Prosthetic Valves

PROSTHETIC CARDIAC VALVES
Brook A. June/2016
Braunwald 10th ed.
INTRODUCTION
 The first successful human replacements of
cardiac valves were accomplished in 1960 by Nina
Braunwald and colleagues, Dwight Harken and co-
workers, and Albert Starr and Lowell Edwards.
 Two major groups of prosthetic valves currently

are available in models designed for the
atrioventricular (mitral and tricuspid) and aortic
positions:
 Mechanical prostheses and
 Bioprostheses
INTRODUCTION
 The major differences are related to
 The risk of thromboembolism (higher with
mechanical valves) and
 The risk of structural deterioration of the
prosthesis (higher with bioprostheses)
MECHANICAL PROSTHESIS: TYPES
 Mechanical prosthetic valves are classified into three
major groups—
 Bileaflet,
 Tilting disc, and
 Ball cage.
 The bileaflet valves: are the most commonly implanted

mechanical valves
 This is because of their low bulk and flat profile and superior
hemodynamics.
 It has favorable flow characteristics and causes a lower
transvalvular pressure gradient at any outer diameter and
cardiac output than caged ball or tilting disc valves.
 The St. Jude bileaflet mechanical valve (St. Jude Medical, West
Berlin, New Jersey) is coated with pyrolytic carbon and has two
semicircular discs that pivot between open and closed positions
without the need for supporting struts
 Bileaflet valves ctd
 Appear to have particularly favorable hemodynamic
characteristics in the smaller sizes.
 Thrombogenicity in the mitral position may be less than

that associated with other prosthetic valves, although,
as with other mechanical prostheses, life-long
anticoagulation is needed.
A variation of the St. Jude valve, the CarboMedics

prosthesis (Sorin Group, Milan, Italy)
 Composed of pyrolytic carbon with a titanium housing that can
be rotated to avoid interference with disc excursion by
subvalvular tissue.
 Tilting disc valve
 An example in current use is the Medtronic-Hall
valve (Medtronic, Minneapolis)
 Has a Teflon sewing ring and titanium housing;
 Its thin, carbon-coated pivoting disc has a central
perforation that allows improved hemodynamics.
 Thrombogenicity appears to be low (less than one

episode/100 patient-years in the mitral position), and
mechanical performance is excellent over the long
term.
 Ball cage valve
 Production of the Starr-Edwards caged ball valve
was discontinued in 2007, but patients in whom this
valve was implanted are still encountered frequently
in clinical practice.
 The poppet is made of silicone rubber, the cage of
Stellite alloy, and the sewing ring of Teflon and
polypropylene cloth.
 Because of the bulky cage design, the Starr-Edwards
valve is not suitable for the mitral position in
patients with a small LV cavity, for the aortic
position in those with a small aortic annulus, or for
those requiring a valve–aortic arch composite graft.
 Ball cage valve
 Ina small number of patients, this valve induces
hemolysis, which may be greatly exaggerated and
become clinically important if a perivalvular leak
develops.
 When they are of small size, Starr-Edwards valves

may cause mild obstruction, and the incidence of
thromboembolism is slightly higher than with the
tilting disc or bileaflet valve.
 Mechanical valves, both bileaflet and tilting disc,
are associated with small (5 to 10 mL/beat)
obligatory (normal) regurgitation.
 All have distinctive auscultatory features (see

table below)
MECHANICAL PROSTHESIS:
DURABILITY & THROMBOGENECITY
 All mechanical prosthetic valves have an
excellent record of durability, up to 40 years for
the Starr-Edwards valve and more than 25 years
for the St. Jude valve.
 In the mitral position, perivalvular regurgitation

appears to occur more frequently with
mechanical than with tissue valves.
 Patients with mechanical valve dysfunction present
with symptoms of HF, systemic thromboembolism,
hemolysis, or a new murmur on auscultation.
 Mechanical valve dysfunction may be due to
 Thrombosis,
 Pannus formation, or
 IE.
 Signs or symptoms of mechanical valve dysfunction

are often acute or subacute because of more abrupt
impairment of leaflet occluder opening or closing by
thrombus or pannus.
 Acute or chronic paravalvular regurgitation may also
be seen due to IE or suture dehiscence.
 Thrombosis and thromboembolism risks are
greater with any mechanical valve in the mitral
than in the aortic position, and higher doses of
warfarin are generally recommended for mitral
prostheses.
 However, patients with any mechanical

prosthesis, regardless of design or site of
placement, require long-term anticoagulation and
aspirin administration because of the hazard of
thromboembolism, which is greatest in the first
postoperative year.
 Without anticoagulants and aspirin, the incidence of thromboembolism
is three to six times higher than when proper doses of these
medications are administered.
• Very rarely, thrombosis of the mechanical valve occurs*

• Incidence of obstructive prosthetic valve thrombosis- rare (0.3-1.3 %
per patient years
• Thromboembolic complications: much more common (0.7-6%)
• Mainly systemic embolization
• Non obstructive valve thrombosis- more common
• Recent TEE study: 10%
• Risk of PVT in general
• 1st postop year: 24%
• Second to fourth year: 15%
• Decreases thenafter
 This may be a fatal event, but when nonfatal, it interferes with
prosthetic valve function
 Warfarin should begin approximately 2 days
after operation, with a goal INR of 2.5 for
patients with the bileaflet disc and the
Medtronic- Hall valve in the aortic position.
 The INR goal is 3.0 for patients at higher risk

for thrombosis (e.g., those with AF or previous
thromboembolism) as well as for patients with
other mechanical valves in the aortic position and
with all valves in the mitral position
 Antiplatelet agents without anticoagulants do
not provide adequate protection.
 However, the addition of aspirin, 75 to 100 mg

daily, together with warfarin reduces the risk of
thromboembolism and is indicated in all patients
with prosthetic valves.
 Although this approach does increase the risk of

bleeding slightly, a favorable risk-benefit profile
is confirmed.
 Dabigatran: Antithrombin agent dabigtran is
contraindicated for thromboembolic prophylaxis
in patients with mechanical valves
 Anti-Xa anticoagulants: have not yet been tested

in this situation
 Should not be used until evidence of safety and
efficacy has been accumulated.
MANAGEMENT OF THROMBOSIS
 Rates of Valve thrombosis
 Aortic position: 0.1%/year
 Mitral position: 0.35%/year and
 Tricuspid position: High (?)
 So bioprostheses are preferred at this site.
 Prosthetic valve thrombosis should be suspected

from the sudden appearance of dyspnea and
muffled sounds or new murmurs on auscultation.
 Diagnosed by 2D TEE and Doppler echocardiography
 Unless surgical risk is high, the preferred
treatment for left-sided valve thrombosis is
emergency surgery in patients with NYHA class
III or IV symptoms or with a large clot burden.
 Fibrinolytic therapy is reasonable for patients
with
 Right-sided valve thrombosis or
 Left-sided valve thrombosis with a small clot burden,
and only mild symptoms.
 Fibrinolytic therapy is followed by intravenous

heparin and aspirin, continued until the INR is
therapeutic
 The following risk data must be recognized:
 The administration of warfarin carries an estimated
mortality risk of 0.2/100 patient-years and serious
hemorrhage of 2.2 episodes/100 patient-years; and
 Despite treatment with anticoagulants, the incidence

of thromboembolic complications with the best
mechanical prosthesis is still
 Fatal complications: ~0.2 fatal
 Non fatal complications
 Aortic valve: and ~1.0 to 2.0/100 patient-years
 Mitral valve: 2.0 to 3.0/100 patient-years

