Valve Recipients Research Articles

Drug Insight: an overview of current anticoagulation therapy after heart valve replacement

Vitamin K antagonists, such as warfarin, are the gold standard approach for the long-term anticoagulant therapy of patients with mechanical heart valves. Management decisions are, however, based predominantly on expert consensus and on data from nonrandomized, follow-up studies, which have inherent limitations in their methods. Low-intensity anticoagulation therapy provides protection against thromboembolic complications in patients with most types of modern prosthetic heart valve. The addition of low-dose aspirin is safe if international normalized ratio values below 3.5 are maintained. A combined regimen should be considered in high-risk patients and those with coexistent coronary artery or cerebrovascular disease, and in patients who have suffered a thromboembolic event despite a therapeutic international normalized ratio. Thromboprophylaxis with unfractionated or low-molecular-weight heparins is restricted to specific situations, such as when a patient is intolerant to vitamin K antagonists, when surgical procedures require discontinuation of oral anticoagulation, or when the patient is pregnant. A lack of uniformity across practice guidelines make it difficult to reach treatment decisions. Each patient's preference, expressed after counseling about the risks and benefits of each treatment strategy, and an individual assessment of the patient's risk factors, should guide treatment decisions. At present, new anticoagulant agents such as factor Xa inhibitors do not represent a treatment option for heart valve recipients.

Could It Happen Again?

Most readers of “Twenty-Five–Year Experience With the Bjork-Shiley Convexoconcave Heart Valve: A Continuing Clinical Concern” in this issue of Circulation have not heard of the valve.1 Many elements of its story parallel those of cerivastatin2,3⇓ and rofecoxib,4 but with a twist: Recalling a heart valve may entail greater risks than leaving a possible “time bomb” in place. The Bjork-Shiley story raises many questions about balancing the benefits of drugs and devices with their risks to public safety. For example: See p 2850 My personal involvement began when a lawyer for Shiley, Inc, with a biostatistical degree read our account of the Braunwald-Cutter heart valve and wanted to understand why the University of Alabama at Birmingham and the Mayo Clinic decided to prophylactically remove every one.5 Subsequently, I served on scientific panels, spearheaded a multi-institutional effort to quantify the risks of prosthesis explant,6 and suggested ways to use this information for the tough decision making ahead.7 The Bjork-Shiley heart valve, developed by Shiley, Inc, in collaboration with Dr Viking Bjork of Sweden, was …

Quality of life after aortic valve replacement with tissue and mechanical implants

Objectives We sought to determine whether changes in quality of life at 18 months following aortic valve replacement differ depending on the use of tissue valves or mechanical valves. Methods We prospectively studied 73 patients with tissue valve replacements and 53 patients with mechanical valve replacements performed from April 1998 through March 1999 at Yale-New Haven Hospital. Quality of life was measured at baseline and at 18 months using the Medical Outcomes Trust Short Form 36-Item Health Survey. Results Baseline unadjusted mean quality-of-life scores were lower in tissue valve recipients than in mechanical valve recipients and, for both groups, were generally lower than US population norms. At 18 months postoperatively, quality-of-life scores were greatly improved in both groups and were comparable to population norms (ie, within one-half a standard deviation). After adjusting for baseline quality of life, age, and other prognostic factors in an analysis of covariance, improvements in quality-of-life scores for tissue valve recipients versus mechanical valve recipients were similar. Of 10 (8 domains and 2 summary) scales examined, the only significant difference between the 2 groups was for the improvement in role limitations due to physical problems (Role Physical), which was more favorable in patients with mechanical valve implants ( P = .04). Conclusions The use of tissue valve implants versus mechanical valve implants has little influence on improvement in quality of life at 18 months following aortic valve replacement. Thus, decisions about whether to choose a tissue valve or mechanical valve implant should depend upon other factors such as rates of complications and differences in the life span of the implants.

