VALVULAR HEART DISEASE

Prosthetic cardiac valves

David E Pontefract
Srikanth S Iyengar
Clifford W Barlow

The number of prosthetic cardiac valve replacements performed

has increased steadily over the last 30 years; over 225,000 valves
are replaced worldwide each year and over 8000 of these are in
the UK. Valve replacement surgery requires the cardiac surgeon to
choose from a wide spectrum of valvular substitutes. This contribution describes the range and the attributes of each valve.
The first successful valve implantations were performed by
Harken (1960) and Starr and Edwards (1961). The techniques used
in cardiac surgery have advanced greatly over the last four decades
and have been mirrored by advances in the design and manufacture
of prosthetic valves, resulting in reduced morbidity and mortality
associated with valve replacement surgery. However, no replacement
valve is perfect, hence the major complications of valve replacement
(haemorrhage, thromboembolism, infection) persist.

Whats new ?
Subtle changes in the design of mechanical valaves
offer an improved haemodynamic profile and effective
orifice area
Advances in preservation of biological tissue vlaves
have lead to improved durability

David E Pontefract MRCS is a Research Fellow at the Wessex Cardiothoracic

Unit, Southampton, UK. He qualified from Manchester University and
completed basic surgical training in Manchester, UK. His research
interests include neo-intimal hyperplasia in coronary artery bypass
grafts. Conflicts of interest: none.
Srikanth S Iyengar FRCS is a registrar in cardiothoracic surgery at
Wessex Cardiothoracic Unit, Southampton, UK. He qualified from
Bombay University, India. His research interests include neurocognitive
dysfunction after cardiac surgery and filtration during cardiopulmonary
bypass. Conflicts of interest: none.
Clifford W Barlow FRCS DPHIL is a Consultant Cardiothoracic Surgeon
at Southampton General Hospital, Southampton, UK. He qualified
from the University of the Witwatersrand, South Africa, and trained in
cardiothoracic surgery at Papworth Hospital, Cambridge, UK, and at
Stanford Univerisity, USA. His interests include heart valve surgery.
Conflicts of interest: none declared.

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manufacturers and many different models (Figure 2). The main

differences between the various models are in the:
sewing cuff
opening angle
valve profile
leaflet hinge mechanism.
The bileaflet design enables washing of the leaflets by allowing
haemodynamically insignificant regurgitation of blood across
the valve during diastole. Bileaflet and tilting disc valves are
constructed with a sewing ring of reinforced Teflon or Dacron
surrounding a carbon-coated metallic housing. The leaflets are
composed of carbon and metal alloy which allow radiological
assessment of disc opening.
Mechanical valves are considered the most durable prostheses
available with freedom from structural degeneration in 98% at 10
years, although many will thrombose to a certain extent by 20 or
30 years.

Features of the valve

The ideal valve should have the same features as any other
implantable material, i.e. it should be:
inert (to offer a low risk of infection and provoke little inflammation or rejection)
durable (to be able to withstand the considerable physical
stresses to which it will be exposed)
reproducible (to be amenable to production with precision and
in number to satisfy demand, and implanted in a way that is
reproducible between surgeons)
acceptable to the patient physically and psychologically.

Types of valve available

Mechanical
Mechanical valves are made from a variety of manufactured materials and are more durable than bioprosthetic valves. Mechanical
valves are all thrombogenic, hence anticoagulation with warfarin
(or alternative) is required. This necessitates lifelong follow up,
therefore the social and geographical circumstances of the patient
are crucial when selecting these valves.
Three designs of mechanical valve are available.
Caged-ball valves were the first commercially available mechanical valves (Figure 1). They are durable and offer a good haemodynamic profile. Problems with haemolysis, thrombogenesis and
regurgitation inspired the development of the tilting disc design.
Tilting disc valves offer an improved haemodynamic profile compared to caged-ball valves, with reduced thrombogenic
potential in the aortic position. However, the original Bjrk-Shiley
tilting disc valve demonstrated a predisposition to thrombosis
in the mitral position. The early hopes for these valves were
further affected by mechanical failure of the strut mechanism in
the predominant Bjrk-Shiley valve which required prophylactic
replacement in many cases.
Bileaflet valves the majority of mechanical valves currently
implanted worldwide are of the bileaflet design with several

