How to Choose? What You Need to Know About Different Types of Heart Valves
One of the first things to consider when a patient is told they need heart valve surgery is the type of valve. Dr. Marc Gillinov, Chairman of the Department of Thoracic and Cardiovascular Surgery, gives an overview of bioprosthetic (tissue) and mechanical valves.
How to Choose? What You Need to Know About Different Types of Heart Valves
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Marc Gillinov, MD:
I'm Dr. Marc Gillinov, chair of the Department of Thoracic and Cardiovascular Surgery at the Cleveland Clinic. Here at the Cleveland Clinic, we perform more than 2000 heart valve operations every year. And before each operation, there's a discussion between the doctor and the patient about the type of heart valve procedure we're going to do. It begins with a discussion of repair of the valve versus replacement of the valve. In almost all cases of mitral valve prolapse, which causes leaking valve, we can repair the valve. So mitral valve prolapse we can usually repair. In contrast, when patients have aortic valve stenosis, meaning the valve is narrowed, that valve would be replaced. But even if we plan on repairing the valve, we always discuss backup options because occasionally we find a valve that we thought we could repair, but there is so much damage that we have to replace it. So, in every heart valve procedure, a discussion of valve replacement is absolutely necessary.
The main point when discussing valve replacement is to answer the question, if I need a valve replacement, what kind of valve do I want? There are two kinds of valve replacements. We have mechanical valves, and bioprosthetic valves. Some people call mechanical valves metal valves. They're actually made out of carbon more than metal, but they do have some metal in them. Mechanical valves and bioprosthetic valves or biological valves are very different. I think the most important point to know is that they're both very, very good, but there are key differences. Mechanical valves usually last forever. Mechanical valves, these carbon-based valves are the most durable valve choice. They almost never wear out, and it is uncommon for someone with a mechanical valve to need a re-operation ever in his or her life.
So mechanical valves are the most durable option that we have, but mechanical valves come with some baggage. The most important thing about mechanical valves after durability is anticoagulation or blood thinners. If you get a mechanical valve, you have to take an anticoagulant or blood thinner, and that anticoagulant has to be Coumadin, which is also called warfarin. The reason that mechanical valves require an anticoagulant is that they tend to cause blood to clot on the surfaces or discs of the valve, therefore, you need a blood thinner. The blood thinner has its own issues. First and foremost, if you are on an anticoagulant and you are involved with a situation that causes bleeding, for example, major trauma or a bleeding ulcer that won't stop, being on an anticoagulant makes this a much bigger deal, harder to manage. The anticoagulants, however, can be reversed.
In addition, if you are on Coumadin, this particular anticoagulant, you require monitoring, meaning you have to get a blood test once a month, or you can test at home with a little finger stick kit to make sure that you are in range. So mechanical valves, the most durable, require an anticoagulant, and then finally, they do make a slight clicking noise. It's not loud, but almost anyone who has a mechanical valve inside their heart can sense or hear this small click it makes every time it closes.
Now, the other type of valve replacement choice is a bioprosthetic valve or biological valve. These valves come from pigs or cows. The pig valves are actually valves. They are pig aortic valves, which are mounted or placed on a sewing ring, a circular ring, and we so that ring into the heart and the ring has the valve in the middle. The cow valves or bovine valves were actually initially made out of pericardium, which is the lining of the cow's heart, and this lining, which is leather-like material, is fashioned into a valve. Both of these kinds of valves, pig valves and cow valves work very well, and there is little difference between them.
The main features of pig or cow valves, bioprosthetic valves are first that they do not require anticoagulants, they do not require blood thinners in general. There's some controversy, but in general, pig or cow valve, no blood thinners. However, the pig and cow valves can wear out. They almost always last at least 10 years, and we've seen as long as 22 years. It's uncommon for them to wear out in five or six years. So, if you get a pig or a cow valve, you should think I ought to have 10 years, maybe even more with this valve. And it turns out that the older you are, the longer pig and cow valves last. So, if you're 65 and you get a cow or a pig valve, there's a very good chance it will last your whole life. These days though, some people in their 50s will choose a pig or a cow valve because they don't want to be on blood thinners. That means when these people get into their 60s, they will likely need a new valve, and there is a reasonable chance that they won't need surgery to get that new valve.
Specifically, let's say you are 65 years old, you come in with a worn-out pig valve, there's a good chance that we can take a new valve, crimp it or fold it like an umbrella, thread it up a vein, or artery from your leg and deploy it in the housing of the old pig or cow valve because the old pig or cow valve gives a perfectly circular landing zone such that we can put a new valve inside. So, there is no guarantee that you won't ever need surgery again if you're 50 or 60 and you get a pig or cow valve, but there is a good chance.
Finally, if someone said, "Well, which kind of valve is better? Which one works better, which one would your heart prefer if your heart could talk?" The answer is they are both very, very good. The blood flow through a mechanical valve is a little bit superior to that of a biological valve, meaning the mechanical valve allows a bit more blood flow, but it's generally not significant. There is some data that people in their 40s and 50s may live longer if they get a mechanical valve than a biological valve. That was from a big study from the state of California published in the New England Journal of Medicine.
However, people should choose the valve based upon their lifestyle and their wishes and needs. If you are 55 years old and your favorite activity is bicycle riding and you ride in races and you are often knocked off your bike such that you get beaten up and bruised, you don't want to be in a blood thinner, so a biological valve might be best for you. On the other hand, if you're 70 years old, you should almost certainly choose a biological valve because that valve is likely to last your whole life. The key point here is it's a discussion, a discussion between you, your needs considered, and the surgeon, and what he or she thinks might be best for you because there are some instances where one valve will fit better than another. But at the end of the day, both of these types of valves, mechanical valves, and bioprosthetic valves are excellent choices.
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