At 15 years, patients undergoing AVR had a better survival with a mechanical valve than with a bioprosthetic valve, largely because primary valve failure was virtually absent with mechanical valve. Primary valve failure was greater with bioprosthesis, both for AVR and MVR, and occurred at a much higher rate in those aged <65 years; in those aged > or =65 years, primary valve failure after AVR was not significantly different between bioprosthesis and mechanical valve. Reoperation was more common for AVR with bioprosthesis. Thromboembolism rates were similar in the two valve prostheses, but bleeding was more common with a mechanical valve.

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Twenty-seven patients presented in the puerperium with cardiomegaly, abnormal 'ECG, and congestive cardiac failure and were considered to have peripartum cardiomyopathy (PPCM). The incidence of PPCM was significantly higher in women over 30 years of age, in women in their third or subsequent pregnancy, and in the presence of twins or toxemia. Within 6 months, 14 patients had normal sized hearts (group A), and 13 patients maintained cardiomegaly (group B).The 14 patients in group A have been followed for 3 to 21 years (average 10.7 years). Two have died of unrelated causes. Of the remaining 12, eight are functional class I and four are functional class II. Eight patients had 21 subsequent pregnancies, with no permanent deterioration of cardiac function. Of 13 patients in group B, 11 (85%) have died of congestive cardiac failure. Their average survival was 4.7 years; six of 11 were dead in 3 years. Their clinical course was punctuated by repeated admissions for congestive cardiac failure. Six had pulmonary emboli, one had a systemic embolus, and three of six patients with subsequent pregnancies deteriorated in the puerperium. Of the two surviving patients, one is functional class I and the other is functional class II.Therefore, in those patients in whom cardiomegaly persisted, the prognosis was poor, and subsequent pregnancies were likely to lead to permanent deterioration. In those in whom the heart size returned to normal the prognosis was excellent.

Valve prostheses have played an important part in the past two decades in the management of patients with valvular heart disease. However, many of the devices used in valve replacement have introduced new clinical problems. This paper deals with some of the problems associated with valve replacement, including one not previously emphasized--valve prosthesis-patient mismatch, which may cause obstruction to ventricular outflow and/or inflow.

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The mechanism of valvular heart disease involves an endochondral bone process that is expressed as cartilage in the mitral valves and bone in the aortic valves. Up-regulation of the Lrp5 pathway may play a role in the mechanism for valvular heart disease.

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