Commentary: Surgical aortic valve replacement for the younger patient, but which one?

Central MessageThe treatment of aortic valve disease in patients age <65 years remains surgical. Patient choice and attitudes toward complications associated with either prosthesis remain key to the device used.See Article page 609. The treatment of aortic valve disease in patients age <65 years remains surgical. Patient choice and attitudes toward complications associated with either prosthesis remain key to the device used. See Article page 609. In this multicenter observational study from Spain,1Rodríguez-Caulo E. Blanco-Herrera O. Berastegui E. Arias-Dachary J. Souaf S. Parody G. et al.the SPAVALVE Study GroupBiological versus mechanical prostheses for aortic valve replacement.J Thorac Cardiovasc Surg. 2023; 165: 609-617.e7Abstract Full Text Full Text PDF Scopus (7) Google Scholar outcomes of 5215 patients age 55 to 65 years who underwent isolated surgical aortic valve replacement (SAVR) were examined. The authors used propensity matching to create 2 groups: patients who received a mechanical prosthesis (n = 1822) and those who received a tissue prosthesis (n = 911). The main finding from the study was that at 15 years, there was no significant difference in survival or freedom from a composite of valve-related morbidities. This study demonstrates why the question of prosthetic choice in younger patients is still pertinent and does not have a straightforward answer. When commenting on the prosthetic type, it is useful, like all good seekers of the truth, to go back to the original source: 2 randomized trials published at the dawn of this millennium.2Oxenham H. Bloomfield P. Wheatley D.J. Lee R.J. Cunningham J. Prescott R.J. et al.Twenty year comparison of a Bjork–Shiley mechanical heart valve with porcine bioprostheses.Heart. 2003; 89: 715-721Crossref PubMed Scopus (271) Google Scholar,3Hammermeister K. Sethi G.K. Henderson W.G. Grover F.L. Oprian C. Rahimtoola S.H. Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial.J Am Coll Cardiol. 2000; 36: 1152-1158Crossref PubMed Scopus (935) Google Scholar These studies demonstrated that patients with aortic mechanical prostheses were more likely to survive for 15 years and more likely to suffer anticoagulant-related bleeding. Those with a tissue prosthesis were more likely to require reintervention. The latter 2 findings have been confirmed in retrospective observational studies,4Glaser N. Jackson V. Holzmann M.J. Franco-Cereceda A. Sartipy U. Aortic valve replacement with mechanical vs biological prostheses in patients aged 50-69 years.Eur Heart J. 2016; 37: 2658-2667Crossref PubMed Scopus (168) Google Scholar including this one. Unlike in many countries, in Spain the utilization of tissue valves in patients under 70 remains low at under 30%. The main strength of this publication is in the large numbers expected in the study of a national registry. The study has some methodological weaknesses. Survival, hospital admissions, and diagnoses were established not by validated national registries, but rather by telephone contact with individual patients. The omission of patients who underwent combined procedures was unfortunate. Concomitant conditions, such as coronary disease, have a profound effect on life expectancy and thus on prosthetic choice. Interesting findings include the lower postoperative gradients in the mechanical group despite no difference in prosthetic sizes, and the fact that patients younger than 55 on warfarin did not have a significantly higher bleeding rate. The nonsignificantly higher stroke rate in patients with mechanical prostheses was unexpected and noted in the abstract. A similar higher tissue prosthetic endocarditis rate was not. For patients age <65 who undergo SAVR, there are pros and cons associated with either type of prosthesis. In the absence of a contraindication to taking warfarin, the choice must be a shared decision, based on life expectancy and a good understanding of the ongoing healthcare needs of the younger patient with either a mechanical or a tissue prosthesis. Biological versus mechanical prostheses for aortic valve replacementThe Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 2PreviewLong-term real-world outcomes are critical for informing decisions about biological (Bio) or mechanical (Mech) prostheses for aortic valve replacement, particularly in patients aged between 50 and 65 years. The objective was to compare long-term survival and major adverse cardiac and cardiovascular events (ie, stroke, reoperation, and major bleeding) within this population. Full-Text PDF