 The incidence of embolization in patients who have
experienced repeated emboli from a prosthetic valve
despite anticoagulants may be reduced by replacement
with a tissue valve.
 Mechanical prostheses regularly cause mild hemolysis,

but this is not severe enough to be of clinical
importance unless the patient develops paraprosthetic
regurgitation
BIOPROSTHETIC VALVES
 Tissue valves (bioprostheses) were developed
primarily to overcome the risk of
thromboembolism that is inherent in all
mechanical prosthetic valves and the attendant
hazards and inconvenience of permanent
anticoagulant therapy
 Can be
 Stented or
 Stent-less
 Stented Bioprosthetic Valves
 Stented porcine aortic heterografts were developed
for the mitral and aortic positions and have been in
wide clinical use since 1965.
 Over the past 49 years, stented bioprosthetic valve

design has improved to maximize orifice area by
reconfiguration of the sewing ring and stents and
improve durability by the use of other biologic
tissues, improved fixation techniques, and
anticalcification treatments.
 Bioprosthetic valves may be constructed from
porcine valve tissue fixed and preserved in
glutaraldehyde and mounted on a Dacron cloth–
covered flexible polypropylene strut
 For example, the Hancock porcine bioprosthesis
(Medtronic, Minneapolis), which was approved by the FDA
in 1989
 Bioprosthetic valves also may be constructed using

bovine pericardium
 For example, the Carpentier-Edwards pericardial valve
(Edwards Lifesciences, Irvine, California), which was FDA-
approved in 1991
 The Medtronic Mosaic valve, FDA-approved in 2000,
 A porcine valve fixed at zero pressure to preserve leaflet
function with an added anticalcification treatment.
 In the United States, the number of bioprostheses

implanted each year greatly exceeds the number of
mechanical valves.
 During the first 3 postoperative months, while the
sewing ring becomes endothelialized, there is a risk
of thromboembolism so that warfarin
anticoagulation is reasonable.
 This is not a uniform practice, particularly for aortic

bioprostheses, but is more uniform in the mitral
position.
 After 3 months, anticoagulants are not needed if
 Mitral prosthesis in sinus rhythm,
 No heart failure or
 No thrombus in the LA or LAA, and
 No history of embolism preoperatively
 Thromboembolic rate (after 3 months) is ~ 1-2

episodes/100 patient-years
 Although one study suggested higher risk up to 6 months
postoperatively
 This rate is comparable to that observed in patients with
the St. Jude or other mechanical valves who are
receiving anticoagulants and are therefore at increased
risk for hemorrhage.
 It is unlikely that any mitral valve replacement can
be associated with a thromboembolic rate much
below 0.5 episode/100 patient-years
 This is because some of the emboli in patients with

longstanding mitral disease are derived from the left
atrium rather than from the valve itself.
 The hazard of thromboembolism and the need for
anticoagulants persist with bioprosthesis in
 Patients with hx of previous embolism
 Whom thrombus is found in the LA at operation, or
 Who remain in AF postoperatively (i.e., approximately
one third of all patients undergoing mitral valve

replacement)
 This risk scenario negates the principal advantage of

the tissue valves, and mechanical prostheses appear
to be preferable to bioprostheses in these patients.
 Stentless Bioprosthetic Valves
 Because the stent adds to the obstruction, thereby
increasing stress on the leaflets, stentless valves
have been developed for the aortic position and are
especially useful for patients with small aortic roots.
 These devices include the

 Toronto SPV stentless valve (St. Jude Medical valve),
 Edwards stentless valve, and
 Medtronic Freestyle valve.

 Stentless Bioprosthetic Valves
 These valves have been reported to allow more
physiologic flow with lower transvalvular gradients
than do stented porcine valves, with the potential
for enhanced regression of LV hypertrophy and
improved LV function.
 However, long-term outcome appears to be similar to

that with other currently implanted tissue valves, in
part because current-generation stented
bioprosthetic valves have better durability than
older-generation valves
PROBLEMS
 The major problem with bioprostheses is their
limited durability.
 Structural deterioration includes
 Cuspal tears,
 Degeneration, fibrin deposition, disruption of the
fibrocollagenous structure,
 Perforation, fibrosis, and calcification
 These begin to appear in some patients in the

fourth or fifth postoperative year and can be
sufficiently severe enough to require
reoperation
Fig. Structural deterioration of bioprosthetic valves. A, Valve failure related to mineralization
and collagen degeneration (C). B, Cuspal tears and perforations. These processes may occur
independently, or they may be synergistic.
PROBLEMS
 By 10 years the rate of primary tissue failure
averages 30%.
 It then accelerates and, by 15 years

postoperatively, the actuarial freedom from
bioprosthetic primary tissue failure has ranged
from 30% to 60% in several series.
PROBLEMS
 Prosthetic valve endocarditis is a serious, often

grave, illness, with the risk of endocarditis
highest in the first few months after valve
implantation
 Bioprosthetic valve dysfunction typically
presents with the
 Insidious onset of exertional dyspnea or
 A louder systolic murmur (MR or AS) or
 A new diastolic murmur (AR or MS) on physical
examination.
 More abrupt and severe symptoms may occur

with bioprosthetic valve endocarditis or with
degenerative rupture of a valve cusp.
PROBLEMS
 Structural valve deterioration- Porcine vs Bovine
pericardial tissue
 Stented pericardial valves have a lower rate of
primary tissue failure, with 86% free of structural
deterioration at 12 years (see graph below)
 Structural valve deterioration vs Valve position