Biological
Biological valves are less durable but may be preferred in certain
patient groups (e.g. the elderly) since anticoagulation is not
routinely required. There are three categories of biological valve:
autografts, homografts and xenografts.
Xenografts are by far the most commonly implanted biological
valve in the UK. There are two types of xenograft.
Stented xenograft these valves are made from porcine aortic
valves or bovine pericardium, with a wire or polyacetal stent
covered in Teflon or Dacron (Figure 3). The animal connective tissue is stabilized using glutaraldehyde to promote collagen
cross-linking and so reduce biodegradation. This treatment can
be performed under high, low or zero pressure. Pericardial valves
offer a more favourable haemodynamic profile than porcine valves
and may be more durable.
Stentless aortic xenografts are also constructed from porcine
aortic valves or bovine pericardium, preserved in a similar fashion
to stented valves, and suspended within a cylinder of pericardium
(Figure 4).
Stentless valves are implanted by suturing the proximal end to
the valve annulus and then suturing the distal end to the ascending aorta. The distal suture line is typically infra-coronary (i.e. the
suture line is shaped to accommodate the coronary ostia), and this

2 A bileaflet valve

1 A caged ball valve

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material in xenografts must also be involved in the pathological

process since xenografts degenerate faster than either homografts
or autografts.
Homograft: a homograft (or allograft) valve is explanted with
some surrounding tissue from a human donor after death or from
the explanted heart of a transplant recipient.
Aortic homografts are usually explanted together with the
ascending aorta, coronary ostia and anterior leaflet of the mitral
valve and are then cryo-preserved. They offer a haemodynamic
performance similar to that of native valves because there is minimal restriction to the valve leaflets by the surrounding structures.
In addition, there is no stent to narrow the effective orifice area.
Anticoagulation is unnecessary as platelet aggregation does not
occur and historical data suggest that homografts are more durable than xenografts. However, there are drawbacks. Homografts
are technically more difficult to implant than stented xenografts
because (like stentless xenografts) proximal and distal suture lines
are required. Also, the availability of homografts and range of sizes
is limited by donor shortages.
For these reasons, homografts are often reserved for children,
and women who wish to become pregnant. They are also reserved
for procedures where the ventricular outflow tract or aortic root
require reconstruction (e.g. in the replacement of an infected aortic
valve when endocarditis also involves the annulus and other surrounding structures). In this situation, the attached anterior leaflet
of the mitral valve may be used to exclude an associated abscess
and the attached ascending aorta of the homograft may be used
to replace the infected aorta of the recipient.

3 A stented xenograft

technique is therefore more challenging than the single suture line

used for implantation of a stented aortic xenograft valve. Stentless valves offer larger effective orifice areas (the cross-sectional
area of the valve through which blood flows) than stented valves.
However, many surgeons do not feel that this benefit justifies the
technically more challenging technique, with associated increase
in cardiopulmonary bypass and cross-clamp times. For this reason,
stented valves remain the most commonly inserted bioprosthetic
aortic valves.
In addition to mechanical wear and tear, stented and stentless xenograft valves are prone to degeneration, affecting about
5% of xenografts in the aortic position at 5 years, and 30% at 10
years, with few lasting beyond 15 years (Figure 5). Degeneration
is caused by calcification of the cusps and in-growth of pannus
from the annulus. Pre-treatment with various new agents (e.g.
a combination of aluminium chloride and ethanol) may reduce
cusp calcification. However, low-grade rejection of the foreign

Autograft: an autograft is taken from a patient and re-implanted

into the same patient in a different position. In heart valve surgery, the aortic valve may be replaced with the structurally similar
pulmonary valve (Ross operation).
Ross operation the abnormal aortic valve is excised and the
pulmonary valve of the same patient is implanted in the aortic
position. The pulmonary valve is then replaced using a homograft. The procedure is favoured by some surgeons for patients
aged <40 years requiring aortic valve replacement because the
pulmonary autograft will not undergo calcific degeneration due to
rejection (unlike a xenograft or homograft). In children, the pulmonary autograft may grow with the child, although this remains
unproven.
The implanted homograft should last longer in the pulmonary
than in the aortic position because of the lower pressures in the
pulmonary circulation compared to systemic pressure. Anticoagulation is not required as a mechanical valve is avoided. Major
disadvantages of the Ross procedure are that:
it is technically more difficult than mechanical replacement of
the aortic valve and therefore carries a greater peri-operative
risk
double-valve surgery is undertaken in a patient with single-valve
pathology.

