doi: 10.1161/01.CIR.0000165305.02689.86
(Circulation. 2005;111:2152-2153.)
© 2005 American Heart Association, Inc.
Editorial |
Use of Heart Valves in Older Patients
From the Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, Mass.
Correspondence to Lawrence H. Cohn, MD, Division of Cardiac Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115. E-mail lcohn{at}partners.org
Key Words: Editorials • aortic valve • bioprosthesis • fibrillation • aged
It has been known for at least 2 decades that the second- and third-generation porcine and pericardial bioprosthetic valves treated with glutaraldehyde are the preferable aortic valve devices in patients 
65 years old who require aortic valve replacement.1 Furthermore, many studies of patients in this age group, especially with coronary artery disease, have repeatedly demonstrated that these patients rarely outlive these valves.2 Bioprosthetic cardiac valves do not need warfarin anticoagulation for patients in sinus rhythm, an advantage for older patients who have many concomitant disease states or existing conditions that contraindicate warfarin anticoagulation.3 Because of recent modifications in valve fabrication, including the use of glutaraldehyde at low fixation pressures, pericardial and porcine bioprosthetic valves have become even more reliable in terms of valve integrity and are clearly the choices for aortic valve replacement in older patients.4
See p 2178
That this principle has been appreciated for some time led to the codification of this concept in the American Heart Association/American College of Cardiology (AHA/ACC) valve guidelines published in 1998.5 Thus, the article in this issue of Circulation by Schelbert et al,6 who review >80 000 patients 65 years old who underwent isolated aortic valve replacement in >1000 US hospitals from 1999 to 2001, is a surprise. Many who work in valve surgery centers have taken the general principal of using tissue valves in older patients as part of today’s established practice guidelines. In our own experience from 1992 to 2004 at the Brigham and Women’s Hospital in 2447 patients 65 years old, 81% of all patients in this age group received a bioprosthetic aortic valve. Schelbert and colleagues’s report documents that only 52% of patients older than age 65 received cardiac tissue valve. Even in patients >90 years old, only 60% overall received a bioprosthetic valve. They also document that the smaller the volume of valvular heart surgery in older patients at a given hospital, the higher the probability of receiving a mechanical heart valve that requires anticoagulation. In their study, as the valve surgery volume increased the use of bioprosthetic valves also increased, so that by the tenth volume decile, 68% of patients received a bioprosthetic valve. This correlation between low valve surgery volume and percentage of older patients receiving mechanical valves may be because mechanical low-profile valves, bileaflet or single leaflet, are easier to insert into the aortic root than are bioprosthetic valves. Technical challenges such as aortic root atherosclerosis, a small aortic root, and excessive concern about patient–prosthesis mismatch7 may be factors that suggest a mechanical valve to less experienced valve centers. This concept that increased experience equals improved quality of care is not new and has been documented for many surgical therapies in addition to cardiac surgical problems.8
Patients in chronic atrial fibrillation or those who have other conditions requiring long-term chronic anticoagulation often will have a prosthetic valve in this age group, but even in these situations tissue valves may be more manageable in older people. As pointed out by the Brigham and Women’s group, the incidence of chronic atrial fibrillation in older patients is 
16% but is not likely to account for the high rates of mechanical valve use observed in the analysis by these authors.9
Clearly, there is a need for further publicity about recommendations for valve type in older patients based on the 1998 AHA/ACC guidelines. Schelbert and associates’s article serves as a reminder that what is published in generally accepted guidelines may not necessarily be translated to real-world practice. This article also is a timely reminder that we will be seeing increasing numbers of older patients referred for aortic valve replacement in the coming decades. Recommendations based on what is acknowledged to be best for patients in the older adult age group should be reemphasized, and our collaborative efforts should be channeled with considerably more energy to attain optimal therapy for older Americans.
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Footnotes |
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The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.
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References |
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 Top References |
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- Cohn LH, Collins JJ Jr, DiSesa VJ, Couper GS, Peigh PS, Kowalker W, Allred EN. Fifteen year experience with 1678 Hancock porcine bioprosthetic heart valve replacements. Ann Surg. 1989; 210: 435–443.[Medline]
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- Jones EL, Weintraub WS, Craver JM, Guyton RA, Shen Y. Interaction of age and coronary disease after valve replacement: Implications for valve selection. Ann Thorac Surg. 1994; 58: 378–384.[Abstract]
- Levine MN, Raskob G, Landefeld S, Kearon C. Hemorrhagic complications of anticoagulant treatment. Chest. 2001; 119: 108S–121S.
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- Banbury MK, Cosgrove DM III, White JA, Blackstone EH, Frater RW, Okies JE. Age and valve size effect on the long-term durability of the Carpentier-Edwards aortic pericardial bioprosthesis. Ann Thorac Surg. 2001; 72: 753–757.
[Abstract/Free Full Text]
- Bonow RO, Carabello B, de Leon AC Jr, Edmunds LH Jr, Fedderly BJ, Freed MD, Gaasch WH, McKay CR, Nishimura RA, O’Gara PT, O’Rourke RA, Rahimtoola SH, Ritchie JL, Cheitlin MD, Eagle KA, Gardner TJ, Garson A Jr, Gibbons RJ, Russell RO, Ryan TJ, Smith SC Jr. Guidelines for the management of patients with valvular heart disease: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 1998; 98: 1949–1984.
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- Schelbert EB, Vaughan-Sarrazin MS, Welke KF, Rosenthal GE. Hospital volume and selection of valve type in older patients undergoing aortic valve replacement surgery in the United States. Circulation. 2005; 111: 2178–2182.
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- Blackstone EH, Cosgrove DM, Jamieson WR, Birkmeyer NJ, Lemmer JH Jr, Miller DC, Butchart EG, Rizzoli G, Yacoub M, Chai A. Prosthesis size and long-term survival after aortic valve replacement. J Thorac Cardiovasc Surg. 2003; 126: 783–796.
[Abstract/Free Full Text]
- Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, Welch HG, Wennberg DE. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002; 346: 1128–37.
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- Aranki SF, Rizzo RJ, Couper GS, Adams DH, Collins JJ Jr, Gildea JS, Kinchla NM, Cohn LH. Aortic valve replacement in the elderly. Effect of gender and coronary artery disease on operative mortality. Circulation. 1993; 88: II-17–II-23.[Medline]
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Related Article:
- Hospital Volume and Selection of Valve Type in Older Patients Undergoing Aortic Valve Replacement Surgery in the United States
- Erik B. Schelbert, Mary S. Vaughan-Sarrazin, Karl F. Welke, and Gary E. Rosenthal
Circulation 2005 111: 2178-2182.[Abstract] [Full Text]
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