There are two main types of heart valves available: bioprosthetic valves made from animal or human tissue, and mechanical valves made from metal materials. Choosing between the two depends on factors like the patient's age, gender, lifestyle, medical compliance, and access to medical services. Bioprosthetic valves are generally preferred for younger patients, females, and those unable to comply with anticoagulation therapy, while mechanical valves require lifelong anticoagulation but last longer. The choice of valve must consider the individual patient's circumstances and priorities.

1. C H O I C E O F H E A R T V A L V E S Criteria for patient selection Presented by Public Awareness Program

2. Four Predictors of Performance of a valve Durability Hemodynamics Implantability Thromboresistance

3. 1960’s - Commercially Available Mechanical Heart Valves Caged-ball valves were improved and became commercially available . 1960: Harken implanted a double-cage ball valve into aortic annulus 1960: first implant of the Starr-Edwards valve - mitral position (first sold in 1965)

4. 1960’s Disc & Cage designs introduced 1964: Kay-Shiley Beall Starr-Edwards Cooley-Cutter

5. 1960’s Low profile, tilting disc valves introduced Late 60’s: Wado developed a tilting disc valve reducing pressure gradients 1969: Bjork-Shiley disk enhanced wear resistance

6. 1960’s Valve replacement became widely accepted, but mortality and complication rates were high Product failures common due to: Metal fatigue in mechanical valves. Limited thromboresistance knowledge. Biomaterials standards not established.

7. Early Product Failures

8. 1977 Introduction of the SJM bileaflet mechanical heart valve. Largest opening angle Lowest pressure gradients Minimal turbulence and lower thrombogenicity .

9. Tissue Valve History Early generation tissue valves Intact porcine valves Septal muscle bar may reduce blood flow High pressure tissue fixation Flattened tissue structure No anti-calcification treatments May have led to early degeneration of tissue

10. Tissue Valve History Next generation tissue valves Intact porcine valves Reduction of muscle shelf bar Composite valves Porcine tissue Three separate leaflets Pericardial tissue Low pressure tissue fixation Maintained tissue structure Introduction of anti-calcification treatments May prolong life of tissue valve

11. What kinds of heart valves are available? Bioprosthetic Valves Mechanical Valves How do you choose between these valves?

12. Two Main Sources of Bioprosthesis Bov ine Pericardium Tissue Source: Valves removed from pigs. Tissue Source: Valves prepared from bovine pericardium. Porcine

13. What kinds of heart valves are available? Bioprosthetic Valves Valve Characteristics Gray = good Blue = acceptable Red = poor Non obstructive Closure is prompt Non-thrombogenic Chemically inert Noise Free Infection resistance Life of Implant Valves from human or animal tissue and sterilized for use How do you choose between these valves?

14. What kinds of heart valves are available? Mechanical Valves Valve Characteristics Gray = good Blue = acceptable Red = poor Closes quickly Durable Non-obstructive Chemically Inert Infection Resistant Noisy Non thrombogenic Valves made from Metal materials How do you choose between these valves?

15. Current Trends in Valve Implants Tissue valves have become more accepted in the U.S. due to concerns about quality of life and improved durability. Mechanical valves, however, still compose a large part of valve implants, particularly in younger patients. U.S. Implant Trends Mechanical vs Tissue Valve Implants Mechanical 45% Tissue 55%

16. Indian Scenario

17. Valvular Heart Disease There are estimated 5 million patients in India suffering from Heart Valve Disease New patients added every year 50,000 Total no. of Heart Valve Surgeries performed all over India in year 2007 12,234 2009 18,587

18. St. Jude Medical Tissue valve usage

19. Myths about Mechanical Valves Mechanical valves last lifelong ! Indeed they last beyond life but patient may not !! You’ll Not Need Another Operation ! Risks of T hromboembolism is minimal on anti –coagulants ! Coumadin therapy is simple Re-operation is very risky Mechanical valves are less expensive

20. Mechanical Prosthesis Cost Analysis : Anticoagulantion therapy INR Test every 15-30 days No. of visits to Physicians Thrombolysis Treatment of Hemorrhage/Struck Valve Repeated Hospitalization

21. Cost Analysis : WARFARIN 5mg (Anticoagulant Therapy): Rs 150 PT / INR : Rs 150 Professional Services: Rs 200 Misc. : Rs 800 – Rs 1000 Total: Rs 1,300 to Rs 1,500 per month Mechanical Prosthesis

22. Choice of Valve The Patient Age Gender Compliance Concomitant Illness Lifestyle Cost Medical services

23. Choice of Valve Indian Scenario : Rheumatic Heart Disease Children & Young Males & Females Rural & Remote Illiteracy & Poverty Ignorance

24. Choice of Valve in Children Mechanical Prosthesis Advantages

25. BIOPROSTHESIS Advantages in Young No Anticoagulation No Excessive Bleeding No INR Testing Free Mobility, active life Noiseless Better Sociability

26. BIOPROSTHESIS Advantages in Females No Anticoagulation No excessive bleeding No embryopathy

27. BIOPROSTHESIS Advantages in Middle Age No Anticoagulation No Dietary Modifications No Lifestyle Modification

28. BIOPROSTHESIS Advantages in the Elderly No anticoagulation No Thromboembolic episodes Anticoagulation associated bleeding No regular follow up No PT/INR testing

29. Life with a Bioprosthetic Valve Safer No sudden emergency events Less hassles of anticoagulation Elective “Re-do” surgery Better Quality of life, socially acceptable

30. If I Need A Valve Surgery VALVE REPAIR Follow Up Leave it to the Cardiologist

31. If Valve Needs to be Replaced TISSUE VALVE ( Young female, old life exp<20 yrs) No major Follow Up Re do after 10-15 yrs

32. If tissue valve cannot be used MECHANICAL VALVE ( young patient, poor, not ready for re op) Regular Follow Up Required Compromised lifestyle Lifetime anticoagulation required

33. Decisions to make Is Lifestyle Important?

34. Thank You!