Evaluating Reference Ages for Selecting Prosthesis Types for Heart Valve Replacement in Korea

Abstract

ImportanceAlthough a patient’s age may be the only objective figure that can be used as a reference indicator in selecting the type of prosthesis in heart valve surgery, different clinical guidelines use different age criteria.ObjectiveTo explore the age-associated survival-hazard functions associated with prosthesis type in aortic valve replacement (AVR) and mitral valve replacement (MVR).Design, Setting, and ParticipantsThis cohort study compared the long-term outcomes associated with mechanical and biologic prostheses in AVR and MVR according to recipient’s age using a nationwide administrative data from the Korean National Health Insurance Service. To reduce the potential treatment-selection bias between mechanical and biologic prostheses, the inverse-probability-of-treatment-weighting method was used. Participants included patients who underwent AVR or MVR in Korea between 2003 and 2018. Statistical analysis was performed between March 2022 and March 2023.ExposuresAVR, MVR, or both AVR and MVR with mechanical or biologic prosthesis.Main Outcomes and MeasuresThe primary end point was all-cause mortality after receiving prosthetic valves. The secondary end points were the valve-related events, including the incidence of reoperation, systemic thromboembolism, and major bleeding.ResultsOf the total of 24 347 patients (mean [SD] age, 62.5 [7.3] years; 11 947 [49.1%] men) included in this study, 11 993 received AVR, 8911 received MVR, and 3470 received both AVR and MVR simultaneously. Following AVR, bioprosthesis was associated with significantly greater risks of mortality than mechanical prosthesis in patients younger than 55 years (adjusted hazard ratio [aHR], 2.18; 95% CI, 1.32-3.63; P = .002) and in those aged 55 to 64 years (aHR, 1.29; 95% CI, 1.02-1.63; P = .04), but the risk of mortality reversed in patients aged 65 years or older (aHR, 0.77; 95% CI, 0.66-0.90; P = .001). For MVR, the risk of mortality was also greater with bioprosthesis in patients aged 55 to 69 years (aHR, 1.22; 95% CI, 1.04-1.44; P = .02), but there was no difference for patients aged 70 years or older (aHR, 1.06; 95% CI, 0.79-1.42; P = .69). The risk of reoperation was consistently higher with bioprosthesis, regardless of valve position, in all age strata (eg, MVR among patients aged 55-69 years: aHR, 7.75; 95% CI, 5.14-11.69; P < .001); however, the risks of thromboembolism and bleeding were higher in patients aged 65 years and older after mechanical AVR (thromboembolism: aHR, 0.55; 95% CI, 0.41-0.73; P < .001; bleeding: aHR, 0.39; 95% CI, 0.25-0.60; P < .001), with no differences after MVR in any age strata.Conclusions and RelevanceIn this nationwide cohort study, the long-term survival benefit associated with mechanical prosthesis vs bioprosthesis persisted until age 65 years in AVR and age 70 years in MVR.

Mechanical versus Bioprosthetic Aortic Valve Replacement in Patients Aged 50 to 70 Years

“…HR, hazard ratio; CI, confidence interval; eGFR, estimated glomerular filtration rate; AV, aortic valve; CABG, coronary artery bypass grafting. [8]. In alignment with these previous studies, our study showed a superior survival benefit associated with the use of mechanical valves compared to bioprosthetic valves, notably persisting within a subset of patients aged 50-65 years (Supplementary Table 4).…”

“…Among numerous studies comparing the clinical outcomes of mechanical and bioprosthetic AVR in middle- aged patients, some studies found that long-term survival was significantly greater with mechanical AVR than bioprosthetic AVR [ 3 , 8 , 10 - 17 ], whereas others found no significant survival difference [ 18 - 21 ]. The most recent meta-analysis, which included 22 publications and involved 32,298 patients, reported greater long-term survival with mechanical AVR than bioprosthetic AVR among individuals aged 50 to 70 years [ 13 ].…”

“…However, they also reported that when they reduced the upper limit of the age range to 65 years, the survival benefit of the mechanical valve disappeared. A nationwide cohort study in Korea also demonstrated that the long-term survival benefit associated with mechanical prostheses versus bioprostheses persisted until the age of 65 years in AVR [ 8 ]. In alignment with these previous studies, our study showed a superior survival benefit associated with the use of mechanical valves compared to bioprosthetic valves, notably persisting within a subset of patients aged 50–65 years ( Supplementary Table 4 ).…”

“…The European guidelines recommend the use of a mechanical valve in patients aged <60 years [6], while the US guidelines advocate a more liberal use of bioprosthetic valves, leaving a gray zone between the ages of 50 and 65 http://www.jchestsurg.org JCS years [7]. Moreover, the complexity surrounding the choice of prosthetic valves is further compounded by the recent favorable clinical outcomes of mechanical valves in this middle-aged group [8].…”

Aortic valve replacement with mechanical prosthesis in small aortic annulus: Keep it simple!

“…However, we think that mechanical AVR should be still included in the therapeutic possibilities. Indeed, recent studies suggested that in patients aged between 54 and 65 years, AVR with mechanical valve is associated with a survival benefit compared to bioprosthesis, 3 and several trials of low-INR and self-anticoagulation management demonstrated excellent early and long-term outcomes for mechanical valve recipients. 4 Small diameter mechanical bileaflets prosthesis have excellent hemodynamic even in small aortic root, especially when implanted in supra-annular position, and can be easily implanted thus avoiding long and complex procedures.…”