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Ann Thorac Surg 1998;65:1557-1558
© 1998 The Society of Thoracic Surgeons
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Discussion |
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 Top Discussion |
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The operation is, as you pointed out, comparable with any other form of aortic valve replacement. I am not surprised that it is cheaper, but I think in the long term it is going to be even cheaper. One thing that shocked me was the price of your homograft valves in this country. I had better not say it too loudly, but it would cost about $1,500 in my country. And my colleague Dr Yacoub, who of course does not sleep and operates all night, takes out a heart or a heart and lung. His assistant then takes out two valves from the recipient, and the next couple of days he puts in both valves. I do not know whether that option is open to you, to use transplantation patients, but it is a very good supply of valves.
The other thing is that in the long term the mechanical valve patient has to have anticoagulant therapy for the rest of his or her life. Has anyone computed the cost of 40 years of anticoagulant therapy? It must be very considerable. Add to that the hematologic costs and check-up costs.
Our patients usually go out after a few days, as yours do, with no medication, and a follow-up once a year. That is pretty cheap. In fact, I had a phone call last week from a patient of mine, in Italy, who had his Ross procedure 10 years ago. He had not bothered to get in touch again because he felt so well. He was wondering how I felt! It is relevant that your long-term costs for mechanical valves are going to be considerable. In addition, you pointed out the increased morbidity with mechanical valves. Each time a patient gets a hemorrhagic condition, or embolism, you probably hospitalize him or her again and that adds to an increase in costs. Therefore I think you could make a stronger case for the cost advantages of the Ross operation.
You pointed out that there was one homograft to be replaced. This worries me because we do not have as much of this problem in my country as you do here. I think it is because of the efficiency and expert cryopreservation that you carry out on your valves. Consequently, those valves are highly antigenic because of having living endothelium. Our valves are usually in a refrigerator at 4°C, the endothelium is absent, and I think we see less reaction than you do. It is something that has to be thought about seriously.
The other thing, of course, is that we are going to need to have an alternative because people are running out of homografts in many countries. And where we cannot get them we are going to have to use pig valves or tissue-engineered valves or valves from transgenic pigs.
DR JAGGERS: I will address Mr Ross on a couple of his points. Thank you for your kind comments.
I actually did do a limited study looking at the cost of warfarin therapy and analysis for the first postoperative year. It costs about $3,000 a year just for that. And what struck me, as I reviewed these charts, was the number of outpatient visits that were required by the mechanical valve. We, as surgeons, do not see that. However, patients are back in the hospital in the emergency departments frequently.
DR JOHN H. CALHOON (San Antonio, TX): I have one brief question for you, and I do not know if you are going to give us the answer. First of all, it is a really nice study and very well presented. But the question would be, what is the cost of a homograft and what was the cost of a mechanical valve, and how do they differ?
DR JAGGERS: Well, the cost of a homograft at our institution is nearly $3,000 more than the mechanical valve. That does not make up the entire difference in surgical service cost, but it is a large portion of it.
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