I had open heart surgery for repair of an aortic aneurysm. I also inherited the same wanky bicuspid aortic valve that has contributed to the death of at least one person (and usually more) in each of the last four generations of my family.
For some reason, the heart surgeon decided not to replace it when he had me opened up. Maybe I'll have the joy of undergoing another $160k operation to fix the valve using this technique.
By the way, in case you're wondering, open heart surgery kind of sucks. I wouldn't recommend it unless you absolutely need it.
Aortic valve disease is bi (Tri- for unileaflet but that usually presents at about 5-10 years) modal; trileaflets around 70-80, bileaflets at 40-50.
There are quite good reasons to not replace, not least of which is that replacement valves are nowhere as good as your native, particularly if it’s still functioning.
Ie if metallic, you need to be on anticoagulants for life which can be a massive pain and cause other complications. Metallic last for around 30 years.
If porcine/bovine or possibly human, then they degrade much faster, 10-15 Years is the average.
So, depending on your age, and depending on the repair your aorta needed, the surgeon likely decided that since you will have to undergo the knife at some point again anyway (either for graft replacement for the Dacron that now makes up the proximal part of your aorta) or eventually due to the valve, you might as well minimise the complexity by only doing one thing at a time.
Plus, since we first started doing TAVIs (transcutaneous aortic valve repairs) they are getting better and better - see article - so possibly you wouldn’t need the on-pump surgery.
Interesting that it costs you $160k; in the Australian public health system a valve is about $30k.
Source: I did my honours thesis on cardiothoracic surgery (actually on mitral valve repair, but spent a lot of time in cardiothoracic theatres dealing with aortic valve-disease)
Thank you for the very informative reply. Frankly I didn't have the energy to really quiz my very excellent surgeon on all the details. I was pretty low energy at the time. I was relatively young for the surgery, mid-50s, so I don't doubt that that was a factor.
I'm not sure a valve will cost $160k. That was the cost of open heart surgery with a double bypass and aortic aneurysm repair. I ended up paying about $8k of that after the insurance did its part.
I would definitely prefer a less invasive procedure. Recovery would probably take less than five months, for example.
> I was relatively young for the surgery, mid-50s, so I don't doubt that that was a factor.
Ex-gf's ex husband needed a valve replaced at 25 due to damage from an infection. That lasted 15 years. So at 40 he had to have it replaced again. And at 55 he died because they can only do it twice. So yes I suspect your surgeon wanted to push that as far into the future as possible. And every decade that passes is an opportunity for better treatment.
> I would definitely prefer a less invasive procedure.
Cross fingers. My friends brother is a young[1] cardiac surgeon that does really whack less invasive valve replacements. So this stuff is becoming available.
That’s not a hard rule, we treated a patient who was an IVDU who had 3 aortic valves in 3 years (IV drug users seed bacteria into their system which then form vegetations on heart valves, and there is an increased predisposition for the vegetations to form on foreign material such as replacement valves).
But depending on the damage to the aortic root, that is going to be the primary determinant on if they are going to be able to undergo repeated procedures.
I have heard of TAVIs being placed inside precious tissue replacements so that’s potentially the next route for a lot of people, which would mean basically x3, the third replacement being more streamlined than the previous two
> There are quite good reasons to not replace, not least of which is that replacement valves are nowhere as good as your native, particularly if it’s still functioning.
The flow dynamics of newer metallic valves (like the Onyx) are superior in many ways. Not the least of which is consistency and durability, with a reduced risk of aortic dissection. Always go with a metallic.
> can be a massive pain and cause other complications.
The complications are not from the valve, of course. The complications are from the surgery which can disrupt electrical pathways (scarring of the chambers) with a worst-case pacemaker (additional risks and effects). _AVOIDING THAT RANDOM STRUCTURAL RISK IS THE BREAKTHROUGH_
The blood thinner is a cautionary medication for the newer valves by policy, until there are a few decades of field data. That being said, taking Sodium Warafin can cause common side effects like light sensitivity and chronic constipation. The excessive bleeding is overblown for a standard long cycle INR target of 2-3. When you get over 4 (due to triple doses or some other unusual circumstance), you will start to have bleeds that don't stop easily, in my experience.
Since you know a bit, can you clarify something not clear from the article? My aortic valve was replaced due to "ectasia", meaning the valve root stretched so the leaflets, which were otherwise fine, no longer met properly. Given the type of reconstruction to fit a porcine tissue replacement then, does this make TAVR more, or less, indicated for the replacement?
One problem with a TAVR in patients with aortic valve regurgitation is that they don’t have enough calcification on their valve in contrast to aortic valve stenosis patients. Some valves need the calcifications to stay in place. As far as I know there are some studies with TAVR in regurgitation patients but it’s not standard
Do you have an idea of the financial cost of trans-catheter versus open surgery?
I’ve heard it said that trans-catheter is more expensive, and a brief search agrees but it seems counterintuitive.
I've heard that the procedure is quite similar in price (ie new tech, high $$), but when you compare a 4 hr open heart procedure, 3 days in CICU and another 3-4 days on the ward with 1 hour in the cath lab and observation overnight there is room for significant savings
I'm not a doctor, but I have had valve-sparing aortic root replacement surgery done myself. think the reason the valve wasn't done was maybe
1) it's a big decision that the surgeon might not have felt comfortable making
2) there are safer valve replacements coming out (neither metal nor animal) that the FDA (in America) should eventually be approving. This caused one surgeon I'd spoken to to wisely delay the decision. Perhaps this article is describing the specific valve but it seemed to be metal.
3) I dont know how bad the regurgitation is on the valve, it might not have been time
My 0.02 - see the absolute best surgeon you can get for this (in NYC his name is Takayama, don't know where you are). And depending on your root/valve dance, get a "gated ct-scan" rather then a run of the mill that most doctors recommend.