Choice of valve
Aortic valve replacement
The key considerations in the choice of implant for aortic valve
replacement are discussed below.

4 A stentless aortic xenograft

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Rates of structural degeneration causing death or requiring further surgery

Aortic

Mitral

Xenograft
Xenograft
Homograft
(Patient age <50) (Patient age >75)

Xenograft

5 year

3050%

010%

010%

1020%

10 year

5070%

2040%

1020%

2040%

15 year

> 75%

4060%

2040%

4060%

Age: generally, patients aged >75 years receive a xenograft.

Aortic xenografts close against the lower diastolic pressure of
the aorta and are therefore more durable than when used in the
mitral position.
In patients aged <50 years, some surgeons would consider
implanting an autograft or a homograft because these are more
durable than xenografts and anticoagulation is avoided. Patients
between the ages of 50 and 70 probably benefit from mechanical
valve replacement because they will last longer than tissue valves,
making the disadvantages of anticoagulation worth while.

mitral valve leaflet to the annulus (prior to implantation of the

valve prosthesis), or
excising the anterior and posterior leaflets and reconstructing
the primary chordae tendinae using Gore-tex between the
papillary muscles and the annulus.

Peri-operative care
Imaging: patients aged over 60 years and those with symptoms
suggestive of ischaemic heart disease require coronary angiography
to assess the need for concurrent coronary artery bypass grafts.
Prior to aortic valve surgery, coronary angiography also provides
information on the length of the left main stem, which will be cannulated under direct vision to allow administration of cardioplegia
solution. In patients with a particularly short left main stem, the
circumflex coronary artery territory may escape administration of
cardioplegic solution if the cannula is advanced too far.

Contraindications to anticoagulation: patients with conditions

that make anticoagulation undesirable should avoid mechanical
valves. Contraindications include:
liver failure
a previous haemorrhagic cerebrovascular accident
a history of gastrointestinal bleeding or other bleeding diatheses
alcoholism or conditions causing multiple falls
women considering current or future pregnancy
poor compliance with medication.

Good dental hygiene: dental infections are a potential source

of prosthetic valve endocarditis. All patients must have a dental
assessment and undergo any necessary treatment before prosthetic
valve implantation. Patients must also be informed of the postoperative risk of prosthetic valve endocarditis, and advised about
dental hygiene and antibiotic prophylaxis for any future dental or
surgical procedures.

Other cardiac pathology: generally, homografts are the implant

of choice for aortic root abscesses or prosthetic valve endocarditis.
Homografts allow exclusion of any abscess cavity and reconstruction of infected tissue debrided during the procedure.

Anticoagulation: patients undergoing mechanical valve replacement must be counselled regarding anticoagulation and the impact
this may have on lifestyle. They need to understand the importance
of a therapeutic International Normalized Ratio (INR) to avoid the
risks of bleeding if the INR is too high or thrombosis and thromboembolic complications if the INR is too low. The potential for
interactions of warfarin with excessive alcohol or other medication also needs to be explained and considered when assessing
the choice of prosthesis.

Mitral valve replacement

Preservation and repair of the native mitral valve is generally
considered to be superior to mitral valve replacement, which
should be undertaken only in patients where mitral valve repair
is not feasible. The implant of choice in the mitral position is a
mechanical valve.
Xenograft valves are generally considered only for the very
elderly due to accelerated degeneration that results from repeated
closure against the systolic pressures of the left ventricle (Figure 5).
Additionally, many patients requiring replacement of the mitral
valve are already anticoagulated as part of the treatment for atrial
fibrillation.
An important consideration during replacement of the mitral
valve is preservation or reconstruction of the subvalvular apparatus in order to prevent postoperative left ventricular dilation and
impairment. This is achieved by:
excising only the anterior leaflets and plicating the posterior

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Complications of valve replacement

Thromboembolism
Thromboembolism is the most common complication of mechanical valve replacement. It affects valves in the mitral position more
frequently than in the aortic position.
The incidence of thromboembolism in the appropriately anticoagulated patient has decreased (12% per patient per year in
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the UK) because valve design has improved. Thromboembolism

is more prevalent with poor anticoagulant control, as seen in
developing countries or in non-compliant patients.
Valve thrombosis is less common than thromboembolism (0.2%
per patient per year in the UK). In some cases, valve thrombosis
may present with minimal haemodynamic compromise and manifests as loss of valve click due to one leaflet being held partially
open. In this situation thrombolytic therapy may be attempted,
although valve replacement is usually unavoidable. More commonly, valve thrombosis presents with haemodynamic instability
or cardiogenic shock and requires emergency replacement of the
prosthesis.