Selecting the Best Heart Valve for Your Patient: Mechanical or Tissue

This review provides general guidance for heart valve selection. Mechanical heart valves exhibit excellent durability and hemodynamic performance but require anticoagulation to reduce thromboembolism, and therefore risk of anticoagulation-related hemorrhage is increased. Tissue valves were introduced to avoid anticoagulation, but in fact often do not, and lack durability. A literature review was performed to compare the complications of thromboembolism, anticoagulation-related hemorrhage, reoperation structural valve deterioration, and reoperative mortality associated with mechanical and tissue valves. The thromboembolism rates for mechanical and tissue valves are equivalent. During their lives, many recipients of tissue valves receive anticoagulation therapy due to comorbid conditions. The anticoagulation-related blood loss rates associated with mitral mechanical valves and mitral tissue valves are equivalent, whereas the blood loss rates associated with aortic tissue valves are less than those associated with aortic mechanical valves.

Decision Guidelines for Prophylactic Replacement of Björk-Shiley Convexo-Concave Heart Valves

Because of risk of outlet strut fracture, prophylactic replacement should be considered for Björk-Shiley convexo-concave (BScc) valve recipients. We assessed the effects of epidemiological and decision-analytic guidelines on actual BScc valve replacement. We performed a retrospective cohort study including all 2263 Dutch BScc patients with a mean follow-up of 11.3 years (range, 0 to 23 years). Outcomes were outlet strut fracture, mortality, and BScc valve replacement. For the surviving patients in 1992 (n=1330), we calculated the expected differences in life expectancy (LE) with and without BScc valve replacement according to decision guidelines developed in 1992. Differences in LE were compared with actual replacements. During 8 years of follow-up, there were 494 deaths (40%), and 11 patients had suffered outlet strut fracture. Of 1330 patients, 96 (10%) had undergone BScc valve replacement, particularly in years after introduction of initial and updated guidelines. One hundred seventeen patients (9%) had an estimated gain in LE after BScc valve replacement. These patients were more likely to undergo replacement than patients with an estimated loss of LE (hazard ratio, 6.6; 95% CI, 4.4 to 10; P<0.0001). A loss in LE after reoperation was predicted for 8 of 11 patients who experienced outlet strut fracture after guidelines were available. Valve replacement for BScc heart valve patients was largely in concordance with guidelines in the Netherlands. Individualized guidelines that are based on high-quality epidemiological data and are updated and implemented rigorously can influence clinical practice in complex decision problems.

Twenty-year experience with the St Jude Medical mechanical valve prosthesis

Background We have prospectively followed all adult St Jude Medical mechanical valve recipients at the Medical University of South Carolina since the initial implant in January 1979 and now present our 20-year experience. Methods We prospectively followed 837 valve recipients (aortic valve replacement; n = 478; mitral valve replacement; n = 359) from January 1979 to December 2000 at 12-month intervals. Results Ages ranged from 19 to 84 years. Follow-up averaged (mean ± standard deviation) 7 ± 5 years (98% complete). Patients were in New York Heart Association class III or IV in 77% (aortic valve replacement) and 89% (mitral valve replacement) preoperatively. A 19-mm valve was implanted in 15.5% of aortic valve replacement patients. Coronary bypass was required in 31% of aortic valve replacements and 20% of mitral valve replacements. Operative mortality was 17/478 (3.6%) in aortic valve replacement and 19/359 (5.3%) in mitral valve replacement, and multivariable predictors were 19-mm valve size, 3 or more coronary bypass grafts, and New York Heart Association class IV for aortic valve replacement and New York Heart Association class IV and age for mitral valve replacement. Actuarial survivorship at 10 and 20 years was 57% ± 3% and 26% ± 5% for aortic valve replacement and 61% ± 3% and 39% ± 4% for mitral valve replacement. Multivariable predictors of late death were African-American ethnicity, New York Heart Association class III or IV, coronary bypass, and age for aortic valve replacement and New York Heart Association class III or IV, coronary bypass, and age for mitral valve replacement. For aortic valve replacement, effective orifice area was univariately ( P = .002) but not multivariately ( P = .378) predictive of late death. Structural valve deterioration was not observed. For aortic valve replacement, actuarial freedom (at 10 and 20 years) from reoperation was 93% ± 1% and 90% ± 2%; thromboembolism, 82% ± 3% and 68% ± 8%; bleeding events, 77% ± 3% and 66% ± 6%; prosthetic valve endocarditis, 94% ± 1% and 94% ± 1%; valve-related mortality, 94% ± 2% and 86% ± 4%; and valve-related mortality or morbidity, 58% ± 3% and 32% ± 8%. For mitral valve replacement, actuarial freedom (at 10 and 20 years) from reoperation was 96% ± 1% and 90% ± 3%; thromboembolism, 77% ± 3% and 59% ± 7%; bleeding events, 86% ± 2% and 65% ± 8%; prosthetic valve endocarditis, 98% ± 1% and 96% ± 2%; valve-related mortality, 89% ± 0.2% and 74% ± 8%; and valve-related mortality or morbidity, 63% ± 3% and 29% ± 7%. Conclusions After 2 decades of observation with close follow-up, the St Jude Medical mechanical valve continues to be a reliable prosthesis.

