May 27th, 2014
Choosing a Prosthetic Valve: What Do You Say to Your Patient?
Harlan M. Krumholz, MD, SM
This post is the second in our series “What Do You Say to Your Patient?” In this series, we ask members to share with us how they interpret a complex or controversial issue for patients and explain whether it relates to their health. For the first post, relating to the CoreValve trial findings, click
The following scenario stems from the recommendations for prosthetic valve choice that are included in the 2014 AHA/ACC Guideline for the Management of Patients with Heart Disease.
Your patient is a 60-year-old man with a bicuspid aortic valve that is severely stenosed. He is mildly symptomatic, has no comorbidities, and takes no medications. He is very athletic and wants to remain active. The patient says that he is trying to decide whether to request a bioprosthetic or mechanical valve.
What do you say to your patient?
How strongly do you push in one direction or the other?
How do you help him understand the trade-off?
5 Responses to “Choosing a Prosthetic Valve: What Do You Say to Your Patient?”
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So the discussion would center about:
a.) valve characteristics- durability, effective orifice area/hemodynamic profile(particularly, in one who is “very athletic”)
b.) requirement for prolonged warfarin( 3 months for bioprostheis vs indefinite- with ASA for mechanical),
c.)requisite INR monitoring with dose adjustments of warfarin,
d.)drug-drug interaction for any contingent unforeseen therapies(eg antibiotics),
e.)risks of interruption and use of complicated bridging strategy for surgery if warfarin indefinite with mechanical valve,
f.)likely, second set surgery if bioprosthesis is chosen(? valve in valve TAVR as future prospect-with lesser orifice area after implant)
Risk calculator for bleeding on antithrombotic therapy(ATRIA, HAS-BLED) of uncertain applicability here(although low).
Decision would not be made in one setting utilizing Valve Heart Team platform for elective shared (triangulated-patient, cardiologist, CT surgeon)decision making.
Of course you choose the most difficult situation to conduct the discussion, this is a good opportunity!
60 y-o, is young, too young enough to undergo another valve replacement 10/15 years later.
Too young to undergo TAVI “valve in valve” (progress will be done but who knows?) He will be 75! So will he accept another open heart surgery (furthermore with CABPG!).
I would strongly recommend to my patient to choose a mechanical valve in spite of anticoagulant treatment and in spite of his athletically activities.(I will say him to avoid dangerous sports like climbing, elastic jump, but skiing if he is a good one)
He definitely will argue (he had consulted Dr Google). So the discussion will be hard.
I will explain the safety and longevity of a mechanical valve in his case: we do not know how long biological valves can last from 7 to 15 years more ? Less??? The anticoagulant treatment is safe in well informed persons (what about food interactions? not so tough!)In US you use autocoagu-check* which allows a very good control of INR.
The other constraints are the same (endocarditis, teeth care…) in both valves.
I hope I will convince him by these explanations
Did I convince you?
What is your expert opinion? Just between?
What do you say to your patient?
I agree with Drs Prida and Usdin.
How strongly do you push in one direction or the other?
I will not push him in any direction.
How do you help him understand the trade-off?
The best way to understand the trade off regarding anticoagulation is living the experience, if the patient were in condition to wait 3 – 4 months I would offer him the opportunity of being anticoagulated with warfarin. This is one of the best ways to find out how stable is his INR, secondary effects, if he has to change his diet, exercise, live style, and if he is comfortable and willing to do so. In the mean time he has time to think how he sees his live in 7 to 15 years and if he is willing to accept the possibility of a second surgery at age 70 – 75. In these cases there is not a right and wrong choice, any direction has pros and cons, most of the patients just want to be sure they weight all the options and at the end feel comfortable with their decision and live a good life without regrets.
I agree with you, dr Guadiana the patient will decide and it is important he feels comfortable with HIS choice.
However the patient waits also for a kick from his doctor.
For example when you buy a car as a client you can choose the color but the (professional) salesman has to indicate if your choice is a good one depending of the model and take in consideration a change in your taste after one year (or less) etc.
In my opinion our patient waits more than “The two options are good YOU decide!” we have to tell him our opinion “Personnally I will go this way…”
Your idea (if I understood well) of trying 2 or 3 months of anticoagulant therapy and see if patient feels comfortable is imaginative but I am not sure it is ethical (In France and elsewhere) Prescribing an anticoagulant just to see, without a real indication will put doctors in serious blames (with or without AVK complications during this period) unfortunatly this does not work.
thank you for your comment and sincerely yours
Structural bioprosthetic valvular regurgitation varies inversely with age. At 60, there is a 25% risk of substantial deterioration in 10 to 15 years… not terrible.The decision is completely the patient’s. It is not even a “shared decision”. We guide the patient in making the choice.