*3.13.5.2 Patient education*

Patient education is the key to compliance with periodic noninvasive monitoring, prevention of complications, and the early recognition of symptoms in patients with valvular heart disease. Each patient should understand the expected long-term prognosis, potential complications, typical symptoms, the rationale for sequential monitoring, and the indications for surgical intervention. Appropriate education avoids needless concern and prompts early reporting of symptoms, allowing

optimal timing of surgical intervention. Increasingly, patients are actively involved in decisions about the timing of surgery and choice of intervention.

Patients also should be knowledgeable about the risk of infective endocarditis and the importance of maintaining optimal oral hygiene, including regular dental care.

Patients undergoing long-term anticoagulation need both education and a reliable and available source for consultation regarding warfarin dose, interactions with other medications, and prompt evaluation of any complications.

### *3.13.5.3 Aortic valve replacement*

The decision for intervention for a faulty aortic valve needs to incorporate the natural history of the medically managed disease, the risks associated with the intervention, and longer-term problems that might build up as a result of prosthetic valve implantation.

Currently, the heart team plays a decisive role in decision making. In addition, it is prudent to cultivate and set up heart valve centres with specialist services in order to generate an ideal environment for the treatment of patients with valvular heart disease.

### *3.13.5.4 Management of Aortic valve stenosis*

Criteria for decision-making are clear for surgical valve and transcatheter aortic valve implantation (TAVI) from the current European guidelines. Recently TAVI is also recommended for patients with intermediate surgical risk. Currently, publish literature also supports TAVI implantation in low risk patients as non-inferior to surgical therapy [55, 56].

For symptomatic, AS recommendations are made with regard to the choice of procedure. For high risk (STS score or EuroSCORE II <4% or a log EuroSCORE <10%) TAVI is the default choice. Surgical replacement is indicated for patients with a low perioperative risk (STS score > 4%). Patients with an intermediate surgical risk, the heart team, should consider other criteria for decision making such as anatomical and functional parameters [57, 58], and frailty to reach the best option for the patients considering the current knowledge.

Current data from two large prospective randomised studies, have confirmed that TAVI was noninferior to surgical treatment with regard to mortality, stroke and additional endpoints in both in patients with a low perioperative risk (the mean STS score in both trials was 1.9%), expansion of the indication for TAVI which would also include younger patients, can be expected [59].

### *3.13.6 Choice of a valve in surgically treated patients*

### *3.13.6.1 Choice of prosthesis*

Choice of prosthesis is a complex decision in a patient undergoing AVR with profound long-term consequences for the patient. Currently available prostheses are different with regard to key features, such as the requirement of anticoagulation, incidence of thromboembolism, durability, ease of implantation, haemodynamic performance, and susbtibilty for infection. Currently age-based guidelines do exist, but the final choice must be tailored to the individual patient including consideration of general lifestyle and physical activity, surgeon expertise, diseases, especially those affecting life expectancy, and, ultimately, overall patient preference.

The patient age is a primary factor in prosthesis selection is. Elderly patients have lower life expectancy and physical activity than Younger patients. Which place

**29**

*Aortic Valve Disease: State of the Art*

even younger.

reoperation in their lifetime.

valves in younger active patients.

solution for patients with endocarditis.

30s when no other good alternatives exist.

*3.13.7.1 Low-flow, low-gradient aortic valve*

*3.13.7 Special situations*

symptomatic patients [60].

*DOI: http://dx.doi.org/10.5772/intechopen.93311*

a greater demand on the prosthesis with regard to durability and hemodynamic performance. Age has long been recognised as a major determinant of bioprosthesis durability. Traditionally target age between 65 and 70 years has been the indications for bioprosthesis and like hood of a second operation for structural valve dysfunction in a life time 65-year-old person is less than 10%. As a result, it is not common to choose a mechanical valve in an old patient. Even if the patient is already treated with warfarin for another condition, for example AF, which should not necessarily favour the choice of a mechanical valve because it converts a relative indication for low-level anticoagulation to an absolute indication for higher levels. It also removes the option to stop warfarin in a case of a significant bleeding event. Moreover even if the patient had previously received mechanical valve, the choice does not mandate a second mechanical valve, because risk of complications thromboembolic and

It is more complex and controversial to choose of prosthesis in patients younger than 65 years. Although traditionally, these patients would receive a mechanical valve; the current, improved durability in bioprosthesis and lower operative risk of a redo operation for a failed prosthesis have increased the number of patients younger than 65 years who receive bioprosthesis, including patients in their 50s and

A particular dilemma women of child-bearing age often it is safer avoid warfarin so they choose a bioprosthesis, with the knowledge that they will face at least one

Stentless valves may provide a larger effective orifice area such as the Toronto

The use of homografts has declined in recent years as a primary aortic valve substitute because without a durability advantage, it is cumbersome to recommend their routine while they have limited availability and the cumbersome storage requirements. However, their ability to resist infection renders them an excellent

The Ross procedure involves replacing the aortic valve with the patient's own

The precise assessment within the heart team of the pathology and anatomy, as well as the evaluation of the patient, are emphasised in the new graduated recommendations regarding low-flow, low-gradient aortic valve stenosis in

pulmonic valve, which have to be is replaced with a homograft or a stentless xenograft. The benefits are near-normal haemodynamic and excellent durability; the disadvantages are the technical complexity and need for reoperation for the homograft or Late AR. The procedure peaked in popularity in the mid to late 1990s, but procedure volume has declined since then. On the basis of the data from the Ross Procedure International Registry, several centres continue to report excellent results [50, 51] although it is now primarily a procedure for paediatric patients, in whom the potential for growth is important, and for young adults in their 20s and

SPV, Freestyle, and Prima Plus valves although the hemodynamic profiles of stentless valves are superior to those of stented valves, especially at the smaller sizes [42] durability and survival benefits still is unproven [47, 48]. Some reports suggest fewer thromboembolic complications [49]. Currently no specifics indication form stentless valve. Maybe these hemodynamic benefits justify implanting stentless

bleeding is higher with two mechanical valves than it is with one.