 More frequent in patients with bioprostheses in the
mitral than in the aortic position, presumably
because of the higher closing pressure
PROBLEMS
 Structural valve failure vs Age
 Significantlylower in patients older than 65 years
than in younger patients, especially in the aortic
position
 In patients older than 65 years undergoing AVR with

a porcine bioprosthesis, the rate of structural
deterioration is less than 10% at 10 years.
 Valve failure is prohibitively rapid in children and in

adults younger than 35 to 40 years.
 Therefore bioprostheses are not advisable for these age
groups.
Fig. Estimates of freedom from structural valve deterioration (SVD)
for patients undergoing porcine (A) and bovine pericardial (B) aortic valve
replacement,stratified according to age
PROBLEMS
 Bioprostheses also have been reported to have
extremely limited durability in patients with
chronic renal failure, but recent studies have
called this into question
 Other factors that increase the likelihood of
bioprosthetic valve deterioration include
 Abnormalitiesof calcium metabolism and, possibly,
 Hypercholesterolemia and
 Pregnancy.
 Fortunately, tissue valves usually do not fail

suddenly, as is often the case with structural
failure or thrombosis of mechanical prostheses.
PROBLEMS
 Re-replacement of a bioprosthetic valve should
be carried out when significant and/or
progressive structural deterioration is evident
or when standard criteria for intervention for
native valve disease are met.
 The second operation, when carried out on an

elective basis, may be associated with a surgical
mortality rate that is two to three times higher
than with the initial valve replacement.
PROBLEMS
 Echocardiographic evaluation is extremely
helpful in the early detection of bioprosthetic
valve malfunction.
 TEE is more sensitive than transthoracic imaging

in detecting bioprosthetic mitral valve
deterioration.
 A baseline echocardiographic study is

recommended 2 to 4 weeks after hospital
discharge for valve replacement.
PROBLEMS
 Annual cardiology follow-up evaluation with
echocardiography is recommended during the
first 5 years only if there are changes in
symptoms or examination findings.
 After 5 years, annual echocardiography is

reasonable, even in the absence of clinical
findings, to evaluate for bioprosthetic valve
deterioration.
 Transcatheter Bioprostheses
 Transcatheter bioprosthetic aortic valves have been
approved for use in the United States and Europe
 These trileaflet bioprosthetic valves are mounted in a wire
mesh stent that can be crimped to allow delivery of the
valve over a catheter
 The stent either is pressure-expanded with a balloon or is
self-expanding.
 TAVI may be performed using a catheter advanced from
the femoral artery in retrograde fashion across the aortic
valve, or from a small thoracotomy with the catheter
positioned in the LV apex and passed in antegrade fashion
across the aortic valve.
 This procedure is used for calcific AS with the native valve
remaining in place, which helps anchor the valve stent.
 Transcatheter Bioprostheses
 TAVI clinical trials have focused on two groups of adults:
 Patients who are not surgical candidates as a result of a
prohibitive surgical risk and
 Patients who are surgical candidates but have a high risk of
adverse surgical outcomes owing to baseline comorbidities.

 Trialsin patients at intermediate risk for surgical AVR are
ongoing.
 The risks of stroke, vascular complications, and paravalvular
regurgitation remain issues to be resolved as TAVI evolves
for use in lower-risk patient groups.
 As noted previously, long-term durability of the TAVI
bioprosthetic valves also has not been adequately defined,
so conventional surgical AVR remains the current procedure
of choice in patients at low or intermediate surgical risk
 Homograft (Allograft) Aortic Valves
 Read note below
 Pulmonary allografts
 An echocardiographic examination performed 6
weeks to 3 months after valve implantation is an
essential component of the first postoperative
visit
 It allows for an assessment of the effects and
results of surgery and serves as a baseline for
comparison should complications or deterioration
occur later.
 Doppler TTE provides accurate measurements of

transvalvular velocities and pressure gradients as
well as detection and quantitation of valvular and
paravalvular regurgitation.
 No further echocardiographic testing is required
after the initial postoperative evaluation in
patients with mechanical valves who are stable
and who have no symptoms or clinical evidence of
prosthetic valve or ventricular dysfunction or
dysfunction of other heart valves.
 The asymptomatic uncomplicated patient is
usually seen at 1–year intervals for a cardiac
history and physical examination.
 ECG and chest x-ray examinations are not

routinely indicated but may be appropriate in
individual patients.
 Additional tests that may be considered include

hemoglobin and hematocrit in patients receiving
chronic anticoagulation.
 When is TEE indicated?
 TTE is the preferred approach for initial assessment
of suspected prosthetic valve dysfunction
 Because it allows correct alignment of the Doppler beam
with transvalvular flow for measurement of velocity,
gradient, and valve area.
 TTE also allows quantitation of LV volumes and LVEF,

an estimate of pulmonary pressures, and evaluation
of right heart function.
 When is TEE indicated?
 However, the left atrial side of a prosthetic mitral
valve is obscured by acoustic shadowing from the
TTE approach, resulting in a low sensitivity for
detection of prosthetic MR and prosthetic mitral
valve thrombus, pannus, or vegetation.
 TEE provides superior images of the left atrial side

of the mitral prosthesis and is accurate for diagnosis
of prosthetic mitral valve dysfunction.
 However, both TTE and TEE are needed for
complete evaluation in a patient with suspected
prosthetic valve dysfunction, particularly for
those with prosthetic aortic valves in whom
 The posterior aspect of the valve is shadowed on the
TTE approach and t
 The anterior aspect of the valve is shadowed on the
TEE approach.
 With suspected mechanical valve stenosis,
fluoroscopy or CT imaging of valve occluder
motion is also helpful for detection of reduced
motion due to pannus or thrombus.
 The incidence of bioprosthetic valve dysfunction is
low within 10 years of valve implantation but
increases markedly after that point
 Routine annual evaluation is a reasonable approach.
 Earlier evaluation may also be prudent in selected

patients at increased risk of early bioprosthetic
valve degeneration, including
 Renalimpairment,
 Diabetes mellitus,
 Abnormal calcium metabolism,
 Systemic inflammatory disease, and
 Age <60 years of age.
 Patients typically remain asymptomatic until
valve dysfunction is severe enough to result in
adverse hemodynamic consequences, such as LV
dilation and systolic dysfunction, pulmonary
hypertension, or AF.
 It may be challenging to distinguish a murmur

due to prosthetic MR or AS from the normal
postoperative flow murmur, and the diastolic
murmurs of prosthetic AR and MS often are
very soft and difficult to hear on auscultation.
 Depending on the valve type and mechanism of
regurgitation, some patients with asymptomatic
significant prosthetic valve regurgitation may
require surgical intervention.
 For example, if prosthetic regurgitation is due

to a bioprosthetic leaflet tear, more severe
acute regurgitation may suddenly occur and
cause clinical decompensation
 Other asymptomatic patients with less severe prosthetic
valve regurgitation or with stable valve anatomy can be
monitored for evidence of progressive LV dilation and
systolic dysfunction with the same criteria for timing of
surgical intervention as those for native valve regurgitation.
 With prosthetic valve stenosis, echocardiographic diagnosis

