Objective: To compare survival and outcome in patients receiving a mechanical or bioprosthetic heart valve prosthesis. Design: Randomised prospective trial. Setting: Tertiary cardiac centre. Patients: Between 1975 and 1979, patients were randomised to receive either a Bjork-Shiley or a porcine prostheses. The mitral valve was replaced in 261 patients, the aortic in 211, and both valves in 61 patients. Follow up now averages 20 years. Main outcome measures: Death, reoperation, bleeding, embolism, and endocarditis. Results: After 20 years there was no difference in survival (Bjork-Shiley v porcine prosthesis (mean (SEM)): 25.0 (2.7)% v 22.6 (2.7)%, log rank test p = 0.39). Reoperation for valve failure was undertaken in 91 patients with porcine prostheses and in 22 with Bjork-Shiley prostheses. An analysis combining death and reoperation as end points confirmed that Bjork-Shiley patients had improved survival with the original prosthesis intact (23.5 (2.6)% v 6.7 (1.6)%, log rank test p < 0.0001); this difference became apparent after 8-10 years in patients undergoing mitral valve replacement, and after 12-14 years in those undergoing aortic valve replacement. Major bleeding was more common in Bjork-Shiley patients (40.7 (5.4)% v 27.9 (8.4)% after 20 years, p = 0.008), but there was no significant difference in major embolism or endocarditis. Conclusions: Survival with an intact valve is better among patients with the Bjork-Shiley spherical tilting disc prosthesis than with a porcine prosthesis but there is an attendant increased risk of bleeding.

Survival with an intact valve is better among patients with the Bjork-Shiley spherical tilting-disk prosthesis than among patients with porcine bioprostheses, but use of the Bjork-Shiley valve carries an attendant increased risk of bleeding associated with the need for anticoagulant treatment.

No abstract

No abstract

SUMMARY Eight hundred and four patients with persistence of the ductus arteriosus were seen in Edinburgh between 1940 and 1979. Thirty-seven of them reached the age of 50 years, and in 32 the shunt was exclusively from left to right. Fifteen of the 32 were subsequently treated surgically.None of the 32 was lost to follow-up. Duration ofclinical observation averaged 17 years and extended to over 30 years in eight patients. Their features have been correlated with those from reports of 48 comparable patients in an attempt to clarify the management of the persistent ductus in the older patient. Impairment of left ventricular function is shown as the major risk, even when the ductus is small. Bacterial endarteritis is infrequent.Surgical treatment carries greater risk than in childhood and early adult life but usually reduces heart size and restores exercise tolerance. Left ventricular dysfunction, however, occasionally vitiates the benefits; symptoms are then incompletely relieved and death from heart failure may occur months or years after operation. Experience in older patients thus emphasises the value of elective operation in childhood, however well the child, however trivial the shunt.It is concluded that in older patients, the presence or the development of symptoms or cardiac enlargement are almost always indications for surgical treatment. As age increases, especially by the eighth decade, medical treatment may be preferable. Continued follow-up of symptomless patients without cardiomegaly is important because increase in heart size usually precedes further deterioration which can then be prevented by timely surgical treatment.Most patients with persistence of the ductus arteriosus die before 50 years of age'-3 unless treated surgically.4 5 Occasional patients, however, survive with little disability and a few live a normal life span.6-9 In the majority of adults, exercise tolerance is liable to deteriorate rapidly'I and in them surgical treatment has been of great benefit, even at over 65 years of age. 1"12 Available information, however, has been based on single case reports with little long term follow-up.The Edinburgh experience of the persistent ductus since 1940, with and without surgical treatment, has therefore been analysed and correlated with earlier reports in an attempt to amplify knowledge of the clinical course and improve the management of these older patients. The 40 years, 1940 to 1979, have been selected in order to encompass periods before and after 1%1 when the first older patient with a persistent ductus was treated surgically in Edinburgh. During this time 37 patients (among a total of 804 with persistence of the ductus) had reached 50 years of age before death, surgical treatment, or their last medical assessment. Twentynine were women and eight were men. In five patients, severe pulmonary hypertension was associated with a right to left shunt. The progress of the 32 patients, in whom the shunt was exclusively from left to right, is the subject of the present study (Table). One of the...