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bioprosthetic (tissue) heart valve

Classification: 1) homograft (human) a) aortic b) pulmonary 2) heterograft (porcine valve) a) Hancock valve b) Carpentier-Edwards valve 3) pericardial (bovine valve) - Ionescu-Shiley valve Advantages: 1) tissue values are not as thrombogenic as mechanical valves 2) most patients in sinus rhythm do not need anticoagulation* * There is a risk of systemic embolization in patients with atrial fibrillation, especially with a prosthetic mitral valve. Disadvantages: 1) tissue valves degenerate & calcify 2) 50% of patients will need valve replacement in 18-20 years [3] (previously 10 years) 3) calcific degeneration of bioprosthetic valves is accelerated in children, adolescents & young adults Special laboratory: - routine monitoring with echocardiography not indicated [2] Management: - 3-6 months of anticoagulation with warfarin after aortic or mitral bioprosthetic valve replacement with target (INR=2-3) - aspirin 81 mg daily indefinitely is reasonable for all patients [2] - antibiotic prophylaxis for bacterial endocarditis indicated [2] - anticoagulation considerations similar for aortic & mitral valves [2] - rivaroxaban for atrial fibrillation & bioprosthetic mitral valve [6] Notes: - valve durability: tricuspid > aortic > mitral - valves more durable in older than in younger patients [2] - lowest thromboembolism risk with aortic valve replacement - generally preferable to mechanical heart valve in patients > 70 years of age - scarcity of useful data on patient-important outcomes with bioprosthetic aortic valves [5]

General

prosthetic heart valve

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 55-56
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Ardehali A, Chief of Cardiothoracic Surgery, VAGLA Advances in Cardiothoracic Surgery Medical Staff Meeting, Wadsworth Theater Veterans Administration, Greater Los Angeles Health Care Jan 23, 2009
  4. Merie C et al Association of Warfarin Therapy Duration After Bioprosthetic Aortic Valve Replacement With Risk of Mortality, Thromboembolic Complications, and Bleeding JAMA. 2012;308(20):2118-2125. PMID: 23188028 http://jama.jamanetwork.com/article.aspx?articleid=1456069 - Mehta SR and Weitz JI Warfarin After Bioprosthetic Aortic Valve Implantation JAMA. 2012;308(20):2147-2148 PMID: 23188033 http://jama.jamanetwork.com/article.aspx?articleid=1456031
  5. Foroutan F, Guyatt GH, O'Brien K et al Prognosis after surgical replacement with a bioprosthetic aortic valve in patients with severe symptomatic aortic stenosis: systematic review of observational studies. BMJ. 2016 Sep 28;354:i5065. PMID: 27683072 Free PMC Article
  6. Guimaraes HP et al. Rivaroxaban in patients with atrial fibrillation and a bioprosthetic mitral valve. N Engl J Med 2020 Nov 14; [e-pub]. PMID: 33196155 https://www.nejm.org/doi/10.1056/NEJMoa2029603