of a bileaflet mechanical heart valve prosthesis"
Surgical Valve Replacement (Bioprosthetic vs
We compiled a complete record of all residents of Olmsted County, MN, who underwent mechanical MVR between 1981 and 2004, for all TE, bleeding episodes, and international normalized ratios (INRs) measured from prosthesis implantation.
Surgical Valve Replacement (Bioprosthetic vs ..
One patient denied a prosthesis reimplantation. In this case, the patient started to increase weight-bearing on the leg 3 months after spacer implantation. 13 months later, X-rays revealed an asymptomatic acetabular fracture without any spacer dislocation. At a follow-up of 52 months the patient is still free of any infection signs and has no complaints at an almost free range of motion.
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LV EF,,, and MVR,, are recognized risk factors for TE after valve replacement that were also observed in our study. Atrial fibrillation precipitates TEs,, with tissue MVR but not mechanical MVR, which is similar to the results of the present study. Prosthesis type as a TE predictor is controversial.,,,,, These uncertainties stem mostly from differences in TE definition between centers, and uniform TE definition may be an advantage of single-center studies. Recent prostheses are considered less thrombogenic than first-generation prostheses.,, However, proof of definite differences in TE rates between various types of prostheses is scant and disputable. The concept of a higher thrombogenicity for ball valves, has led to the European guidelines recommendation of higher INRs as a presumed compensation for higher thrombogenicity. This recommendation should be reconsidered, as more intense anticoagulation in patients receiving MVR with ball prostheses did not compensate for higher thrombogenicity. Furthermore, higher intensity anticoagulation never reduced TEs, complicating the use of mechanical prostheses.,, The occurrence of excess TEs, particularly stroke, with use of a ball valve in MVR concurs with the results of small single-center studies, and is quite considerable (8.5 vs 3.1 per 100 patient-year, respectively; p was a life saver in its time and has economic advantages for developing countries, but it carries with it an unacceptable TE rate and should be retired from use worldwide. Safer valve substitutes should be available with similar cost-effectiveness. The management of the MVR ball valve in place is more conjectural. Whether target anticoagulation intensity should be an INR of 2.5 to 3.5,,,– or whether an INR of 2 to 3 is also acceptable cannot be ascertained from our data. The absence of a link to the INR-average TE rate in our study may be an incentive for recommending an INR of 2 to 3. A lower goal would reduce variability and minimize bleeding. Finally, the recommendation of using low-dose aspirin in combination with anticoagulation is not affected by our study,, and there is no rationale to alter this guideline.