Prosthetic Heart Valves

Sir, this patient has got mechanical mitral/aortic valve which has been done for an
underlying mitral/aortic stenosis/regurgitation.

I say this because there presence of a mid-line sternotomy scar associated with
audible metallic clicks to the unaided ear.

There is presence of a mitral valve replacement with a metallic first heart sound and a
normal second heart sound. There is no pan-systolic murmur to suggest a valve
leakage.

(There is presence of an aortic valve replacement as evidenced by a normal first heart

sound followed by a metallic click and a metallic second heart sound. There is no
early diastolic murmur or a collapsing pulse to suggest a valve leakage.)

(There are both mitral and aortic valve replacement as evidenced by dual metallic
heart sounds. There is no pan-systolic murmur to suggest a mitral valvular leakage or
an early diastolic murmur which indicates an aortic valve leakage.)

Ther metallic sounds are crisps (no valvular thrombosis) and there is no conjunctival
pallor or jaundice to suggest hemolytic anaemia. The apex beat is displaced at the 6th
IC at the ant axillary line. (Displaced and MVR = MR; undisplaced and MVR = MS;
Displaced and AVR = AR). There is no evidence of pulmonary hypt(MVR). Patient is
in CCF as evidenced by presence of bibasal crepitations, raised JVP of 3 cm and
bipedal edema.
Patient is not in AF(MVR) and pulse is not collapsing in nature (mention this if AVR
for leakage). There is no peripheral stigmata of IE such as clubbing, Janeways lesion,
Oslers nodes or splinter haemorrhages. This is associated with bruises which suggest
overanticoagulation.

There is no evidence of any Marfans, RA, AS or Syphilis (mention this if AVR for
AR or MVR for MR)

I would like to complete my examination by taking the BP of the patient and looking
at his temperature chart and neurological examination for strokes.

In summary, this patient has got MVR/AVR or both which is most likely done for
MR/MS/AR/AS (which is due to underlying Marfans syndrome). There is no clinical
evidence of valvular leakage, thrombosis or haemolytic anaemia. There is also no
pulm hypt but pt is in heart failure and in AF. There are no signs of IE or
overanticoagulation.

Questions
What are the indications of a mitral/aortic valve replacement?
o See respective MS/MR/AS/AR

What are the types of prosthetic valves?

Mechanical valves

Ball and cage valve (Starr-Edwards)

Single tilting disc (Bjork-Shiley)

Double tilting disc (St Jude)

Bioprosthetic Homograft or heterograft

What are their differences?

Duration

Mechanical valves last 20-30yrs

Bioprosthetic may fail within 10-15 years

Thrombogenecity

Mechanical require lifelong anticoagulation (Starr-Edwards>single
disc>double disc)

Bioprosthetic does not require lifelong anticoagulation

Therefore in the young and those who already require long term anticoagulation,
mechanical valves preferred

And in the elderly(lifespan <10-15 years) or those that cannot tolerate
anticoagulation, bioprosthetic valve preferred

What are the complications?

Complications of prosthesis

Valve leakage (mild- hemolytic anaemia, severe CHF)

Valve thrombosis

Valve strut failure (rare, acute presentation with high mortality, Bjork-Shiley)

Hemolytic anaemia (from valvular leakage due to partial dehiscence; Rx with
Fe, folate, transfusions, B blockers or if fit for op, repair of valve replacement)

Complications of valvular heart disease

Infective endocarditis

Congestive cardiac failure

Thromboembolism (rule out IE and thrombosis)

Complications of management

Overanticoagulation

Bleeding

What are the causes of anaemia in such patients?

Bleeding from anticoagulant

Hemolytic anaemia

Infective endocarditis

How do you tell clinically that the valve has malfunction?

New murmur

Change in characteristic of a preexisting murmur

Change in intensity or characteristic of an audible sound

How would you investigate a patient suspected of having valve dysfunction?

Cinefluoroscopy rapid, fast ad inexpensive for structural integrity

TTE often difficulty study due to reverberations from the metal

TEE useful for assessing MV prosthesis but limited in AV prosthesis

Can MRI be done for a patient with mechanical heart valves?

Yes it is safe except those with pre 6000 Starr-Edwards prosthesis (1960-64)
Valve thrombosis

Up to 5% per patient-year

Factors inadequate anticoagulation and mitral location

Manisfest as

pulmonary congestion, poor peripheral perfusion or systemic embolisation,
acute deterioration

Change in audible sounds or murmur

Ix shows reduced movement of the disc or poppet, reduced orifice area, increased
regurgitation or transvulvular pressure

Mx

<5mm IV heparin

>5mm Fibrinolysis (if high operative mortality) or valve replacement