Bioprosthetic aortic valve replacement: Revisiting prosthesis choice in patients younger than 50 years old

Objective: Aortic prosthesis choice is controversial in young adults because robust comparative outcome data are lacking. We therefore compared mortality and morbidity in young adults after bioprosthetic versus mechanical aortic valve replacement. Methods: This was a retrospective analysis of 5111 patients aged 18 to 50 years undergoing primary aortic valve replacement in California and New York State from 1997 to 2006. Median follow-up time was 11.8 years (maximum 18.9 years). The primary endpoint was mortality; secondary endpoints were stroke, bleeding, and reoperation. Propensity score matching yielded 1175 patient pairs. Results: Bioprosthetic valves increased from 14% to 47% of aortic valve replacements between 1997 and 2014 (P <.001). There was no survival difference with bioprosthetic versus mechanical aortic valves in the propensity score-matched cohort: actuarial 15-year survival was 79.0% (95% confidence interval [CI], 75.8%-81.8%) versus 81.5% (95% CI, 78.5%-84.2%) respectively (hazard ratio [HR], 1.14; 95% CI, 0.93-1.40, P =.20). No interaction was found between age and prosthesis choice on survival (P_interaction = 0.16). After bioprosthetic valve replacement, stroke rates were lower (5.4% [95% CI, 3.8%-7.2%] vs 8.1% [95% CI, 6.3%-10.2%], HR 0.62 [95% CI 0.43-0.91]), bleeding rates were lower (4.2% [95% CI, 3.0-5.6%] vs 8.4% [95% CI, 6.6-10.4%], HR 0.48 [95% CI, 0.33-0.69]), but reoperation rates were greater (24.5% [95% CI, 21.3%-27.8%] vs 9.3% [95% CI, 7.2%-11.7%], HR 5.9 [95% CI 3.2-11.0]) at 15 years versus mechanical valve replacement. Conclusions: Although lifetime risks are represented incompletely, these findings suggest that in adults aged 18-50 years, bioprostheses are a reasonable alternative to mechanical valves for aortic valve replacement.