If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Address for reprints: Prashanth Vallabhajosyula, MD, MS, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104.
Long-term outcomes of prosthetic aortic valve/root replacement in patients aged 30 years or younger are not well understood. We report our single institutional experience in this young cohort.
Methods
From 1998 to 2016, 99 patients (age range, 16-30 years) underwent aortic valve replacement (n = 57), aortic valve replacement and supracoronary ascending aorta replacement (n = 6), or aortic root replacement (n = 36). A prospectively maintained aortic valve database was retrospectively reviewed to complete longitudinal functional and clinical data. Total follow-up was 493 patient years.
Results
Surgical indications included primary stenosis/insufficiency (52% [n = 51]), Marfan syndrome (10% [n = 10]), and endocarditis (33.3% [n = 33]). Fifty-eight patients (59%) underwent mechanical valve replacement, with 41 patients (41%) receiving a biologic/bioprosthetic valve. Twenty-five patients underwent aortic valve reoperation after index procedure with following indications: prosthesis–patient mismatch 1.0% (n = 1), prosthetic valve degeneration/dysfunction 10% (n = 10), connective tissue 2% (n = 2), and endocarditis 12% (n = 12). Mortality (30-day/in-hospital) and stroke rate were 3.0% (n = 3) and 1% (n = 1), respectively. One-, 5-, and 10-year actuarial freedom from aortic valve reoperation by valve type was 89.1%, 84.6%, and 69.4% for the Mechanical Valve group and 89.6%, 70.9%, and 57.6% for the Biologic/Bioprosthetic Valve group, respectively (log rank P = .279). Replacement valve size ≤21 mm was a significant risk factor for reoperation, and was associated with progression of mean aortic valve transvalvular gradients over follow-up. Valve type had no effect.
Conclusions
The choice of mechanical versus biologic/bioprosthetic valve does not affect freedom from reoperation or survival rates in this young cohort during mid- to long-term follow-up. Smaller aortic valve replacement size (≤21 mm) is a significant risk factor for reoperation and progression of mean aortic valve gradients.
In patients aged 30 years or younger undergoing aortic valve replacement, prosthetic valve size rather than type influences mid- to long-term risk of reoperation.
In young patients (aged 30 years or younger) requiring aortic valve replacement, there is a paucity of data on long-term comparative outcomes of mechanical versus biologic/bioprosthetic valves. Over follow-up of 493 patient years, we found valve choice did not affect patient survival or valve durability. Aortic valve size is identified as a significant risk factor for reoperation and progression of mean valve gradients.
Surgical treatment of aortic valve disease in pediatric and young adult patients is a complex decision process with no consensus regarding the optimal surgical procedure. Although primary valve repair or replacement with pulmonary autograft are well-established options, long-term outcomes in young patients undergoing prosthetic aortic valve/root replacement are not well studied. In young children, the Ross procedure is associated with significantly lower immediate and late mortality, and lower long-term complication rates compared with prosthetic valves.
In pediatric populations, somatic growth and accelerated degeneration of bioprosthetic aortic valves leading to prosthesis–patient mismatch (PPM) have been a primary consideration. However, in young adults, somatic growth concerns no longer exit. Instead, valve choice is often driven by the considerations of left ventricular function, lifestyle, occupation, future pregnancy, requirement for anticoagulation therapy, and need for reoperation.
In young adult patients, surgical management of aortic valve disease is a lifelong process. A major concern of the Ross procedure in this patient population is that a single aortic valve disease requires double valve replacement.
For young adults with preserved aortic cusp integrity with or without aortopathy, aortic valve repair or valve-sparing root reimplantation has presented as a viable alternative to prosthetic valve replacement.
If the aortic valve cannot be preserved, either mechanical, stented bioprosthetic, or stentless biologic/bioprosthetic aortic valve replacement remains the procedure of choice, but often with recognized suboptimal mid- to long-term outcomes.
