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eComment: Mechanical valve replacement in the elderly: does anticoagulation have benefit?

Dr. Siayami Ersek Thoracic and Cardiovascular Surgery Center, Istanbul, Turkey

Long-term follow-up of elderly patients subjected to aortic valve replacement with mechanical prostheses

We read with great interest the recent report by Coutinho and coworkers regarding the outcome of mechanical aortic valve replacement (AVR) in the elderly patients [1]. AVR surgery is increasing and will increase even further as a result of population aging. Surgical treatment for symptomatic aortic stenosis in the elderly has an acceptable operative risk with excellent long-term results. De Vincentiis et al. have demonstrated that survival rate with mechanical valve prosthesis is higher than bioprosthetic valve [2].

Biologic valves are considered the optimal choice in patients older than 65 years by the American College of Cardiology/American Heart Association 2008 guidelines [3]. Mechanical AVR has still some reservations to offer, because it may be associated with complications, such as anticoagulation and thromboembolism. However, the choice of mechanical prosthesis in the elderly patients often depends on different factors, including chronic atrial fibrillation, the use of anticoagulation for other diseases, less need of re-operation, preference of the cardiologist or surgeon as well as patients’ wishes, and technical reasons related to aortic annulus. We recently reported a cohort of patients who underwent aortic valve replacement and coronary artery bypass surgery [4]. We did not find any differences between the two types of prosthesis. Which mechanisms were responsible for neurological injury in patients who received mechanical valve prosthesis is obscure. Central neurological events may be due to not only the valve itself but also to other causes, such as aortic, particularly carotid and vertebral artery disease in this older age group. Furthermore, many patients are prone to cerebrovascular events at the advanced age. So, what is the explanation for this finding? Does the mechanical valve, whether from the valve itself or from its associated anticoagulation, in the elderly patient really have some advantages? A randomized prospective trial of mechanical vs. biological valves would answer the question.

The controversial aspect of this article is that the authors presented only patients who received a mechanical valve with excellent survival. It would be better to compare them with those who received a tissue valve. We would like to congratulate the authors for their excellent long-term results with an acceptable mortality and morbidity rate.

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1. Coutinho GF, Pancas R, Antunes PE, Antunes MJ. Long-term follow-up of elderly patients subjected to aortic valve replacement with mechanical prostheses. Interact CardioVasc Thorac Surg 2009;9:576–582.[Abstract/Free Full Text]
2. de Vincentiis C, Kunkl AB, Trimarchi S, Gagliardotto P, Frigiola A, Menicanti L, Di Donato M. Aortic valve replacement in octogenarians: is biologic valve the unique solution? Ann Thorac Surg 2008;85:1296–1302.[Abstract/Free Full Text]
3. Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT, O’Rourke RA, Otto CM, Shah PM, Shanewise JS. 2006 Writing Committee Members American College of Cardiology/American Heart Association Task Force. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines 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 (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008;118:e523–e661.[Free Full Text]
4. Gunay R, Sensoz Y, Kayacioglu I, Tuygun AK, Balci AY, Kisa U, Demirtas MM, Yekeler I. Is the aortic valve pathology type different for early and late mortality in concomitant aortic valve replacement and coronary artery bypass surgery? Interact CardioVasc Thorac Surg 2009;9:630–634.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Rafet Gunay Permission Requests Google Scholar Articles by Gunay, R. PubMed PubMed Citation Articles by Gunay, R. Related Collections Related Article