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Prosthetic valve selection for middle-aged patients with aortic stenosis

Nature Reviews Cardiology volume 7, pages 711–719 (2010)Cite this article

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Abstract

Choosing the optimal aortic valve prosthesis for middle-aged patients (late 40s to early 60s) with aortic stenosis presents a challenge. The available options all have substantial drawbacks that must be considered in the decision-making process. Current data indicate that there is little or no difference in survival between mechanical and bioprosthetic aortic valve replacement in middle-aged patients at 10–15 years after surgery. Patients who receive a mechanical valve replacement have an annual risk of major hemorrhagic or embolic events of 2–4% per year for life compared with about 1% per year for patients who have a bioprosthetic valve. However, bioprostheses are associated with an increasing risk of structural valve degeneration from 10 years postimplantation, and most patients will require reoperation if they survive much longer than a decade. The mortality risk associated with reoperation is similar to that of primary surgery for most patients, and does not seem to impact on the 15-year survival in this patient group. The Ross procedure, in which the aortic valve is replaced with a pulmonary autograft, can provide improved freedom from morbidity, but operative mortality is probably double that of isolated aortic valve replacement and most patients will require reoperation. Informed patient choice is the most important factor in deciding which valve to use, with biological valves increasingly favored over mechanical valves in middle-aged patients.

Key Points

  • Valve replacement for aortic stenosis can be performed using a mechanical or bioprosthetic valve, or a pulmonary autograft

  • Current data indicate that there is little or no difference in patient survival between mechanical and bioprosthetic aortic valve replacement in middle-aged patients at 10–15 years after surgery

  • Informed patient choice is the most important factor in deciding which valve to use; biological valves are increasingly favored over mechanical valves in middle-aged patients

  • Patients with a mechanical valve replacement have a higher risk of major hemorrhagic or embolic events than with a bioprosthesis, but biological valves often suffer from structural degeneration, requiring reoperation

  • The mortality risk associated with reoperation is about the same as for primary surgery in most patients, and does not seem to impact on the 15-year survival of middle-aged patients

  • The Ross procedure, in which the aortic valve is replaced with a pulmonary autograft, could provide greater freedom from morbidity; however, operative mortality is increased, and most patients require reoperation

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Figure 1: Etiology of aortic valve stenosis.
Figure 2: Trends in choice of aortic valve replacement.
Figure 3: INR-specific incidence of all adverse events (all episodes of thromboembolism, all major bleeding episodes, and unclassified stroke) in patients with mechanical valves.
Figure 4: Thromboembolic rates reported in published series.
Figure 5: Life expectancy by age and valve type.
Figure 6: Outcomes following freestyle versus homograft aortic root replacement.
Figure 7: An algorithm for choice of prosthetic heart valve.
Figure 8: The influence of patient age on the choice of aortic valve replacement strategy.

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Author information

Authors and Affiliations

  1. Department of Cardiothoracic Surgery, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, 10029-6574, NY, USA

    Joanna Chikwe & Farzan Filsoufi

  2. Department of Cardiovascular Surgery, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, Paris, 75015, France

    Alain F. Carpentier

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All the authors contributed to discussion of content for the article, researched data to include in the manuscript, reviewed and edited the manuscript before submission, and revised the manuscript in response to the peer-reviewers' comments.

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Correspondence to Alain F. Carpentier.

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Competing interests

F. Filsoufi is a speaker for Edwards Lifesciences. A. F. Carpentier is a consultant and speaker for Edwards Lifesciences. J. Chikwe declares no competing interests.

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Chikwe, J., Filsoufi, F. & Carpentier, A. Prosthetic valve selection for middle-aged patients with aortic stenosis. Nat Rev Cardiol 7, 711–719 (2010). https://doi.org/10.1038/nrcardio.2010.164

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