Prosthetic Heart Valves & Management

Prosthetic heart valves are used to treat patients with stenosis or insufficiency
(regurgitation) of any of the four valves. Many patients will develop symptoms of heart
failure and so valve replacement is indicated for these patients. Others can be identified
through echocardiogram and are asymptomatic. Indication for valve replacement in
these patients is based on measurements taken on echo.

Mechanical vs. Biologic

- Mechanical valves are better for younger patients (when the valve needs to last a
long time) or patients who are already on anticoagulation
- Biologic valves are better for older patients or those who are at greater risk of
bleeding as only 3 months of postop anticoagulation is required

Infective Endocarditis Prophylaxis

- There is conflicting data on prophylaxis of IE as a whole

- Some high-risk groups may benefit from prophylaxis
o COR: IIa; LOE: C-LD
 Prophlyaxis in people undergoing dental procedures who:
 Have prosthetic valves/prosthetic material for valve repair
 Have had previous IE
 Congenital heart disease
 Heart transplant recipient
TAVR vs. Surgical

- TAVR and Surgical repair show no benefit between one over the other in patients
with severe and symptomatic aortic stenosis who have a high or medium surgical
risk
o In patients with low surgical risk, surgical repair is indicated
o In patients with a prohibitive surgical risk, TAVR is indicated

Anticoagulation

- After receiving a prosthetic valve, patients need to be anticoagulated with

warfarin and aspirin
o If biological, 6 months of anticoagulation is required, then only aspirin
moving forwards
o If mechanical, lifelong anticoagulation is required
 Initially bridge with heparin for at least 5 days, while INR is
subtherapeutic, then continue on warfarin and aspirin only
 DOACs and direct thrombin inhibitors are contraindicated
 Goal INR is different for different valve types and different patient
comorbidities; in general, between 2 and 3

Follow-up Care

- First follow-up at 6 weeks to 3 months provided the patient is asymptomatic

o Assess for signs of infection, conduction disturbance, or MI, and obtain
baseline echo to assess valve function
o Any changes suggestive of valve dysfunction at any point in the follow-up
care warrants an echo to work-up
- Annual follow-up for patients that are asymptomatic
o Annual echo in asymptomatic patients is not necessary
 o For transcatheter aortic and pulmonic bioprosthetic valves, annual echo is
recommended since no long-term data yet exists for these valves
Complications

- Thromboembolism
- Valve obstruction
o Treatment depends on the valve affected and the degree of obstruction
 Can be anticoagulation, fibrinolytics, or surgery
- Valve regurgitation and paravalvular regurgitation
o Uncommon and associated with poor outcomes
- Bleeding related to anticoagulation
- Hemolytic anemia
o Mechanical valves can lyse RBCs
o This is common but is often subclinical
o Significant hemolysis resulting in anemia due to mechanical valves is rare,
but can present as jaundice, dark urine, or elevated LDH
- Infectious endocarditis
o In first 2 months: S. Aureus, coagulase-neg. staph > Gram-neg. rods,
Candida
o 2-12 months: coagulase-neg. staph, S. Aureus, strep > enterococci
o 12+ months: strep, S. Aureus > coagulase-neg. staph, enterococci

Pregnancy

- Pregnant women with a bioprosthetic valve should continue aspirin throughout

pregnancy
- With mechanical valves, can either continue on warfarin with aspirin or switch to
LMWH with aspirin
o Warfarin is associated with fetal anomalies and late fetal loss
o LMWH is associated with a higher maternal mortality
- In choosing the type of valve replacement, women wishing to conceive may elect
to use a bioprosthetic valve so that they do not need to be on anticoagulation
during pregnancy

References

Management of antithrombotic therapy for a surgical prosthetic heart valve during

pregnancy. UpToDate.

Overview of the management of patients with prosthetic heart valves. UpToDate.

Nishimura RA et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline
for the Management of Patients With Valvular Heart Disease: A Report of the American
College of Cardiology/American Heart Association Task Force on Clinical Practice
Guidelines. J Am Coll Cardiol. 2017; 70(2): 252-289.
Valvular Heart Disease. AMBOSS.