Native-valve endocarditis due to Candida parapsilosis

Candida parapsilosis endocarditis is associated with a high mortality rate. Usually occurring in intravenous-drug abusers and prosthetic valve recipients, native-valve endocarditis is rarely reported. We describe a case of Candida parapsilosis endocarditis involving the aortic and mitral valves, with the patient surviving prompt double-valve replacement with amphotericin B and fluconazole treatment. Five years after the surgery, the patient was still free of recurrent symptoms. Although the results suggests that prompt surgery combined with pre- and postoperative intravenous amphotericin B and 6 months of oral antifungal antibiotic is adequate for such cases, life-long regular follow-up with echocardiography is still required.

A broad and strong humoral immune response to donor HLA after implantation of cryopreserved human heart valve allografts

Cryopreserved human heart valves are used for valve replacement in patients with congenital or acquired heart disease. Although no blood group or human leukocyte antigens (HLA) matching is performed and no immunosuppression is administered, the clinical results are relatively good. After valve replacement, the majority of the patients develop HLA antibodies, whereas a smaller group of patients shows valve-related events at the long term after right ventricular outflow tract reconstruction. Therefore, we hypothesized that not the mere presence, but rather the titers of antidonor HLA antibodies may be related to valve allograft failure. The presence and specificity of HLA class I antibodies were determined by complement-dependent microlymphocytotoxicity (CDC) test in longitudinally taken peripheral blood samples of 35 valve allograft recipients. In eight patients with an antibody response specific against donor-HLA class I, the titers were measured by this CDC method after stepwise dilution of the plasma. Panel reactive antibodies of more than 10% were found in 31 of 35 (89%) valve allograft recipients. From these 31 patients, 24 (77%) developed donor-specific HLA class I antibodies. All eight selected patients had detectable donor-specific antibody titers, ranging from 1:2 to 1:8000. Two donor valve recipients before retransplantation had (donor-specific) HLA antibodies and showed high titers of 1:256 and 1:8000 shortly after the second allograft valve replacement, which was associated with an early graft failure in the latter patient. We conclude that transplantation of cryopreserved human heart valve allografts leads to a broad and strong humoral response, which is probably the result of a lack of immunosuppressive therapy after valve transplantation. Patients receiving a second or following valve allograft appeared to be sensitized and developed early and high allo-antibody titers after second valve allograft implantation. Valve failure was diagnosed in a patient with extremely high titers. These findings suggest that preoperative cross-matching may identify patients with high donor-specific HLA antibody titers and may reduce the risk for early recurrent graft failure.

