Letter by Mokhles et al Regarding Article, “Prosthetic Heart Valve”
To the Editor:
Drs Huang and Rahimtoola1 presented an interesting clinician update discussing several factors that have to be taken into consideration in choosing a prosthetic heart valve. However, the authors' considerations for prosthetic heart valve selection are, in our opinion, not complete, and deserve further discussion.
With respect to the section on biological valves that need additional aortic root replacement, the Ross procedure and stentless xenograft valve implantation can also be performed successfully and durably by using the subcoronary implantation technique, which does not necessitate root replacement. These techniques can also provide patients with a hemodynamically superior valve substitute.2,3
However, the main point we would like to address concerns the position of the patient in the selection of the most appropriate prosthesis. The factors that the authors discuss are mainly related to clinical status and patient characteristics, whereas patient preferences are also important in choosing the most appropriate prosthesis. The patient that served as an example in the clinician update was a 55-year-old interventional cardiologist, a highly educated individual who, through his extensive experience in the field of cardiology, was clearly able to, by himself, make an informed decision according to his values and preferences in life. However, the average patient who faces this difficult decision is less well educated, and has no knowledge of heart valves. There are many replacement options, uncertain outcomes, and benefits and harms in choosing a particular prosthetic heart valve, especially in patients who are middle-aged and in whom life expectancy is comparable between mechanical and bioprosthetic heart valve substitutes.4 Therefore, there is no single best choice in selecting a prosthetic valve for an individual patient, because all these factors can be valued differently by individual patients; a patient may very well prefer a 60% lifetime risk of a reoperation with a bioprosthesis over a 20% lifetime risk of a major thromboembolic event or bleeding with a mechanical valve, or vice versa, depending on his or her preferences. Although doctors are the ones responsible for applying evidence-based medicine, patients should be informed adequately and according to their educational background, and next be able to discuss their preferences with their doctors. The concept of shared decision making recognizes the importance of having patients and doctors work together in the selection of most appropriate treatment option. Using this concept, well-informed patients and doctors can determine which option best matches what is most important to patients. This approach will not only result in providing evidence-based care, but also in providing patient-centered care. We plead for a patient-centered approach that incorporates evidence on outcome with different therapeutic strategies with preferences of the informed patient. In this respect, in Table 1 of the clinician update, the item “patient's wishes and expectations” should be on top of the list, and renamed “informed patient's wishes and expectations.”
M. Mostafa Mokhles, MSc
Ad J.J.C. Bogers, MD, PhD
Johanna J.M. Takkenberg, MD, PhD
Department of Cardio-thoracic Surgery
Erasmus University Medical Center
Rotterdam, The Netherlands
Sources of Funding
Dr Mokhles is funded by a Mosaic grant of the Netherlands Organisation for Scientific Research (NWO 017.006.058).
- © 2011 American Heart Association, Inc.
- Huang G,
- Rahimtoola SH
- Stoica S,
- Goldsmith K,
- Demiris N,
- Punjabi P,
- Berg G,
- Sharples L,
- Large S