Overview of the management of patients with prosthetic heart valves
- William H Gaasch, MD
William H Gaasch, MD
- Section Editor — Valvular Disease
- Professor of Medicine
- University of Massachusetts Medical School
- Tufts University School of Medicine
- Senior Consultant in Cardiology
- Lahey Clinic
- William A Zoghbi, MD, FASE, FAHA, MACC
William A Zoghbi, MD, FASE, FAHA, MACC
- Professor and Chairman
- Department of Cardiology
- Elkins Family Distinguished Chair in Cardiac Health
- Houston Methodist DeBakey Heart & Vascular Center
- Houston Methodist Hospital
Surgical replacement of a diseased heart valve with a prosthetic valve or transcatheter implantation of a prosthetic valve exchanges the native disease for prosthesis-related complications [1-3]. The frequency of various complications depends upon the valve type and position, and other clinical risk factors. Complications include embolic events, bleeding, valve obstruction (due to thrombosis or pannus), infective endocarditis, structural deterioration (particularly for bioprosthetic valves), paravalvular regurgitation, hemolytic anemia, and prosthesis-patient mismatch.(See "Complications of prosthetic heart valves".)
Management of patients with prosthetic valves, including monitoring for complications, is reviewed here. Issues related to antithrombotic therapy in patients (including pregnant women) with prosthetic valves, management of complications, choice of prosthetic valve, transcatheter aortic valve replacement, and prosthesis-patient mismatch are discussed separately. (See "Antithrombotic therapy for prosthetic heart valves: Indications" and "Antithrombotic therapy for prosthetic heart valves: Management of bleeding and invasive procedures" and "Complications of prosthetic heart valves" and "Management of pregnant women with prosthetic heart valves" and "Choice of therapy for symptomatic severe aortic stenosis" and "Surgical procedures for severe chronic mitral regurgitation" and "Choice of prosthetic heart valve for surgical replacement", section on 'Prosthetic valve-patient mismatch'.)
Goals — The goals of serial follow-up of patients with prosthetic valves include identification of changes in clinical status, management of antithrombotic therapy, monitoring for complications, identification of changes in valve function, and provision of patient education.
Patient education — Patients should be educated about prosthetic valve outcomes, the need for proper care (including optimal dental care, the need for antibiotic prophylaxis for dental procedures, and when required, appropriate antithrombotic therapy) and should be instructed to seek prompt medical attention for any new sign or symptom that might be related to a valve complication such as a significant change in the audible click of a mechanical prosthesis, persistent or recurrent fever, decrease in exercise tolerance, ischemic cerebral events, or palpitations. Repeat evaluation with echocardiography should be performed any time there is a change in clinical status or examination findings. (See 'Infective endocarditis' below.)
Schedule of follow-up — The main components of follow-up are history, physical examination, and echocardiography. We suggest the following approach to evaluation after prosthetic valve implantation, largely based on the 2014 American College of Cardiology/American Heart Association guidelines on the management of valvular heart disease :
- Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012; 33:2451.
- Whitlock RP, Sun JC, Fremes SE, et al. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e576S.
- Nishimura RA, Otto CM, Bonow RO, et al. 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 Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
- Vongpatanasin W, Hillis LD, Lange RA. Prosthetic heart valves. N Engl J Med 1996; 335:407.
- Zoghbi WA, Chambers JB, Dumesnil JG, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, developed in conjunction with the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography and the Canadian Society of Echocardiography, endorsed by the American College of Cardiology Foundation, American Heart Association, European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography, and Canadian Society of Echocardiography. J Am Soc Echocardiogr 2009; 22:975.
- Olmos L, Salazar G, Barbetseas J, et al. Usefulness of transthoracic echocardiography in detecting significant prosthetic mitral valve regurgitation. Am J Cardiol 1999; 83:199.
- Shiran A, Weissman NJ, Merdler A, et al. Transesophageal echocardiographic findings in patients with nonobstructed prosthetic valves and suspected cardiac source of embolism. Am J Cardiol 2001; 88:1441.
- Saad RM, Barbetseas J, Olmos L, et al. Application of the continuity equation and valve resistance to the evaluation of St. Jude Medical prosthetic aortic valve dysfunction. Am J Cardiol 1997; 80:1239.
- Horstkotte D, Friedrichs W, Pippert H, et al. [Benefits of endocarditis prevention in patients with prosthetic heart valves]. Z Kardiol 1986; 75:8.
- Skoularigis J, Essop MR, Skudicky D, et al. Frequency and severity of intravascular hemolysis after left-sided cardiac valve replacement with Medtronic Hall and St. Jude Medical prostheses, and influence of prosthetic type, position, size and number. Am J Cardiol 1993; 71:587.
- Shapira Y, Vaturi M, Sagie A. Hemolysis associated with prosthetic heart valves: a review. Cardiol Rev 2009; 17:121.
- Kloster FE. Diagnosis and management of complications of prosthetic heart valves. Am J Cardiol 1975; 35:872.
- Ismeno G, Renzulli A, Carozza A, et al. Intravascular hemolysis after mitral and aortic valve replacement with different types of mechanical prostheses. Int J Cardiol 1999; 69:179.
- Enzenauer RJ, Berenberg JL, Cassell PF Jr. Microangiopathic hemolytic anemia as the initial manifestation of porcine valve failure. South Med J 1990; 83:912.
- Maraj R, Jacobs LE, Ioli A, Kotler MN. Evaluation of hemolysis in patients with prosthetic heart valves. Clin Cardiol 1998; 21:387.
- Hirawat S, Lichtman SM, Allen SL. Recombinant human erythropoietin use in hemolytic anemia due to prosthetic heart valves: a promising treatment. Am J Hematol 2001; 66:224.
- Bonow RO, Nishimura RA, Thompson PD, Udelson JE. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 5: Valvular Heart Disease: A Scientific Statement From the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015; 66:2385.
- Bonow RO, Cheitlin MD, Crawford MH, Douglas PS. Task Force 3: valvular heart disease. J Am Coll Cardiol 2005; 45:1334.
- SERIAL FOLLOW-UP
- Patient education
- Schedule of follow-up
- History and physical examination
- Other diagnostic studies
- Infective endocarditis
- Hemolytic anemia
- - Incidence
- - Clinical manifestations
- - Diagnosis and evaluation
- - Management
- ANTITHROMBOTIC THERAPY
- ENDOCARDITIS PROPHYLAXIS
- EXERCISE RECOMMENDATIONS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS