The Answer: You ask two important questions: Why do people sometimes develop thrombosis or abnormal blood clots in arm veins? And how does one find a doctor who specializes in thrombosis?

With respect to your specific circumstances, Dr. Geerts, a thrombosis specialist at Sunnybrook Health Sciences Centre, stated that arm DVT and blacking out spells are almost never directly related. These are nearly always related to separate causes.

Arm DVT is usually not a dangerous condition and the symptoms are usually not severe. Arm DVT results in swelling and discomfort of the arm sometimes with a dusky skin color. The cause of arm DVTs can usually be determined, according to Dr. Geerts, with the overwhelming majority being due to the use of a central venous line or a pacemaker inserted into an arm vein. The second relatively common cause of arm DVT is called thoracic outlet syndrome which occurs because of compression of the arm vein near the shoulder as it passes through the thoracic outlet, the space between the upper ribs and the collarbone.

Dr. William Geerts

An arm DVT is treated with anticoagulants given anywhere from a few weeks to indefinitely depending on the specific patient’s circumstances. “There is no evidence that aspirin provides any protection against recurrent arm DVT,” according to Dr. Geerts “and I do not use aspirin for this purpose.” “Although there are no tests that can be done to predict your risk of another arm clot,” stated Dr. Geerts, “it is important to try to determine the cause of the arm clot since this may influence the treatment duration.”

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The Answer: The short answer is yes, the Ontario Health Insurance Plan does cover the cost of all aortic valve replacement surgery – something that is true across Canada. The operation is typically done on those with narrowed or leaking aortic valves, due to a congenital condition or a disease acquired in later life. The valves can be mechanical or bio-prosthetic and made of porcine, equine or bovine material.

“The mechanical valves require lifelong anticoagulation [treatment with so-called blood thinners] while bio prosthetic valves typically don’t. On the other hand bioprosthetic valves typically wear out in the 10 to 20 year range, requiring a repeat surgical procedure,” said Dr. Sam Radhakrishnan, director of Sunnybrook’s catheterization laboratory. Sunnybrook has performed about 150 of the operations.

There’s a newer type of minimally invasive valve replacement available, called transcatheter aortic valve implantation [TAVI], now being funded by the Ontario government. It is offered to patients who are ineligible for open-heart surgery because their risk of death or developing severe disability post surgery is deemed too high.

Patients eligible for TAVI suffer from severe aortic stenosis, an increasingly prevalent disease among the elderly. With the onset of significant symptoms, particularly progressive shortness of breath, severe uncorrected aortic stenosis carries with it a death rate of up to 50 per cent over the next two years. The average age for the TAVI procedure at Sunnybrook has been 83.

Before government began funding the surgery this winter, Sunnybrook Foundation has raised $2.5-million since 2010 for the surgical devices, allowing eligible patients to undergo the operation, according to Pamela Ross, the foundation’s executive vice-president and chief marketing officer. The foundation paid for the valve device, with each one costing $22,650, while the province funded the cost of the surgical procedure.

Almost always, this is how innovations start: through philanthropy. Before governments decide to fund new operations they want to see evidence that they work and are cost-effective, which for hospitals, means raising money to try new procedures. [The Ontario Health Technology Advisory Committee recommended the province fund TAVI for patients ineligible for open-heart surgery, which the province agreed to earlier this year.]

In addition to Sunnybrook, five other hospitals – University Health Network, Hamilton Health Sciences Centre, St. Michael’s Health Sciences Centre, the University of Ottawa Heart Institute and London Health Sciences Centre – are being funded to perform the minimally invasive operation on a pilot basis over the next three years, according to Ontario health ministry spokesman David Jensen.

To cover the cost of the new operation, Ontario is providing an additional $15,000 extra per case, bringing the total reimbursement for the TAVI procedure to $35,000 – the same amount funded by the British Columbia Ministry of Health, said Mr. Jensen.

The procedure involves inserting a replacement valve made of porcine or bovine tissue mounted on a metal frame, into the diseased aortic valve. The procedure is done with fluoroscopic (X-ray) guidance and often can be accomplished through an incision in the groin that is less than half an inch.

According to results of the Placement of Aortic Transcatheter Valves trial [PARTNERS], in patients who were not candidates for conventional open-heart surgery, TAVI provided a survival benefit over medical therapies. “In this trial, for patients who were deemed inoperable, performing TAVI led to a substantial reduction in the one year rate of dying or being rehospitalized for heart failure. Indeed, for just about every three patients treated with TAVI compared to medical therapies alone, one life was saved or repeat hospitalization prevented.” In patients who were deemed high risk for a conventional operation (but operable) those who underwent TAVI had virtually the same survival rates at one year as compared to patients who had open-heart surgical repair. However, in this trial the stroke rate was higher for the TAVI patients at 30 days and again at one year compared to those that underwent open-heart surgery.

“There’s no doubt the recovery with TAVI is a lot faster,” said Dr. Radhakrishnan, noting that patients spend seven to eight days in hospital compared to almost two weeks for open-valve replacement in these higher risk patients.

Sunnybrook is expected to do 75 TAVI procedures this year.

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