Chapter 18 Valvular Heart DiseaseSelection of a mitral valve prosthesis
1 Mitral valve repair is recommended when anatomi-
cally possible for patients with severe degenerative MR
who fulfi ll clinical indications, and patients should be
referred to surgeons who are expert in repair. (Level of
Evidence: B) No ESC recommendation
2 A bioprostheses is indicated for MV replacement
in a patient who will not take warfarin, is incapable
of taking warfarin, or has a clear contraindication to
warfarin therapy. (Level of Evidence: C) ESC recom-
mendation, I (C)
Class IIa
1 A mechanical prosthesis is reasonable for MV
replacement in patients less than 65 years of age with
long-standing atrial fi brillation. (Level of Evidence:
C) ESC recommendation, IIa (C)
2 A bioprosthesis is reasonable for MV replacement
in patients 65 years of age or older. (Level of Evi-
dence: C) ESC recommendation, IIa (C)
3 A bioprosthesis is reasonable for MV replacement
in patients under 65 years of age in sinus rhythm
who elect to receive this valve for lifestyle consider-
ations after detailed discussions of the risks of anti-
coagulation versus the likelihood that a second MV
replacement may be necessary in the future. (Level
of Evidence: C) ESC recommendation: Desire of the
informed patient, I (C)
Future directions
Guidelines in valvular heart disease are limited
by an inadequate number of prospective random-
ized clinical trials, so that the vast majority of
recommendations are based on expert consensus
alone (Level of Evidence C). There is a major unmet
need for the development of clinical trials to deter-
mine the effi cacy of medical therapy and the indica-
tions for and timing of surgical interventions. This
is particularly true in the decisions for surgery in
asymptomatic patients and in patients with ischemic
MR and other forms of functional MR, in which
there is considerable equipoise regarding patient
management. There is also a need for development
of biomarkers in valvular heart disease, which may
identify patients with incipient LV dysfunction at an
earlier stage than can now be determined by symp-
toms or echocardiography evidence of declining
systolic function and enlarging chamber size. BNP
is a good candidate marker, and with further clinical
research, this biomarker and others may become the
object of future guidelines. Finally, the fi eld of per-
cutaneous aortic valve replacement and mitral valve
repair is moving very rapidly, with prospective ran-
domized trials already underway. These exciting
developments are much too preliminary at present
for guidelines considerations, but undoubtedly
future iterations of the valvular heart disease guide-
lines with include recommendations for patient
selection and device selection. These new devices
will also spur the development of clinical trials from
which a prospectively derived evidence base will
emerge, thus addressing the main limitation noted
above in the current guidelines in valvular heart
disease.References available online at http://www.Wiley.com/go/
AHAGuidelineHandbook.