Analysis

Is there a risk in avoiding risk for younger patients with aortic valve disease?

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d2466 (Published 26 May 2011) Cite this as: BMJ 2011;342:d2466
  1. Tom Treasure, professor of cardiothoracic surgery1,
  2. Asif Hasan, consultant cardiac surgeon2,
  3. Magdi Yacoub, professor of cardiac surgery3
  1. 1Clinical Operational Research Unit, UCL (Department of Mathematics), London WC1H 0BT, UK
  2. 2Freeman Hospital, Newcastle-upon-Tyne, UK
  3. 3Heart Science Centre, Harefield Hospital, Harefield, UK
  1. Correspondence to: T Treasure tom.treasure{at}gmail.com
  • Accepted 14 March 2011

Tom Treasure, Asif Hasan, and Magdi Yacoub argue that a culture of risk avoidance in cardiac surgery may mean patients are not getting the most appropriate treatment

Around 30 000 patients in the UK and Ireland had open heart surgery to replace the aortic valve in the five years up to March 2008, 40% of whom also had coronary bypass grafts. The annual number of replacements steadily increased, reaching 7000 in the last recorded year.1 Valve replacement is highly effective in averting the risk of sudden death and fatal deterioration in cardiac function, and the risk of perioperative death is now below 2.5% for all patients under 80 years old and 1% in patients under 40 years.2 Nevertheless, patients living with a replacement valve face a time related accrual of life threatening and disabling events.3 Tissue valves fail over time, and recipients of mechanical valves must take anticoagulants for life, which reduces but does not entirely prevent thrombosis and embolism and increases the risk of bleeding. We pose the question whether in ensuring that surgeons’ and institutional death rates are brought to the lowest possible levels, as they have been superbly well for older patients, insufficient consideration may have been given to younger patients.

Downsides of valve replacement

The shortcomings of heart valve substitutes have not been overcome despite years of effort.4 Mechanical valves, typically made of pyrolitic carbon and titanium steel, are extremely durable, but lifelong anticoagulation is mandatory. In a meta-analysis of 35 observational studies, including 23 000 patients and over 100 000 patient years the annual rate for combined thrombotic events (valve thrombosis and embolic events) for mechanical aortic valves was 1.4% at the usual intensity of anticoagulation.5 Higher intensity anticoagulation (international normalised ratio >3) reduces the rate to 1%, but the gain is balanced by higher bleeding rates. …

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