Comparison of outcomes after mitral valve replacement with a mechanical versus a bioprosthetic valve in patients between forty and sixty years of age

Abstract

IntroductionAlthough many advances have been made since the first successful human valve replacement with mechanical valve by Starr and Edwards 1 and Harken et al 2 in 1960 and the first Hancock II porcine valve Abstract Background: The American College of Cardiology/American Heart Association (ACC/AHA), guidelines for choice of prosthetic valve based on patients' age are difficult to apply to the developing world because of a lower life expectancy and difficulty in maintaining correct levels of anticoagulation for a variety of reasons. While there is general agreement on the choice of prosthetic valves for patients below 40 years of age (mechanical) and above 60 years of age (biologic), the 40 to 60 age group remains a grey zone. The goal of our study was to compare outcomes after mitral valve replacement with a mechanical versus a bioprosthetic valve in patients between forty and sixty years of age.Methods: From Jan 2003 to July 2008, 250 patients between the ages of 40 and 60, undergoing mitral valve replacement at our institution were randomized to receive either a mechanical or a bioprosthetic valve. Outcomes in the form of incidence of valve thrombosis and thromboembolism, bleeding complications, incidence of prosthetic valve endocarditis and survival were compared in the two groups.Results: Out of 250 patients, 135 patients received mechanical valve and 115 patients were implanted with a bioprosthetic valve. Patients were followed up for a mean period of 3 years (range 6 months to 4.8 years). The incidence of valve thrombosis was higher in mechanical valve as compared to bioprosthetic valve (6% vs. 0.9%, p= 0.04). Similarly there was a higher incidence of thromboembolism in mechanical valves as compared to bioprosthetic valves (4.5% vs. 0%, p=0.03). Bleeding complications occurred more frequently in mechanical than bioprosthetic valve (6% vs. 0.9%, p=0 .04). There was no significant difference in the incidence of prosthetic valve endocarditis (2.2% vs. 2.7%, p >0.05) or survival at three years (96.2% vs. 97.2%, p > 0.05) in the two groups.Conclusions: Patients in the age group of 40 to 60 years undergoing mitral valve replacement with a mechanical valve have a higher incidence of thrombotic and bleeding complications as compared to bioprosthetic valve, even though short term survival is similar. This favours implantation of a bioprosthetic valve in this age group. (Ind J Thorac Cardiovasc Surg 2009; 25: 12-17)

Comparison over short term of mortality and morbidity of mechanical and bioprosthetic heart valves in the Indian population

“…Against this background, and with few practical alternatives [3], more liberal usage of biological valve merits serious thinking, despite its limitations, as it offers definite advantages peculiar to developing countries [15] as detailed below 1. Freedom from acute prosthetic valve dysfunction and sudden death as SVD of biological valve occurs gradually providing ample time for diagnosis and treatment.…”

“…In view of illiteracy and poor follow up, coupled with illdeveloped health care structure the current recommendation of ACC/AHA guidelines with reference to management of anticoagulation also has few practical implications in our set up [15,16].…”

Follow-up and management of valvular heart disease patients with prosthetic valve: a clinical practice guideline for Indian scenario

“…The rate of valve thrombosis and bleeding was more with mechanical valve than in patients with bioprosthetic valves. The authors concluded implantation of a bioprosthetic valve in patients with this age group [61]. Abraham S et al evaluated the outcomes of Carpentier Edwards (Porcine) bioprosthesis in 18 MVR, 14 AVR, 1 TVR, and 12 DVR patients.…”

“…In a study on Indian patients with MVR, the incidences of bleeding complication are common in patients with a mechanical valve (6%) than those with a bioprosthetic valve (0.9%) [61]. Evidence suggests that fresh frozen plasma (FFP) and packed red cell transfusion are used as antithrombotic therapies for the management of bleeding incidences in prosthetic valves patients in India [41,61,64].…”

Search for the best heart valve- from replacement to repair

“…While there is general consensus among surgeons in India, that patients above the age of 60 years should receive biologic valves, while those below the age of 40 years should receive mechanical valves, the age group of 40 to 60 years remains a grey zone with there being no definite evidence to prove the superiority of one valve type over the other. Agarwal et al [11] in a study declared that even in patients as young as 40 years of age, bioprosthetic valves should be the preferred valve, as the mechanical valves are associated with a higher complication rate, but a similar short term survival. However, the follow up period in this study was small, and it is only after 5 years, when bioprosthesis start degenerating that reoperation and related morbidity/ mortality become issues.…”