SDL 20 - Prosthetic Heart Valves BMS16091064 Jonathan

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TYPES OF PROSTHETIC HEART VALVES

Mechanical Valves
The three basic types of mechanical prosthetic valves are bileaflet, tilting disc, and
caged ball. The St.Jude bileaflet valve was first used in 1977 and is the most
frequently implanted mechanical prosthesis worldwide. It consists of two pyrolytic
semicircular “leaflets” or discs with a slitlike central orifice between the two leaflets
and two larger semicircular orifices laterally. The opening angle of the leaflets
relative to the annulus plane ranges from 75 to 90 degrees. The CarboMedics valve is
a variation of the St. Jude prosthesis that can be rotated to prevent limitation of leaflet
excursion by subvalvular tissue. For a given valve annulus size, effective orifice area
(EOA) is generally larger and transprosthetic pressure gradient lower for the bileaflet
mechanical valves compared to the tilting disc valves. Because the central orifice is
smaller than the lateral orifices in bileaflet valves, the blood flow velocity may be
locally higher within the inflow aspect of the central orifice; this phenomenon may
lead to overestimation of gradient and underestimation of EOA by transthoracic
echocardiography (TTE). Bileaflet valves typically have a small amount of normal
regurgitation (“washing jet”), designed in part to decrease the risk of thrombus
formation. A small, central jet and two converging jets emanating from the hinge
points of the discs can be visualized on color Doppler flow imaging.

Tilting disc or monoleaflet valves use a single, circular disc that rotates within a rigid
annulus to occlude or open the valve orifice. The disc is secured by lateral or central
metal struts. The opening angle of the disc relative to the valve annulus ranges from
60 to 80 degrees, resulting in two orifices of different size. The nonperpendicular
opening angle of the valve occluder tends to slightly increase the resistance to blood
flow, particularly in the major orifices. Tilting disc valves also have a small amount of
regurgitation, arising from small gaps at the perimeter of the valve.
The bulky Starr-Edwards ball-in-cage valve, the oldest commercially available
prosthetic heart valve first used in 1965, is now very rarely implanted. The ball-cage
valve is more thrombogenic and has less favorable hemodynamic performance
characteristics than either bileaflet or tilting disc valves. Currently available
mechanical valves have excellent, long-term durability, with up to 45 years for the
Starr-Edwards valve and more than 30 years for the St. Jude valve. Structural
deterioration, exemplified by some older-generation Björk-Shiley (strut fracture with
disc embolization) and Starr-Edwards (ball variance) prostheses, is now extremely
rare.

Ten-year freedom from valve-related death exceeds 90% for both St. Jude and
CarboMedics bileaflet valves. All patients with mechanical valves require lifelong
anticoagulation with a vitamin K antagonist (VKA). Long-term issues associated with
mechanical valves include infective endocarditis, paravalvular regurgitation (PVR),
hemolytic anemia, thromboembolism/valve thrombosis, pannus ingrowth, and
hemorrhagic complications related to anticoagulation.

Tissue Valves
Tissue or biologic valves include stented and stentless bioprostheses (porcine, bovine),
homografts (or allografts) from human cadaveric sources, and autografts of
pericardial or pulmonic valve origin.

Tissue valves provide an alternative, less thrombogenic heart valve substitute that
does not require long-term anticoagulation in the absence of additional risk factors for
thromboembolism.

Stented Bioprosthetic Valves

The traditional design of a heterograft valve consists of three biologic leaflets made
from the porcine aortic valve or bovine pericardium treated with glutaraldehyde to
reduce its antigenicity. The leaflets are mounted on a metal or polymeric stented ring;
they open to a circular orifice in systole, resembling the anatomy of the native aortic
valve. The vast majority of bioprosthetic valves are treated with anticalcifying agents
or processes. The newer generations of bovine pericardial valves (Carpentier-Edwards
Magna or St. Jude Trifecta) offer improved hemodynamic performance compared
with earlier-generation bioprostheses. A small degree of regurgitation can be detected
by color Doppler flow imaging in 10% of normally functioning bioprostheses.