while the patient is asymptomatic alerts the clinician to the
need for more frequent follow-up.
 Patients with asymptomatic prosthetic valve stenosis should

be educated about symptoms, the likely need for repeat
valve intervention, and the importance of promptly reporting
new symptoms.
 In patients with mechanical valve prostheses,
routine annual echocardiographic evaluation is
not needed if the postoperative baseline study is
normal in the absence of signs or symptoms of
valve dysfunction.
 However, many of these patients require TTE

for other indications, such as residual LV
systolic dysfunction, pulmonary hypertension,
aortic disease, or concurrent valve disease.
HEMODYNAMICS OF PROSTHETIC
VALVES
 The most commonly used prosthetic valves—mechanical
prostheses and stented porcine or pericardial xenografts—
have an effective in vitro orifice size that is smaller than
the normal valve at the same site
 Current generation tissue and mechanical valves have larger

effective valve areas than older valves, particularly stented
valves, but still do not restore valve area or hemodynamics
to normal.
 Although all prosthetic valves are inherently mildly stenotic,

postoperative hemodynamic measurements show reasonably
good function, with effective mitral valve orifice areas
averaging 1.7 to 2.0 cm2 and mitral valve gradients of 4 to 8
mm Hg at rest
VALVES
 The degree of physiologic stenosis of a normally
functioning prosthetic valve is considered
 Significant(often called patient-prosthesis
mismatch): when the effective valve orifice < 0.85
cm2/m2
 Severe: when the effective orifice area is < 0.65
cm2/m2
 Patient prosthetic mismatch adversely affects

short- and long-term survival after valve
surgery.
VALVES
 Mismatch can be avoided by choosing a valve
with an adequate orifice area for the patient’s
body size.
 In some cases, an annular enlarging procedure

may be necessary.
 Rarely, reoperation to correct a malfunctioning

prosthesis may be necessary.
SELECTION OF AN ARTIFICIAL VALVE
 Most comparisons of mechanical and
bioprosthetic valves indicate similar overall
results in terms of
 Early and late mortality,
 Prosthetic valve endocarditis and
 Other complications, and
 The need for reoperation, at least for the first 5
years postoperatively.
 As indicated, there appear to be no significant

differences when a valve size appropriate for
the patient’s body size is implanted.
 Patients with a small aortic annulus may be
better candidates for unstented homografts,
heterografts, or pulmonary autografts.
 In general, patient outcome after valve surgery

is related more to preoperative factors than to
the prosthesis itself, such as
 Age,
 LV function,
 Associated coronary artery disease, and
 Comorbid conditions
 The major task in selecting an artificial valve is
to weigh
 The advantage of durability and the disadvantages of
the risks of thromboembolism and anticoagulant
treatment inherent in mechanical prostheses vs
 The advantage of low thrombogenicity and the

disadvantage of abbreviated durability of
bioprostheses
 Overall survival after AVR is better with a
mechanical than with a bioprosthetic aortic
valve, principally because of the higher rate of
structural deterioration of the bioprosthesis
(especially in patients younger than 65 years).
 Much of the increased mortality in patients

receiving a tissue valve is because of
reoperation, which is associated with
approximately twice the mortality of the initial
procedure
FIGURE 63-48 A, Survival after mechanical versus bioprosthetic mitral valve replacement.
B, Freedom from valve-related complications after mechanical versus bioprosthetic mitral
valve replacement.
 As surgical risk declines, however, this balance
may change, and this concern is not applicable in
older patients who are unlikely to require a
second valve replacement.
 The option of valve-in-valve transcatheter valve

replacement for prosthetic valve dysfunction
also may tilt the balance toward a bioprosthetic
valve
 With mitral valve replacement, the prosthetic
valve type does not influence
 Survivalnor
 The probability of developing other valve-related
complications, including endocarditis, valve
thrombosis, and systemic embolism
 With mechanical valves, though,

 Higher anticoagulant-related bleeding
 Higher incidence of paravalvular regurgitation in the
mitral position
 A trend for this complication in the aortic position has
been noted.
 The higher survival rates with mechanical than
with bioprosthetic valves have been confirmed in
several studies.
 Therefore mechanical prostheses, usually of the

bileaflet variety, are the valves of choice for
most patients younger than 65 years
 But bleeding risks with mechanical valves are not
inconsequential and should be discussed with the
patient regarding valve selection
 In a prospective randomized study of 575
patients undergoing older-generation mechanical
versus bioprosthetic valve replacement
 Overall survival was similar at 15 years in both
groups.
 However, in patients <65 years of age undergoing
AVR, primary valve failure occurred in 26% of those
with a bioprosthetic valve compared with 0% of
patients with a mechanical valve.
 Similarly, in those <65 years of age undergoing MVR,
primary valve failure occurred in 44% of patients
with a bioprosthetic mitral valve compared with 4%
with a mechanical mitral valve (p=0.0001)
 In a propensity score-matched comparison of
103 patients <60 years of age undergoing
mechanical versus biological AVR,
 Those with a mechanical valve had lower mortality
rates (HR:0.243; 95% CI: 0.054 to 0.923; p¼0.038)
despite similar rates of valve-related complications.
 This is possibly related to better valve

hemodynamics and the beneficial effects of
anticoagulant therapy in those with a mechanical
valve.
 Overall, patients <60 years of age at the time of
valve implantation have a higher incidence of
primary structural deterioration and a reoperation
rate
 Ashigh as 40% for patients 50 years of age,
 55% for patients 40 years of age,
 75% for patients 30 years of age, and
 90% for patients 20 years of age.
 Thus, the balance between valve durability versus

risk of bleeding and thromboembolic events favors
the choice of a mechanical valve in patients <60
years of age.
 However, the following groups of patients should receive
bioprostheses:
1. Coexisting disease who are prone to hemorrhage and who
therefore tolerate anticoagulants poorly, such as those with
bleeding disorders, intestinal polyposis, and angiodysplasia
2. Patients who are likely to be noncompliant with permanent
anticoagulant treatment, who are unwilling to take
anticoagulants on a regular basis, or who live in developing
nations and cannot be monitored;
3. Patients older than 65 years, in whom bioprosthetic valves
deteriorate very slowly, who are unlikely to outlive their
bioprostheses, and who because of their age may also be at
greater risk of hemorrhage while taking anticoagulants;
4. Patients with a small aortic annulus in whom an unstented (free)
bioprosthetic graft may provide superior hemodynamics; and
5. Younger women wishing to bear children who require AVR.
 Patient preference plays an important role in
determining the choice of a prosthetic valve.
 A bioprosthesis is reasonable for AVR in

