Prosthetic Heart Valve

Aka: Prosthetic Heart Valve, Prosthetic Cardiac Valve, Mechanical Heart Valve, Artificial Cardiac Valve Prosthesis, Bioprosthetic Heart Valve, Biologic Cardiac Valve Prosthesis, Heart Valve Replacement, Valve Replacement, Prosthetic Cardiac Valve Disorder, Prosthetic Cardiac Paravalvular Leak, Prosthetic Valve Thrombosis, Prosthetic Cardiac Valve Obstruction, Transcatheter Aortic Valve Implantation, TAVI, Transcatheter Aortic Valve Replacement, TAVR

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II. Epidemiology

  1. Heart Valve Replacement Incidence
    1. Worldwide: 290,000 per year
    2. U.S.: Up to 95,000 per year

III. Types

  1. Mechanical Heart Valves (Artificial Heart Valves)
    1. Composed of metal or carbon alloys
    2. Subtypes include caged ball, single tilting disk or bileaflet tilting disk
  2. Transcatheter Aortic Valve Implantation (TAVI)
    1. Previously known as Transcatheter Aortic Valve Replacement (TAVR)
    2. Mechanical Heart Valve deployed within native valve via catheter (similar to a cardiac stent placement)
  3. Bioprosthetic Heart Valves (biologic Heart Valves)
    1. Heterografts
      1. Porcine or bovine tissue mounted on metal support
    2. Homografts
      1. Preserved human valve tissue

IV. Management: Valve Type Selection

  1. Historically, Valve Replacement type is chosen based on age
    1. Mechanical Heart Valves (Artificial Heart Valves) for younger patients (age <60 years)
      1. More short-term complications in first 1-2 decades (bleeding and Thromboembolism risk)
      2. Requires Anticoagulation
        1. See Anticoagulation after Heart Valve Replacement
    2. Bioprosthetic Heart Valves (biologic Heart Valves) for older patients (age >70 years)
      1. Structural integrity decreases overtime and requires earlier repeat replacement
  2. Transcatheter Aortic Valve Implantation or Replacement (TAVI, TAVR)
    1. Higher surgical risk patients with severe Aortic Stenosis
    2. Failed prior bioprosthetic valves
  3. Some experts argue that bioprosthetic valves should be considered for all patients
    1. Require Anticoagulation and greater complications in the first 2 decades
    2. Equivalent morbidity and mortality for the first 15 years after Valve Replacement with either technique
    3. Repeat Valve Replacements for bioprosthetic valves are safe (and required less frequently then prior studies)
    4. http://www.acc.org/latest-in-cardiology/articles/2015/03/03/09/28/surgical-aortic-valve-replacement-biologic-valves-are-better-even-in-the-young-patient

V. Management: Anticoagulation

  1. See Anticoagulation after Heart Valve Replacement
  2. Mechanical Heart Valves (Artificial Heart Valves)
    1. Warfarin with target INR 2 to 3 for most patients
    2. Warfarin with target INR 2.5 to 3.5 for mitral Valve Replacement, Atrial Fibrillation and aortic Valve Replacement
    3. Do NOT Use DOACs (e.g. Apixaban) or Pradaxa for mechanical valve Anticoagulation
      1. Higher risk of thrombosis when compared with Warfarin
      2. Eikelboom (2013) N Engl J Med 369(13):1206-14 +PMID: 23991661 [PubMed]
  3. Transcatheter Aortic Valve Implantation or Replacement (TAVI, TAVR)
    1. Single Antiplatelet Therapy with Aspirin 75 to 100 mg orally daily
    2. Single agent replaces Dual Antiplatelet Therapy since 2020
    3. Granger (2022) J Clin Med11(8):2190 +PMID: 35456283 [PubMed]
  4. Bioprosthetic Heart Valves (biologic Heart Valves from human, pig or cow)
    1. Aspirin 75 to 100 mg orally daily for most patients
    2. If Anticoagulation is indicated for other reason (e.g. Atrial Fibrillation), DOACs, Warfarin or Pradaxa may be used

