It is usually recommended to use a tissue heart valve in ladies in child bearing age, requiring a heart valve replacement, to avoid the complications of anticoagulation during pregnancy. But prosthetic tissue valves get degenerated in a few years, much faster than in older patients, in patients of this age group. These patients may need a repeat surgery for their tissue valve before they complete their family. Thus the purpose of implanting a tissue valve may not be achieved.
At first go,, we should avoid the use of prosthetic valve itself in this age group of patients,,,, for example,,, BMV for MS, and valve repair for MR, AR etc,,,, if not possible i would recommend the tissue valve ,,, because it will be functional upto 7 to 10 years which would be enough for the patient to complete her family eventhough there is fast structural valve deterioration in this group of patients as the problems of taking anticoagulants for mechanical valve in this group of patients are much more and now a days redo surgery is not high risk at all,,,,,
I totally agree. When implanting a valvular prosthesis to a teenage girl we must consider future pregnancies, even accidental ones, which may occur in the lifespan of the prosthesis. New biological valves have a quite long life, even in young people and can give a teenage girl enough time to complete her family. Of course, the patient must be aware that repeated surgery will be necessary in her life as well as that any pregnancy shortens the life of her prosthesis.
Ross procedure is a better alternative to be considered in such cases and they do pretty well post operatively. But this could be considered only for aortic valve problems. I agree with @ Gopi suggestions.
It depends what the condition is and which valve we are talking about.
While it is difficult to generalize and specify one valve or another it will have to be tailored to meet the requirements in the specific situation taking the patient into the equation and having a broad based discussion of pros and cons.
I think that the great problem is with mitral valve replacement. In young people is impossible to afirm that tissue valve will be good function during 7 or 10 years. Besides is necessary evaluate the anatomic condictions of the mitral apparatus. Young people have a good evolution with mechanical prosthesis. The warfarim use is a problem to be managed after the good surgical result
Metaliic valves should be recommended to youngsters as tiisue valves get degenerated in a very short time.
Metallic valves in aortic position are the first choice. Recommendations about bio valves are not based on reliable evidence; they are rather wishful thinkings.
In most parts of the world, mitral valve replacement is commonly needed. Longevity of modern bioprosthetic mitral valve is 7-10 years, which is good enough to complete family. On the other hand, monitoring of warfarin therapy is often difficult and sometimes impractical in resource-constraint areas, thereby, imposing high risk of under or over anticoagulation on the recipient. So, bioprosthesis may overall be a better choice.
All depends on the valve that has to be replaced. Possible pregnacy and young age related to valve longevity ( and expectd growth? (often not a major issue in a teenage girl?)) are the main predominators of the prosthesis' choice in a young girl. Aortic valve: Ross operation with a bioprosthesis (homograft or allograft) in pulmonic position which could be replaced later in life by a percutaneous pulmonic valve when necessary. This will avoid metallic valve related thrombotic and fetal problems during pregnancy and percutaneous replacement of the pulmonic valve seems to be a reliable alternative for surgery. Moreover, the neo-aortic valve (pulmonic autograft) seems to grow up to adult size and has a excellent longevity. Pulmonic valve: by preference a bioprosthesis, percutaneous or surgical depending on the anatomy and size of the RVOT. Anyhow, metallic valves are performing worse in pulmonic position (increased thrombosis rate). For the tricuspid valve, a conservative approach (repair and ring) or bioprosthesis seems reasonable, since degeneration takes place in a low pressure system and even percutaneous replacement of the tricuspid bioprosthesis in the future might become a real option (case reports and small series already available). For the mitral valve, I would prefer a metallic valve if replacement is really necessary, since the fate of a bioprosthesis in this position is really unpredictable. Of course, all depends on the local health care system, resources and follow-up issues.
I agree with all previous comments. However I believe in making decision should include the patient that I will be carrying the valve. The surgeon should explain the risks and benefits of both the mechanical and the biological prosthesis and should be considered the opinion of the patient.
Anticoagulation, even with the best control, is not a minor issue and morbidity is not negligible because of it.
Particularly I am in favor of the biological valves.
It is obvious that no consensus here is achieved. It's all right in views of doctors. How about think in patients' shoes? What's your choice if you were the teenage girl? If I were the teenage girl, I would like to choose metallic valve. First, the incidence of teratogenicity of warfarin is less than 3% if the dosage is lower than 5mg/d, so maybe I can accept the risk. Second, if it is too risky to have a baby, I may choose not to have. Lastly, if I choose biological one, it is nearly 100% that I need a second major risky redo operation.
Always a tricky grey area.
Mitral: Ideal would be a bioprosthetic valve which will hopefully go on for say 8 to 10 years maximum. By then, if she has become a mother, a mechanical valve can be inserted.
Also depends on how open the family and the patient is to undergo another major redo surgery.
Aortic: ideal: Ross OR
Mechanical valve better as bioprosthetic valve will degenerate faster.
Risk of warfarin induced teratogenecity to be explained.
A tissue valve till she completes her family,which can be later replaced by a mechanical prosthesis when needed.
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