
Transcatheter aortic valve replacement effective in younger, healthier patients - matt4077
https://www.nytimes.com/2019/03/16/health/aortic-valve-replacement-heart.html
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sverige
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.

~~~
robbiep
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)

~~~
fernly
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?

~~~
rasmus1610
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

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fernly
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.

Well, 50% ain't bad, I guess.

~~~
justinjlynn
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.

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et2o
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.

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tuukkah
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](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](https://www.jtcvs.org/article/S0022-5223\(17\)31124-8/fulltext)

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dmead
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.

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Tharkun
> “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.

~~~
yostrovs
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.

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superbaconman
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.

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ignoramous
/offtopic

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](https://sites.google.com/site/steveyegge2/really-no-big-deal)

\--

[0]
[https://en.wikipedia.org/wiki/Femoral_artery#Clinical_signif...](https://en.wikipedia.org/wiki/Femoral_artery#Clinical_significance)

~~~
snazz
That letter’s wonderful. It was the first time I’d read it and I’m really glad
I did. It’s funny, slightly sad, and really well-written.