### *Aortic Valve Disease: State of the Art DOI: http://dx.doi.org/10.5772/intechopen.93311*

*Advances in Complex Valvular Disease*

*3.13.5.3 Aortic valve replacement*

with valvular heart disease.

surgical therapy [55, 56].

*3.13.6.1 Choice of prosthesis*

*3.13.5.4 Management of Aortic valve stenosis*

for the patients considering the current knowledge.

also include younger patients, can be expected [59].

*3.13.6 Choice of a valve in surgically treated patients*

valve implantation.

optimal timing of surgical intervention. Increasingly, patients are actively involved

Patients also should be knowledgeable about the risk of infective endocarditis and the importance of maintaining optimal oral hygiene, including regular dental care. Patients undergoing long-term anticoagulation need both education and a reliable and available source for consultation regarding warfarin dose, interactions

The decision for intervention for a faulty aortic valve needs to incorporate the natural history of the medically managed disease, the risks associated with the intervention, and longer-term problems that might build up as a result of prosthetic

Currently, the heart team plays a decisive role in decision making. In addition, it is prudent to cultivate and set up heart valve centres with specialist services in order to generate an ideal environment for the treatment of patients

Criteria for decision-making are clear for surgical valve and transcatheter aortic valve implantation (TAVI) from the current European guidelines. Recently TAVI is also recommended for patients with intermediate surgical risk. Currently, publish literature also supports TAVI implantation in low risk patients as non-inferior to

For symptomatic, AS recommendations are made with regard to the choice of procedure. For high risk (STS score or EuroSCORE II <4% or a log EuroSCORE <10%) TAVI is the default choice. Surgical replacement is indicated for patients with a low perioperative risk (STS score > 4%). Patients with an intermediate surgical risk, the heart team, should consider other criteria for decision making such as anatomical and functional parameters [57, 58], and frailty to reach the best option

Current data from two large prospective randomised studies, have confirmed that TAVI was noninferior to surgical treatment with regard to mortality, stroke and additional endpoints in both in patients with a low perioperative risk (the mean STS score in both trials was 1.9%), expansion of the indication for TAVI which would

Choice of prosthesis is a complex decision in a patient undergoing AVR with profound long-term consequences for the patient. Currently available prostheses are different with regard to key features, such as the requirement of anticoagulation, incidence of thromboembolism, durability, ease of implantation, haemodynamic performance, and susbtibilty for infection. Currently age-based guidelines do exist, but the final choice must be tailored to the individual patient including consideration of general lifestyle and physical activity, surgeon expertise, diseases, especially those affecting life expectancy, and, ultimately, overall patient preference. The patient age is a primary factor in prosthesis selection is. Elderly patients have lower life expectancy and physical activity than Younger patients. Which place

in decisions about the timing of surgery and choice of intervention.

with other medications, and prompt evaluation of any complications.

**28**

a greater demand on the prosthesis with regard to durability and hemodynamic performance. Age has long been recognised as a major determinant of bioprosthesis durability. Traditionally target age between 65 and 70 years has been the indications for bioprosthesis and like hood of a second operation for structural valve dysfunction in a life time 65-year-old person is less than 10%. As a result, it is not common to choose a mechanical valve in an old patient. Even if the patient is already treated with warfarin for another condition, for example AF, which should not necessarily favour the choice of a mechanical valve because it converts a relative indication for low-level anticoagulation to an absolute indication for higher levels. It also removes the option to stop warfarin in a case of a significant bleeding event. Moreover even if the patient had previously received mechanical valve, the choice does not mandate a second mechanical valve, because risk of complications thromboembolic and bleeding is higher with two mechanical valves than it is with one.

It is more complex and controversial to choose of prosthesis in patients younger than 65 years. Although traditionally, these patients would receive a mechanical valve; the current, improved durability in bioprosthesis and lower operative risk of a redo operation for a failed prosthesis have increased the number of patients younger than 65 years who receive bioprosthesis, including patients in their 50s and even younger.

A particular dilemma women of child-bearing age often it is safer avoid warfarin so they choose a bioprosthesis, with the knowledge that they will face at least one reoperation in their lifetime.

Stentless valves may provide a larger effective orifice area such as the Toronto SPV, Freestyle, and Prima Plus valves although the hemodynamic profiles of stentless valves are superior to those of stented valves, especially at the smaller sizes [42] durability and survival benefits still is unproven [47, 48]. Some reports suggest fewer thromboembolic complications [49]. Currently no specifics indication form stentless valve. Maybe these hemodynamic benefits justify implanting stentless valves in younger active patients.

The use of homografts has declined in recent years as a primary aortic valve substitute because without a durability advantage, it is cumbersome to recommend their routine while they have limited availability and the cumbersome storage requirements. However, their ability to resist infection renders them an excellent solution for patients with endocarditis.

The Ross procedure involves replacing the aortic valve with the patient's own pulmonic valve, which have to be is replaced with a homograft or a stentless xenograft. The benefits are near-normal haemodynamic and excellent durability; the disadvantages are the technical complexity and need for reoperation for the homograft or Late AR. The procedure peaked in popularity in the mid to late 1990s, but procedure volume has declined since then. On the basis of the data from the Ross Procedure International Registry, several centres continue to report excellent results [50, 51] although it is now primarily a procedure for paediatric patients, in whom the potential for growth is important, and for young adults in their 20s and 30s when no other good alternatives exist.