VI. Complications

  1. General
    1. Overall complication rate: 6%
    2. Echocardiogram (TTE or TEE) is the first-line tool for Prosthetic Heart Valve complication evaluation
      1. Acoustic shadowing with Mechanical Heart Valves may limit diagnostic efficacy
  2. Mechanical valves
    1. Thromboembolism (often non-obstructive thrombi)
      1. Always consider as source in thromboembolic disease
    2. Valvular obstruction (due to valve thrombus from under-anticoagulated)
      1. Fibrinolytics: Small valve thrombus with mild symptoms (NYHA Class 1-2)
      2. Emergent Surgery: Large thrombus is critically ill patients
    3. Hemorrhage (typically associated with Anticoagulation)
    4. Valve regurgitation (due to paravalvular leak)
    5. Hemolytic Anemia (less common with modern mechanical valves)
  3. Bioprosthetic valves
    1. Structural dysfunction (e.g. valve degeneration, calcification or Fracture)
      1. Results ultimately in repeat Valve Replacement
    2. Valve regurgitation (due to paravalvular leak or structural degeneration)

VII. References

  1. (2023) Presc Lett 30(8): 44
  2. Schauer et al. (2016) Crit Dec Emerg Med 30(9):13-9
  3. Otto (2021) Circulation 143(5):e35-e71 +PMID: 33332149 [PubMed]
  4. Vahanian (2022) Eur Heart J 43(7):561-632 +PMID: 34453165 [PubMed]

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Related Studies

Ontology: Heart Valve Prosthesis (C0018825)

Definition (UMD) Prostheses designed to replace natural heart valves. These prostheses may consist of biological or artificial valves. Bioprosthetic valves consist of either processed cardiac valves from human cadavers (i.e., allografts) or animals (i.e., xenografts) or valves manufactured from tissue (e.g., pericardium, dura mater) taken from the same sources. Artificial valves are typically made of metals and plastics or silicone rubber. Cardiac valve prostheses are available in appropriate sizes and configurations to replace any of the cardiac valves, namely the mitral, tricuspid, aortic, and pulmonary valves. These prostheses are indicated for patients in whom extensive valvular damage resulting from acquired or congenital diseases precludes repair.
Definition (MSHCZE) Zařízení, které nahrazuje srdeční chlopeň. Může být zhotoveno z biologického materiálu (BIOPROTÉZY) a/nebo ze syntetického materiálu.
Definition (SPN) An external limb prosthetic component is a device intended for medical purposes that, when put together with other appropriate components, constitutes a total prosthesis. Examples of external limb prosthetic components include the following: Ankle, foot, hip, knee, and socket components; mechanical or powered hand, hook, wrist unit, elbow joint, and shoulder joint components; and cable and prosthesis suction valves.
Definition (MSH) A device that substitutes for a heart valve. It may be composed of biological material (BIOPROSTHESIS) and/or synthetic material.
Definition (CSP) device that substitutes for a heart valve; may be composed of biological material and/or synthetic material.
Concepts Medical Device (T074)
MSH D006350
SnomedCT 25510005
English Heart Valve Prostheses, Heart Valve Prosthesis, Prostheses, Heart Valve, Valve Prostheses, Heart, Valve Prosthesis, Heart, prosthetic heart valve, Valves, Heart, Prostheses, Cardiac Valve, Cardiac Valves, Valves, Cardiac, Heart Valves, VALVE, PROSTHESIS, Cardiac valve prosthesis, device, artificial heart valves, Heart valve prosthesis, Cardiac valve prosthesis, Cardiac valve prosthesis, device (physical object), heart valve prosthesis, Prosthesis, Heart Valve, Cardiac Valve Prostheses, Cardiac Valve Prosthesis, Prosthesis, Cardiac Valve, Valve Prostheses, Cardiac, Valve Prosthesis, Cardiac
Swedish Hjärtklaffprotes
Finnish Läppäproteesit
Russian SERDECHNYKH KLAPANOV PROTEZY, СЕРДЕЧНЫХ КЛАПАНОВ ПРОТЕЗЫ
Japanese 心臓人工弁, 人工弁
Spanish Prótesis Valvular Cardíaca, prótesis de válvula cardíaca (objeto físico), prótesis de válvula cardíaca, prótesis valvular cardíaca, válvula cardíaca protésica, Prótesis Valvulares Cardíacas
French Prothèse valvulaire cardiaque, Prothèse de valvule cardiaque, Prothèse de valve cardiaque
Croatian SRČANI ZALISTAK, PROTEZE
Polish Protezy zastawek serca
Czech srdeční chlopně umělé, chlopenní náhrady, srdce - chlopenní protézy
Norwegian Hjerteklaffprotese
Portuguese Próteses das Valvas Cardíacas, Prótese de Valva Cardíaca, Prótese Valvular Caríaca, Próteses Valvulares Cardíacas
German Herzklappenprothesen, Prothesen, Herzklappen-
Italian Protesi valvolari cardiache
Dutch Hartklepprothese, Prothese, hartklep-
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Artificial cardiac valve prosthesis (C0182440)

