Clinical Characteristics and Long-Term Outcome of Patients with Bio-Prosthetic Mitral Valve – Experience From a South Asian Country
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Abstract:
Objectives: The aim of this study is to evaluate clinical characteristics and long-term outcome of the patients with bio-prosthetic mitral valve replacement at a tertiary care hospital of a South Asian country.
Methodology: The study is a retrospective observational observational study involving patients who underwent bio-prosthetic mitral valve replacement at a tertiary care hospital in Karachi, Pakistan, between 2006 and 2020, and had at least two complete echocardiograms. Patients with incomplete clinical data, no electronic reports of echocardiograms, and mechanical mitral valve replacement were excluded.
Results: This is a retrospective observational study, conducted at a tertiary care hospital. We included a total of 502 patients who underwent bio-prosthetic mitral valve replacement from the year 2006 to 2020. Patients were divided into two groups based on normal functioning bio-prosthetic mitral valve and bio-prosthetic mitral valve dysfunction (BMVD). Out of 502 patients, 322 (64%) were female, mean age at the time of surgery was 49.42 ± 14.56 years. Mitral regurgitation was more common, found in 279 (55.6%) patients followed by mitral stenosis in 188 (37.5%) patients. Mitral valve replacement was done as an elective procedure due to NYHA II to IV symptoms at the time of surgery in 446 (88.8%) patients. In the mean follow-up of 6.59 + 2.99 years, bio-prosthetic mitral valve dysfunction (BMVD) was observed in 183 (36.5%) patients. However, re-do mitral valve surgery was done in only 49 (9.8%) patients. Comparing the two groups, individuals with normal functioning bio-prosthetic mitral valve had a mean age of 51.6 + 14.27 years, while those with BMVD had a mean age of 45.639 + 14.33 years at the time of index surgery (p value=0.000). There were more long-term complications including heart failure (n = 16, 8.74%), atrial fibrillation (n = 11, 6.01%) and death (n = 6, 3.28%) in BMVD group which were statistically significant.
Conclusion: This study is distinct because it demonstrates the outcomes of bio-prosthetic valve replacement in a relatively younger South Asian population. Due to rapid degeneration of bio-prosthetic valve in younger patients, a significant number of cases developed BMVD along with poor long-term clinical outcomes even at a short follow up period of less than ten years. These findings are like international data and signify that mechanical mitral valve replacement may be a more reasonable alternative in younger patients.Keywords:
Mitral valve replacement
Tertiary care
Mitral valve stenosis
Mechanical valve
The optimal approach to anticoagulation during the early postoperative period after mechanical valve replacement, by which early thromboembolism is prevented without bleeding complications, is not yet known. The study aim was to examine the practice patterns of Canadian cardiac surgeons with regard to early postoperative anticoagulation after mechanical valve implantation.A questionnaire was sent to 100 Canadian cardiac surgeons in July 2004, and 57 responses were received. Data were collected regarding the approaches to early postoperative anticoagulation following uncomplicated isolated mechanical aortic valve replacement (AVR) and mitral valve replacement (MVR).Heparin was administered routinely after AVR and MVR by 63% and 68% of surgeons, respectively. This was most commonly initiated on postoperative day (POD) 1, and given either subcutaneously (AVR, 28%; MVR, 25%) or intravenously (AVR, 33%; MVR, 42%). Alternatively, low-molecular-weight heparin was used by 21% and 23% of surgeons after AVR and MVR, respectively. Oral warfarin was usually started on POD 1 (72% and 68%, respectively), with 40% prescribing an initial dose between 2.5 and 5.0 mg, and 51% administering between 5.1 and 7.5 mg. When heparin was not used, oral anticoagulation was more often administered earlier (AVR, p = 0.003; MVR, p = 0.006), but not at higher doses (AVR, p = 0.07; MVR, p = 0.2). Following surgery, aspirin was prescribed by 61% and 65% of surgeons after AVR and MVR, respectively.The study results highlighted a significant variability in the management of early postoperative anticoagulation after mechanical valve implantation. The clinical impact of these findings is unknown, and can only be assessed through a prospective trial.
