Are we throwing the baby out with the bath water: Redux

摘要

In the modem age of heart valve replacement, biologic valves and transarterial/apical valve replacement increasingly have been used, mainly due to the required chronic oral anticoagulation necessary with mechanical valve replacement. In this issue of the Journal, Johnson and colleagues1 have continued their series of superb reports on mechanical valve replacement using the St Jude Medical mechanical valve prosthesis, this publication out to 30 years of follow-up. Despite excellent outcomes, low incidence of valve-related events, and unquestioned durability, this experienced group has lowered the use of the St Jude Medical mechanical valve from 61% to 24%, echoing the common trend. This decreased mechanical valve replacement use flies in the face of limited long-term (ie, >20 years) data on biologic valve replacements and even less on transarterial/apical valve replacement used for the treatment of intrinsic valve disease or biologic valves replacement structural valve degeneration. In fact, in 2001 Khan and colleagues,2 in a report on the Cedars Sinai cumulative valve experience over 20 years, noted that for the first 10 years following surgery, valve-related events were greater in mechanical valve replacements related to anticoagulant-related hemorrhage and the Kaplan-Meier curves then crossed and valve-related events were more common in biologic valves replacements related to structural valve degeneration. Importantly, Johnson and colleagues found no wear-related valve failure with the St Jude Medical mechanical valve, similar to our report of 25 years' follow-up covering more than 30,000 patient years.1'3 The extraordinary durability, particularly as the general population is living longer and having fewer resources, becomes increasingly important.