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Any heart valve can become stenotic or insufficient, causing hemodynamic changes long before symptoms. Most often, valvular stenosis or insufficiency occurs in isolation in individual valves, but multiple valvular disorders may coexist.
Treatment depends on severity of disease but usually involves catheter-based valvuloplasty (eg, percutaneous balloon commissurotomy, valvotomy) or surgery (eg, surgical commissurotomy, valve repair, valve replacement). Two kinds of valve prosthesis are used: bioprosthetic (porcine) and mechanical (metal).
Traditionally, a mechanical valve has been used in patients < 65 and in older patients with a long life expectancy, because bioprosthetic valves deteriorate over 10 to 12 yr. Patients with a mechanical valve require lifelong anticoagulation to an INR of 2.5 to 3.5 (to prevent thromboembolism) and antibiotics before some medical or dental procedures (to prevent endocarditis). A bioprosthetic valve, which does not require anticoagulation beyond the immediate postoperative period, has been used in patients > 65, younger patients with a life expectancy < 10 yr, and those with some right-sided lesions. However, newer bioprosthetic valves may be more durable than 1st-generation valves; thus, patient preference regarding valve type can now be considered.
Women of childbearing age who require valve replacement and plan to become pregnant must balance the increased risk of teratogenicity from warfarin with mechanical valves against that of accelerated valve deterioration with bioprosthetic valves. These risks can be reduced by use of heparin instead of warfarin in the first 12 wk and last 2 wk of the pregnancy, but management is difficult and careful discussion is required before surgery.
Endocarditis prophylaxis is also indicated for nearly all patients with valvular heart disorders (see Table 3: Endocarditis: Procedures Requiring Antimicrobial Endocarditis Prophylaxis ).
Last full review/revision March 2007 by Paul H. Tanser, MD
Content last modified March 2007
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