Commentary: Shades of gray: The right aortic valve for the right patient in 2022.

Central MessageAdvances in technology are changing the landscape for valve selection; patients should be actively involved in the decision-making process.See Article page 728. Advances in technology are changing the landscape for valve selection; patients should be actively involved in the decision-making process. See Article page 728. There may be no greater dynamic landscape within cardiac surgery than the field of aortic valve surgery given recent advances in technology. Cardiologists and cardiac surgeons must assimilate data from recent transcatheter aortic valve replacement (TAVR) trials that have included younger and healthier patient populations with results equivalent to or better than surgical AVR.1Mack M.J. Leon V.H. Thourani V.H. Makkar R. Kodali S.K. Russo M. et al.Transcatheter aortic valve replacement with a balloon-expandable valve in low-risk patients.N Engl J Med. 2019; 380: 1695-1705Crossref PubMed Scopus (2772) Google Scholar TAVR valves have also showed sustained durability on echocardiography with improved orifice area and gradients reported out to at least 6 years.2Thyregod H.G.H. Ihelman N. Jorgensen T.H. Nissen H. Kjeldsen B.J. Petursson P. et al.Five- year clinical and echocardiographic outcomes from the nordic aortic valve intervention (NOTION) randomized clinical trial in lower risk surgical patients.Circulation. 2019; 139: 2714-2723Crossref PubMed Scopus (175) Google Scholar,3Søndergaard L. Ihlemann N. Capodanno D. Jørgensen T.H. Nissen H. Kjeldsen B.J. et al.Durability of transcatheter and surgical bioprosthetic aortic valves in patients at lower surgical risk.J Am Coll Cardiol. 2019; 73: 546-553Crossref PubMed Scopus (231) Google Scholar At the same time, the third generation of tissue valve preservation technology has arrived with no signs of structural valve deterioration out to 5 years and promise for extended long-term durability.4Bavaria J.E. Griffith B. Heimansohn D.A. Rozanski J. Johnston D.R. Bartus K. et al.Five-year outcomes of the COMMENCE trial investigating aortic valve replacement with RESILIA tissue.Ann Thorac Surg. January 19, 2022; ([Epub ahead of print])https://doi.org/10.1016/j.athoracsur.2021.12.058Abstract Full Text Full Text PDF Scopus (23) Google Scholar,5Kiali B.B. Moront M.G. Patel H.J. Ruel M. Bensari R.N. Kress D.C. et al.Outcomes of surgical bioprosthetic aortic valve replacement in patients <65 and >65 years of age.Ann Thorac Surg. January 19, 2022; ([Epub ahead of print])https://doi.org/10.1016/j.athoracsur.2021.12.057Abstract Full Text Full Text PDF Scopus (4) Google Scholar Reoperative surgical mortality risk for failed open surgical bioprosthetic valves (BVs) was reported again this year to mirror the primary surgery risk at an experienced center.6Mahboubi R. Kakavand M. Soltesz E.G. Rajeswaran J. Blackstone E. Svensson L.G. et al.The decreasing risk of reoperative aortic valve replacement: implications for valve choice and transcatheter therapy.J Thorac Cardiovasc Surg. March 16, 2022; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (6) Google Scholar In the case that either surgical AVR or TAVR valves fail, they can now be more easily be treated with valve-in-valve TAVR. Among patients with patient–prosthesis mismatch, BV fracture is a promising technique to improve valve performance.7Allen K.B. Chhatriwalla A.K. Saxon J.T. Huded C.P. Sathananthan J. Nguyen T.C. et al.Bioprosthetic valve fracture: a practical guide.Ann Cardiothorac Surg. 2021; : 564-570Crossref PubMed Scopus (8) Google Scholar At the same time, a novel oral anticoagulant agent is being evaluated as an alternative to warfarin among patients with a mechanical valve (MV).8Jawitz O.K. Wang T.Y. Lopes R.D. Chavez A. Boyer B. Hwason K. et al.Rationale and design of PROACT Xa: a randomized, multicenter, open-label, clinical trial to evaluate the efficacy and safety of apixaban vs. warfarin in patients with a mechanical On-X aortic heart valve.Am Heart J. 2020; 227: 91-99Crossref PubMed Scopus (44) Google Scholar With the above scenario as background, we must look with circumspect at the study offered by Sotade and colleagues.9Sotade O. Falster M.O. Pearson S.A. Jorm L.R. Sedrakayan A. Comparison of long-term outcomes of bioprosthetic and mechanical valve replacement in patients under 65.J Thorac Cardiovasc Surg. 2023; 166: 728-737.e13Abstract Full Text Full Text PDF Scopus (5) Google Scholar Their multicenter retrospective cohort study compares outcomes of earlier-generation bioprosthetic and mechanical mitral valve replacement in patients younger than age 65 years.9Sotade O. Falster M.O. Pearson S.A. Jorm L.R. Sedrakayan A. Comparison of long-term outcomes of bioprosthetic and mechanical valve replacement in patients under 65.J Thorac Cardiovasc Surg. 2023; 166: 728-737.e13Abstract Full Text Full Text PDF Scopus (5) Google Scholar The authors examined patients younger than age 65 years undergoing AVR from 2002 to 2018 in 2 cohorts: age 18 to 54 years and age 55 to 64 years. The authors found no difference in mortality in patients aged 55 to 64 years for BVs versus MVs at 0 to 10 years (hazard ratio, 0.87; 95% CI, 0.72-1.06), but higher at 10 