LETTER TO THE EDITOR
Reply
Shahbudin Rahimtoola, MB, FRCP, MACP, MACC, DSc (Hon)
University of Southern California, Keck School of Medicine, Division of Cardiovascular Medicine, 2025 Zonal Avenue, Los Angeles, CA 90033, USA
luzcanlas{at}yahoo.com
I am glad Dr. Bloomfield concurs with and re-emphasizes the importance of obtaining long-term ( 15 to 20 years) follow-up data in patients with prosthetic heart valves (PHVs). The 20-year results of the Edinburgh Heart Valve trial (1) (Edinburgh trial) are reviewed in the Journal of the American College of Cardiology series entitled "The Year in Cardiology" (2). This trial showed that at 20 years the incidence of re-operation in patients receiving the porcine PHV was very much higher than in patients receiving the mechanical PHV; after mitral valve replacement it was 77.6% versus 13.4% ± p < 0.0001 (1), and after aortic valve replacement it was 56.2% versus 7.4%, p < 0.0001. In the Veterans Affairs (3) and Edinburgh trials (1), major differences between the mechanical and bioprostheses that were statistically significant appeared after about 10 to 12 years of follow-up.
I agree that the Edinburgh and Veterans Affairs trials are very important and provide useful data, but they should not be used as the sole source on which to choose a PHV (3–5). In the Edinburgh trial (1), at 20 years the survival with original prosthesis intact was better with mechanical valve, but the total mortality was not significantly different between a mechanical and porcine PHV. Noncardiac causes accounted for 23% to 28% of the deaths; data (PHV vs. non-PHV) on the cardiac causes of death in those with mechanical and porcine PHVs are not provided. This information might help to understand why all-cause mortality was not significantly different. It is of interest that the 30-day mortality of re-operation was 14.2% (18.3% before 1987 and 9.4% after 1987) (1).
Finally, the review (4) had not dealt with stentless PHVs in any detail because long-term follow-up data was not available. The Commentary (5) was able to show that Dr. Bach's (6) unbridled enthusiasm for the stentless porcine valve was not supported by the available data.
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References
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- Oxenham H, Bloomfield P, Wheatley DJ, et al. Twenty-year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprostheses. Heart. 2003;89:715–721[Abstract/Free Full Text]
- Rahimtoola SH. The year in valvular heart disease. J Am Coll Cardiol. 2004;43:491–504[Free Full Text]
- Hammermeister KE, Sethi GK, Henderson WG, Grover FL, Oprian C, Rahimtoola SH. Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial. J Am Coll Cardiol. 2000;36:1152–1158[Abstract/Free Full Text]
- Rahimtoola SH. Choice of prosthetic heart valve for adult patients. J Am Coll Cardiol. 2003;41:893–904[Abstract/Free Full Text]
- Rahimtoola SH. The next generation of prosthetic heart valves needs a proven track record of patient outcomes at 15 to 20 years. J Am Coll Cardiol. 2003;42:1720–1721[Abstract/Free Full Text]
- Bach DS. Choice of prosthetic heart valves: update for the next generation. J Am Coll Cardiol. 2003;42:1717–1719[Abstract/Free Full Text]
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E B Schelbert, M S Vaughan-Sarrazin, K F Welke, and G E Rosenthal
Valve type and long-term outcomes after aortic valve replacement in older patients
Heart,
September 1, 2008;
94(9):
1181 - 1188.
[Abstract]
[Full Text]
[PDF]
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