Ask the Doctor: Mick Jagger’s Heart; Enlarged Prostate; Ketamine for Depression
Q: I read that Mick Jagger had a heart-valve replacement called TAVR. What is that?
A: Transcatheter aortic valve replacement (TAVR) is surgical procedure for aortic stenosis, a heart-valve problem that can lead to heart failure. The aortic valve, one of four heart valves, controls the oxygenated blood that runs from the heart through the aorta (the largest and main artery) to the rest of the body. The aorta originates from the heart’s left ventricle and extends in two directions, up into chest and down into the abdomen. All arteries branch from the aorta. Valves are very strong, yet paper-thin tissues that constantly open and close, creating the lub-dub sound of the heartbeat. Aortic stenosis refers to the narrowing of the valve opening due to a buildup of calcium. That impedes the flow of blood, making the heart work harder. The benefit of TAVR is that it does not require open-heart surgery to fix the valve. A cardiologist threads a thin, flexible tube (catheter) through the aorta and guides it to the malfunctioning valve. Inside the catheter is a folded replacement valve. It pops open, pushing the other valve aside. Because this procedure is less invasive, hospital stays are shorter, and patients can return to daily activities sooner than with open-heart surgery. A recent multicenter study published in the New England Journal of Medicine showed that TAVR outcomes were better than open-heart surgery in low-risk patients with severe aortic stenosis. Mick Jagger had this procedure at age 75.
Q: I have to urinate frequently. What might be causing this? I’m a healthy 68-year-old man.
A: It could be an enlarged prostate. By age 60 about 50 percent of men will have benign prostatic hyperplasia (BPH). This condition doesn’t increase prostate cancer risk, but it does affect quality of life in the way you have described. We’re not exactly sure why the prostate enlarges as some men get older, though hormones may be responsible. The prostate can grow from the size of a walnut to a lemon. Because it’s positioned just under the bladder, an enlarged prostate pushes on it and the urethra (the tube that carries urine through the penis). The increased pressure can result in urge frequency and feel like you haven’t emptied the bladder completely. If urine isn’t completely expelled, infections may occur. Medications that treat BPH fall into two basic categories. Alpha- blockers relax the muscles around the prostate so urine can flow more easily, and 5-ARIs slowly shrink the prostate in six months to a year. If erectile dysfunction (ED) occurs along with BPH, once-daily, low-dose tadalafil (Cialis) has been FDA-approved to treat men who have both conditions.
Q: I’ve heard that a ketamine nasal spray can help people with depression. Does it work?
A: It’s been shown to ease symptoms for some people who have severe treatment-resistant depression. In March of this year, the FDA approved esketamine (Spravato) nasal spray, a form of ketamine designed to quickly absorb into the bloodstream by entering the lining of the nasal passages. It is the first major depression treatment released in the U.S. in decades. The approval was based on four clinical trials, three short and one longer in duration. The shorter trials did not show a clinically significant effect, but the longer one did. Data for those over age 65, however, is less encouraging. Some experts are reluctant to offer it due to the lack of long-term data. Esketamine is powerful and fast-acting, but also has a black box warning for potentially very serious side effects. Still, it may be a lifesaver for those with suicidal thoughts. Dispensing guidelines are tight: The patient self-administers Spravato nasal spray under the supervision of a health-care provider in a certified doctor’s office or clinic. The spray cannot be taken home. During and after each use of the nasal spray, the health-care provider checks the patient and determines when he or she is ready to leave. The price ranges from $590 to $885 per treatment. An initial month of therapy can be as much as $4,000 before insurance.
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