From personal experience, I would say that one should generally be most thankful if the surgeon decided to not do something. Surgeons are the kind of people you generally need to restrain, not encourage.
I don’t know, but it may well make sense. Private treatment often is quite reasonable because the alternative is free. You can get a private self-referral MRI for instance for £200-400 in the UK. I haven’t heard of people coming from the US for treatment though, only about people from the UK going to Poland for dentistry, which apparently is cheap and good quality.
Dental might or might not make sense. Depends on how many surgeries you need usually. Implants here in the us costs ~5-6k. Implants where i came from is around 700$, but thing with implants is it needs a lot of time during recovery. Like 3 months after bonegraft etc. You can also det double insurance for cheap-ish and get it covered like that in the us for about 1/6th the price.
For most non emergency surgeries (some heart surgeries are in that category, you can plan in advance), europe does make sense, especially insurance is not good.
At some point i thought that could be oretty good way to balance out cost here.
I was advised to have a mole removed. The private clinic in London wanted £700 for the removal, and the initial consultation was £250.
I flew to Poland instead, and had it removed at another private clinic for £80.
All the staff in the top clinic in London are Polish anyway.
Paying crazy amounts of money for medical procedures is just dumb. I cannot understand why Americans would pay tens or hundreds of thousands of dollars for surgery when they could fly to Europe, live the highlife, and also buy a house with the change.
$160K sounds cheap to me if you're in the US. I had a heart ablation a few years back for an irregular heart beat. Like the procedure in the article its minimally invasive where they go in through the groin to zap some electricity at a few cells in the heart. I was conscious throughout and was back at work the next day. They billed $400K for that, and insurance negotiated it down to around ~$120K. For something as complex as what you've mentioned I'd have expected 7 figures.
People get eye surgeries and a pretty nice vacation for the same price in europe. Private you pay cash but it may even be cheaper than office visit there :)
There was an ad for Impella (a form of mechanical circulatory support - basically advanced life support) during the Super Bowl 1-2 years back [1]. Which is basically even more absurd than advertising aortic valve replacement...
Well, I would say if you are given a choice of a procedure like the one described in the article or open heart surgery, choose the less invasive one. Although in my experience, they don't really consult with you about what you'd prefer so much as tell you what they are going to do.
I had an "aortic root reconstruction" by open heart surgery about 18 years ago, and my animal-tissue valve will no doubt need replacement sometime reasonably soon.
At that time, I made the optimistic prediction that by the time I needed a replacement, they will be able to grow me a new valve from my stem cells, and install it laparoscopically.
Progress seems to always be extremely slow, and then it just happens remarkably fast. The scary part is you never know when the punctuated equilibrium will flip. Take CRISPR for example... sheesh.
You never know when they'll figure out scaffolding, could be sooner than you think. Could be later. Hopefully sooner.
TAVR is a remarkable advance. Interventional cardiologists are taking away lots of cardiotoxic surgery volume, and it's great for patients because it's much less invasive.
Note that 'younger' in the title refers to people in their 70s as opposed to 80s, so perhaps confusing on Hacker News. From the article:
> Aortic valve replacements have been performed for decades, and surgeons know the valves placed during surgery last at least 10 to 15 years. It remains to be seen if TAVR valves will fare as well. The question is especially important for younger patients. The average age of subjects in the current studies was the low to mid 70s, younger by a decade or more than most patients getting TAVR now.
If anyone here needs a new aortic valve, you might also want to read about the latest results on the less-known Ross procedure and whether it might be suitable in your situation.
It's been a thing since the 1960s especially for young patients (children) but I hadn't even heard of it until last year: https://en.m.wikipedia.org/wiki/Ross_procedure
Ouzounian, Maral et al. 2017. The Ross procedure is the best operation to treat aortic stenosis in young and middle-aged adults.
The Journal of Thoracic and Cardiovascular Surgery https://www.jtcvs.org/article/S0022-5223(17)31124-8/fulltext
I'm 'young' and getting my second open heart surgery soon. Headlines like this are slightly misleading in that you have to have a pathology that will support tavr. In my case, I have a dilation of the annulus that apparently makes it less likley that a tavr valve can find a basis to stay in place. It has to be sown in.
> “Open-heart surgery, particularly in low-risk patients, is very profitable,” Dr. Herrmann said.
Sheesh. For-profit hospitals are a foreign concept to me. Seems incredibly cynical to crack open someone's chest, leaving them with a very slow and painful recovery, to then think about profit instead of patient welfare.
Do you think the same about farmers who optimize profits on something that sustains life itself? Doctors just make you feel better and extend life a few years at best. Farmers, though, they make you tick every day.
I found out a few years back I've been living with ebstein's. I was surprised at the time to learn just how limited we are when it comes to heart surgery... It all seems to last 10-15 years and that about it. I'm glad to hear things are progressing for younger patients, but there's so much more work to be done.
Due to congenital defect I have a bicuspid valve that will have to be replaced before I'm 55, likely in the next 10-15 years, innovation can't come soon enough.
This article reminds me of Steve Yegge's dad and his experience with heart failure and having to go through a bypass surgery, post which, unfortunately, his femoral artery [0] burst, compounding more hardships on what had been an already tough ordeal. He wrote a letter to the hospital staff once he was back living his normal life: https://sites.google.com/site/steveyegge2/really-no-big-deal
For some reason, the heart surgeon decided not to replace it when he had me opened up. Maybe I'll have the joy of undergoing another $160k operation to fix the valve using this technique.
By the way, in case you're wondering, open heart surgery kind of sucks. I wouldn't recommend it unless you absolutely need it.