Prosthetic heart valves: a review.

There are a number of difficulties inherent in the analysis of such a large and diverse quantity of data. In a substantial number of clinical trials, there is no significant effort made to evaluate prosthetic performance as a function of preoperative cardiac anatomy. Hemodynamics have not been systematically studied in relation to preexisting left ventricular size, shape, or configuration, mitral annular orientation, or left atrial size. Postoperative anticoagulation protocols vary from one institution to another and occasionally within study groups themselves. Less tangible variables such as alteration in surgical technique over time and differential familiarity of cardiovascular surgeons with the prostheses employed are chronic problems in any study of this sort. Perhaps the greatest variable in evaluating the postoperative performance of valvular prostheses over the past 20 yr is the radical improvement in techniques of intraoperative myocardial preservation. Notwithstanding, comparisons are possible within the confines of certain criteria. The caged ball value remains in use after 20 years of clinical experience. It has sustained the greatest number of modifications, probably because it has been the most extensively studied. Hemodynamics are adequate although its centrally obstructed design is responsible for increased turbulence, hemolysis, and neointimal proliferation, particularly in the aortic position. The device has been shown to be durable with virtually no reports of ball variance since the alteration of the silicone curing procedure in 1965. Thromboembolic rates are acceptable in the anticoagulated patient while prosthetic thrombosis is not a grave threat in the non-close clearance device. Incidence of endocarditis is not particularly different from that associated with all nonbioprosthetic valves, although there is a much greater published volume of clinical experience concerning recognition and treatment of late prosthetic valve endocarditis in patients with caged ball valves than there is for any other replacement device. Perhaps the most serious disadvantage to caged ball design is its size. Its large spatial requirements have led to anatomic complications in patients with small aortic roots, isolated mitral stenosis, left ventricular hypertrophy, and double valve replacement, among others. Nevertheless, this is still the valve of choice in some centers.(ABSTRACT TRUNCATED AT 400 WORDS)