Ann Thorac Surg 1997;64:132-133
© 1997 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
Bradford P. Blakeman, MD
Cardiac Surgical Associates, 1325 N Highland, Aurora, IL 60506
See also page 129.
The most impressive message in this article is summarized by Figure 1. It shows that at 16 months, almost 50% of the patients with end-stage renal disease (ESRD) are dead. This is the same piece of data we found from our ESRD group of patients in 1988 that included coronary artery bypass graft and valve replacement patients. With this information in mind, the valve of choice would be the biologic valve to prevent possibilities of bleeding. One must remember that the mitral valve should be repaired if possible. It should also be emphasized that the three most common causes of death in patients with ESRD for the past many decades remain coronary artery disease, sepsis, and bleeding problems. Anything such as anticoagulation that increases the risk of bleeding probably should be eliminated. This is another reason to vote for the biologic valve.
Although Lucke and associates note that no reports of premature degeneration of biologic valves are in the literature, I had a porcine aortic valve that in 1 short year was so heavily calcified in an ESRD patient, that it had to be replaced by a mechanical valve. Unfortunately this patient was also a Jehovah's Witness, but the reoperation was performed successfully without blood replacement. Granted this is only one unfortunate experience. Lucke and associates present only 19 total patients. Despite the arguments in the above paragraph, the issue of which valve should be used in patients with ESRD is still not fully answered. More experiences using biologic versus mechanical valves in this population are still needed. It is quite possible the central-flow mechanical valves (eg, St. Jude), with lower doses of Coumadin may not present the same problems with stroke and bleeding Lucke and associates noted. Lucke and associates also were not clear exactly which mechanical valves were used in their population. Their early experience included tilting-disc valves and ball-valve valves, which need a higher prothrombin time or international normalized ratio for anticoagulant therapy. This of course translates into more bleeding problems. Also, these valves have a higher incidence of embolization versus the currently used central flow bileaflet mechanical valves. In short, to settle the issue of which valve for the ESRD patient, a greater experience of comparing central flow bileaflet mechanical valves on low-dose Coumadin versus biologic valves needs to be made. But going back to my original statement, noting the early mortality of these patients, the candidates with ESRD need to be carefully chosen for any valve operation.
Related Article
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Results of Valve Replacement With Mechanical and Biological Prostheses in Chronic Renal Dialysis Patients
- John C. Lucke, Ravi N. Samy, B. Zane Atkins, Scott C. Silvestry, James M. Douglas, Jr, Steven J. Schwab, Walter G. Wolfe, and Donald D. Glower
Ann. Thorac. Surg. 1997 64: 129-132.
[Abstract]
[Full Text]
