Choice Of Valve Prosthesis For The Individual Patient

In synthesising the results from these trials and observational studies, how should we advise individual patients on what type of prosthesis is most suitable for them? For most patients undergoing mitral valve replacement who are in atrial fibrillation and already on anticoagulant treatment the advice is easy. Bioprosthetic valves confer no advantage as the patient will continue anticoagulant treatment. Mechanical prostheses have better durability: modern bileaflet valves have good long term durability and can safely be managed with low intensity warfarin, and appear to be the optimal choice. Even for the minority of patients requiring mitral valve replacement who remain in sinus rhythm unless elderly or at risk from anticoagulant treatment, the enhanced durability of mechanical prostheses and the likelihood of atrial fibrillation developing

Table 13.1 Summary of class I and II AHA/ACC recommendations for choice of prosthetic valve

Recommendations for valve replacement with a mechanical prosthesis

Class

1. Patients with expected long life spans

2. Patients with a mechanical prosthetic valve already in place in a different position than the valve to be replaced

3. Patients in renal failure, on haemodialysis, or with hypercalcaemia

4. Patients requiring warfarin treatment because of risk factors* for thromboembolism

5. Patients <65 years for AVR and <70 years for MVR

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