Bioprosthetic vs Mechanical Aortic Valve Replacement in Patients 40 to 75 Years of Age

Michael E Bowdish¹, J Hunter Mehaffey², Shu-Ching Chang³, Patrick T O'Gara⁴, Michael J Mack⁵, Andrew B Goldstone⁶, Joanna Chikwe⁷, A Marc Gillinov⁸, Changfu Wu⁹, Gregory P Fontana¹⁰, Joseph E Bavaria¹¹, Chris S Malaisrie¹², Tsuyoshi Kaneko¹³, Ibrahim S Sultan¹⁴, Moritz C Wyler von Ballmoos¹⁵, Kathrine B Harrington⁵, Jeffrey P Jacobs¹⁶, Vinod H Thourani¹⁷, Wilson Y Szeto¹⁸, Joseph F Sabik¹⁹, Robert H Habib³, Vinay Badhwar²

Affiliations

¹ Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA. Electronic address: Michael.Bowdish@cshs.org.
² Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia, USA.
³ Research and Analytic Center, Society of Thoracic Surgeons, Chicago, Illinois, USA.
⁴ Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.
⁵ Division of Cardiothoracic Surgery, Baylor Research Institute, Baylor Health Care System, Plano, Texas, USA.
⁶ Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University, New York, New York, USA.
⁷ Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.
⁸ Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
⁹ U.S. Food and Drug Administration, Silver Spring, Maryland, USA.
¹⁰ Cardiovascular Research, HCA Healthcare Research Institute, Nashville, Tennessee, USA.
¹¹ Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
¹² Division of Cardiac Surgery, Department of Surgery, Northwestern University, Chicago, Illinois, USA.
¹³ Division of Cardiothoracic Surgery, Washington University in St Louis, St Louis, Missouri, USA.
¹⁴ Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
¹⁵ Department of Cardiovascular and Thoracic Surgery, Texas Health Fort Worth, Fort Worth, Texas, USA.
¹⁶ Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida, USA.
¹⁷ Department of Cardiothoracic Surgery, Piedmont Healthcare, Atlanta, Georgia, USA.
¹⁸ Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
¹⁹ Department of Surgery, University Hospitals, Cleveland, Ohio, USA.

PMID: 40139884
DOI: 10.1016/j.jacc.2025.01.013

Comparative Study

Bioprosthetic vs Mechanical Aortic Valve Replacement in Patients 40 to 75 Years of Age

Michael E Bowdish et al. J Am Coll Cardiol. 2025.

. 2025 Apr 1;85(12):1289-1298.

doi: 10.1016/j.jacc.2025.01.013. Epub 2025 Jan 25.

Authors

Affiliations

¹ Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA. Electronic address: Michael.Bowdish@cshs.org.
² Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia, USA.
³ Research and Analytic Center, Society of Thoracic Surgeons, Chicago, Illinois, USA.
⁴ Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.
⁵ Division of Cardiothoracic Surgery, Baylor Research Institute, Baylor Health Care System, Plano, Texas, USA.
⁶ Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University, New York, New York, USA.
⁷ Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.
⁸ Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
⁹ U.S. Food and Drug Administration, Silver Spring, Maryland, USA.
¹⁰ Cardiovascular Research, HCA Healthcare Research Institute, Nashville, Tennessee, USA.
¹¹ Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
¹² Division of Cardiac Surgery, Department of Surgery, Northwestern University, Chicago, Illinois, USA.
¹³ Division of Cardiothoracic Surgery, Washington University in St Louis, St Louis, Missouri, USA.
¹⁴ Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
¹⁵ Department of Cardiovascular and Thoracic Surgery, Texas Health Fort Worth, Fort Worth, Texas, USA.
¹⁶ Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida, USA.
¹⁷ Department of Cardiothoracic Surgery, Piedmont Healthcare, Atlanta, Georgia, USA.
¹⁸ Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
¹⁹ Department of Surgery, University Hospitals, Cleveland, Ohio, USA.

PMID: 40139884
DOI: 10.1016/j.jacc.2025.01.013

Abstract

Background: The choice of bioprosthetic or mechanical surgical aortic valve replacement (AVR) should balance individual valve durability with the potential liabilities of oral anticoagulation.

Objectives: To inform clinical practice, this study sought to evaluate contemporary, real-world, long-term AVR outcomes from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD).

Methods: All patients undergoing primary isolated bioprosthetic or mechanical AVR were identified. Patients aged <40 and >75 years with endocarditis, emergency/salvage status, shock, ejection fraction ≤25%, and any prior cardiac surgery were excluded. Validated methodology was applied for linkage to the National Death Index to define longitudinal all-cause mortality (2008-2019). Robust risk adjustment was performed by using age-specific inverse probability weighting and restricted cubic splines to model nonlinear age relationships. Sensitivity analyses excluded pure aortic insufficiency, intermediate/high risk (STS predicted risk of operative mortality >4%), and discontinued valve types.

Results: A total of 109,842 patients underwent bioprosthetic (n = 94,125) or mechanical (n = 15,717) AVR during the study period. After risk adjustment, freedom from all-cause mortality favored mechanical valves in patients aged 60 years and younger. Age group-specific analyses showed that mechanical valves were associated with lower all-cause mortality in all age groups ≤60 years. These results remained consistent across all sensitivity analyses.

Conclusions: In patients aged ≤60 years, mechanical AVR was associated with an independent risk-adjusted survival benefit compared with bioprosthetic AVR. These contemporary 12-year survival data further inform patient and provider shared clinical decision-making regarding prosthetic aortic valves.

Keywords: aortic valve replacement; bioprosthetic; mechanical; survival.

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Conflict of interest statement

Funding Support and Author Disclosures Dr Bowdish has received research funding from Renibus Therapeutics. Dr Mack is a trial co–primary investigator for Edwards Lifesciences and study chair for Medtronic. Dr Gillinov has served as a consultant for Edwards, Medtronic, Artivion, Abbott, ClearFlow, and AtriCure. Dr Bavaria has served as a consultant for Abbott. Dr Malaisrie has received funding from Medtronic, Edwards Lifesciences, Terumo Interventional Systems, and Artivion, Inc. Dr Kaneko has served as a member of the Advisory Board for Edwards, Abbott, and Johnson & Johnson; and has served as a consultant for Medtronic and 4C Medical. Dr Sultan reports a relationship with Abbott, AtriCure, Artivion, Gore, Edwards, Medtronic, and Terumo Aortic. Dr Thourani has served as an advisor or received research funding from Abbott Vascular, AtriCure, Boston Scientific, CroíValve, Edwards Lifesciences, JenaValve, Laplace, Medtronic, Tricares, and Trisol. Dr Szeto has received grant funding from Edwards Lifesciences, Medtronic Inc, and W L Gore & Associates Inc; and has served as a consultant for Terumo Interventional Systems, Micro Interventional Devices, Inc, and Cardiac Dimensions Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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Bioprosthetic vs Mechanical Aortic Valve Replacement in Patients 40 to 75 Years of Age

Affiliations

Bioprosthetic vs Mechanical Aortic Valve Replacement in Patients 40 to 75 Years of Age

Authors

Affiliations

Abstract

Conflict of interest statement

Publication types

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LinkOut - more resources

Full Text Sources