Choosing To Repair or To Replace

When valve repair is an option, it is preferred over replacement. Advanced technical skills and sufficient experience in complex repair procedures are crucial to achieve a high success rate of repair procedures. Valve reconstruction (repair) surgeries are more often feasible in the mitral or tricuspid position than in aortic valve. This is mainly due to larger leaflet sizes of the mitral and tricuspid valves (better tolerating partial tissue resection and suturing). The greater prevalence of extensive tissue destruction in the aortic IE also reduces the feasibility of aortic valve repair.

There are no randomized clinical trials to evaluate the outcomes of valve repair versus replacement in patients with IE. The views provided are, therefore, observational. Native valve preservation has been associated with significantly lower perioperative morbidity and shorter hospital recovery time than replacement [23,24]. Mortality also tends to be lower with valve repair, even though the difference is not statistically significant. The benefits of valve repair also include eliminating the need for aggressive anticoagulation therapy, thus reducing the immediate risk of bleeding complications as well as the need for lifetime anticoagulation.

There is no significant difference in mortality between mechanical and bioprosthetic valves. Therefore, the choice is based on balancing the advantages and disadvantages of each in the individual patient. Mechanical valves are very reliable and durable, but they require lifelong oral anticoagulation. On the other hand, bio-prostheses do not need anticoagulation, but they degenerate after 10-15 years and require reoperation and replacement with another prosthetic valve. Thus, in younger patients with a long life expectancy and in whom there is no significant risk of hemorrhage, mechanical valves are preferred. In patients with shorter life expectancy where durability is not an issue, in patients with high risk of hemorrhage, in young women with an intention of childbearing who should not be exposed to the teratogenic effects of warfarin, and in patients who choose not to receive a mechanical valve, bioprosthetic (porcine or bovine) valves are a valuable substitute for mechanical valves. It should be mentioned that in the case of women with childbearing intentions, an option is to implant a mechanical valve with oral anticoagulation, and then switch to heparin preconception and during pregnancy. However, the required close monitoring of heparin injections and anticoagulation renders this choice less practical and unadvisable for most patients.

When the aortic root is extensively damaged, a composite graft incorporating a prosthetic valve and a vascular graft can be used. The other option is the use of homografts, which usually have very good results in experienced hands [25]. Although no conclusive data is available comparing homografts and prosthetic valves in terms of durability and risk of recurrent IE, current data from surgical series indicate satisfactory results with the use of homografts [25]. However, the limited availability of homografts precludes the widespread use of this treatment modality.

In any instance, the final choice to repair or replace the valve can only be made after thorough anatomical and functional assessment by the surgeon intraoperatively.

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