to 15 years (hazard ratio, 1.56; 95% CI, 1.01-2.42); however, there were only 57 patients in the BV group and 84 in the MV group remaining at 15 years. They found no differences in reoperation rates between BV versus MV at 0 to 10 years, but it became higher for BV at 10 to 15 years. For the patients aged 18 to 54 years, there was no difference in mortality for BV versus MV, but reoperation rates were higher with BV at all times. An important limitation of the Australian study was the absence of data regarding bleeding and stroke.9Sotade O. Falster M.O. Pearson S.A. Jorm L.R. Sedrakayan A. Comparison of long-term outcomes of bioprosthetic and mechanical valve replacement in patients under 65.J Thorac Cardiovasc Surg. 2023; 166: 728-737.e13Abstract Full Text Full Text PDF Scopus (5) Google Scholar A recent analysis of aortic root replacement from the Society of Thoracic Surgeons Database, which was linked to the Medicare Database found higher-than-expected rates of stroke (12.9%) and bleeding (20%) in MV patients at 7 years. Another key data element missing from the Australian dataset was the mortality rate for their reoperations, which can sway overall long-term mortality outcomes. For example, a study from Finland examined 1152 propensity-score matched pairs of patients receiving BV versus MV and reported higher mortality in the BV group, but there was a 23% mortality in their reoperations—which could drive that finding.10Kyoto V. Sipila J. Elina A. Rautava P. Gunn J. Mechanical versus biologic prosthesis for surgical aortic valve replacement in patients aged 50-70.Ann Thorac Surg. 2020; 110: 102-110Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Studies from the United States differ. Although the California Database article cited found an increase in mortality with BV versus MV in patients aged 45 to 54 years at 15 years, there was no statistically significant increase in mortality with BV versus MV in patients aged 55 to 64 years and the reoperative mortality rate was 7%.11Goldstone A.B. Chiu P. Baiocchi M. Lingala B. Patrick W.L. Fischbein M.P. et al.Mechanical or biologic prosthesis for aortic- valve or mitral-valve replacement.N Engl J Med. 2017; 377: 1847-1857Crossref PubMed Scopus (369) Google Scholar A review from The Northern New England Database of 9388 patients aged 50 to 65 years undergoing isolated AVR found no significant difference in adjusted 15-year survival between BV and MV with a reoperative mortality rate of just 2.4%.12Irbane A. Leavitt B.J. Robich M.P. Sardella G.L. Gelb D.J. Baribeau Y.R. et al.Tissue versus mechanical aortic valve replacement in younger patients: a multicenter analysis.J Thorac Cardiovasc Surg. 2019; 158: 1529-1538Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar In a retrospective cohort study with 1001 propensity-score matched pairs of patients aged 50 to 69 years from The New York State Database, there was no mortality difference between BV and MV patients; and the authors state that “these findings suggest that BVs may be a reasonable choice in patients aged 50 to 69 years.”13Chiang Y.P. Chikwe J. Moskowitz A.J. Itagaki S. Adams D. Egorova N.N. Survival and long-term outcomes following bioprosthetic vs mechanical aortic valve replacement in patients aged 50-69 years.J Am Med Assoc. 2014; 312: 1323-1329Crossref PubMed Scopus (211) Google Scholar Based on these studies and others, the American College of Cardiology/American Heart Association guidelines recommend mechanical aortic valves for patients younger than age 50 years (Class 2a recommendation, level of evidence B); shared decision making for ages 50 to 65 years (Class 2a recommendation, level of evidence B) and biologic valves for patients older than age 65 years (Class 2a recommendation, level of evidence B).14Otto C.M. Nishimura R.A. Bonow R.O. Carabello B.A. Erwin III, J.P. Gentile F. et al.2020 ACC/AHA guideline for the management of patients with valvular heart disease.J Am Coll Cardiol. 2021; 77: e25-e197Crossref PubMed Scopus (623) Google Scholar A class I recommendation (level of evidence C) is that patients of any age for whom anticoagulant therapy is contraindicated cannot be managed appropriately, or is simply not desired, a bioprosthetic AVR is recommended. We must interpret data from historical cohorts with previous-generation valves and health care systems different from our own with caution to make informed contemporary decisions. Especially in the dynamic field of aortic valve surgery, there are many shades of gray. Ultimately as the American College of Cardiology/American Heart Association guidelines recommend, we should respect each patient's desire as part of a shared decision-making process. Comparison of long-term outcomes of bioprosthetic and mechanical aortic valve replacement in patients younger than 65 yearsThe Journal of Thoracic and Cardiovascular SurgeryVol. 166Issue 3PreviewThe objectives of this study were to compare rates of mortality and reoperations for patients aged younger than 65 years who underwent surgical aortic valve replacement (AVR). AVR with a bioprosthetic valve (BV) is increasing among younger patients, however evidence to inform the choice between BV or mechanical valve is limited. Full-Text PDF