Aortic value replacement: choosing a program/surgeon edition

[neurofan22]

Hope this is an okay topic to post about. I'm a physician in another specialty and am trying to help a loved one choose a program for undergoing what will likely be an aortic valve replacement (cardiologist says repair won't be possible, but she'd be open to it if the surgeon feels it is). This is a relatively young woman w/ congenital heart dz s/p an initial surgery as a toddler, now with expected progression of both aortic valve regurgitation and stenosis requiring reoperation. The two centers I'd most like to hear about are Stanford and UCLA, but I'd love any and all recommendations. We checked out the STS database but very small differences in those ratings are hard to interpret. Any insider information would be much appreciated. Not trying to start a war over which is "the best" program but hoping for more nuanced thoughts, perhaps comparing pros and cons. Or reassurance that all the top programs are essentially equal in quality, if that's the case!

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[ThoracicGuy]

Just curious why you feel they need to go off to Stanford or UCLA? This is a sort of surgery that she would likely see a congenital cardiac surgeon for treatment. Just about any major academic center should have one that is fully capable of the procedure.

 

[neurofan22]

ThoracicGuy, thanks so much for your reply.

I'm not assuming that it's necessary to check out multiple programs or travel, but some people who have limited knowledge of the surgical side of this have recommended checking out multiple programs, and I don't have the expertise to assess that advice. I've also heard (again, not assuming this is true) that surgeons who've have extensive experience doing an aortic valve repair in this type of case may be rarer.

If your rec is that (generally speaking) one wouldn't expect clinically significant differences in outcomes between the major academic medical centers, that would be very helpful to hear.

Thanks again for taking the time to reply.

 

[ThoracicGuy]

ThoracicGuy, thanks so much for your reply.

I'm not assuming that it's necessary to check out multiple programs or travel, but some people who have limited knowledge of the surgical side of this have recommended checking out multiple programs, and I don't have the expertise to assess that advice. I've also heard (again, not assuming this is true) that surgeons who've have extensive experience doing an aortic valve repair in this type of case may be rarer.

If your rec is that (generally speaking) one wouldn't expect clinically significant differences in outcomes between the major academic medical centers, that would be very helpful to hear.

Thanks again for taking the time to reply.

I would expect most any will be able to do it. Aortic valve repair is pretty rare and had to have favorable anatomy for it. Valve replacement is far more common.

Given her prior heart surgery as a child, I suspect a congenital surgeon would still be the one to do the surgery even if she's in her 20s or 30s.

 

[akwho]

You are asking the wrong question. You shouldn't be asking which program, you should be asking which surgeon.

Excellent surgeons and bad surgeons reside in both community and academic practices. Some of the worst surgeons I've seen have been in highly respected academic programs because they were hired for their research productivity not their surgical ability. I would be willing to bet at both Stanford and UCLA you will find a mix of excellent and terrible surgeons. The trick is to find out who is the real deal. Personal referrals, online research and word of mouth are the best way to go into this very important decision of selecting a surgeon for a major operation well informed.

If you don't get a good feeling with the first one you meet, don't feel bad saying you need time to think about it and going to get a second opinion.

 

[neurofan22]

You are asking the wrong question. You shouldn't be asking which program, you should be asking which surgeon.

Excellent surgeons and bad surgeons reside in both community and academic practices. Some of the worst surgeons I've seen have been in highly respected academic programs because they were hired for their research productivity not their surgical ability. I would be willing to bet at both Stanford and UCLA you will find a mix of excellent and terrible surgeons. The trick is to find out who is the real deal. Personal referrals, online research and word of mouth are the best way to go into this very important decision of selecting a surgeon for a major operation well informed.

If you don't get a good feeling with the first one you meet, don't feel bad saying you need time to think about it and going to get a second opinion.

akwho, belated thanks for your comment! That makes total sense. I was shying away from posing a question about specific surgeons here because I was concerned it would look like an invitation to critique specific people in the forum. If anyone who sees this does have insider info you want to share, I think you can use the conversations tool to contact me.

 

[drmwvr]

What does her cardiologist have to say? I understand the concern and the desire to be of assistance in such a critical time in a loved one's life, but I really have to say that, having been in a similar place as you, I'd be cautious about inserting myself into this kind of decision for the sake of being the doctor in the family.

As difficult as it is, having been down this road myself, I've learned to let the pro's do their jobs and get out of the way. They're the pros. If you're not in the CT surgery business, be supportive and vigilant. You don't want anyone treating your loved one as a VIP. It's asking for trouble.

 

[Medstart108]

You are asking the wrong question. You shouldn't be asking which program, you should be asking which surgeon.

Excellent surgeons and bad surgeons reside in both community and academic practices. Some of the worst surgeons I've seen have been in highly respected academic programs because they were hired for their research productivity not their surgical ability. I would be willing to bet at both Stanford and UCLA you will find a mix of excellent and terrible surgeons. The trick is to find out who is the real deal. Personal referrals, online research and word of mouth are the best way to go into this very important decision of selecting a surgeon for a major operation well informed.

If you don't get a good feeling with the first one you meet, don't feel bad saying you need time to think about it and going to get a second opinion.

This is very true. Don't just blindly chase the big name centers, also its often a mistake to associate with number of degrees/titles to surgical competency because what that may actually represent is research comptency. Some of the surgeons with the biggest research and most titles are actually the worst clinically.

The right surgeon for her is something that will depend strongly on her specific case and she should likely be handled by a surgeon with expertise in adult congenital which is usually a congenital heart surgeon with an interest in it but not always.

Also. point of note, unless her surgery is considered an incredibly complex and rare operation, most cardiac surgeries come with something like a 1-2% mortality rate. Her choice of surgeon may not matter as much as you think as well. In fact, the ICU and anesthesia care can play just as big a role.