The absence of an ideal definitive treatment option in this patient population requires an informed decision between patient and surgeon, and a meticulous assessment of surgical risk versus benefit that includes lifestyle considerations.
Given the need for more long-term data in this surgical cohort, we reviewed our institutional outcomes with aortic valve replacement procedures in patients aged 30 years or younger. Our primary objectives were to define long-term valve hemodynamic profiles, durability, and survival stratified by valve type in this young patient population aged 30 years or younger.
Methods
Patients
This study was approved by our institutional review board. From 1998 to 2016, 99 patients between age 16 and 30 years, inclusive, who did not meet criteria for valve repair underwent an elective aortic valve or composite valve root replacement for valvulopathy. All urgent and emergent procedures were excluded. All patients undergoing primary valve repair and valve sparing root reimplantation were excluded from this study. To account for the heterogeneous disease processes underlying aortic valvulopathy, we stratified the patient population by type of aortic valve replacement (AVR) (41 patients received a biologic/bioprosthetic valve and 58 patients received a mechanical valve), and by the valve size (≤21 mm vs ≥23 mm). In this study, bioprosthetic refers to both stentless and stented tissue AVR.
Clinical and Echocardiographic Follow-up
Patients were contacted to ensure accurate follow-up. Patients followed at our Aortic Valve Center had prospectively collected clinical and imaging follow-up. For those patients not primarily followed at our institution, transthoracic echocardiographic and clinical data were obtained from their primary care physicians and cardiologists. Total follow-up was 493 patient years.
Valve Selection
The decision of valve choice was made individually between patient and surgeon based on lifestyle choice, desire for pregnancy, and/or contraindication/desire to avoid anticoagulation therapy.
Statistical Analysis
General statistics, multivariate models, and graphs were coded in STATA/MP version 14.2 (StataCorp, College Station, Tex). First, data were checked for normality. Descriptive statistics were presented as mean ± standard deviation for continuous variables, median (interquartile range) for continuous variables in cases of nonnormality, and percentage (frequency) for categorical variables. Continuous variables were compared using the unpaired t test, 1-way analysis of variance and Wilcoxon signed-rank test in cases of nonnormality. Fisher exact test and χ2 statistics were used to compare categorical variables. All tests were 2-sided with the alpha level set at 0.05 for statistical significance.
Competing-risk regression was fitted with aortic valve reoperation as dependent variable. Covariates were age, gender, valve type (bioprosthetic vs mechanical), valvular morphology at baselines (tricuspid aortic valve [TAV] vs bicuspid aortic valve [BAV]), and prosthetic valve size (as continuous variable). Competing risk of mortality was taken into account. Cumulative incidences were plotted stratified by prosthetic valve type and prosthetic valve size (≤21 mm vs 23-31 mm).
Threshold regression was used to identify a sample split in prosthetic valve size as risk factor for aortic valve reoperation. Reoperation was used as the dependent variable (binary), independent variables were age, gender, valve type (bioprosthetic vs mechanical valve), and valvular morphology at baseline (TAV vs BAV). Prosthetic valve size (as continuous variable) was introduced as the threshold variable and model was run with 5000 bootstrap replications, default White correction for heteroscedasticity indicator was used. Graph of the normalized likelihood ratio statistic as a function of the threshold in prosthetic valve size is outlined in Figure 1.
Figure 1Threshold regression. Normalized likelihood ratio (LR) as a function of aortic valve replacement size.
A linear mixed-effects model was fitted to assess trends in mean aortic valve pressure gradient patterns over postoperative follow-up time and to validate risk factors associated with progression of mean aortic valve pressure gradients. Postoperative time course (time as continuous variable), age, gender, valve type (bioprosthetic vs mechanical), valvular morphology at baseline (TAV vs BAV) and prosthetic valve size (categorical ≤ 21 mm vs ≥23 mm) were included as fixed effects with a random-intercept term at the patient level with a random slope on the postoperative time course. Covariance structure for random effects was unstructured. Model was fit using maximum likelihood. Default gradient-based Newton Raphson iterations were used.
