Replacement Valve Choice

[Jeanete__0]

Posted by Jeanette on June 12, 1999 at 14:03:52
I am a 65 year old woman with mitral valve regurgitation.
I've been told that I need  mitral valve repair/replacement
and that right now I am in that "window of opportunity" for
the surgery.
I was also told that if valve repair is not feasible I must choose, beforehand of course, between the mechanical St. Jude's valve and
a bio-prosthetic (pig tissue) valve. I am leaning towards the bio-prosthetic because I do not want to take coumadin for the rest of my
life.
1. What do you advise patients regarding choice of replacement valve
types?
2. Can you recommend a surgeon or surgeons in the Los Angeles
metropolitan area since I cannot travel to Cleveland?

Posted by CCF CARDIO MD - CRC on June 14, 1999 at 11:00:58
Dear Jeanette,
Thank you for your question.  Your question is a classic debate and one that we hear often in this forum. "Which is better - a tissue valve or a mechanical valve?"  There are pros and cons of each which I outline below. Ultimately the decision is between you and your doctors.  I don't know any surgeons specifically in the LA area but I would start first at Cedars or UCLA.  Good Luck.
Tissue Valve.
Examples: CE Valve, Homograft, Porcine
Pros: Do not require anticoagulation. (unless there is another indication such as atrial fibrillation)
Cons: Have a limited life span (average 10 years although some may go longer) often requiring repeat surgery.
Mechanical Valves
Examples: St. Judes, Medtronic-Hall
Pros: Long life span
Cons: Require anticoagulation to prevent blood clot complications
***********************
Here are some articles of interest that your local medical library should be able to help you find.
Authors
Starr A. Grunkemeier GL. Fessler CL.
Title
Tissue and mechanical valves: mutually advantageous
interplay. [Review] [78 refs]

Source
Journal of Cardiac Surgery. 3(3 Suppl):437-47, 1988 Sep.

Abstract
This report is concerned with the dynamic interplay between glutaraldehyde preserved tissue valves (bioprostheses) and mechanical valves. These two classes of valve replacement devices are not competitive, but provide some nonoverlapping characteristic advantages and disadvantages. By proper selection, it may be possible to tailor the kind of device used for a particular patient, thus improving the overall results of bioprosthetic and mechanical valve replacement. Careful selection of patients according to age and the safety of anticoagulation should achieve a series of patients with mechanical and bioprosthetic valves that would be superior to a series in which all patients received a single device. Thus, these devices should be viewed as complimentary rather than competitive since the value of properly matching a prosthesis to the patient will be reflected in improved overall results with each class of prosthesis. [References: 78]
/
Authors
Wernly JA. Crawford MH.
Title
Choosing a prosthetic heart valve. [Review]
[59 refs]

Source
Cardiology Clinics. 16(3):491-504, 1998 Aug.
Abstract
Although most of the available prosthetic heart valves function remarkably well, the variety of available choices attests to the inability of any single one to fulfill the requirements of the ideal valve substitute. The mechanical prostheses include the caged-ball, tilting-disc, and bileaflet valves. Tissue valves available in the United States are the Carpentier-Edwards and Hancock porcine heterograft valves and the Carpentier-Edwards pericardial valve. Review of several large comparative studies on valve performance reveals that the overall results with tissue and mechanical valves are about equal at the end of 10 years. The characteristics of each type of valve substitute dictate the selection of one prosthesis in preference to others for a particular patient. Mechanical prostheses are recommended for patients without contraindications for anticoagulants. Tissue valves are reserved for patients over 65 years of age or for patients in whom anticoagulation is contraindicated. Multiple other patient-related factors need to be considered in selecting the appropriate valve, including the psychosocial situation and patient preference. [References: 59]

Authors
Antunes MJ. Franco CG.
Title
Advances in surgical treatment of acquired valve disease
[published erratum appears in Curr Opin Cardiol 1996 Jul;11(4):454]. [Review]
[111 refs]

Source
Current Opinion in Cardiology. 11(2):139-54, 1996 Mar.

Abstract
After the first two decades of constant improvements in valve prostheses, no major advance has occurred since the mid 1980s. Hence, valve replacement remained the exchange of one disease for another. With minor and, for the most part, statistically nonsignificant variations, the spectrum of late valve-related complications remained unaltered and the few series published in the year under review brought no additional information of relevance. By contrast, in the past few years there has been a growing enthusiasm for the use of allografts, stentless porcine bioprostheses, and pulmonary autografts. Not only was there a surge of interest in the allografts as aortic valve substitutes, but in the past year there have also been several reports of use for whole or partial mitral or tricuspid valve replacement. On the other hand, stentless bioprostheses are also gaining increasing acceptance, and all major manufacturers of heart valve prostheses have models for use in different situations and with different techniques. Finally, the Ross operation is now being performed around the world. Despite these advances, valve repair still merits the preference of many surgeons. Mitral valvuloplasty preserves left ventricular function much better than valve replacement. By contrast, the results of aortic valve repair look much less impressive. Lastly, this work focuses on recent reports on special aspects of surgery for native or prosthetic valve endocarditis, especially with the use of allografts or autografts; on the results of valve surgery in elderly patients, a fast growing group; and on the controversial issues of anticoagulation in patients with artificial valves. [References: 111]
I hope you find this information useful.  Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies.  Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.  The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.