The choice of valve prosthesis: are the guidelines for everyone?

Choice of prosthetic heart valve in a developing country

Mechanical prostheses and stented xenografts (bioprosthesis) are most commonly used substitutes for aortic and mitral valve replacement. The mechanical valves have the advantage of durability but are accompanied with the risk of thromboembolism, problems of long-term anticoagulation, and associated risk of bleeding. In contrast, bioprosthetic valves do not require long-term anticoagulation, but carry the risk of structural valve degeneration and re-operation. A mechanical valve is favoured in young patients (<40 years) if reliable anticoagulation is ensured. In elderly patients (>60 years), a bioprosthesis is a suitable substitute. In middle-aged patients (40-60 years), risk of re-operation in a bioprosthesis is equal to that of bleeding in a mechanical valve. Traditionally, a bioprosthesis is opted in patients with limited life expectancy. Calculation of life expectancy, based solely upon chronological age, is erroneous. In developing countries, the calculated life expectancy is much lower than that of Western population, hence age related Western cut-offs are not valid in developing countries. Besides age, cardiac condition of the patient, systemic illnesses, socio-economic status, gender and geographical location also decide the life expectancy of the patients. Selection of the prosthetic valve substitute should be based on: aspiration of the patient, life expectancy, socio-economic and educational background, occupation of the patient, availability, cost, monitoring of anti-coagulation, monitoring of valve function and other valve related complications, and possibility of re-operation.