Kaplan-Meier method and log-rank statistics were used to determine, compare and plot survival estimates (Figure 2) stratified by valve type (plotted with 95% confidence interval bands). One-, 5-, and 10-year freedom from reoperation and freedom from mortality were reported actuarially.
Demographic characteristics and preoperative parameters are listed in Table 1. In total, 99 patients met inclusion criteria with a total follow-up of 493 patient years. Average age at valve implantation was 24.7 ± 3.2 years for mechanical aortic valve and 24.5 ± 3.0 years for biologic/bioprosthetic aortic valve. Patients were stratified according to tissue versus mechanical valve implantation. We observed a rather homogenous patient population at baseline with only a few differences between groups. There was no significant difference in the number or type of previous valve interventions. Indications for primary and reoperative valve surgery were not significantly different between the Mechanical and Biologic/Bioprosthetic groups (Table 1). Preoperative echocardiographic parameters differed in peak aortic transvalvular pressure gradient (P = .03). However, no significant differences in mean aortic transvalvular pressure gradient (P = .07), or left ventricular end-diastolic dimension (P = .05) existed between groups (Table 1).
Table 1Demographic characteristics and preoperative parameters
Variable
Mechanical valve (n = 58)
Bioprosthetic valve (n = 41)
P value
Demographic characteristic
Age
24.7 ± 3.2
24.5 ± 3.0
.69
Male gender
49 (84.5)
23 (65.1)
<.01
BAV
29 (50)
30 (73.2)
.01
BMI
26.6 ± 7.1
25.1 ± 5.9
.29
Previous native valve procedure
n = 12
n = 8
Valvuloplasty, open
2 (16.7)
2 (25.0)
.65
Valvuloplasty, balloon
1 (8.3)
3 (37.5)
.11
Ross procedure
5 (41.7)
1 (12.5)
.16
Primary valve repair
2 (16.7)
2 (25.0)
.65
VSRR
2 (16.7)
0 (0)
.22
Echocardiographic data
Mean AV gradient (mm Hg)
15.8 ± 13.9
29.2 ± 20.5
.07
Peak AV gradient (mm Hg)
27.1 ± 21.5
53.7 ± 36.1
.03
LVEDD (mm)
63.6 ± 8.7
58.1 ± 10.3
.05
EF (%)
51.7 ± 15.2
57.6 ± 11.3
.11
Surgical indication at index operation
n = 58
n = 41
TAV-AS
1 (1.7)
0 (0)
.40
TAV-AI
7 (12.1)
2 (4.9)
.22
BAV-AS
10 (17.2)
12 (29.3)
.16
BAV-AI
9 (15.5)
10 (24.4)
.27
Marfan syndrome
8 (13.8)
2 (4.9)
.15
Endocarditis
20 (34.5)
13 (31.7)
.77
Rheumatic valve degeneration
3 (5.2)
2 (4.9)
.95
Data are presented as mean ± standard deviation or n (%). BAV, Bicuspid aortic valve, BMI, body mass index; VSRR, valve sparing root replacement; AV, aortic valve; LVEDD, left ventricular end-diastolic dimensions; EF, ejection fraction; TAV, tricuspid aortic valve; AS, aortic stenosis; AI, aortic insufficiency.
There were 3 primary aortic valve procedures: AVR, AVR and supracoronary ascending aortic replacement, and aortic root replacement (ARR) (Video 1). There was no significant difference between the percentages of mechanical and biologic/bioprosthetic valves utilized in AVR or ARR procedures, but more female patients underwent biologic/bioprosthetic AVR/ARR (P = .002), and a significantly higher subpopulation of BAV patients received a biologic/bioprosthetic valve (P = .01) (Table 1). There were significantly more biologic/bioprosthetic valves placed for AVR and supracoronary ascending aortic replacement (P = .03) (Table 2). Implant valve size was similar (P = .29). In-hospital/30-day mortality, stroke, renal failure, and reoperation for bleeding rates were also similar (Table 2).
