The document discusses options for aortic valve replacement prostheses. Mechanical valves require lifelong anticoagulation but last longer, while bioprosthetic valves do not require anticoagulation but are subject to structural deterioration over time. Patient factors like age, lifestyle, ability to adhere to medication, and plans for pregnancy must be considered. The best prosthesis is chosen through shared decision making between the patient and doctor based on individual clinical situation and quality of life preferences. No single prosthesis is perfect for all cases.

1. A O RT I C VA LV E R E P L A C E M E N T :
C H O O S I N G T H E R I G H T P R O S T H E S I S
N AV Y L A K S M O N O
T H O R A C I C , C A R D I A C A N D VA S C U L A R S U R G E RY P R O G R A M
FA C U LT Y O F M E D I C I N E U N I V E R S I TA S I N D O N E S I A
Supervisor : dr. Arinto Bono Adji, SpBTKV, MARS

2. “What prosthesis should I choose doctor?,
what is your recommendation?”
• A 35 y.o male, indicated for AVR with severe AS, rheumatic, lives
in a remote island in Natuna island, working as a fisherman.
• A 27 y.o female, not married. Severe symptomatic AR, works as a
TV anchor.
• A 75 y.o male, retired. Severe AR, lives in Jakarta near RSCM. No
problems to strict anticoagulant therapy.

3. A N AT O M Y O F A O R T I C VA LV E

4. I N D I C AT I O N O F AV R E P L A C E M E N T
Nishimura RA, Otto CM, Bonow RO, 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. Circulation 2017;135:e1159-e95.

12. Nishimura RA, Otto CM, Bonow RO, 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. Circulation
2017;135:e1159-e95.

13. Rahimtoola SH. Choice of prosthetic heart valve in adults an update. J Am Coll Cardiol 2010;55:2413-26.

14. What prosthesis should we choose?

15. Harken DE. Heart valves. Ten commandments and still
counting. Ann Thorac Surg. 1989;48(suppl 3):S18 –S19.

16. C H O I C E S O F R E P L A C E M E N T S
• Mechanical Prosthesis
• Bileaflet
• Single Tilting Disc
• Caged ball
• Xenografts
• Porcine stented heterograft
• Bovine pericardial valves
• Homograft
• Autograft

17. M E C H A N I C A L A O R T I C
VA LV E
• 50 years of evolution
• Most are dependent to anticoagulant
• Easy to implant
• Long lasting*
• Valve related complication are severe and
emergency
• Non valve complications rates is high especially in
old patients
• Clicking sound

18. X E N O G R A F T S
• To answer all limitation of MHV
• First described by Carpentier in 1971, with a
porcine allograft*
• Porcine stented allograft or Bovine
pericardial tissue
• Anticoagulant only for the first 3 months
• Structural Valve Deterioration is the issue,
especially in younger patient
• Multiple operation
• Valve related complications is gradual, could
be medically managed while wait for
reoperation/ invasive intervention
Carpentier A. The concept of bioprosthe-sis. Thoraxchir Vask Chir 1971;19:379-83
El Oakley R, Kleine P, Bach DS. Choice of prosthetic heart valve in today's practice. Circulation 2008;117:253-6.
Rahimtoola SH. Choice of prosthetic heart valve in adults an update. J Am Coll Cardiol 2010;55:2413-26.

22. A L L A G E

23. 50 - 70 years old
60 - 70 years old

24. Less than 65 years old

30. Nishimura RA, Otto CM, Bonow RO, 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. Circulation 2017;135:e1159-e95.

32. “How to choose?”

33. Nishimura RA, Otto CM, Bonow RO, 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. Circulation 2017;135:e1159-e95.

34. Rahimtoola SH. Choice of prosthetic heart valve in adults an update. J Am Coll Cardiol 2010;55:2413-26.

35. Rahimtoola SH. Choice of prosthetic heart valve in adults an update. J Am Coll Cardiol 2010;55:2413-26.

36. P R O S T H E S I S VA LV E I N P R E G N A N C Y
• The patients and family should be fully informed and
decide together about the risk, premarital counseling is
advised
• SVD accelerated in bioprosthesis valve
• Thromboembolic event rate increased in mechanical valve
• Vit-K antagonist crosses placenta barrier and teratogenic
Editorial. Journal of the American College of Cardiology 1999;33:1642-5.
Elkayam U, Bitar F. Valvular heart disease and pregnancy: part II: prosthetic valves. J Am Coll Cardiol 2005;46:403-10.

37. Elkayam U, Bitar F. Valvular heart disease and pregnancy: part II: prosthetic valves. J Am Coll Cardiol 2005;46:403-10.

38. Patient Prosthesis Mismatch: Size Does Matter.
Pibarot P, Dumesnil JG. Prosthesis-patient mismatch: definition, clinical impact, and prevention. Heart 2006;92:1022-9.

39. Pibarot P, Dumesnil JG. Prosthesis-patient mismatch: definition, clinical impact, and prevention. Heart 2006;92:1022-9.

40. Pibarot P, Dumesnil JG. Prosthesis-patient mismatch: definition, clinical impact, and prevention. Heart 2006;92:1022-9.

41. EOA : BSA x 0.85 cm2 / m2
Pibarot P, Dumesnil JG. Prosthesis-patient mismatch: definition, clinical impact, and prevention. Heart 2006;92:1022-9.

42. H O M O G R A F T S / A U T O G R A F T S

46. Andreas M, Wiedemann D, Seebacher G, et al. The Ross procedure offers excellent survival compared with mechanical aortic valve replacement in a real-world setting.
Eur J Cardiothorac Surg 2014;46:409-13; discussion 13-4.

47. Andreas M, Wiedemann D, Seebacher G, et al. The Ross procedure offers excellent
survival compared with mechanical aortic valve replacement in a real-world setting.
Eur J Cardiothorac Surg 2014;46:409-13; discussion 13-4.

48. R O S S
P R O C E D U R E
• Highly selected patients
• Very high risk procedure
• Highly skilled surgeons, with
major learning curve
• Pulmonary homograft is hard to
get, not available in many
countries,
• Evidence of allograft/heterograft
pulmonary graft is limited
• Best outcome for younger
patients

49. Nishimura RA, Otto CM, Bonow RO, 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. Circulation 2017;135:e1159-e95.

50. • A 35 y.o male, indicated for AVR with severe AS, rheumatic, lives
in a remote island in Natuna island, working as a fisherman.
• A 27 y.o female, not married. Severe symptomatic AR, works as a
TV anchor.
• A 75 y.o male, retired. Severe AR, lives in Jakarta near RSCM. No
problems to strict anticoagulant therapy.

51. C O N C L U S I O N
• Prosthetic valve should be decided by the patient with a good guidance by the
doctor, based on clinical situation and patient preference of quality of life
• Each prosthetic had drawbacks either MPV or BPV
• MPV dependent on anticoagulant, quality of life in somehow is reduced with the risk of
bleeding
• BPV deteriorates more rapid in younger patients, and risk of reoperation is a certain
• Ross procedure is an option for aortic replacement in younger patients, although
requires a highly skillfull experienced surgeon and a long learning curve in real
life. It has a excellent outcome.
• There is no single perfect prosthetic that could be chosen, a complete
understanding of the nature of prosthetic by the patient and doctor is mandatory

52. T H A N K Y O U

62. Nishimura RA, Otto CM, Bonow RO, 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. Circulation 2017;135:e1159-e95.