Intravascular hemolysis in patients with new-generation prosthetic heart valves: A prospective study

Objective: A prospective clinical study was designed to assess the frequency and severity of intravascular hemolysis in patients with new-generation, normally functioning prosthetic heart valves. Methods: Hemolysis was evaluated in 172 patients with a mechanical prosthesis (53 CarboMedics and 119 Sorin Bicarbon) and in 106 patients with a bioprosthesis (15 St Jude Medical Toronto, 19 Baxter Perimount, and 72 Medtronic Mosaic) in the aortic position, mitral position, or both. Aortic valve replacement was performed in 206 patients, mitral valve replacement in 59 patients, and double valve replacement in 13 patients. The presence of hemolysis was assessed on the basis of the level of serum lactic dehydrogenase and serum haptoglobin and the presence and amount of reticulocytes and schistocytes in the peripheral blood. Severity of intravascular hemolysis was estimated on the basis of serum lactic dehydrogenase. Clinical, echocardiographic, and hematologic evaluations were performed 1, 6, and 12 months after discharge. Results: None of the 278 patients experienced decompensated anemia, whereas at 12 months, mild subclinical hemolysis was identified in 49 patients, 44 (26%) with a mechanical prosthesis and 5 (5%) with a bioprosthesis (P <.001). At multivariate analysis, independent predictors of the presence of subclinical hemolysis were mitral valve replacement (P <.001), use of a mechanical prosthesis (P =.002), and double valve replacement (P =.02). Frequency of hemolysis in patients with stented aortic bioprostheses was 3%, whereas it was absent in those with stentless valves. Among mechanical valve recipients, double versus single valve replacement (P =.04) and mitral versus aortic valve replacement (P =.05) were correlated with the presence of hemolysis; double valve recipients also showed a more severe degree of hemolysis (P =.03). In patients with a Sorin Bicarbon prosthesis, hemolysis was less frequent (22% vs 34%, P =.09) and severe (P <.001) than in those with a CarboMedics prosthesis. Conclusions: In normally functioning prosthetic heart valves, subclinical hemolysis is a frequent finding. A low incidence of hemolysis is found in stented biologic prostheses, and it is absent in stentless aortic valves. Modifications of valve design may contribute to minimize the occurrence of hemolysis in mechanical prostheses.J Thorac Cardiovasc Surg 2002;123:550-6

Clinical outcome in patients with 19-mm and 21-mm St. Jude aortic prostheses: comparison at long-term follow-up

Background. Small-sized prostheses for aortic valve replacement may result in residual left ventricular outflow tract obstruction. Aim of the study was to verify whether implantation of 19-mm versus 21-mm St. Jude Medical standard prostheses (St. Jude Medical, Inc, St. Paul, MN) influences long-term clinical outcome. Methods. Two hundred twenty-nine patients who underwent aortic valve replacement with 19 mm (group 1, 53 patients) or 21-mm St. Jude Medical standard prostheses (group 2, 176 patients) were included in the study. Mean follow-up of current survivors was 10 ± 4 years. Results. Operative mortality was 7.5% in group 1 and 8.5% in group 2. At discharge, an important patient-prosthesis mismatch (effective orifice area index ≤ 0.60 cm 2/m 2) was present in 18% of group 1 versus 5% in group 2 ( p = 0.004). Among patients with body surface area less than 1.70 m 2, such mismatch was present in 15% of group 1 versus 2% of group 2 ( p = 0.008). At last follow-up New York Heart Association (NYHA) functional class ( p < 0.001), left ventricular mass reduction ( p = 0.02), mean ( p = 0.002) and peak transprosthetic gradients ( p < 0.001), and effective orifice area index ( p = 0.005) were significantly better in group 2. Freedom from sudden death (92% ± 5% vs 99% ± 1%, p = 0.01), valve-related death (84% ± 6% vs 90% ± 5%, p = 0.02), and cardiac events (56% ± 13% vs 86% ± 4%, p = 0.008), were significantly lower in group 1. Effective orifice area index was an independent predictor of late cardiac events. Conclusions. Although long-term results after aortic valve replacement with small-sized St. Jude Medical standard prostheses are satisfactory, 19-mm valve recipients show a high prevalence of important patient-prosthesis mismatch with less evident functional improvement and higher rate of cardiac events, suggesting a very cautious use of this prosthesis.