Rates of structural degeneration causing death or

requiring further surgery
Aortic

Mitral

Xenograft
Age <50

Xenograft
Age >75

Homograft

Xenograft

5 years 30 50%
10 years 50 70%
15 years > 75%

0 10%
20 40%
40 60%

0 10%
10 20%
20 40%

10 20%
20 40%
40 60%

Haemorrhage
Haemorrhage resulting from anticoagulation has decreased during
recent years since newer models of mechanical valves require less
aggressive anticoagulation. The earlier generations of mechanical
valves required an INR of 3.54.5; an INR of 2.53.5 is now acceptable for most modern mechanical valves in the aortic position.
In addition, the development of alternatives to mechanical prostheses for patients with contraindications to anticoagulation (e.g.
active peptic ulcer disease) has reduced the rate of haemorrhage.
However, significant anticoagulant-associated haemorrhage
remains a major risk of morbidity and mortality following mechanical valve replacement (2% per patient per year).

repair the leak is indicated if significant haemolysis or haemodynamic compromise occurs.

The future
Advances in bioprosthetic valve preservation developed for the
new generation pericardial valves may lead to:
increased durability of these valves
an increase in their use in younger patients
an increase in their use in the mitral position.
In addition, early clinical studies using a stentless mitral bioprosthesis (which includes a prosthetic subvalvular apparatus)
have been promising, and may become an alternative for mitral
valve replacement. Mitral valve homografts are currently experimental.
A particularly interesting development is of an entirely prosthetic valve that has polyurethane cusps. These valves are likely
to be as durable as mechanical valves whilst avoiding the need
for anticoagulation.

Cerebrovascular accidents
Cerebrovascular accidents occur at a rate of 12% per patient year
in the UK and may be either ischaemic (secondary to thrombus
formation on the valve or alternative causes of cerebrovascular
ischaemia) or haemorrhagic (secondary to or exagerated by anticoagulant therapy).
Structural degeneration
Structural degeneration affects biological valves much more frequently and rapidly than mechanical valves, particularly those
implanted into younger patients (Figure 5). This umbrella term
includes wear-and-tear of the valve causing torn leaflets, and
calcification of the valve, probably due to chronic rejection of the
valve material.
Structural degeneration can therefore present with signs and
symptoms of stenosis in the case of a calcified valve or regurgitation
due to tearing of leaflets (whether or not these are also calcified). The
most significant clinical sign is the existence of a new murmur.
Infection
Infection of a prosthetic valve may be disastrous, but because
the use of prophylactic antibiotics has improved, the incidence of
prosthetic valve endocarditis has fallen (0.51% per patient per
year in the UK). Infection may present with signs of sepsis, valve
failure, embolization or with the development of a new murmur.
High-dose antibiotics given i.v. are mandatory; however, revision
valve replacement surgery will almost certainly be needed, particularly if abscesses have developed.

FURTHER READING
Moffatt-Bruce S D, Jamieson W R E. Long-term performance of prostheses
in mitral valve replacement. J Cardiovasc Surg 2004; 45: 42747.
(Discusses the long-term outcome of patients with mechanical and
biological prostheses in the mitral position.)
Sievers H-H. Prosthetic aortic valve replacement. J Thorac Cardiovasc
Surg 2005; 129: 9615.
(Reviews the anatomy of the aortic root and the effects valve
characteristics have on haemodynamics.)
Simionescu D T. PRevention of calcification in bioprosthetic heart
valves: challenges and perspectives. Expert Opin Biol Ther 2004; 4:
197185.
(Reviews the methods of biological valve preservation.)

Paravalvular leak
Paravalvular leak occurs as a result of infection or as a result of
a technically inadequate implantation. While small paravalvular
leaks may be well tolerated, re-operation to replace the valve or

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