patients under 65 years of age who elect to
receive this valve for lifestyle considerations
after detailed discussions of the risks of
anticoagulation versus the likelihood that a
second AVR may be necessary in the future
 In patients >70 years of age at the time of
bioprosthetic valve implantation, the likelihood of
primary structural deterioration at 15 to 20 years is
only about 10%.
 In addition, older patients are at higher risk of
bleeding complications related to VKA therapy and
more often require interruption of VKA therapy for
noncardiac surgical and interventional procedures.
 Expected life expectancy also is considered*
 Thus, it is reasonable to use a bioprosthetic valve in

patients >70 years of age to avoid the risks of
anticoagulation because the durability of the valve
exceeds the expected years of life.
 Replacement of the aortic valve with a pulmonary
autograft (the Ross procedure) is a complex
operation intended to provide an autologous
substitute for the patient’s diseased aortic valve
by relocating the pulmonic valve into the aortic
position and subsequently replacing the pulmonic
valve with a homograft
 In the most experienced hands, hospital

mortality can be similar to mortality for a simple
bioprosthetic or mechanical valve replacement
 The failure mode of the Ross procedure is most
often due to regurgitation of the pulmonary
autograft (the neoaortic valve) in the second
decade after the operation.
 Regurgitation is due to
 Leaflet prolapse if the autograft is implanted in the
subcoronary position or
 Aortic sinus dilation if the autograft is implanted
starting at the aortic sinuses
ANTI-THROMBOTIC THERAPY
FOR PROSTHETIC VALVE
 Effective antithrombotic therapy in patients with
mechanical heart valves requires continuous effective
VKA anticoagulation with an INR in the target range.
 It is preferable to specify a single INR target in each

patient, recognizing that the acceptable range is 0.5
INR units on each side of this target; this is
preferable because it avoids patients having INR
values consistently near the upper or lower edge of
the range.
 In addition, fluctuations in INR are associated with
increased incidence of complications in patients with
prosthetic valves, so patients and caregivers should strive
to attain the single INR value
 All patients with mechanical valves require
anticoagulant therapy.
 Mechanisms of thrombosis
 Thrombogenecity of the intravascular prosthetic
material
 Abnormal flow conditions, with zones of low flow

within their components, as well as areas of high-
shear stress, which can cause platelet activation,
leading to valve thrombosis and embolic events.
 Cumulative data show that anticoagulation with a
VKA is protective against
 Valve thrombosis (OR: 0.11; 95% CI: 0.07 to 0.2) and
 Thromboembolic events (OR: 0.21; 95% CI: 0.16 to
0.27)
 Many centers initiate heparin early after

surgery for anticoagulation until the INR
reaches the therapeutic range.
 The rate of thromboembolism in patients with
bileaflet mechanical AVR on VKA and antiplatelet
regimen is estimated to be 0.53% per patient-
year over the INR range of 2.0 to 4.5.
 In a large retrospective study, adverse events

increased if the INR was >4.0 in patients with
mechanical AVR.
 In patients with the new-generation AVR without
other risk factors for thromboembolism, the risk
of thromboembolic events was similar, but the risk
of hemorrhage was lower in the group with an INR
of 2.0 to 3.0 versus the group with an INR of 3.0
to 4.5 (p<0.01).
 In a study comparing an INR target of 1.5 to 2.5

with the conventional 2.0 to 3.0 in 396 patients
with low-risk mechanical aortic prosthetic valves
and no other risk factors the lower INR target
was noninferior, but the quality of the evidence
was low.
 Thus, for bileaflet and current-generation single
tilting disc valve prostheses in the aortic
position, an INR of 2.5 (between 2.0 and 3.0)
provides a reasonable balance between optimal
anticoagulation and a low risk of bleeding for
mechanical aortic valves with a low
thromboembolic risk.
 In patients with an aortic mechanical prosthesis
who are at higher risk of thromboembolic
complications, INR should be maintained at 3.0
(range 2.5 to 3.5).
 These patients include those with
 AF,
 Previousthromboembolism, and
 A hypercoagulable state.
 Many would also include patients with severe LV

dysfunction in this higher-risk group
 What about for MVR?
 In patients with mechanical prostheses, the
incidence of thromboembolism is higher for the
mitral than the aortic position
 And the rate of thromboembolism is lower in patients with
a higher INR goal compared with those with a lower target
INR.
 GELIA (German Experience With Low Intensity

Anticoagulation) study
 Patients with a mechanical mitral prosthesis
 A lower INR (2.0 to 3.5) was associated with lower survival
rates than a higher target INR range (2.5 to 4.5) in those

with a second mechanical valve.
 What about for MVR?
 Patient compliance may be challenging with higher
INR goals.
 In 1 study, patients with a target INR between 2.0
and 3.5 were within that range 74.5% of the time.
 In contrast, patients with a target INR of 3.0 to 4.5
were within range only 44.5% of the time.
 An INR target of 3.0 (range 2.5 to 3.5) provides a
reasonable balance between the risks of under- or
overanticoagulation in patients with a mechanical
mitral valve
 VKAs for bioprosthetic valves
 The risk of ischemic stroke after all types of mitral
valve surgery is about 2% at 30 days, 3% at 180
days, and 8% at 5 years.
 This is observed even with routine use of early
heparin followed by VKA in patients with a
mechanical valve or other indications for long-term
anticoagulant therapy.
 The risk of ischemic stroke at 5 years is
 Lower with mitral valve repair (6.1%+0.9%) compared with
 Bioprosthetic (8.0%+2.1%) and
 Mechanical valve replacement (16.1%+2.7%).

 In 1 study, patients with a bioprosthetic MVR who
received anticoagulation had a lower rate of
thromboembolism than those who did not receive
therapy with VKA (2.5% per year with
anticoagulation versus 3.9% per year without
anticoagulation; p=0.05).
 However, another study showed that even with
routine anticoagulation early after valve surgery, the
incidence of ischemic stroke within the first 30
postoperative days was higher after
 Biological prosthesis (4.6%+1.5%; p<0.0001) than after
 Mitral valve repair (1.5%+0.4%) or
 Mechanical prosthesis (1.3%+0.8%; p<0.001).

