Response to Letter Regarding Article, “Prosthetic Heart Valve”
We thank Mr Mokhles and Drs Borger and Takkenberg for their interest in our article.1 We will address several of the issues they have raised.
The intent of the clinician update is to describe a patient and the ensuing discussion related to that patient. In this instance, the clinical practice issue related to the process of selecting a prosthetic heart valve (PHV) for a young 55-year-old person. This is important because it evaluated the pros and cons of reducing the age for the use of bioprosthesis that is becoming a more common issue in clinical practice. This patient had no associated comorbid conditions and also was otherwise fit and healthy, which made this case relatively unique. The discussion was not intended to be applicable to all patients; we have published extensive reviews of choice of PHV for all patients2,3 that had a detailed section, “Choosing a PHV for an Individual Patient.”
The article by Stoica et al4 to which they referred in their letter was published after our article was submitted to the journal; it provides data supporting our conclusion.
The patient is most important, and therefore we had stated, “the final choice of a PHV should be a joint decision by patient, cardiologist, and cardiac surgeon.”2,3 They have added “informed adequately” to this, but did not define what constitutes, and who determines, “adequately.” In our view, individuals presenting the information to the patient (1) should have a thorough knowledge of, as well as critical evaluation of, the published data and should be able to effectively communicate this to patients; (2) ensure that their biases, goals, priorities, and conflicts (of the individuals or institutions), whether intentional or unintentional, even if subtle, are scrupulously avoided when presenting this information to the patient; and (3) take adequate time and effort to do it.
Factors that should be considered in choosing a PHV were not prioritized or numbered in our tables.1,2 Their suggestion of what constitutes the number 1 factor is not based on data. Although we respect their opinion, we are not convinced the factors listed in the table should be prioritized.
In conclusion, there is agreement that the choice of a PHV should be individualized and the patient is an important and integral part of the decision.
Grace Huang, MD
Shahbudin H. Rahimtoola, MB, FRCP
Division of Cardiovascular Medicine
Department of Medicine
LAC+USC Medical Center
Keck School of Medicine at University of Southern California
Los Angeles, CA
Dr Huang reports no conflicts. Dr Rahimtoola has received honoraria only for educational lectures from Edwards Life Sciences.
- © 2011 American Heart Association, Inc.
- Huang G,
- Rahimtoola SH
- Stoica S,
- Goldsmith K,
- Demiris N,
- Punjabi P,
- Berg G,
- Sharples L,
- Large S