Choice of prosthetic heart valve for adult patients

This review summarizes the major long-term (> or =10 to 15 years) patient outcomes after insertion of many Food and Drug Administration approved prosthetic heart valves (PHV). Mechanical PHV was associated with a better survival (p < 0.02) at 15 years after aortic valve replacement (AVR) than with a bioprosthesis in the Department of Veterans Affairs (DVA) trial. In both the DVA and the Edinburgh Heart Valve trials, bioprosthesis were associated with structural valve deterioration (SVD) (mitral valve replacement [MVR] > AVR) and, therefore, for replacement of the PHV. Thromboembolism and bleeding rate were higher with mechanical PHV. Mortality after AVR and MVR is high at 10 to 15 years because of the associated comorbid conditions and older age of patients. Outcomes with "new" good valves are similar to that with "older" good valves. Complication rates of thromboembolism, bleeding, endocarditis, and leak vary widely; the rates of these complications are not different among different mechanical PHV and among different bioprosthetic PHV. Structural valve deterioration is rare with mechanical PHV. Structural valve deterioration of bioprosthesis after MVR is higher than after AVR; after AVR, homografts and bioprosthesis have similar rates of SVD. The exact rate of SVD of the pulmonary autograft is uncertain. Valve prosthesis-patient mismatch is clinically important when it is severe and in selected patients when it is moderate. Bioprosthesis have a low rate of SVD in the older patient and, thus, are the PHV of choice for AVR in patients > or =60 to 65 years of age and for MVR in patients > or =65 to 70 years of age; in younger patients mechanical valves are the PHV of choice. In individual patients there may be exceptions to these general rules.