Twenty-year comparison of tissue and mechanical valve replacement

Objective: We sought to compare outcomes with tissue and St Jude Medical mechanical valves over a 20-year period. Methods: Valve-related events and overall survival were analyzed in 2533 patients 18 years of age or older undergoing initial aortic, mitral, or combined aortic and mitral (double) valve replacement with a tissue valve (Hancock, Carpentier-Edwards porcine, or Carpentier-Edwards pericardial) or a St Jude Medical mechanical valve. Total follow-up was 13,390 patient-years. There were 666 St Jude Medical aortic valve replacements, 723 tissue aortic valve replacements, 513 St Jude Medical mitral valve replacements, 402 tissue mitral valve replacements, 161 St Jude Medical double valve replacements, and 68 tissue double valve replacements. The mean age was 68 ± 13.3 years (St Jude Medical valve, 64.5 ± 12.9; tissue valve, 72.0 ± 12.6). Results: There were no overall differences in survival between tissue and mechanical valves. Multivariable analysis indicated that the type of valve did not affect survival. Analysis by age less than 65 years or 65 years or older and presence or absence of coronary disease revealed similar long-term survival in all subgroups. The risk of hemorrhage was lower in patients receiving tissue aortic valve replacements but was not significantly different in patients receiving mitral valve or double valve replacements. Thromboembolism rates were similar for tissue and mechanical valve recipients. However, reoperation rates were significantly higher in patients receiving both aortic and mitral tissue valves. The reoperation hazard increased progressively with time both in patients receiving aortic and in those receiving mitral tissue valves. Overall valve complications were initially higher with mechanical aortic valves but not with mechanical mitral valves. However, valve complication rates later crossed over, with higher rates in tissue valve recipients after 7 years in patients undergoing mitral valve replacement and 10 years in those undergoing aortic valve replacement. Conclusions: Tissue and mechanical valve recipients have similar survival over 20 years of follow-up. The primary tradeoff is an increased risk of hemorrhage in patients receiving mechanical aortic valve replacements and an increased risk of late reoperation in all patients receiving tissue valve replacements. The risk of tissue valve reoperation increases progressively with time.J Thorac Cardiovasc Surg 2001;122:257-69

Quality of life in aortic valve replacement: pulmonary autografts versus mechanical prostheses

OBJECTIVESWe sought to determine whether the quality of life (QoL) is different in patients after aortic valve replacement with mechanical prostheses or pulmonary autografts.BACKGROUNDQuality of life after mechanical valve replacement may be affected by the risk of thromboembolism and anticoagulation, and after autograft implantation, by the risk of degeneration and re-operation especially of the homograft.METHODSTwo groups of 40 patients each—one after the autograft procedure (group I) and one after mechanical valve implantation (group II)—were matched for age, gender and length of follow-up. At latest follow-up, all patients underwent routine echocardiography, the short-form health survey (SF-36) QoL survey and an extensive psychological investigation.RESULTSPatients with an autograft showed better QoL scales, as compared with mechanical valve recipients. The difference was significant for both the physical (72.72 ± 20.00 vs. 60.27 ± 26.07, p = 0.021) and psychological health sum scores (74.71 ± 21.03 vs. 64.71 ± 23.49, p = 0.046) and for the subtests of physical functioning (73.72 ± 22.44 vs. 62.77 ± 25.42, p = 0.049), physical pain (88.39 ± 19.13 vs. 73.36 ± 27.08, p ≤ 0.006), general health perception (64.37 ± 17.88 vs. 51.86 ± 22.86, p ≤ 0.008) and health change (61.89 ± 18.94 vs. 50.11 ± 24.37, p = 0.02). The QoL variables did not correlate to pressure gradients, ejection fraction and New York Heart Association functional class. Psychometric tests revealed no meaningful differences between the groups.CONCLUSIONSThis study provides some evidence that patients with pulmonary autografts have greater benefit in terms of QoL, as compared with recipients of mechanical valve substitutes.