 Thus, anticoagulation with a target INR of 2.5 (range
2.0 to 3.0) is reasonable early after bioprosthetic
mitral valve implantation.
 Many centers start heparin as soon as the risk of

surgical bleeding is acceptable (usually within 24 to
48 hours); after an overlap of heparin and VKA for 3
to 5 days, heparin may be discontinued when the INR
reaches 2.5.
 After 3 months, the tissue valve can be treated like
native valve disease, and VKA can be discontinued in
more than two thirds* of patients with biological
valves.
 In the remaining patients with associated risk

factors for thromboembolism, such as AF, previous
thromboembolism, or hypercoagulable condition,
lifelong VKA therapy is indicated to achieve an INR
of 2 to 3.
 Is additional Antiplatelet needed?
 Even with the use of VKA, the risk of thromboemboli
is 1% to 2% per year.
 The addition of aspirin 100 mg daily to oral VKA

anticoagulation
 Decreases the incidence of major embolism or death (1.9%
versus 8.5% per year; p<0.001)
 Decreases stroke rate to 1.3% per year versus 4.2% per
year (p<0.027) and

 Decreases overall mortality to 2.8% per year versus 7.4%
per year (p<0.01).

 The combination of low-dose aspirin and VKA is
associated with a slightly increased risk of minor
bleeding such as epistaxis, bruising, and hematuria
 But the risk of major bleeding does not differ

significantly between those who received aspirin
(8.5%) versus those who did not (6.6%; p=0.43).
 The risk of GI irritation and hemorrhage with aspirin

is dose dependent over the range of 100 mg to 1,000
mg per day, but the antiplatelet effects are
independent of dose over this range.
 The addition of lowdose aspirin (75 mg to 100 mg per
day) to VKA therapy (INR 2.0 to 3.5) also decreases
mortality due to other cardiovascular diseases.
 Aspirinis recommended for ALL patients with

PROSTHETIC HEART VALVES, including those with
mechanical prosthetic valves receiving VKA therapy.
 The addition of aspirin (75 mg to 100 mg per day) to
VKA should be strongly considered unless there is a
contraindication to the use of aspirin (i.e., bleeding
or aspirin intolerance).
 This combination is particularly appropriate in

patients
 Who have had an embolus while on VKA therapy with a
therapeutic INR,
 Those with known vascular disease, and
 Those who are known to be particularly hypercoagulable.

 ASA for bioprosthesis?
 The risk of a clinical thromboembolism is on average
0.7% per year in patients with biological valves in
sinus rhythm*
 Among patients with bioprosthetic valves, those with

mitral prostheses have a higher rate of
thromboembolism than those with aortic prostheses
in the long term (2.4% per patient-year versus 1.9%
per patient-year, respectively).
 ASA for bioprosthesis?
A prospective study of bioprosthetic AVR
 Patients were in sinus rhythm and had no other indications
for anticoagulation
 The incidence of thromboembolic events, bleeding, and
death was similar between those who received aspirin or

aspirin like antiplatelet agents only versus those who
received VKA.
 No studies examining the long-term effect of

antiplatelet agents in patients with bioprosthetic
MVR or mitral valve repair, but the beneficial
effects seen with AVR may apply
 Addition of Clopidogrel for TAVR?
 In prospective RCTs of balloon-expandable TAVR for
treatment of AS, the research protocol included
dual antiplatelet therapy with aspirin and clopidogrel
for the first 6 months to minimize the risk of
thromboembolism.
 The current recommendation is based on outcomes in these
published studies, although the issue of antiplatelet
therapy was not assessed.
 Recent small study failed to show benefit of adding

clopidogrel*
 Place of NOACs for Prosthetic Valve
 The RE-ALIGN trial
 Randomized, Phase II Study to Evaluate the Safety and
Pharmacokinetics of Oral Dabigatran Etexilate in Patients
after Heart Valve Replacement
 Stopped prematurely for excessive thrombotic
complications in the dabigatran arm.

 N= 252 patients, ischemic or unspecified stroke occurred
in 9 patients (5%) randomized to dabigatran compared with

no patients treated with warfarin.
 In addition, a major bleeding episode occurred in 7 patients
(4%) in the dabigatran group and 2 patients (2%) in the

warfarin group, and bleeding of any type occurred in 45
patients (27%) and 10 patients (12%), respectively (HR:
2.45; 95% CI: 1.23 to 4.86; p¼0.01).
 Place of NOACs for Prosthetic Valve
 FDA has issued a specific contraindication for use of
this product in patients with mechanical heart valves.
 The FXa inhibitors are also not recommended, due to

lack of data on their safety and effectiveness, in
patients with prosthetic valves who require
anticoagulation.
 No data for bioprosthesis: Not to be used

BRIDGING THERAPY FOR
PROSTHETIC VALVES
BRIDGING ANTICOAGULATION
 When noncardiac surgery is required for patients
with prosthetic valves who are receiving
anticoagulants, the risk depends on the valve type,
location, and associated risk factors.
 Isolated AVR and no associated risk factors

 Anticoagulant is stopped 1 to 3 days preoperatively and
 Resumed as soon as possible postoperatively without
the need for heparin therapy
 Isolated AVR and higher thromboembolic risk
 Intravenous heparin is started when the INR falls
below 2.0 and resumed postoperatively until the INR is
again therapeutic
BRIDGING ANTICOAGULATION
 High-risk patients include those with
A mechanical mitral valve prosthesis,
 AF,
 Previous thromboembolism,
 LV dysfunction,
 Hypercoagulable condition,
 Older generation thrombotic valve,
 Mechanical tricuspid valve, or
 More than one mechanical valve.
 The use of subcutaneous low-molecular-weight

heparin in this situation has been advocated by
some experts, but this topic represents another
area of controversy
MANAGEMENT OF EXCESSIVE
ANTICOAGULATION
 Excessive anticoagulation (INR 5) greatly
increases the risk of hemorrhage.
 However, a rapid decrease in the INR that leads

to INR falling below the therapeutic level
increases the risk of thromboembolism.
 High-dose vitamin K should not be given

routinely, because this may create a
hypercoagulable condition.
 In most patients with an INR of 5 to 10, excessive
anticoagulation can be managed by withholding VKA
and monitoring the level of anticoagulation with
serial INR determinations
 In patients with an INR >10 who are not bleeding, it

is prudent to administer 1 mg to 2.5 mg of oral
vitamin K1 (phytonadione) in addition to holding VKA
therapy.
 When the INR falls to a safe level, VKA therapy is

restarted with the dose adjusted as needed to
maintain therapeutic anticoagulation
 In emergency situations, such as uncontrollable
bleeding, administration of fresh frozen plasma
or prothrombin complex concentrate is
reasonable because the onset of action of
vitamin K is very slow.
MANAGEMENT OF
THROMBOEMBOLIC
COMPLICATIONS
 The annual risk of thromboembolic events
A mechanical heart valve is 1% to 2% versus
 Bioprosthetic valve: 0.7%
 This is despite appropriate antithrombotic therapy.

