Which Type Of Prosthetic Valves To Offer To Our Patients In Developing Countries

Abstract

INTRODUCTION:
A cardiac valve is a device which allows the flow of blood in only unidirectional manner. Starr¹ implanted on September 21st, 1960 the first long-term successful mitral valve replacement with a caged ball valve in a 52-year old man with mitral stenosis and regurgitation. Successful implantations were enthusiastically performed all over the world and four basic types of cardiac valve prosthesis, caged ball, caged disc,  tilting disc and tissue valves were developed. However, soon, many . Potential complications of even fatal nature, such as thromboembolism2, degeneration3, calcification4, days f unction5 ,6 metal fatigue7 with breakage, infections8 and outgrowing a prosthesis9 were encountered.

PATIENTS & METHODS:
701 patients underwent open heart surgery for replacement of their cardiac valves in Saudi Arabia, Sudan, Yemen and Mauritius by the same surgical team which performed 10 overseas open heart projects outside the Kingdom of Saudi Arabia between 1981-1987. 262 were males (37%) and 439 were females (62%) 152 patients were children below the age of 14 years (21%). Indications for valve replacement were severe fibrosis and dystrophic changes in 668 patients, advanced calcification in 14 patients, infective endocarditis with ulceration and perforation of valve cusps in 13 patients, and failed trials of reconstructive surgery in 6 patients.

RESULTS:
701 cardiac valve replacements were performed. Aortic valve replacement was performed in 398 patients and mitral valve replacement in 417 patients. 38 patients died postoperatively (within 30 days) reflecting an early mortality rate of 5.4%. 12 patients died later due to complications related to cardiac prosthesis [6 patients), Prosthetic valve endocarditis(2 patients), car accident (1 patient), electrocution (1 patient), leukemia (1 patient) and unknown cause (1 patient) reflecting a late mortality rate of 2.3%!patient/year.

DISCUSSION:

Cardiac valve replacement with prosthetic valves is an event which is connected with a series of potential complications as the ideal prosthetic valve does not exist. Thrombogenicity, non-durability, liability to infections and obstructive and peripheral flow and other valve related complications are important factors restricting and prohibiting wide and generous valve replacement. A valve replacement is an ultima ratio and the last palliation. The decision to use any particular heart valve is often based on personal clinical experience, an experience complicated by the evolutionary nature of prosthetic heart valve design and the myriad of devices now available in addition, to a multifactorial evaluation of age, sex, origin, compliance to anticoagulation, psychological makeup,literacy, awareness, availability of facilities for Prothrombin estimation and different medical criteria such as size of LV cavity, presence of anemia or a bleeding diathesis, ulcer disease and hypertension.