Long-term survival after valve replacement with björk-shiley CC valves

Information on the life expectancy of Björk-Shiley convexo-concave (BScc) valve recipients is necessary when considering prophylactic replacement. However, little is known about the late results after valve replacement with BScc valves. We describe long-term survival and its determinants of the Dutch BScc cohort and compare mortality figures with those of the general population and those used in guidelines for prophylactic replacement. Follow-up was obtained on all Dutch BScc valve recipients (n = 2,264) (end of study 1996). Survival over a 15-year period and its determinants were described using the Kaplan-Meier product-limit method and Cox regression, respectively. Standardized mortality ratios (SMRs) were used to compare mortality rates of BScc valve recipients who survived at least 30 days after surgery with the Dutch population rates. Survival at 15 years for aortic, mitral, and double valve recipients was 55.0% (95% confidence interval [CI] 51.9 to 58.1), 40.8% (95% CI 37.1 to 44.4), and 38.6% (95% CI 33.2 to 43.9), respectively. The determinants of survival were patient, history, and procedure related. The SMR for all BScc valve recipients was 4.2 (95% CI 3.4 to 5.2) in the first year of follow-up, after which it decreased to 2.0 (95% CI 1.8 to 2.3) and remained constant until the 14th year. SMRs depended on time since implantation, age at the time of implantation, and position of the valve replaced. Most of life expectancy estimates in prophylactic replacement guidelines of BScc valves underrate the true survival estimates. Age, valve position, and time- specific risks of death after valvular surgery should be accounted for. Different excess mortality rates should be applied for patients from different age groups: the older the patient the lower the excess.

Early fungal endocarditis in homograft recipients

Retrospective analysis of 200 homograft valve recipients at our institution revealed two cases of fungal endocarditis. Pathogenesis appears to be related to either recipient seeding in one elderly immunocompromised patient or a previously contaminated donor valve implanted in an otherwise healthy recipient. Therefore, our experience underscores the need for both meticulous prevention of fungal infection preoperatively in the recipient and elimination of previously contaminated homograft valves from the donor pool.

Actual failure rates: A method of assessing tissue valve reoperation rates

Background Patients older than age 70 with coronary disease undergoing mitral valve replacement have a limited survival rate, suggesting that few of these patients will require reoperation if they receive a tissue mitral valve. However, traditional actuarial analysis of valve durability censors patients who die before valve failure and doesn’t reflect the lower frequency of reoperation in patient subgroups with limited survival rates. Methods Actual or cumulative reoperation rates represent the rates of reoperation in patients without censoring for death and estimate the risk that the valve will fail before the patient dies. The actual rates of valve rereplacement were determined in 255 recipients of tissue mitral valves, categorizing patients by age and presence of coronary artery disease at 8 years after surgery and compared with standard actuarial estimates of valve durability. Results Operative mortality rates were 17.5% for patients with coronary artery disease and 6.0% for those without ( P < .001). At 8 years, the actual reoperation rates for patients younger than age 70 with and without coronary artery disease were 9.2% (n = 76) and 10% (n = 90), respectively. In patients older than age 70 without coronary artery disease the reoperation rate was 9.4% (n = 32). In contrast, the actual reoperation rate was only 1.7% (n = 58) in patients older than age 70 with coronary artery disease. This rate was significantly lower ( P = .05) than the other groups. The difference in reoperation rates was not significant if standard actuarial analysis was used. Conclusions Actual reoperation rates are significantly lower in patients older than 70 years with CAD receiving mitral tissue valves than in younger patients or in patients without coronary artery disease. Calculation of actual reoperation rates provides a unique and clinically useful perspective in evaluating data on prosthetic valve reoperation rates. (Am Heart J 1999;138:108-13.)

