For Dr. David Cohen, it’s not just about medical breakthroughs, it’s also about making them affordable.
Cohen, a cardiologist with Saint Luke’s Mid America Heart Institute in Kansas City, was one of the more than 120 specialists who attended the 24th annual Rocky Mountain Valve Symposium, a three-day conference at St. Patrick Hospital that ended on Saturday.
During the convention, one of the subjects he spoke about was how to make a fairly recent advancement in cardiac surgery, one that is particularly successful in otherwise inoperable or high-risk cases, more cost effective.
The procedure, called Transcatheter Aortic Valve Replacement, or TAVR, allows a surgeon to mount an artificial heart valve onto a flexible cable. That catheter is then inserted through a centimeter-long incision in a patient’s groin area and up into the heart. The procedure replaces a valve in people with aortic stenosis, where a normal heart valve has narrowed through calcification or deterioration.
Currently, the Food and Drug Administration has guidelines that require patients to either be a high-risk case or unable to have traditional open heart valve replacement surgery to be eligible for TAVR.
One of the issues with TAVR is the cost, Cohen said. The procedure’s artificial valve, a roughly two-inch long wire mesh cone and seal that gets wider at one end, costs $32,000. That’s compared to a more traditional replacement valve, typically about $5,000. Those costs don’t include the actual procedure itself, or the time in the hospital recovering either, with a full TAVR procedure running $60,000 to $75,000.
Currently, studies are showing TAVR is a good value. The baseline used for a cost effectiveness ratio is about $50,000 per year of life gained, and the new procedure is outperforming that marker, Cohen said.
Because it is far less invasive, TAVR patients have shorter hospital stays and quicker recovery times.
“The patients we are treating are very sick and have complex cases. Some of them stay in the hospital for a week or more. For high risk patients, it pays for itself by shortening the length of stay,” Cohen said.
There are two primary approaches to further lowering the cost of the procedure, Cohen said. As TAVR becomes more widely available, competition from manufacturers will lower the cost of the device itself. That part isn’t under a hospital’s control.
What they can control is lowering the number of complications that come up in surgery.
“Somewhere around a quarter of the costs are due to complications. So we need to learn to do it more carefully, more skillfully,” Cohen said.
The other thing hospitals can do to lower TAVR’s bill is shortening the length of stay after the procedure. This is a mix of several factors, including better selecting patients who are healthy enough for the procedure, and doing the operation while the person is awake, rather than under full anesthesia.
“It’s been known in Europe for some time if you’re very skilled at it, you can do it under conscious sedation,” Cohen said.
He said while only two groups, inoperable and high risk, are currently approved for TAVR, studies are currently underway to expand eligibility.
“The vision in most people’s projections is this becomes the predominate mode of valve replacement,” Cohen said.
St Patrick Hospital has performed 64 TAVR therapy operations in the year and a half it has been doing the procedure said Dr. Matt Maxwell, director of cardiovascular surgery at the hospital’s International Heart Institute of Montana.
One of the biggest benefits Maxwell sees about TAVR is not just the operation itself, but the recovery. He said especially for older, higher-risk patients, the two to three months of recovery from traditional open heart surgery was a massive investment for people who might not have a long life expectancy.
With TAVR, a patient is typically out of St. Patrick within four days, and then can largely return to their normal everyday functions.
Maxwell said the conference helps the TAVR team at St. Patrick learn from the experts, especially those in other countries like France, Canada and Germany where there are fewer regulations.
“Some people naturally want to be the tip of the spear. Then there are those of us, I’m more conservative, who would rather see the proof of concept and benefit to the patients. But we can ride their coattails, sitting in the peloton just behind them,” Maxwell said.