 Many complications are likely related to suboptimal
anticoagulation
 Even in clinical trials, the time in therapeutic range for
patients on VKA varies from only 60% to 70%.
 However, embolic events do occur even in patients who
are in the therapeutic range at every testing interval.
 Annual follow-up in patients with prosthetic heart
valves should include review of the adequacy of
anticoagulation and any issues related to compliance
with medical therapy
 TTE is the first step in evaluation of suspected
prosthetic valve thromboembolism to evaluate
valve hemodynamics in comparison to previous
studies, and TEE often is needed, particularly
for mitral prosthetic valves.
 However, the prosthetic valve should be

considered the source of thromboembolism even
if echocardiographic findings are unchanged
 If embolic events have occurred despite a
therapeutic INR when other contraindications
are not present, a prudent approach to
antithrombotic therapy is:
 Increase the INR goal from 2.5 (range 2.0 to 3.0) to
3.0 (range 2.5 to 3.5) for patients with an AVR; or,
 Increase the INR goal from 3.0 (range 2.5 to 3.5) to
4.0 (range 3.5 to 4.5) for patients with an MVR.
 In patients with a bioprosthetic valve with

embolic events who are only on aspirin 75 mg to
100 mg daily, a possible approach includes
consideration of anticoagulation with a VKA.
 Surgical intervention is rarely needed for
recurrent thromboembolic events but might be
considered in some situations.
 In patients with degenerated bioprosthetic

valves, calcific emboli may complicate thrombotic
embolism, often in association with prosthetic
valve stenosis and/or regurgitation.
 In patients with mechanical valves who have
recurrent serious adverse effects of over- or
underanticoagulation despite all efforts to
improve compliance, replacement of the
mechanical valve with a bioprosthetic valve might
be considered after a discussion of the potential
risks and benefits of this approach
PROSTHETIC VALVE
THROMBOSIS
 Obstruction of prosthetic heart valves may be
caused by thrombus formation, pannus ingrowth,
or a combination of both.
 Mechanical prosthetic heart valve thrombosis has
a prevalence of only 0.3% to 1.3% per patient-year
in developed countries but is as high as 6.1% per
patient-year in developing countries.
 Bioprosthetic valve thrombosis is less common.
 Differentiation of valve dysfunction due to

thrombus versus fibrous tissue ingrowth (pannus)
is challenging because the clinical presentations
are similar.
 Fibrinolytic therapy- Left side valves
 Although fibrinolytic therapy of a left-sided obstructed
prosthetic heart valve is associated with an overall rate
of thromboembolism and bleeding of 17.8%, the degree
of risk is directly related to thrombus size.
 When thrombus area is measured in the 2D TEE view

showing the largest thrombus size, an area of 0.8 cm2
provides a useful breakpoint for clinical decision making.
A mobile thrombus or a length >5 mm to 10 mm is also

associated with increased embolic risk.
 Patients with a small thrombus (<1.0 cm in diameter
or 0.8 cm2 in area) have fewer thrombolysis-related
complications, whereas those with a large thrombus
(>1.0 cm diameter or 0.8 cm2 in area) have a 2.4–fold
higher rate of complications per 1.0 cm2 increase in
size
 With mild symptoms due to aortic or mitral valve
thrombosis with a small thrombus burden, it is
prudent to reassess after several days of
intravenous UFH.
 If valve thrombosis persists, fibrinolysis with a

recombinant tissue plasminogen activator dose of a
10 mg IV bolus followed by 90 mg infused IV over 2
hours is reasonable
 Heparin and glycoprotein IIb/IIIa inhibitors are

held, but aspirin can be continued
 If fibrinolytic therapy is successful, it is followed by
intravenous UFH until VKA achieves an INR of 3.0 to
4.0 for aortic prosthetic valves and 3.5 to 4.5 for
mitral prosthetic valves.
A structured institutional protocol with indications,

contraindications, and a specific timeline for
medication administration and patient monitoring is
recommended.
 Fibrinolytic therapy for Tricuspid prosthesis
 In nonrandomized, retrospective cohorts of
thrombosed mechanical or biological tricuspid valve
prostheses, fibrinolysis was as successful in
normalization of hemodynamics as surgical
intervention.
 With fibrinolysis of right-sided valve thrombosis,

the resultant small pulmonary emboli appear to be
well tolerated and systemic emboli are uncommon.
 Surgery
 Prompt surgical treatment of a thrombosed
prosthetic
 heart valve is an effective treatment to ameliorate
clinical
 symptoms and restore normal hemodynamics, with a
 success rate close to 90% in patients who do not
have a
 contraindication to surgical intervention.
 Metanalysis of 7 studies: Success rates of only 60-
70%
 Surgery
 There was no difference in mortality between
surgical and fibrinolytic therapy for left-sided
prosthetic valve thrombosis
 Butin addition to a higher success rate for restoring

normal valve function, surgery was associated with
 Lower rates of thromboembolism (1.6% versus 16%),
 Lower rates of Major bleeding (1.4% versus 5%), and
 Lower rates of Recurrent prosthetic valve thrombosis
(7.1% versus 25.4%).

PROSTHETIC VALVE STENOSIS
& REGURGITATION
 In patients with bioprosthetic valves who show
evidence of prosthetic valve stenosis, TTE is
used to
 Monitor the appearance of the valve leaflets,
 Valve hemodynamics,
 LV size, and Systolic function, and
 To estimate pulmonary pressures.
 Transthoracic imaging is usually adequate, with
TEE imaging reserved for patients with poor-
quality images.
 In patients with mechanical valves, fluoroscopy

or CT imaging can be helpful for showing disc
motion.
 CT may also visualize paravalvular pannus

formation with either bioprosthetic or
mechanical valves.
 There are no medical therapies known to prevent
bioprosthetic valve degeneration other than
those integrated into the valve design.
 Medical therapy is not effective for treatment

of symptoms due to significant prosthetic valve
stenosis, except with valve thrombosis
 But standard medical therapy may help stabilize
patients before surgical intervention and may be
used for palliative care in patients who are not
surgical candidates.
 The indications for surgical intervention for
prosthetic valve stenosis are the same as those
for native stenosis of the aortic or mitral valve.
 Surgery is primarily needed for bioprosthetic

valve degeneration.
 In this situation, the choice of a new valve
prosthesis depends on the same factors as those for
patients undergoing a first valve replacement.
SPECIAL POPULATION
SPECIAL POPULATION
 Pregnancy
 Between weeks 1 and 36, the options include
1. Continued oral therapy with warfarin to maintain a
therapeutic INR;
2. Replacement of warfarin with dose-adjusted

subcutaneous heparin or dose-adjusted subcutaneous low-
molecular weight heparin between weeks 6 and 12 (when
the risk of fetal defects is highest); and
3. Continuous intravenous or dose-adjusted subcutaneous