Likelihood of underreporting of outlet strut fracture from examination of the Dutch Björk-Shiley CC cohort

The Dutch Björk-Shiley convexo-concave (BScc) cohort serves as a reference population on the risk of outlet strut fracture and is being used to formulate guidelines for prophylactic replacement. Fractures, however, may be undetected at death. The aim of this study was to quantify the degree of underestimation of strut fracture in the Dutch BScc cohort. Multivariate Cox regression analysis was used to assess the relative and absolute risk of death from different causes within 14 years. The unexplained “excess” mortality among 70° BScc valve recipients was attributed to unreported fatal strut fractures and used to estimate its extent in this group, which then was extrapolated to the 60° BScc valve recipients. For 70° BScc valve recipients, the adjusted hazard ratio for death from all causes except strut fracture was 1.2 (95% confidence interval [CI] 1.0 to 1.5). The 14-year absolute risks for 70° and 60° BScc valve recipients were 44% and 37%, respectively. Among 70° and 60° BScc valve recipients, underreporting of fracture was estimated to be 25% (95% CI 0 to 49) and 26% (95% CI 0 to 52), respectively. Estimates based on sudden death and fatal congestive heart failure yielded essentially the same results. Thus, underreporting of fatal strut fracture in the Dutch BScc cohort is estimated to be approximately 25%. Hence, the risk and lethality of fracture of BScc valves are underestimated and indications for prophylactic replacement should be adjusted accordingly. For example, the advantage of valve replacement in a 40-year-old patient with a 29-mm 60° BScc mitral valve would almost double to 0.82 years.

The dilemma of discontinuation of anticoagulation therapy for patients with intracranial hemorrhage and mechanical heart valves.

Anticoagulant-related hemorrhage occurs with an incidence of approximately 1%/patient-year in mechanical heart valve recipients. Intracranial hemorrhage poses a difficult clinical choice; continuing anticoagulation therapy may enlarge the volume of the hemorrhage, early reinstitution of anticoagulation therapy may predispose patients to recurrence, and reversal of anticoagulation therapy may place patients at risk for systemic embolization involving the brain. The risk of embolization may also be greater for patients with atrial fibrillation, cage-ball valves in the mitral position, and reduced ventricular function. This dilemma exists because of a lack of data for a large series of patients. We reviewed the medical records and neuroimaging studies for a consecutive group of patients admitted with intracranial hemorrhage and mechanical heart valves. We reviewed neurological presenting data, cardiac risk factors for systemic embolization (atrial fibrillation, enlarged atrial chambers, reduced ventricular function, and the type and location of the metallic valve), and hospital management. We studied 39 patients with intracranial hemorrhage and mechanical heart valves (median age, 69 yr). Four patients had experienced previous transient ischemic attacks or minor strokes. The time from valve replacement to intracranial hemorrhage ranged from 2 months to 19 years (median, 6 yr). The type of intracranial hemorrhage was acute subdural hematoma (n = 20), lobar hematoma (n = 10), subarachnoid hemorrhage (n = 4), cerebellar hematoma (n = 3), or basal ganglionic hematoma (n = 2). Thirteen patients died within 2 days of admission. All 26 surviving patients received fresh frozen plasma and vitamin K. Fifteen patients underwent evacuation of acute subdural hematoma, and in one patient an anterior communicating aneurysm was clipped. The duration of discontinuation of anticoagulation therapy varied from 2 days to 3 months (median, 8 d). None of the patients developed transient ischemic attacks, ischemic strokes, valve thrombosis, or systemic embolization. No recurrence of intracranial hemorrhaging was observed during hospitalization and reinstitution of anticoagulation or antiplatelet agent administration. Temporary interruption of anticoagulation therapy seems safe for patients with intracranial hemorrhage and mechanical heart valves but without previous evidence of systemic embolization. For most patients, discontinuation for 1 to 2 weeks should be sufficient to observe the evolution of a parenchymal hematoma, to clip or coil a ruptured aneurysm, or to evacuate an acute subdural hematoma.