Video 1Intraoperative video demonstrating aortic valve replacement with a bioprosthetic valve for aortic stenosis and aortic insufficiency in a patient with bicuspid aortic valve disease. Video available at: https://www.jtcvs.org/article/S0022-5223(18)32933-7/fulltext.
Table 2Intraoperative data and postoperative outcomes
Variable
Mechanical valve (n = 58)
Bioprosthetic valve (n = 41)
P value
AV procedure
AVR
33 (56.9)
24 (58.5)
.87
AVRSCAAR
1 (1.7)
5 (12.2)
.03
ARR
24 (41.4)
12 (29.3)
.22
Concomitant procedure
Ventricular septal defect
2 (3.4)
3 (7.3)
.39
Atrial septal defect
2 (3.4)
2 (4.9)
.72
Mitral valve repair/replacement
11 (19.0)
2 (4.9)
.04
Intraoperative parameter
Crossclamp (min)
148.8 ± 67.9
121.8 ± 57.1
.04
Bypass time (min)
197.8 ± 87.0
173.7 ± 103.8
.22
Valve characteristic
Median valve size (mm)
25 (23-27)
23 (21-27)
.29
Postoperative outcome
In-hospital/30-d mortality
1 (1.7)
2 (4.9)
.35
Stroke
1 (1.7)
0 (0)
.41
TIA
1 (1.7)
1 (2.4)
.80
Renal failure
0 (0)
1 (2.4)
.22
Reoperation for bleeding
1 (1.7)
0 (0)
.51
Follow-up
Median follow-up (mo)
50.0 (15.8-97.5)
48.0 (16.0-97.0)
.98
Median echocardiographic follow-up
47.0 (16.0-89.5)
41.0 (6.0-97.0)
.81
Data are presented as mean ± standard deviation, median (interquartile range), or n (%). AV, Aortic valve; AVR, aortic valve replacement; AVRSCAAR, aortic valve replacement with supracoronary ascending aorta replacement; ARR, aortic root replacement; TIA, transient ischemic attack.
Median clinical and echocardiographic follow-up was similar between groups (Table 2). Total median follow-up for the entire group was 49 months (interquartile range, 16-97 months).
Indications and Risk Factors for AVR
There was no significant difference in indications for reoperation by AVR type (Table 3). The most common indication in both groups was endocarditis, followed by biologic/bioprosthetic structural valve deterioration, and mechanical valve dysfunction. To further understand risk factors for aortic reoperation, we fitted a competing-risk regression model, taking into account the competing-risk of mortality (Table 4). Covariate structure for this model is detailed in the Methods section. The type of valve implant (biologic/bioprosthetic vs mechanical valve) and aortic valve morphology at baseline (BAV vs TAV) were not associated with increased risk of reoperation (subdistribution hazard ratio [SHR], 1.72 [P = .18] and SHR, 1.32 [P = .57], respectively). The SHR for AVR size was < 1, and statistically significant (P = .04), suggesting that small valve size was a significant independent risk factor for aortic valve reoperation.
Table 3Indications for reoperation
Indication for reoperation
Mechanical valve (n = 58)
Bioprosthetic valve (n = 41)
P valve
Total reoperations
13
12
–
Biologic/bioprosthetic valve degeneration or mechanical valve dysfunction
Effect of Prosthetic Valve Size and AVR Type on Aorta Reoperation
Using AVR size as a continuous variable did not permit the identification of the exact valve size or range of valve sizes that carry the highest risk for aortic valve reoperation. A threshold regression analysis identified a single sample split at ≤21 mm AVR size, suggesting that prosthetic valve sizes of 19 mm and 21 mm have the highest risk of reoperation (Figure 1). Covariate structure is outlined in the Methods section and a graph of the normalized likelihood ratio statistic as a function of the threshold in AVR size is outlined in Figure 1. Based on the threshold of ≤21 mm valve size, a cumulative incidence plot was constructed to better understand the pattern of prosthetic valve failure over follow-up stratified by valve size (≤21 mm vs 23-31 mm) and valve type (biologic/bioprosthetic vs mechanical valve) (Figure 3). Smaller AVR sizes (≤21 mm) were associated with a 1.9-fold increased risk of aortic valve reoperation (P = .04), but the valve type had no effect over follow-up time (P = .18).