Definition (UMD) Cardiac valve prostheses made of synthetic materials, such as silicone rubber, Teflon, polypropylene, or Dacron. These prostheses are available in several configurations, such as caged ball, tilting disk, and leaflet; the size and configurations used depend on the type of cardiac valve to be replaced (i.e., mitral, tricuspid, aortic, or pulmonary) and the anatomic characteristics of the particular patient.
Concepts Medical Device (T074)
SnomedCT 24073000
English Mech cardiac valve prosthesis, Mechanical Cardiac Valves, Artificial Cardiac Valves, Cardiac Valves, Mechanical, Prostheses, Cardiac Valve, Artificial, Synthetic Cardiac Valves, Cardiac Valves, Artificial, Artificial cardiac valve prosthesis, device, Artificial cardiac valve prosthesis, Mechanical cardiac valve prosthesis, Artificial cardiac valve prosthesis, device (physical object)
Spanish prótesis artificial de válvula cardíaca (objeto físico), prótesis artificial de válvula cardíaca, prótesis valvular cardíaca artificial
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Biologic cardiac valve prosthesis (C0182441)

Definition (UMD) Cardiac valve prostheses manufactured using human or animal tissues. These valves may consist either of cardiac valves from human cadavers (i.e., allografts) or animals (i.e., xenografts), such as pigs or cows, that are taken, processed, and/or mounted on stents or of valves manufactured using bioengineering technologies from tissue (e.g., pericardium, dura mater) taken from the same sources. Biological cardiac valve prostheses are available in several sizes and types, depending on the cardiac valve to be replaced (e.g., mitral, tricuspid, aortic, or pulmonary) and the anatomic characteristics of the particular patient.
Concepts Medical Device (T074)
SnomedCT 24290003
English Cardiac Valves, Biological, Prostheses, Cardiac Valve, Biological, Biologic cardiac valve prosthesis, device, Biologic cardiac valve prosthesis, Heart valve graft, Cardiac valve bioprosthesis, Biologic cardiac valve prosthesis, device (physical object)
Spanish prótesis biológica de válvula cardíaca (objeto físico), prótesis biológica de válvula cardíaca, prótesis valvular cardíaca biológica
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Disorder of prosthetic cardiac valve (C0340880)

Concepts Disease or Syndrome (T047)
SnomedCT 271984008
English Disorder prosth cardiac valve, Disorder prosth heart valve, Disorder of prosthetic cardiac valve, Disorder of prosthetic heart valve, Disorder of prosthetic cardiac valve (disorder)
Spanish trastorno de válvula cardíaca protésica (trastorno), trastorno de válvula cardíaca protésica
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Prosthetic cardiac paravalvular leak (C0340884)

Concepts Disease or Syndrome (T047)
SnomedCT 234184000
English PPVL - Prosth paravalv leak, Prosth card paravalvular leak, PPVL - Prosthetic paravalvular leak, PVL - Paravalvular leak, Prosthetic cardiac paravalvular leak, Prosthetic paravalvar leak, Prosthetic cardiac paravalvular leak (disorder)
Spanish filtración paravalvular de prótesis cardíaca, filtración paravalvular de prótesis cardíaca (trastorno), filtración cardíaca paravalvular protésica, filtración cardíaca paravalvular protésica (trastorno)
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Prosthetic cardiac valve obstruction (C0340886)

Concepts Pathologic Function (T046)
SnomedCT 234186003
English Prosth cardiac valve obstructn, prosthetic heart valve malfunction obstruction, prosthetic heart valve obstruction, prosthetic heart valve obstruction (diagnosis), Prosthetic cardiac valve obstruction, Prosthetic cardiac valve obstruction (disorder)
Spanish obstrucción de prótesis de válvula cardíaca, obstrucción de prótesis de válvula cardíaca (trastorno), obstrucción de la válvula cardíaca protésica (trastorno), obstrucción de la válvula cardíaca protésica
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Prosthetic Valve Thrombosis (C1709735)

Concepts Disease or Syndrome (T047)
English Prosthetic Valve Thrombosis
Derived from the NIH UMLS (Unified Medical Language System)

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