Biologic and Mechanical Mitral Valve Prostheses: Outcomes in 50- to 69-Year-Olds

Summary and Comment |
April 22, 2015

Biologic and Mechanical Mitral Valve Prostheses: Outcomes in 50- to 69-Year-Olds

  1. Howard C. Herrmann, MD

Mechanical prostheses are associated with more bleeding and stroke but with less reoperation risk.

  1. Howard C. Herrmann, MD

Patients undergoing mitral valve replacement (MVR) need to balance the long-term risk of structural deterioration of biologic prostheses with the anticoagulation risks of mechanical ones. In this retrospective cohort study, investigators utilized a New York State database to examine outcomes in 3433 patients aged 50 to 69 who had MVR between 1997 and 2007.

The 2638 patients with mechanical prostheses (77%) tended to be younger and to have fewer comorbidities than bioprostheses recipients. Propensity scoring on age and comorbidities was used to identify 664 pairs of patients (mechanical prosthesis in one, biologic prosthesis in the other); 30-day mortality in the prosthesis groups was similar (about 5%). They were followed for a median of 8 years.

Actuarial 15-year estimates of survival were similar with mechanical (58%) and biologic (60%) prostheses. However, the mechanical group had higher incidence of ischemic or hemorrhagic stroke (14% vs. 7%; hazard ratio, 1.62) and bleeding events (15% vs. 9%; HR, 1.50) by 15 years. Mitral valve reoperation at 15 years, which had a 30-day reoperative mortality of 5%, was lower in the mechanical group (5% vs. 11%; HR, 0.59).

Comment

This observational study using a large database provides quantitative estimates to allow relatively younger patients and their clinicians to balance the trade-offs between the incremental risk for reoperation after bioprosthetic MVR with the long-term risk for stroke and major bleeding with mechanical prostheses. The higher risk for stroke in patients with mechanical prostheses, even with optimal anticoagulation, has been demonstrated elsewhere. In my practice, more young patients are choosing biologic valves to avoid anticoagulation (and stroke) when possible, despite the greater risk for reoperation. Eventually, transcatheter MVR may offer bioprosthesis recipients another option to avoid reoperation.

Editor Disclosures at Time of Publication

  • Disclosures for Howard C. Herrmann, MD at time of publication Consultant / Advisory board Gerson Lehrman Group; Siemens; Leerink Swann; Wells Fargo; Massachusetts Medical Society; Edwards Lifesciences; O’Bryan, Brown, and Toner; ExpertConnect; Merck Sharp and Dohme; Guidepoint Global Speaker's bureau Society for Cardiovascular Angiography and Interventions; Pinnacle Health; Mayo Foundation; Cardiovascular Institute; ACC Foundation Equity Micro Interventional Devices, Inc. Grant / Research support Abbott Vascular; Edwards Lifesciences; Gore; Medtronic; St. Jude Medical; Siemens; Boston Scientific; Cardiokinetix; University of Laval; MitraSpan Editorial boards Catheterization and Cardiovascular Interventions; Circulation: Cardiovascular Interventions; Journal of Interventional Cardiology; Journal of Invasive Cardiology; Journal of the American College of Cardiology

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