Anticoagulation After Mechanical Heart Valve Replacement: Risks and Management

Cost primarily depends on two things: which valve is used — mechanical valves are significantly less expensive than tissue valves, and among tissue valves, third-generation valves cost more than second-generation ones — and the patient's clinical course, since a straightforward surgery without a long hospital stay or comorbidities costs less. The average cost generally starts from $9,000 and goes up to $15,000–$16,000.

Cardiac tumours in children are well known, though this exact pathology is not very common. The echo gives us an idea, but I would suggest also doing an MRI and a CT to further delineate it. I would like the details of this patient sent to our institute so we can forward it to our paediatric cardiac surgeon, since paediatric cardiac surgery is a separate subspecialty from the adult cardiac surgery I practise, and we do have a dedicated paediatric cardiac surgical team. This child needs very close follow-up and further investigation.

Tetralogy of Fallot is one of the commonest surgical procedures, and the outcome depends on the exact anatomy delineated by a proper paediatric echo, but six years is not a very late stage — in India a lot of patients are operated on at this age or even older. The outcome of tetralogy repair even at 6 years is excellent, so this patient certainly needs surgical correction.

Myocardial bridging is not uncommon and is often seen on angiography. If it is asymptomatic, nothing needs to be done. If it is symptomatic, we normally do a stress thallium test — if positive, we recommend surgery; if negative, which is most of the time, only medical treatment is needed. If it is only myocardial bridging with no stenosis involved in other arteries (the circumflex or right coronary artery are normal), nothing needs to be done, but if the stress test is positive, surgery is recommended.

Tetralogy of Fallot is one of the commonest procedures in paediatric cardiac surgery, alongside ASD and VSD repair. It is a very commonly performed procedure with excellent outcomes — any paediatric cardiac centre does this routinely, and the clinical outcomes are excellent.

Mechanical heart valves are made of durable materials that do not degenerate like biological tissue, but blood tends to clot when it contacts these artificial surfaces. Lifelong anticoagulation with a vitamin K antagonist such as warfarin or acitrom prevents this clotting and protects the valve from thrombosis and thromboembolism.

The main risk is bleeding, alongside the valve thrombosis and thromboembolism the anticoagulation is meant to prevent. Patients must also monitor their International Normalised Ratio regularly and report to a valve clinic or hospital so their dose can be adjusted.

Mechanical valves are generally preferred for patients in their 50s and 60s, since they last longer and anticoagulation is easier to manage at a younger age.

Tissue valves are preferred for women who want to become pregnant, regardless of age, because the anticoagulants used with mechanical valves carry risks to both mother and foetus.