The multidisciplinary teams of the “heart team” take the field to direct the patient towards the most suitable valve prosthesis and surgery
When a heart valve, most often the aortic or mitral valve, malfunctions, the heart fails to work efficiently, with dangerous consequences. Often the only curative treatment is the replacement of the diseased valve with a biological or mechanical valve prosthesis. But not all tubes are good for all ages. Here then comes the Heart team, the heart team, at the service of the patient. It is a group of professionals with different skills (cardiac surgeon, hemodynamist, imaging expert, cardiologist, neurologist and geriatrician) which allows the most suitable path to be tailored to each patient, with positive effects on the outcomes of the treatments, as he points out Alessandro Parolari, president of the Italian Society of Cardiac Surgery as well as professor of cardiac surgery at the University of Milan. «The heart team evaluates and studies the individual case in depth in order to be able to offer the patient the most suitable type of valve prosthesis as well as the preferable procedure, be it traditional surgery or a less invasive method such as Tavi (valve implantation transcatheter aortic valve).
Pros and cons of the different types of prosthetic valves
Replacing a diseased valve requires the implantation of a prosthetic valve. Basically there are two large families of prostheses: biological valves, of animal extraction, and mechanical valves, made of various artificial components, mainly metal. «Mechanical valves have an indefinite duration, but in order to function adequately they require lifelong anticoagulant therapy, with periodic monitoring tests – explains Lorenzo Menicanti, president of the Cardiovascular Network of Scientific Hospitalization and Care Institutes (IRCCS) as well what scientific director of the San Donato Polyclinic -. The mechanical valve is in fact recognized by the body as something foreign, which can lead to the formation of thrombi that can lead to its blockage or favor strokes and embolisms. Anticoagulant therapy allows to prevent such thrombotic events. Biological valves do not require any support therapy because they are more compatible with the human organism, however they have a limited duration, depending on the implant site (in the mitral position they last less than in the aortic one) because the elements of which they are made they wear out. Just to give you an idea, in a relatively young population a biological valve in the mitral position can lose function after 10 years, in the aortic position after 15 years”.
How to choose
The choice of the most suitable valve prosthesis for the individual patient must be calibrated carefully: the guidelines give indications in terms of age and life expectancy on which type is more suitable, but the divide is not so clear-cut and then we must also consider the preferences of the patient, provided, however, that he is adequately informed about the pros and cons. «The younger the patient, the more the biological valve deteriorates. If we place a biological valve on a 20-year-old patient, there is a 50% probability that after 15 years the prosthesis will need to be changed, a percentage which drops to 20% if the patient is 50 and 10% if the prosthesis is placed on a 65-year-old – adds Professor Parolari -. The general orientation is therefore to resort to the mechanical prosthesis in the younger subjects and to the biological one in the older ones».
The type of intervention
Mechanical valves can only be implanted with standard surgery (they cannot be compressed into a catheter), while biological valves can be placed with both traditional surgery and Tavi. «A biological valve surgically implanted in a patient with aortic stenosis, after the age of 60-65, has a duration of at least 15-20 years, while the duration times of the same valve implanted with Tavi are less defined. This procedure, which has allowed us to treat very elderly and high-risk patients in case of standard surgery, was in fact introduced more recently, so there are no long-term data yet» notes Parolari. If in a relatively young patient, under 50-60 years of age, the indication of the guidelines is always to use a mechanical prosthesis and then resort to standard surgery, except for particular needs of the individual patient, the choice becomes more complex in the case of patients above this age. “This is where the heart team takes the field to direct the patient towards the most suitable valve and surgery, taking into consideration age, life expectancy as well as possible operative complications” Menicanti points out. One of the most frequent complications when a heart valve is implanted is the onset of heart rhythm disturbances which may require the implantation of a pacemaker. This occurrence, which has an impact on survival because it leads to a reduction in life expectancy, is more common in TAV (about 10 percent of cases compared to less than 3 percent in traditional surgery). «The choice must therefore always be well thought out and it is essential to provide clear information to the patient» concludes Parolari.
February 25, 2023 (change February 25, 2023 | 10:31)
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