Although I did not know her name, or anything about her other than her medical history, my heart went out to the 97-year-old woman who, with her family, had a very big decision to make.
I learned about her situation recently at a weekly conference at Temple University Hospital that I often attend. This type of meeting, bringing together interventional cardiologists, cardiac surgeons, nurses, allied health professionals, and cardiologists specializing in cardiac imaging, is held regularly in many hospitals across the country. In the case of this patient, we needed to figure out whether a new and enormously popular cardiac valve procedure that can be done without open heart surgery would likely help her live longer and better — or potentially make things worse, at enormous expense both emotionally and financially.
Still active despite her age, this woman had critical aortic stenosis, a cardiac valve problem that without treatment would almost certainly lead to death within a year. The only way to help her would be transcatheter aortic valve replacement (TAVR, for short), which allows people at higher risk, such as the elderly, to have aortic valve surgery. After discussing all of the issues in her case, we agreed in the meeting that she could be a candidate for the procedure, if she and her family understood the risks and wanted to proceed.
TAVR can be lifesaving. A normal aortic valve has a circumference about the size of a quarter as it opens with each beat of the heart to allow blood to go from the left ventricle to the aorta. As we age, the valve can become so calcified that it shrinks to the size of a pencil or less. There are no "natural" fixes — lifestyle changes and a careful diet will not help. Surgery is the only option, and traditional open-heart surgery is tough on the elderly. Yet, if the aortic valve closes off so much that there is chest pain, fluid on the lungs, or a loss of consciousness, this valve problem will likely prove fatal in less than a year.
In the TAVR procedure, a new heart valve is delivered through an artery accessed in the patient's leg. With no need for open heart surgery, patients are home from the hospital in just a few days. It has given thousands of people a longer life, and a better quality of life. The procedure is so popular that it may replace standard valve surgery in a few years.
But studies have shown that 25 percent of people who have TAVR die within the first year, and 4 percent will have a major stroke. While 40 percent more may experience some kind of mild cognitive impairment after the procedure, nine in 10 of those patients improve significantly after one year. After the procedure, some patients require a permanent pacemaker, as the electrical mechanics of the heart can be disturbed. All this must be weighed against the even greater risks of standard aortic valve heart surgery — which isn't an option for people like our 97-year-old patient.
Additionally, and not talked about as much: TAVR is not easy to learn, requiring a significant number of procedures before a physician is proficient. But if you've seen ads for hospitals promoting the procedure, it's clear that this is a big business for many medical centers.
These thoughts were all going through my mind as the Temple group discussed another case, that of an 85-year-old man who was also a candidate for this procedure. Physically, he seemed a good match for it. But he had poor short-term memory, and the concern was raised that he could have mild Alzheimer’s disease. How could we know whether he was truly capable of giving his consent for the procedure?
The ethical implications of who should be a candidate for one of these new procedures are staggering. If nothing is done, death is virtually certain. But, if things go wrong, the patient can end up in a coma, leaving family members with extremely tough choices. And let us not forget, the costs of these procedures can be astronomical — the TAVR device alone costs an estimated $32,000, compared with $4,000 to $7,000 for other heart valves.
The question arises: Can doctors do a better job of predicting who might benefit most — and least — from TAVR? If so, doctors, nurses, and experts in ethics could speak clearly and simply to the patient and family members to help them make a decision about proceeding.
There is help on the way. Tools are rapidly being developed to predict outcomes after TAVR. Patients who are older than 85, frail, disabled, or require constant use of oxygen generally don't do very well after TAVR, these evidence-based tools indicate. Of course, patients are all individuals, so tools cannot do the entire assessment. Still, they are potentially helpful and should be standard practice. Difficult choices could be eased by including palliative care experts on the TAVR team, who could help make patients who opt against having the procedure more comfortable, and also assist family members who are facing the mortality of their loved ones.
The 85-year-old man was further evaluated, and his doctors thought him capable of making a decision to proceed. Both he and the 97-year old woman we discussed in the valve conference made the choice to have TAVR. They did very well with their procedures, and are safely home with their families. In both cases, the fact that they were otherwise fairly healthy, and wanted to get back to their active lives, helped the patients, families and TAVR team decide to proceed.
Other patients will understandably come to a different conclusion. Dying in one’s own bed at an advanced age, with close family in attendance as well as support from palliative care, does not sound so bad compared with what modern medicine can sometimes offer. This is especially true if what is billed as a simple operation goes awry. We cannot afford to forget that surgery, even less-invasive surgery, may not be for everyone.
David Becker, M.D., is a board-certified cardiologist with Chestnut Hill Temple Cardiology in Flourtown, Pa. He has been in practice for 25 years.