Trends in SAVR with biological vs. mechanical valves in middle-aged patients: results from a French large multi-centric survey

Abstract

Background/introduction: Currently, despite continued issues with durability ( 1), biological prosthetic valves are increasingly chosen over mechanical valves for surgical aortic valve replacement (SAVR) in adult patients of all ages, at least in Western countries. For younger patients, this choice means assuming the risks associated with a redo SAVR or valve-in-valve procedure.

Purpose: To assess the use of mechanical vs. biological valve prostheses for SAVR relative to patient's age and implant time in a large population extracted from the French National Database EPICARD.

Methods: Patients in EPICARD undergoing SAVR from 2007 to 2022 were included from 22 participating public or private centers chosen to represent a balanced representation of centre sizes and geographical discrepancies. Patients with associated pathology of the aorta (aneurysm or dissection) and requiring a vascular aortic prosthesis were excluded. Comparisons were made amongst centers, valve choice, implant date range, and patient age.

Results: We considered 101,070 valvular heart disease patients and included 72,375 SAVR (mean age 71.4 ± 12.2 years). We observed a mechanical vs. biological prosthesis ratio (MBPR) of 0.14 for the overall population. Before 50 years old (y-o), MBPR was >1.3 (p < 0.001) while patients above 60 years-old received principally biological SAVR (p < 0.0001). Concerning patients between 50 and 60 years-old patients, MPVR was 1.04 (p = 0.03). Patients 50-60 years-old from the first and second study duration quartile (before August 2015) received preferentially mechanical SAVR (p < 0.001). We observed a shift towards more biological SAVR (p < 0.001) for patients from the third and fourth quartile to reach a MBPR at 0.43 during the last years of the series. Incidentally, simultaneous mitral valve replacement were more common in case of mechanical SAVR (p < 0.0001), while associated CABGs were more frequent in case of biological SAVR (p < 0.0001).

Conclusion: In a large contemporary French patient population, real world practice showed a recent shift towards a lower age-threshold for biological SAVR as compared to what would suggest contemporary guidelines.

Keywords: France; aortic valve; bioprosthesis; database; mechanical and biological prosthetic valves; mechanical prosthesis; surgical aortic replacement; trend.

Figure 1

Carbon-Free survey, distribution of participating centres.

Figure 2

Proportion of patients with regards to age for each type of valvular prothesis in aortic position according to the ESC and AHA-ACC recommendations.

Figure 3

Proportion of SAVR with mechanical versus biological prosthetic valve per class of age during the overall study time (2007–2022).

Figure 4

Proportion of SAVR with biological versus mechanical prosthetic valves for patients between 50 and 60 years-old per year during study time (2007–2022).

Figure 5

Proportion of mechanical valve for patients operated on for SAVR between 50 and 60 years-old per centre (sample) and per quartile during study time (2007–2022). Patients operated on between 01/01/2007 and 24/10/2011 (Q1); between 24/10/2011 and 02/07/2015 (Q2); between 02/07/2015 and 29/01/2019 (Q3) and between 29/01/2019 and 31/12/2022 (Q4).