heparin or dose-adjusted subcutaneous low-
molecularweight heparin for the duration of pregnancy.
SPECIAL POPULATION
 Pregnancy
 Women with artificial valves can tolerate the
hemodynamic burden of pregnancy well, but the
hypercoagulable state of pregnancy increases the
risk of thromboembolism in pregnant patients with
mechanical prostheses
 Anticoagulation must not be interrupted, although an

increased risk of fatal fetal hemorrhage occurs in
women in whom anticoagulants are continued.
 There is also a risk of fetal malformation caused by

the probable teratogenic effect of warfarin.
SPECIAL POPULATION
 Pregnancy
 Although these problems represent rationales for
the use of tissue valves in all women of childbearing
age, their limited durability in young adults makes
their use unacceptable.
 Therefore, every effort should be made to defer
valve replacement until after childbirth
 In pregnant women with critical MS or AS, balloon
valvuloplasty should be considered, and if at all
possible, mitral valve repair instead of replacement
should be undertaken for patients with MR.
 Women of childbearing potential who have a
mechanical prosthesis should be counseled against
pregnancy.
SPECIAL POPULATION
 Pregnancy
 When a woman who already has a mechanical
prosthetic valve becomes pregnant, the risk of fetal
defects with oral anticoagulants must be balanced
against the risk of inadequate anticoagulation if oral
therapy is interrupted.
 Themanagement of anticoagulation in pregnant

women with mechanical valves is controversial.
 Allagree that the goal is continuous, effective,

monitored anticoagulation and avoidance of fetal
defects.
SPECIAL POPULATION
 Pregnancy
 In pregnant patients who receive warfarin, oral
therapy is discontinued at week 36 of gestation and
replaced with continuous intravenous unfractionated
heparin.
 Heparin should be discontinued at the onset of labor

but may be restarted, along with warfarin, several
hours after delivery.
SPECIAL POPULATION
 Pregnancy
 The most important management principle is
 To ensure that anticoagulation is not interrupted and
 Thatthe dose of anticoagulation is adequate as indicated by
frequent monitoring of the PTT for UFH, INR for warfarin,
or anti-Xa levels for LMWH
SPECIAL POPULATION
 Children
 The high incidence of bioprosthetic valve failure in
children and adolescents almost prohibits their use
in these groups.
 In young adults between the ages of 25 and 35

years, the failure of bioprosthetic valves is
somewhat higher than in older adults; this serves as
a relative, but not an absolute, contraindication to
their use in this age group
SPECIAL POPULATION
 Children
 In children, a mechanical prosthesis (generally the
St. Jude valve), with its favorable hemodynamics and
established durability, is preferred despite the
disadvantages inherent in the need for
anticoagulants in this age group.
 Alternatively, if an experienced surgical team is

available and the patient requires an AVR, a
pulmonary autograft is an excellent alternative
SPECIAL POPULATION
 Patients with chronic dialysis
 Previous studies indicated a high rate of
bioprosthetic structural deterioration in patients
receiving chronic renal dialysis.
 However, several studies have reported no
difference in survival of patients with a
bioprosthesis or a mechanical valve, coupled with an
unacceptably high rate of stroke and major bleeding
in patients with the mechanical valves.
 Current guidelines no longer recommend mechanical
valves for these patients, but this clearly is an area
in which physician judgment is important for
individual patients.
SPECIAL POPULATION
 Tricuspid Position
 The risk of thrombosis for all valves is highest in the
tricuspid position because of the lower pressures
and velocity of blood flow.
 This complication appears to be highest for tilting

disc valves, intermediate for caged ball valves, and
lowest for bioprostheses, which are the valves of
choice as tricuspid replacements.
 Fortunately, bioprostheses exhibit a much slower

rate of mechanical deterioration in the tricuspid
position than in the mitral or aortic positions
THANK YOU!

Prosthetic Valves

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Prosthetic Valves

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PROSTHETIC CARDIAC VALVES

 Two major groups of prosthetic valves currently

 The bileaflet valves: are the most commonly implanted

 Thrombogenicity in the mitral position may be less than

A variation of the St. Jude valve, the CarboMedics

perforation that allows improved hemodynamics.

 Thrombogenicity appears to be low (less than one

 When they are of small size, Starr-Edwards valves

 All have distinctive auscultatory features (see

 In the mitral position, perivalvular regurgitation

 Signs or symptoms of mechanical valve dysfunction

 However, patients with any mechanical

• Very rarely, thrombosis of the mechanical valve occurs*

 The INR goal is 3.0 for patients at higher risk

 However, the addition of aspirin, 75 to 100 mg

 Although this approach does increase the risk of

 Anti-Xa anticoagulants: have not yet been tested

 Prosthetic valve thrombosis should be suspected

 Fibrinolytic therapy is followed by intravenous

 Despite treatment with anticoagulants, the incidence

 Aortic valve: and ~1.0 to 2.0/100 patient-years

 Mitral valve: 2.0 to 3.0/100 patient-years

 Mechanical prostheses regularly cause mild hemolysis,

 Over the past 49 years, stented bioprosthetic valve

 Bioprosthetic valves also may be constructed using

 In the United States, the number of bioprostheses

 This is not a uniform practice, particularly for aortic

 No thrombus in the LA or LAA, and

 No history of embolism preoperatively

 Thromboembolic rate (after 3 months) is ~ 1-2

 This is because some of the emboli in patients with

 Who remain in AF postoperatively (i.e., approximately

one third of all patients undergoing mitral valve

 This risk scenario negates the principal advantage of

 These devices include the

 Medtronic Freestyle valve.

 However, long-term outcome appears to be similar to

 These begin to appear in some patients in the

 It then accelerates and, by 15 years

 Prosthetic valve endocarditis is a serious, often

 More abrupt and severe symptoms may occur

 Structural valve deterioration vs Valve position

 In patients older than 65 years undergoing AVR with

 Valve failure is prohibitively rapid in children and in

 Fortunately, tissue valves usually do not fail

 The second operation, when carried out on an

 TEE is more sensitive than transthoracic imaging

 A baseline echocardiographic study is

 After 5 years, annual echocardiography is

adverse surgical outcomes owing to baseline comorbidities.

 Doppler TTE provides accurate measurements of

 ECG and chest x-ray examinations are not

 Additional tests that may be considered include

 TTE also allows quantitation of LV volumes and LVEF,

 TEE provides superior images of the left atrial side

 Earlier evaluation may also be prudent in selected

 It may be challenging to distinguish a murmur

 For example, if prosthetic regurgitation is due

 With prosthetic valve stenosis, echocardiographic diagnosis

 Patients with asymptomatic prosthetic valve stenosis should

 However, many of these patients require TTE

 Current generation tissue and mechanical valves have larger

 Although all prosthetic valves are inherently mildly stenotic,