a major Dallas area heart center, so is probably up on the matter--at least, one would hope!).
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ALCapshaw2
Well-known member
You realize that the Bovine Pericardial Tissue Valves have a high percentage of "freedom from explant" at 20 years when placed in patients over 60 (or is it 65?). The 'new and improved' versions have an anti-calcification coating that is hoped to extend that number by several years.
Are your parents still living?
If not, how old were they when they passed?
Finally, how long do you think you might live?
(or how long would you like to live?)
There are good arguments for both Tissue and Mechanical valves and both would give you the promise of extended life. In the end, it comes down to personal choice.
Neither one is a Bad Choice.
'AL Capshaw'
well said al
