Choice of Prosthetic Heart Valve in Today’s Practice

Abstract

In this update, current guidelines addressing prosthesis selection published by the American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) are discussed, along with additional data that affect choices in valve prostheses. The case of a 50-year-old man undergoing aortic valve replacement is used to address anticipated operative mortality, risk of reoperation, and valve-related morbidity and mortality. The apparent advantages associated with the use of a bioprosthesis even in a relatively young patient help to explain current clinical trends toward the increasing use of tissue valves. We also provide a simplified algorithm that may be used to facilitate the choice of valve procedure in patients with heart valve disease. The outcomes after surgery for valvular heart disease in terms of survival, functional status, and quality of life are determined primarily by patient-related factors such as age, ventricular function, and other comorbidities.1 However, outcomes also are influenced by surgical factors; the best clinical outcomes often are associated with valve repair, although mitral repair is not always possible and aortic valve repair in adults remains the exception rather than the rule. For patients who require valve replacement, the valve prosthesis can significantly influence outcome. The ideal prosthetic valve that combines excellent hemodynamic performance and long-term durability without increased thromboembolic risk or the need for long-term anticoagulation does not exist. Hence, patients and their physicians need to choose between a mechanical and a tissue (bioprosthetic) valve. In general, the advantageous durability of mechanical valves is offset by the risk of thromboembolism and the need for long-term anticoagulation and its associated risk of bleeding. In contrast, bioprosthetic valves do not require long-term anticoagulation yet carry the risk of structural failure and reoperation.2,3 Two historic randomized clinical trials compared outcomes after valve replacement with a first-generation porcine heterograft …