Management and follow up of prosthetic heart valves.

Correspondence to: Professor Christian Seiler, University Hospital, Swiss Cardiovascular Center Bern, Freiburgstrasse, CH-3010 Bern, Switzerland; christian. [email protected] _________________________ F or most haemodynamically relevant heart valve lesions, surgical therapy remains the treatment of choice. It has been consistently shown to provide long lasting relief of symptoms, and its superiority over medical treatment in this regard has been well established. However, in patients undergoing the most prevalent type of heart valve surgery, prosthetic valve replacement, survival rate analysis late after treatment has revealed an impaired prognosis (10 year survival rates of 65% for aortic valve replacement, 55% for mitral and combined valve replacement) in all but a minority. 2 This comprises patients older than 65 years undergoing aortic valve replacement for aortic stenosis, in whom survival relative to an age and sex matched population is normalised following the first postoperative year. It is similarly well known that late mortality is greater in patients undergoing replacement of the mitral than the aortic valve, and for regurgitant versus stenotic valvar lesions. Thus, prognosis after valve replacement is predominantly reflected by the underlying disease with its preoperative condition of the myocardium as well as the state of the coronary circulation. Consequently, the course after valve replacement may be determined decisively by early recognition of significant valvar lesions, in particular, valve insufficiency. In turn, improved follow up can be achieved by timely selection of the appropriate surgical therapy—that is, mitral valve reconstruction instead of replacement in the case of valve prolapse with severe regurgitation. Furthermore, ‘‘good management’’ of prosthetic heart valves starts preoperatively with the choice of the right valve—for example, a bioprosthesis, thus avoiding the risks of oral anticoagulation in patients requiring aortic valve replacement > 65 years (without atrial fibrillation, severe left ventricular dysfunction, previous thromboembolism, hypercoagulable state), or in patients undergoing mitral valve replacement . 70 years. Finally, and in the majority of patients with prosthetic valves, postoperative management aiming at an enhanced prognosis consists of controlling antithrombotic and antibiotic medication, of performing the first and subsequent follow up visits, and in a minority, of promptly recognising potentially devastating complications.