Bioprosthetic and mechanical aortic valve replacement yield similar results in younger patients

1. For patients aged 50-69 years, there was no significant difference in long-term survival when comparing bioprosthetic and mechanical aortic valve replacement.

2. Mechanical valve replacement was associated with a lower rate of reoperation and higher rate of major bleeding compared to bioprosthetic valve replacement.

Evidence Rating Level: 2 (Good)

Study Rundown: In patients with severe aortic valve disease, valve replacement is necessary to preserve left ventricular function and prolong lifespan. Currently, two major types of valves are used – bioprosthetic and mechanical. In patients older than 70 years of age, bioprosthetic valves are currently recommended, as there is low lifetime risk of reoperation and there is lower risk of thrombotic and hemorrhagic complications, more commonly seen with mechanical valves. The decision is less clear in patients who are younger.

This retrospective study analyzed data on patients 50-69 years of age from a New York statewide database. They concluded that mechanical aortic valve replacement was associated with significantly lower rates of reoperation at 15 years (HR 0.52; 95%CI 0.36-0.75), but were also linked with a significantly higher risk of bleeding (HR 1.75; 95%CI 1.27-2.43). There was no difference in 15-year survival between the groups (HR 0.97; 95%CI 0.83-1.14). The findings of this trial suggest that both bioprosthetic and mechanical valves are viable options in patients between 50-69 years of age. The risk of reoperation must be balanced against the risk of major bleeding in making such a decision. Study limitations include not accounting for confounding variables, such as frailty, the etiology of aortic valve dysfunction, and degree of coronary artery disease.

Click to read the study in JAMA

Relevant Reading: 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease

In-Depth [retrospective cohort study]: This study evaluated 4,253 patients between 50-69 years of age in New York state between 1997 and 2004. Of these, 1,466 (34.5%) received bioprosthetic valves and 2,787 (65.5%) received mechanical valves. Median follow-up was 10.8 years. The 15-year survival was 60.6% (95% CI 56.3%-64.9%) in the bioprosthetic group and 62.1% (95%CI 58.2%-66.0%) in the mechanical group (HR 0.97; 95%CI 0.83-1.14). Incidence of aortic valve reoperation at 15 years was significantly lower in the mechanical valve group as compared with the bioprosthetic group (HR 0.52; 95%CI 0.36-0.75). Incidence of major bleeding events at 15 years was 6.6% (95% CI, 4.8%-8.4%) for the bioprosthetic group versus 13.0% (95% CI, 9.9%-16.1%) for the mechanical group (HR 1.75; 95%CI 1.27-2.43).

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