Figure 3Competing-risk cumulative incidence of reoperation. Incidence of reoperation does not depend on aortic valve replacement type (biologic/bioprosthetic vs mechanical) but rather on aortic valve replacement size.
Effect of Valve Type and Size on Longitudinal Mean Aortic Transvalvular Gradient Trends
Raw data of mean transvalvular aortic valve gradients over follow-up are plotted in Figure 4, stratified by valve type, valve size, and whether the patient was undergoing primary valve replacement or aortic valve reoperation. To validate factors associated with mean gradient trends over time, a repeated measures mixed effects longitudinal model was fitted (Table 5). Mixed effects, random effects, random effects covariate structure, and interaction terms are specified in the Methods section. The coefficient on postoperative time was positive (coefficient = 1.54) and highly significant (P < .01), suggesting that there was a significant increase in mean aortic valve gradients over time (Figure 5). But overall, both valve types showed similar transvalvular mean pressure gradients (P = .25). Small AVR (≤21 mm) was significantly associated with increased mean aortic valve pressure gradients over time (coefficient, 7.1; P < .01) (Figure 5). Overall, mean aortic valve pressure gradients are expected to exceed 20 mm Hg after 8 years in the Biologic/Bioprosthetic Valve group, and after 9.5 years in the Mechanical Valve group (Figure 5).
Figure 4Spaghetti plot. Mean aortic transvalvular gradients stratified by aortic valve replacement type and size (≤21 mm vs 23-31 mm). Plot shows patients who did not require aortic valve reoperation (blue) and patients who underwent reoperation (red).
Figure 5Predicted progression of mean aortic transvalvular gradients stratified by aortic valve replacement type. Mean aortic transvalvular gradients increase over time (P ≤ .01) but do not differ between groups (P = .25).
One-, 5-, and 10-year actuarial freedom from reoperation by valve type was 89.1%, 84.6%, and 69.4% for the Mechanical Valve group, and 89.6%, 70.9%, and 57.6% for the Biologic/Bioprosthetic Valve group, respectively (log rank P = .279). One, 5-, and 10-year actuarial survival stratified by prosthetic valve type was 94.5%, 92.3%, and 92.3% for the Mechanical Valve group and 92.2%, 92.2%, and 85.4% for Biologic/Bioprosthetic Valve group, respectively (log rank P = .597) (Figure 2).
Discussion
Aortic valvulopathy in children and young adults is a lifelong disease. After AVR, progressive left ventricular dysfunction, prosthetic valve degeneration or dysfunction requiring reoperation, and complications associated with valve replacement are risks throughout adulthood. Young adults differ from the pediatric population in that somatic growth is not a primary determinant of aortic valve procedure choice. However, these young patients are at risk for major adverse prosthetic valve-related events that include structural biologic/bioprosthetic valve deterioration; mechanical valve dysfunction; endocarditis; and paravalvular leak with associated hemolysis leading to anemia, bleeding, and thromboembolic events.
Therefore, therapeutic management plans require lifetime surveillance. For patients with nonrepairable aortic valves, recommendations for the optimal aortic valve prosthesis/procedure are not clear and, specifically, the long-term clinical and functional valvular outcomes are not as well understood in this young patient population. As a result, these are often complex and multifactorial decisions undertaken together by a patient, cardiologist, and surgeon.
Important considerations include the patient's age, gender, lifestyle, occupation, medical adherence, dimensions of the aortic root complex, left ventricular function, need for and degree of anticoagulation, risk of surgery and postoperative anticoagulation, and the long-term risk/benefit assessment of valve durability (vs reoperation) and anticoagulation (thromboembolic vs bleeding events).
