Statins may not prevent structural valve degeneration of aortic bioprosthetic valves, but should probably be prescribed to patients undergoing heart valve surgery nonetheless

Based on a hypothetical clinical scenario, Gilmanov et al. [1] performed an extensive review of the literature to address the question, whether statins slow the calcification/degeneration of aortic bioprosthetic valves. The authors correctly concluded that ‘even though the data is conflicting, statin therapy does not prevent structural valve degeneration (SVD) of bioprosthetic valves in the aortic position’ [1]. Certain issues may need to be clarified to avoid any possible misunderstandings. Even if statins do not prevent SVD of aortic bioprosthetic valves, they are associated with several beneficial actions in patients undergoing cardiac valve replacement [2]. Firstly, statins improve renal function [2]. Renal dysfunction is a strong predictor of mortality in patients undergoing valve surgery [2]; thus, statins may influence mortality rates following valve surgery in this indirect way. Secondly, postoperative atrial fibrillation is a common complication following cardiac surgery and is associated with considerable morbidity including stroke, ventricular arrhythmias, heart failure, myocardial infarction, prolonged hospital stay, as well as short- and long-term mortality [3]. High-dose statin administration successfully reduces the incidence of postoperative atrial fibrillation [3]. Thirdly, there is evidence suggesting that preoperative statin use is associated with a reduction in the patients’ odds of developing a postoperative infection following cardiac surgery [4]. Finally, a large (n=3829 patients; 1044 statin users; 2785 statin non-users), eight-year retrospective study on patients undergoing cardiac surgery concluded that statin use is associated with improved postoperative mortality and morbidity rates in these patients [5]. In conclusion, although the data regarding this issue is indeed conflicting, it may be misleading to conclude that statins do not prevent SVD and should therefore not be prescribed to patients undergoing aortic bioprosthetic valve replacement [1]. Due to their pleiotropic effects [2–5], statins should be prescribed to these patients, whether they prevent SVD or not. Ideally, statins should be employed preoperatively [4, 5]. However, statin treatment is associated with several beneficial actions in patients undergoing heart valve surgery even if initiated postoperatively [2]. Thus, routine statin use in patients undergoing heart valve surgery should probably be recommended.