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STATE-OF-THE-ART PAPER

Choice of prosthetic heart valve for adult patients

^* Griffith Center, Division of Cardiovascular Medicine, Department of Medicine, LAC + USC Medical Center, Keck School of Medicine at the University of Southern California, Los Angeles, California, USA

Manuscript received April 23, 2002; revised manuscript received October 11, 2002, accepted October 17, 2002.

^* Reprint requests and correspondence: Dr. Shahbudin H. Rahimtoola, University of Southern California, 2025 Zonal Avenue, Los Angeles, California, USA 90033.

This review summarizes the major long-term (10 to 15 years) patient outcomes after insertion of many Food and Drug Administration approved prosthetic heart valves (PHV). Mechanical PHV was associated with a better survival (p < 0.02) at 15 years after aortic valve replacement (AVR) than with a bioprosthesis in the Department of Veterans Affairs (DVA) trial. In both the DVA and the Edinburgh Heart Valve trials, bioprosthesis were associated with structural valve deterioration (SVD) (mitral valve replacement [MVR] > AVR) and, therefore, for replacement of the PHV. Thromboembolism and bleeding rate were higher with mechanical PHV. Mortality after AVR and MVR is high at 10 to 15 years because of the associated comorbid conditions and older age of patients. Outcomes with "new" good valves are similar to that with "older" good valves. Complication rates of thromboembolism, bleeding, endocarditis, and leak vary widely; the rates of these complications are not different among different mechanical PHV and among different bioprosthetic PHV. Structural valve deterioration is rare with mechanical PHV. Structural valve deterioration of bioprosthesis after MVR is higher than after AVR; after AVR, homografts and bioprosthesis have similar rates of SVD. The exact rate of SVD of the pulmonary autograft is uncertain. Valve prosthesis-patient mismatch is clinically important when it is severe and in selected patients when it is moderate. Bioprosthesis have a low rate of SVD in the older patient and, thus, are the PHV of choice for AVR in patients 60 to 65 years of age and for MVR in patients 65 to 70 years of age; in younger patients mechanical valves are the PHV of choice. In individual patients there may be exceptions to these general rules.

Abbreviations and Acronyms   AVR   aortic valve replacement   CABG   coronary artery bypass graft surgery   CAD   coronary artery disease   DVA   Department of Veterans Affairs   FDA   Food and Drug Administration   INR   international normalized ratio   NYHA   New York Heart Association   LVEF   left ventricular ejection fraction   MO   modified orifice   MVR   mitral valve replacement   OPC   optimal performance characteristics   PHV   prosthetic heart valve   SVD   structural valve deterioration   VP-PM   valve prosthesis-patient mismatch

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