Poorly suited heart valve prostheses heighten the plight of patients with rheumatic heart disease
Introduction
Contemporary replacement heart valves were developed for the patients of industrialised countries with their advanced medical systems. To keep complication rates within an acceptable range mechanical valves need reliable anti-coagulation monitoring and bioprosthetic valves should preferentially go into older patients. Both these preconditions are insufficiently met in low- to middle-income countries (LMICs) where the dominant valve pathology is rheumatic rather than degenerative [[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13]] (Fig. 1).Typically, these patients are young, poor, uneducated, and often have difficulty in accessing medical care [11,14,15]. Unsurprisingly, even if they have access to cardiac surgery, clinical results are disappointing. Low anticoagulation compliance due to socioeconomic and cultural circumstances leads to a high incidence of lethal or debilitating thromboembolic complications in patients with mechanical valves [[16], [17], [18], [19], [20], [21]]. Alternatively, many patients have no choice but receiving a bioprosthetic valve at a relatively young age notwithstanding the possibility of needing several re-operations over their life span [22] (Fig. 2).
Section snippets
Heart valve surgery for RHD
Rheumatic heart disease (RHD) is not limited to developing countries. Contrary to perceptions, RHD still claims a large proportion of its global burden of deaths in middle-income countries (MICs) [23]. While these countries increasingly have access to open heart surgery, they share many of the specific challenges associated with RHD in low-income countries (LICs) foremost the poor suitability of replacement heart valves for a significant proportion of patients.
Locally produced valves continue
Valve failures
As much as valve sparing operations even in the presence of severe fibrosis [84] have significantly expanded the spectrum of mitral repairs [6,44,[85], [86], [87], [88]] and aortic valve repairs [89] including the Ross operation [90] are beginning to be applied to patients with RHD [91] a significant proportion of patients will continue to rely on valve replacements. The lack of repair skills in frontline low-volume centres [11] and the high incidences of endocarditis [32] are only two of the
In summary
In the absence of large, multicentred, randomised clinical trials, using the current generations of bioprostheses and mechanical valves across all age groups [143] valve choices will be least harmful if sensible and appropriate criteria rather than Western guidelines are being uncritically applied.
At the outset of such an approach must be an assessment of a patient's life expectancy taking his/her geographic, socioeconomic and medical background into consideration. Assessment criteria must be
Glimmers of hope
The quest for longer lasting tissue valves and anticoagulation-free mechanical valves of young patients of HICs who are eager to live an active life may add weight to the efforts of middle-income countries addressing the needs of their patients with RHD.
Low-thrombogenicity designs of mechanical valves have been a holy grail for decades but with tri-leaflet concepts [154] they may eventually be within reach. A novel design that placed the hinges of a tri-leaflet valve distinctly into the central
Declaration of Competing Interest
PZ is a shareholder in the University of Cape Town start-up company 'Strait Access technologies'
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