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A 55-year-old male underwent combined coronary artery bypass grafting and mitral valve replacement with a No. 31 St. Jude Medical mechanical prosthetic valve. Over the next few months, the patient experienced severe difficulty with the 'clicking' noise of the mechanical valve, to the extent that it affected his daily activities. At approximately four months after the first operation, and at the patient's insistence, he underwent redo sternotomy and replacement of the mechanical mitral valve with a Mosaic porcine bio-prosthesis, with an uneventful recovery. While this case represents an unusual indication for valve replacement, it illustrates the importance of considering non-traditional factors when choosing the optimal prosthetic valve.
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Over the last decade there has been an increasing number of patients aged 80 years and over undergoing heart valve replacement. However, literature on the outcome of mitral valve replacement (MVR) in this age group is still limited.We conducted the present study by analysing data extracted from the UK Heart Valve Registry. From January 1986 to December 1994, 86 patients underwent isolated MVR and 10 underwent combined MVR with aortic valve replacement (AVR) and were reported to the Registry.The 30 day mortality was 10.4% (9/86) in the MVR group and 10% (1/10) in the MVR and AVR group. The actuarial survival was 79.8, 64.1 and 40.7% at 1, 3 and 5 years, respectively, in the MVR group. Of the 10 early (30 day) deaths, 8 were due to cardiac reasons and 19 of the 28 late deaths were due to non-cardiac reasons. A total of 55 (57.2%) patients received a bioprosthetic valve implant and 41 (42.8%) patients received a mechanical valve implant. There was no difference in survival between the two groups.The above results suggest that MVR in octogenarians produces a satisfactory early postoperative outcome and moderate medium-term benefit. There is no difference in survival between patients receiving bioprosthetic and patients receiving mechanical valve implants.
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Mitral valve replacement
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Mitral valve replacement
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Abstract Background For patients who undergo mechanical valve replacement, the greatest disadvantage is that they require long-term or permanent use of anticoagulant therapy to prevent thromboembolism. To date, mechanical valve replacement without anticoagulation has been published in the literature. Case summary We present the case of a 75-year-old female who underwent mechanical mitral valve replacement (MVR) on mid-June, 2007. However, this patient had not been taking anticoagulant medication since she experienced warfarin overdose in the first month after the operation. She had been well without using any anticoagulation, and there were no complications of the mechanical valve. Discussion There was no thrombosis for such a long period of time because she suffered from FX deficiency. To the best of our knowledge, she may be the only patient who has been well without any anticoagulation since not taking warfarin 12 years ago.
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valvular heart disease
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The valve replacement for valvular disease has been safely performed with a recent development in cardiac valve prosthesis. However, there are increasing cases obliged to undergo re-replacement in a late period after the operation. Recently, we successfully performed a re-replacement with a mechanical valve because of valve failure and left atrial thrombosis after replacement with a bioprosthesis. A 34-year-old female underwent a replacement of Hancock bioprosthesis for mitral stenosis seven years before when she was 27 years old. Postoperative anticoagulants were not administered, and she successfully delivered. Eight years later, she had mitral regurgitation causing prosthetic insufficiency and left atrial thrombosis. Re-replacement using mechanical valves (SJM 29 mm) and left atrial thrombectomy were carried out. The postoperative course was uneventful and she was discharged from the hospital 2 months after the reoperation. In this case the huge thrombosis was in the left atrial wall and no direct correlation with the eplaced bioprosthesis was thought. Even for the replacement using a bioprosthesis, anticoagulant regimen appears necessary as a rule.
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Abstract
Transcatheter mitral valve replacement (TMVR) is a rapidly evolving treatment for mitral regurgitation. As with transcatheter aortic valve replacement, multidetector computed tomography analysis plays a central role in defining the candidacy, device selection and safety for TMVR procedures. This contemporary review will describe in detail the multidetector computed tomography data collection, analysis, and planning for TMVR procedures in patients with native mitral regurgitation as well as in those with failed surgical prosthetic mitral valve replacement or surgical mitral valve repair.Mitral valve replacement
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