A logistic problem with current recommendations for mechanical or bioprosthetic valves in young adults is that most studies that evaluate the valve risk/benefit, durability, and outcomes have been extrapolated from either a pediatric or older patient population, with few studies delineating these results in the young adult population.
An ideal AVR for this young population therefore would include a valve that has lifelong durability, is available off-the-shelf in all necessary sizes, has excellent hemodynamic parameter profiles, is easily implantable, requires no anticoagulation therapy, and has no risk of thromboembolic events.
The 2017 American College of Cardiology/American Heart Association guidelines for the use of mechanical valves have been modified with respect to age, prosthetic valve, and anticoagulation recommendations for patients younger than age 50 years who have absolute contraindications, inability to manage anticoagulation, or personal aversion to anticoagulation therapy.
2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines.
However, despite these less rigorous age guidelines, in the current era few young adults want to receive anticoagulation therapy or alter their lifestyle.
; however, lifetime durability in a patient younger than age 30 years has not been as well established. The recent rise of transcatheter valve procedures has prompted the recommendation of transcatheter valve-in-valve for structural valve disease of bioprosthetic valves. However, long-term durability of the valve-in-valve procedure in a young adult may be less than optimal, requiring multiple procedures and increased risk of heart block as well as PPM by middle age.
Given these concerns, the primary objective of our study was to identify factors that influence the use of either mechanical or biologic/bioprosthetic AVR in young adults and to analyze mid- to long-term outcomes in these patients.
For young adults with irreparable aortic valvulopathy, a mechanical valve has the benefit of potentially providing long-term durability. However, mechanical valves do not carry a 100% freedom from reoperation, and long-term survival is lower than that seen in age-matched and gender-matched control cohorts.
Thromboembolic events are reported to occur at a linearized rate of 1.5% to 2% per patient year, and bleeding events occur at a linearized rate of about 3% per patient year.
In our study, 58.6% patients had a mechanical valve placed with a 1-, 5-, and 10-year actuarial freedom from reoperation of 89.1%, 84.6%, and 69.4%, and survival of 94.5%, 92.3%, and 92.3%, respectively. Thromboembolic and bleeding rates were seen in 1.7% of the cohort.
Compared with mechanical valves, biologic/bioprosthetic valves have a low thromboembolic risk and do not mandate lifelong anticoagulation.
However, biologic/bioprosthetic valves have a known risk of structural valve deterioration and variable freedom from reoperation that is closely related to patient age.
for all aortic valve pathologies. However, each new generation of stented bioprosthetic valves employing innovative fixation and antimineralization processes has a reported improved 10-year freedom from reoperation.
This is especially relevant in young patients with lifestyle considerations and in young women considering future pregnancies. In our study, we observed 1-, 5-, and 10-year actuarial freedom from reoperation of 89.6%, 70.9%, and 57.6%, and actuarial survival of 92.2%, 92.2%, and 85.4%, respectively, in our Biologic/Bioprosthetic cohort.
Identification of factors that influence prosthetic valve use and outcomes is critical in this young adult population. It is becoming evident that hemodynamic profile has a major influence on prosthetic valve durability and longitudinal outcomes.
Echocardiographic delineation of effective orifice area indexed to body surface area of the prosthetic aortic valve using a 3-tier method has been utilized to identify PPM.
The influence of PPM on left ventricular function, exercise capacity, and need for reoperation in the young patient population is well established, emphasizing the need to select a prosthetic valve with optimal effective orifice area at implant.
found that 10 mm Hg increase in postoperative peak gradient was associated with a >2-fold increase in 20-year risk for reoperation.