Psychological distress among recipients of Björk-Shiley convexo-concave valves: the impact of information

ObjectiveTo establish whether there is more psychological distress among recipients of Björk-Shiley convexo-concave (BScc) valves than among recipients of other valves not known to fracture.DesignCross sectional study.Patients137 patients who received...

Thirty years experience with heart valve surgery: isolated aortic valve replacement.

Thirty years have elapsed since the commencement of open-heart surgery in South Australia. A retrospective study was performed to evaluate mortality and complication rates and to identify factors associated with poor outcomes in all patients who underwent prosthetic aortic valve replacement during this period. Questionnaires and personal contact have been used to generate a combined database of pre-operative and post-operative information and long-term follow-up on 1322 patients who underwent isolated prosthetic aortic valve replacement at the Cardio-Thoracic Surgical Unit of the Royal Adelaide Hospital between 1963 and 1992. Complete survival follow-up data were obtained for 94% (1241) of the patients. The Bjork-Shiley valve was used in 66% (875) of the patients, a Starr-Edwards prosthesis in 31% (412), a St Jude prosthesis in 2% (26), and only 0.7% (9) bioprosthetic valves were inserted. The hospital mortality rate for the 30-year period was 2.9%. Progressively older and less fit patients have undergone surgery in recent years. The long-term survival of patients with aortic stenosis and aortic incompetence was not significantly different. Long-term survival was significantly shorter for patients with higher New York Heart Association (NYHA) functional classifications, and for patients in pre-operative atrial fibrillation. Pre-operative dyspnoea was significantly improved following aortic valve replacement. The rates of postoperative haemorrhagic and embolic complications were low by comparison with other published series. Aortic valve replacement can be performed with low hospital mortality and complication rates, and significant symptomatic improvement can be expected. Aortic valve recipients have a favourable prognostic outcome compared with an age- and sex-matched population, and risk factors that determine long-term survival can be identified pre-operatively.

Thirty years experience with heart valve surgery: isolated mitral valve replacement.

Thirty years have elapsed since the commencement of open-heart surgery in South Australia. A retrospective study was performed to evaluate mortality and complication rates and to identify factors associated with poor outcomes in all patients who underwent prosthetic mitral valve replacement during this period. Questionnaires and personal contact have been used to generate a combined database of pre-operative and post-operative information and long-term follow-up on 938 patients who underwent isolated prosthetic mitral valve replacement at the Cardio-Thoracic Surgical Unit of the Royal Adelaide Hospital between 1963 and 1993. Complete survival follow-up data were obtained for 92% (865) of the patients. The Starr-Edwards valve was used in 95% (891) of the patients, a Bjork-Shiley prosthesis in 2.5% (23) of the patients, and only 24 (2.5%) other valves were inserted. The hospital mortality rate for the 30-year period was 4.7%. The mean age of the patients who underwent surgery was greater in each of the three successive decades. A long-term survival advantage was observed for patients with mitral stenosis, however, survival was significantly shorter for patients with higher New York Heart Association (NYHA) functional classifications and for patients in pre-operative atrial fibrillation. Pre-operative dyspnoea was significantly improved following mitral valve replacement. The rates of postoperative haemorrhagic and embolic complications were low by comparison with other published series. Mitral valve recipients do not regain a normalized life expectancy, but risk factors that determine long-term survival can be identified pre-operatively to aid appropriate patient selection.