Strategic choice of heart valve prosthesis

STRATEGIC CHOICE OF 
HEART VALVE 
PROSTHESIS 
DUNG VAN HUNG , MD.PhD 
HO CHI MINH HEART INSTITUTE 
BACKGROUND 
 1st mechanical valve replacement in 1960 ( Starr-Edwards) 
 1967 : Ross procedure was introduced 
 1969: 1st aortic porcine valve was implanted 
 1980 : pericardial valve was created ( Carpentier-Edwards) 
 Early 1990s : 1st generation of stentless tisue valve ( Prima, Freestyle & 
Toronto valve) 
 2012 : # 20.000 valve in Japan, 90.000 valve in USA & 280.000-300.000 
valve in the world were implanted 
 In Viet Nam ( 2015) # 800 valve 
CLASSIFICATION OF HEART VALVE PROSTHESIS 
Mechanical Valves : Caged-ball, Tilting disc, Bileaflet 
Tissue Valves : Bioprosthetic : Porcine 
 ( heterograft) Pericardial 
 Biological : Aortic homograft 
 Pulmonary autograft 
 Self-expandable : TAVI ( Core valve, Sapien 3) 
 TAVI ( Lotus valve) 
 Sutureless : Perceval ( Sorin) 
PROSTHETIC VALVE: INTERVENTION 
Recommendations COR LOE 
Choice of valve intervention and prosthetic valve type should 
be a shared decision process I C 
A bioprosthesis is recommended in patients of any age for 
whom anticoagulant therapy is contraindicated, cannot be 
managed appropriately, or is not desired I C 
A mechanical prosthesis is reasonable for AVR or MVR in 
patients <60 years of age who do not have a contraindication 
to anticoagulation 
IIa B 
PROSTHETIC VALVE: INTERVENTION (CONT.) 
Recommendations COR LOE 
A bioprosthesis is reasonable in patients >70 years of age 
IIa B 
Either a bioprosthetic or mechanical valve is reasonable in 
patients between 60 years of age and 70 years of age IIa B 
Replacement of the aortic valve by a pulmonary autograft 
(the Ross procedure), when performed by an experienced 
surgeon, may be considered in young patients when VKA 
anticoagulation is contraindicated or undesirable 
IIb C 
1ST AND 2ND GENERATION BIOPROSTHETIC VALVES 
0
20
40
60
80
100
2 4 6 8 10 12 14 16 18 20
Years
%
 f
r
e
e
 f
r
o
m
 f
a
il
u
r
e
Hancock Hancock II
Hancock - Stanford 
Hancock II - Toronto 
THROMBOSIS, BLEEDING, 
STROKE, PANNUS 
Emergent treatment 
Very high mortality 
Linear risk 
STRUCTURED 
DEGENERATION 
Planned treatment 
Moderate mortality 
Late risk 
1. Patients’ age is probably the most important factor in 
recommending tissue or mechanical valve 
2.Bioprosthetic valves are ideally suitable for older patients (>70 
years) or those who are not likely to outlive the valve (co-
morbidities) 
3. Mechanical valves should be recommended to younger patients 
(<60 years) 
4. If anticoagulation is a perceivable problem, tissue valves can be 
used in younger patients but the probability of reoperation is high 
AVR: Choice of Prosthesis 
 FACTOR DETERMINING SELECTION OF 
 VALVE PROSTHESIS 
Age ( life expectancy) 
SR or AF 
Anti-coagulation ( will, risk, benefit, complication related) 
Underlying disease ( quality of life) 
Permanent address ( healthcare condition) 
Hemodynamic performance ( supra-annular valve) 
 Income 
 AGE 
Longevity age (WEF 2016) VN : 75.6 ; Singapore : 82.6 ; 
Thailand : 74.4; Philippines : 68.3 ; China : 75.8 ; 
HongKong : 84; Japan : 86.3 ; USA : 78.9 ; France : 82.4 ; 
Italia : 82.7; UK : 81.1; Australia : 82.3 .. 
Physical activity by age : lower than western countries 
Healthcare-Geriatric care : in big city only 
 HEART RHYTHM 
Not always select by patient’s rhythm ( SR = Tissue, AF = 
Mechanic ) 
Associated with AF surgery : Tissue valve > Mechanical 
Special situation : Tissue valve 
 ANTI-COAGULANT & ANTI- PLATELET 
Can ‘t take OAC or will not take OAC : Tissue valve 
Can ‘t follow up closingly : Tissue valve 
Need to minimize bleeding : Tissue valve 
Special jobs : Tissue valve 
Lifestyle 
Pregnancy 
 CO – MORBIDITY (CARDIAC & NON-CARDIAC) 
1. Need to aortic or mitral valve replace associated with CABG : 
Bioprosthetic > Mechanical valve. 
2. History of haemorrhage ( stroke, severe GI tract bleeding, 
cancer) : Bioprosthetic valve 
3. Chronic renal failure needs to dialyse : the same (Bioprosthetic 
versus mechanical prostheses for valve replacement in end-stage renal disease patients: 
systematic review and meta- analysis . Kevin Phan et al. J Thorac Dis 2016;8(5):769-777 ) 
 If life expectancy > 5y : Mechanical > Bioprosthetic valve (Contemporary perioperative 
results of heart valve replacement in dialysis patients: analysis of 1,616 patients from the Japan 
adult cardiovascular surgery database. Tadeka K et al. J Heart Val Dis 2013 Nov;22(6):850-8.) 
 PERMANENT ADDRESS 
Regular examinations and echocardiograms, anti-thrombotic 
therapy, and appropriate antibiotic prophylaxis against 
endocarditis 
Nearly heart center or provincial hospital : Mechanical > 
Tissue valve 
Far away heart center or cannot FU regularly : Tissue valve 
Ethnics group : Tissue valve 
 HEMODYNAMIC PERFORMANCE OF 
VALVE 
New choice : new generation of heart valve prosthesis ( 
CE Magna Ease, SJM Trifecta, Solo Freedom, OnX, 
Regent, ATS-Medtronic, Slimline.) 
For AVR : supra-annular valve is better 
+ SOCIO-ECONOMIC STATUS 
+ EDUCATIONAL BACKGROUND 
+ COST AND AVAIBILITY OF PROSTHESIS 
+ QUALITY AND AVAIBILITY OF MEDICAL 
SERVICES 
 INCOME 
 Durable valve repair 
> 10y possible 
No 
Yes 
Life expectancy < 15y 
 Major co-morbidity 
Life expectancy 15-30 y 
No co-morbidity 
Life expectancy >30 y 
No co-morbidity 
1.Accept risk of 
reoperation 
2.No coagulation 
3.Minimal life style 
change 
1. Minimize reoperation 
2.Will take 
anticoagulation 
3.Accept life style 
change 
Tissue valve Mechanical valve 
Physician 
assessment 
Patient ‘s 
preference 
Valve repair 
 Reida El Oakley et al. Circulation. 
2008;117:253-256 
Algorithm for selecting 
a valve procedure 
 CONCLUSION 
1. No ideal heart valve prosthesis until now ( ideal # valve for 
life ! ) 
2. Appropriate chosen > Desirable chosen 
3. Healthcare condition is one of the most important thing.