In our study, we evaluated valve-related hemodynamic factors that influenced freedom from reoperation in both the Mechanical and Biologic/Bioprosthetic valve groups. Specifically, we investigated the effect of valve type and size on longitudinal mean aortic transvalvular gradients. We delineated a single sample split at ≤21 mm aortic valve replacement size, and identified that prosthetic valve sizes of 19 mm and 21 mm had a 1.9-fold increased risk of aortic valve reoperation over time, compared to larger valve sizes. For both mechanical and biologic/bioprosthetic valves, there was a significant increase in mean aortic transvalvular gradient over time (20 mm Hg after 8 years for the Biologic/Bioprosthetic Valve cohort, and 20 mm Hg after 9.5 years for the Mechanical Valve cohort), but no significant difference between the Mechanical versus Biologic/Bioprosthetic groups was noted. Therefore, it is clear that small AVR size (≤21 mm) is associated with a significant increase in mean aortic valve pressure gradients over time, and importantly, AVR size (≤21 mm) is a significant risk factor for reoperation.
Therefore, in this study cohort, likelihood of reoperation for patients aged 30 years or younger was more dependent upon size of the valve as opposed to type of valve. This supports the concept that in young adults with small aortic root complex dimensions, aortic root and annular enlargement procedures should be considered to optimize the effective orifice area and minimize PPM, especially in the elective setting. Special consideration might also be given toward left ventricular outflow tract enlargement procedures as needed in those patients who otherwise cannot accommodate a valve >21 mm.
Limitations
As with all retrospective studies, extensive work was done to obtain echocardiographic data for long-term outcome analysis; however, complete follow-up on all patients was not possible. Multiple attempts were made to contact all patients, their primary care physicians, and their cardiologists to obtain complete follow-up data. Due to referral patterns, centralized and standardized echocardiographic reads by 1 echocardiographer were not possible, which may contribute to variability in technique, operator bias, and reader bias. Finally, the overall cohort size was not large enough to perform reliable propensity score matching due to sample size. A multi-institutional investigation may help address this concern.
Conclusions
Our results suggest that the choice of mechanical versus biologic valve does not affect freedom from reoperation or survival rates in young patients (aged 30 years or younger) at mid- to long-term follow-up. AVR size is a significant risk factor for reoperation and progression of mean aortic valve gradients. Although smaller prosthetic valve sizes (≤21 mm) are associated with a significantly higher risk of aortic valve reoperation, valve type, preoperative valve anatomy, or pathology have no significant effect over follow-up. Further longitudinal follow-up may elucidate the relative risks of mechanical aortic and biologic/bioprosthetic valves in this young patient cohort. A prospective and matched study with the latest generation biologic/bioprosthetic valves will be important to understand optimal valve choice in young patient populations.
Intraoperative video demonstrating aortic valve replacement with a bioprosthetic valve for aortic stenosis and aortic insufficiency in a patient with bicuspid aortic valve disease. Video available at: https://www.jtcvs.org/article/S0022-5223(18)32933-7/fulltext.
References
Etnel J.R.
Elmont L.C.
Ertekin E.
Mokhles M.M.
Heuvelman H.J.
Roos-Hesselink J.W.
et al.
Outcome after aortic valve replacement in children: a systematic review and meta-analysis.
2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines.
Surgical options for the treatment of aortic valve disease in young patients remain suboptimal despite the time that has passed since the ideal valve substitute was characterized.1 The quest for a perfect valve substitute continues while we receive long-term data of different treatment strategies. The decision to use either a bioprosthetic or a mechanical heart valve substitute in patients whose valves are not amenable for a repair becomes critical in younger patient populations. Myriad factors influence surgical decision making in each case.
32933-7&id=fx1.jpg){kind=link}
32933-7&id=gr1.jpg){kind=link}
32933-7&id=gr2.jpg){kind=link}
32933-7&id=fx2.jpg){kind=link}
32933-7&id=gr3.jpg){kind=link}
32933-7&id=gr4.jpg){kind=link}
32933-7&id=gr5.jpg){kind=link}
32933-7&id=fx3.jpg){kind=link}