Decision Guidelines for Prophylactic Replacement of Björk-Shiley Convexo-Concave Heart Valves

Abstract

Background-Because of risk of outlet strut fracture, prophylactic replacement should be considered for Björk-Shiley convexo-concave (BScc) valve recipients. We assessed the effects of epidemiological and decision-analytic guidelines on actual BScc valve replacement. Methods and Results-We performed a retrospective cohort study including all 2263 Dutch BScc patients with a mean follow-up of 11.3 years (range, 0 to 23 years). Outcomes were outlet strut fracture, mortality, and BScc valve replacement. For the surviving patients in 1992 (nϭ1330), we calculated the expected differences in life expectancy (LE) with and without BScc valve replacement according to decision guidelines developed in 1992. Differences in LE were compared with actual replacements. During 8 years of follow-up, there were 494 deaths (40%), and 11 patients had suffered outlet strut fracture. Of 1330 patients, 96 (10%) had undergone BScc valve replacement, particularly in years after introduction of initial and updated guidelines. One hundred seventeen patients (9%) had an estimated gain in LE after BScc valve replacement. These patients were more likely to undergo replacement than patients with an estimated loss of LE (hazard ratio, 6.6; 95% CI, 4.4 to 10; PϽ0.0001). A loss in LE after reoperation was predicted for 8 of 11 patients who experienced outlet strut fracture after guidelines were available. Conclusions-Valve replacement for BScc heart valve patients was largely in concordance with guidelines in the Netherlands. Individualized guidelines that are based on high-quality epidemiological data and are updated and implemented rigorously can influence clinical practice in complex decision problems.

Tricuspid Valve Ring Annuloplasty in a Patient with 36-year <i>in-situ</i> Functioning Bjork-Shiley Valve in Mitral Position

“…Prophylactic replacement of these valves which were prone to fracture was a concern especially in the early years of implantation of BSV and this peak of replacement was mainly due to infective endocarditis (9) . The other peaks of replacement were mainly after the identification and publication of risk factors for outlet strut fracture in 1992 (10) . However, there have been debates on the necessity of these replacements.…”

Spontaneous leaflet fracture resulting in embolization from mechanical valve prostheses

“…Furthermore, analysis of manufacturers data showed that several aspects of the manufacturing process (eg, repetitive testing) also increased the risk of outlet strut fractures . Based on these risk factors, advisory algorithms were devised to aid cardiothoracic surgeons in making a case‐to‐case decision on prophylactic BSCC replacement . It was concluded that each case should be assessed individually for a proper balance between surgical mortality and gain in life expectancy after reoperation, against the risk of OSF and subsequent loss of life expectancy.…”

Prosthetic heart valves: Types and echocardiographic evaluation

“…pening angle, valve size greater than or equal to 29 mm, mitral position) prophylactic valve replacement has been shown to increase the life expectancy [46]. The strut fracture usually results in the abrupt onset of dyspnea, loss of consciousness, or cardiovascular collapse due to embolization of the disk and acute severe valvular regurgitation.…”