One limitation of earlier generations of bioprosthetic valves was their limited

durability due to structural valve deterioration (SVD), typically beginning within 5 to
7 years after implantation, but varying by position and age at implant, with tissue
changes characterized by calcification, fibrosis, tears, and perforations. SVD occurs
earlier for mitral than for aortic bioprosthetic valves, perhaps because of exposure of
the mitral prosthesis to relatively higher left ventricular (LV) closing pressures. The
process of SVD is accelerated in younger patients, in those with disordered calcium
metabolism (end-stage renal disease), and possibly in pregnant women, independent
of younger age. With newer-generation bioprosthetic pericardial valves, the durability
is excellent, with SVD rates of 2% to 10% at 10 years, 10% to 20% at 15 years, and
40% at 20 years.
 Stentless Bioprosthetic Valves
The rigid sewing ring and stent-based construction of certain bioprostheses allow for
easier implantation and maintenance of the three-dimensional relationships of the
leaflets. However, these features also contribute to impaired hemodynamic
performance. Stentless porcine valves were developed in part to address these issues.
Their use has been restricted to the aortic position. Implantation is technically more
challenging, whether deployed in a subcoronary position or as part of a miniroot, and
thus these valves are preferred by only a minority of surgeons. Early postoperative
mean gradients can be less than 15 mm Hg, with further improvement in valve
performance over time from aortic root remodeling, lower peak exercise transvalvular
gradients, and more rapid reduction in LV mass.8 Sutureless bioprosthetic valves
have also been developed to decrease the complexity and duration of implantation of
bioprosthetic valves
.
Homografts
Aortic valve homografts are harvested from human cadavers within 24 hours of death
and are treated with antibiotics and cryopreserved at −196°C. They are now usually
implanted in the form of a total root replacement with reimplantation of the coronary
arteries. Homograft valves appear resistant to infection and are preferred by some
surgeons for management of aortic valve and root endocarditis in the active phase.
Neither immunosuppression nor routine anticoagulation is required. Despite earlier
expectations, long-term durability beyond 10 years is not superior to that for
current-generation pericardial valves, and reoperation may be technically more
challenging.

Autografts
In the Ross procedure the patient’s own pulmonic valve or autograft is harvested as a
small tissue block containing the pulmonic valve, annulus, and proximal pulmonary
artery and is inserted in the aortic position, usually as a complete root replacement
with reimplantation of the coronary arteries. The pulmonic valve and right ventricular
outflow tract are then replaced with either an aortic or pulmonic homograft. Thus the
procedure requires two separate valve operations, a longer time on cardiopulmonary
bypass, and a steep learning curve. With appropriate selection of young patients by
expert surgeons at experienced centers of excellence, operative mortality rates are less
than 1% and 20-year survival rates as high as 95%, similar to the general population.

Advantages of the autograft include the ability to increase in size during childhood
growth, excellent hemodynamic performance characteristics, lack of thrombogenicity,
and resistance to infection. The hemodynamic performance characteristics of the
pulmonary autograft are similar to those of a normal, native aortic valve. The
procedure is usually reserved for children and young adults, but should be avoided in
patients with dilated aortic roots, given the unacceptably high incidence of accelerated
degeneration, pulmonary autograft dilation, and significant regurgitation.

Transcatheter Bioprosthetic Valves

Transcatheter aortic valve replacement (TAVR) is a valuable alternative to surgical
aortic valve replacement in patients with symptomatic severe aortic stenosis (AS)
considered to be at extreme, high, or intermediate surgical risk. Two main types of
transcatheter aortic valves are currently used: balloon-expandable valves and
self-expanding valves.
The Edwards SAPIEN XT and SAPIEN 3 balloon-expandable valves consist of a
three-leaflet pericardial bovine valve mounted in a cobalt chromium frame. These
valves are available in 20, 23, 26 and 29 mm sizes. Common access routes for TAVR
are transfemoral, transapical, and transaortic. Approximately 75% to 80% of TAVR
procedures are now performed by a transfemoral approach. As catheter sheath sizes
decrease (now 14F or 16F for most valves), the balance is anticipated to shift even
more toward the transfemoral approach. The transfemoral approach is associated with
lower mortality and quicker recovery compared to alternative access approaches.

The CoreValve balloon-expandable valve consists of three leaflets of porcine

pericardium seated relatively higher in a nitinol frame to provide true supra-annular
placement and is available in 26, 29, and 31 mm sizes. The CoreValve is most
frequently implanted using the transfemoral approach. For a given aortic annulus size,
transcatheter valves have larger EOAs and lower gradients compared to surgical
bioprosthetic valves. PVR, however, occurs much more often following TAVR and
has adverse long-term consequences. Mild regurgitation occurs in 25% to 60% of
patients and moderate or severe regurgitation in 3% to 20%.13,14 Moderate or severe
PVR is associated with a 2.0- to 2.5-fold increase in mortality. The most recent
transcatheter balloonexpandable valve (SAPIEN 3) was designed with a skirt to
reduce PVR. The rate of moderate or severe regurgitation has dropped to less than 3%
with its use. Some studies suggest that self-expanding valves have slightly larger
EOAs and lower gradients but somewhat higher rates of PVR than
balloon-expandable valves.
 Algorithm for choice of prosthetic heart valves.

Management for common potential complication of prosthetic valve replacement