Mechanical versus bioprosthetic valve replacement in middle-aged patients

• Published in: European journal of cardio-thoracic surgery Vol. 30; no. 3; pp. 485 - 491
• Main Authors: Kulik, Alexander, Bédard, Pierre, Lam, B-Khanh, Rubens, Fraser D., Hendry, Paul J., Masters, Roy G., Mesana, Thierry G., Ruel, Marc
• Format: Journal Article
• Language: English
• Published: Amsterdam Elsevier Science B.V 01.09.2006; Elsevier Science
• Subjects: Aged; Aortic Valve - surgery; Aortic valve replacement; Biological and medical sciences; Bioprosthesis; Cardiology. Vascular system; Endocarditis - etiology; Female; Heart valve; Heart Valve Diseases - mortality; Heart Valve Diseases - surgery; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation - adverse effects; Heart Valve Prosthesis Implantation - methods; Heart Valve Prosthesis Implantation - mortality; Hemorrhage - etiology; Humans; Male; Mechanical; Medical sciences; Middle Aged; Mitral Valve - surgery; Mitral valve replacement; morbidity; Outcomes (includes mortality; Pneumology; Postoperative Complications - etiology; Prospective Studies; Reoperation; Stroke - etiology; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the heart; Thromboembolism - etiology; Treatment Outcome; Mechanical; Outcomes (includes mortality; Bioprosthesis; Aortic valve replacement; Heart valve; morbidity; Mitral valve replacement; Human; Mitral valve; Prognosis; Mortality; Replacement; Epidemiology; Morbidity; Evolution; Valve; Circulatory system; Cardiology; Aortic valve; Comparative study
• ISSN: 1010-7940; 1873-734X
• DOI: 10.1016/j.ejcts.2006.06.013

Objective: The current trend towards decreasing the age for selection of a tissue over a mechanical prosthesis has led to a dilemma for patients aged 50–65 years. This cohort study examines the long-term outcomes of mechanical versus bioprosthetic valves in middle-aged patients. Methods: Patients (N = 659) aged between 50 and 65 years who had first-time aortic valve replacement (AVR) and/or mitral valve replacement (MVR) with contemporary prostheses were followed prospectively after surgery. The total follow-up was 3402 patient-years (mean 5.1 ± 4.1 years; maximum 18.3 years). Outcomes were examined with multivariate actuarial methods. A composite outcome of major adverse prosthesis-related events (MAPE) was defined as the occurrence of reoperation, endocarditis, major bleeding, or thromboembolism. Results: Ten-year survival was 73.2 ± 4.2% after mechanical AVR, 75.1 ± 12.6% after bioprosthetic AVR, 74.1 ± 4.6% after mechanical MVR, and 77.9 ± 7.4% after bioprosthetic MVR (P = NS). Ten-year reoperation rates were 35.4% and 21.3% with aortic and mitral bioprostheses, respectively. Major bleeding occurred more often following mechanical MVR (hazard ratio [HR]: 3.3; 95% confidence interval [CI] 1.2, 9.0; P = 0.022), and the incidence of any thromboembolic event was more common after mechanical MVR (HR: 4.7; CI 1.4, 13.3; P = 0.01). Overall freedom from MAPE at 10 years was 70.2 ± 4.1% for mechanical AVR patients, 41.0 ± 30.3% for bioprosthetic AVR patients, 53.3 ± 8.8% for mechanical MVR patients, and 61.2 ± 9.2% for bioprosthetic MVR patients. Although a trend existed towards more MAPE amongst middle-age patients with tissue valves, multivariate analysis did not identify the presence of a bioprosthesis as an independent risk factor for MAPE (HR: 1.3; CI 0.9, 2.0; P = 0.22). Conclusions: In middle-aged patients, MAPE may occur more often in patients with bioprosthetic valves, but definitive conclusions necessitate the accumulation of additional follow-up. At present, these data do not support lowering the usual cutoff for implantation of a tissue valve below the age of 65.