IMMEDIATE AND LONG-TERM RESULTS OF MINIMALLY INVASIVE ACCESS IN AORTIC VALVE SURGERY: SINGLE CENTER RETROSPECTIVE STUDY

Highlights

• Mechanical aortic valve prostheses demonstrate significant long-term advantages in patients aged 50–65 years compared with bioprosthetic valves, including higher survival, a lower risk of reoperation, and a reduced incidence of prosthetic valve endocarditis.
• Both types of prostheses showed comparable outcomes with respect to postoperative complications, in-hospital mortality, and the incidence of stroke.
• These findings underscore the need for an individualized approach to prosthesis selection, taking into account patient age and concomitant risk factors.

Aim. To compare the immediate and long-term outcomes of aortic valve replacement (AVR) using mechanical and biological prostheses in patients aged 50–65 years.

Methods. This retrospective study included data from 792 patients who underwent AVR with mechanical or biological prostheses between 2009 and 2019. After pseudorandomization, 374 patients were selected and divided into two groups: Group 1 (n = 187) – mechanical prostheses, Group 2 (n = 187) – biological prostheses. Inclusion criteria: age ≥ 18 years, isolated AVR. Exclusion criteria: left ventricular ejection fraction < 35%, double or triple valve replacement, age < 50 or > 65 years. The median follow-up period was 90 months (range: 53–118 months). Immediate and long-term outcomes were evaluated, including survival, reoperation rates, stroke incidence, and prosthetic endocarditis.

Results. There were no statistically significant differences in immediate postoperative outcomes between the groups. The 1-, 3-, 5-, and 10-year survival rates in the mechanical prosthesis group were 94.9%, 93%, 89.7%, and 86.4%, respectively, which were higher than in the biological prosthesis group (93%, 88.7%, 84.2%, and 66.4%; p = 0.001). Freedom from reoperation at 1, 3, 5, and 10 years in the mechanical prosthesis group was 97.7%, 97.7%, 97.7%, and 97.7%, while in the biological prosthesis group, it was 98.3%, 96.9%, 95.4%, and 76.4% (p < 0.001). The incidence of stroke at 1, 3, 5, and 10 years in the mechanical prosthesis group was 2.7%, 5.4%, 5.4%, and 12.2%, while in the biological prosthesis group, it was 2.1%, 5.8%, 6.7%, and 9.4% (p = 0.486). Freedom from prosthetic endocarditis at 1, 3, 5, and 10 years in the mechanical prosthesis group was 100%, 100%, 100%, and 100%, while in the biological prosthesis group, it was 99.4%, 97.3%, 97.3%, and 94.5% (p = 0.003).

Conclusion. Mechanical AV prostheses demonstrate significant long-term advantages in patients aged 50–65 years compared to biological prostheses. They are associated with higher survival rates, lower risks of reoperation, and reduced incidence of prosthetic endocarditis. However, both types of prostheses showed comparable results in terms of postoperative complications, in-hospital mortality, and stroke incidence. These findings highlight the importance of an individualized approach to prosthesis selection, taking into account patient age and associated risk factors.

1. Bevan GH, Zidar DA, Josephson RA, Al-Kindi SG. Mortality Due to Aortic Stenosis in the United States, 2008-2017. JAMA 2019;321:2236–8. https://doi.org/10.1001/jama.2019.6292.

2. Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2022;43:561–632. https://doi.org/10.1093/eurheartj/ehab395.

3. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, et al. 2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. 2021. https://doi.org/10.1161/CIR.0000000000000923.

4. Bockeria L.A. (ed.). Cardiovascular Surgery – 2023. Moscow: NMITsSSKh im. A.N. Bakuleva Minzdrava Rossii, 2023: 368 p. (in Russian)

5. Head SJ, Çelik M, Kappetein AP. Mechanical versus bioprosthetic aortic valve replacement. Eur Heart J 2017;38:2183–91. https://doi.org/10.1093/eurheartj/ehx141.

6. Lu R, Dismorr M, Glaser N, Sartipy U. Aortic Valve Replacement With Mechanical Valves vs Perimount Bioprostheses in 50- to 69-Year-Old Patients. JACC Adv 2023;2. https://doi.org/10.1016/j.jacadv.2023.100359.

7. Stassano P, Di Tommaso L, Monaco M, Iorio F, Pepino P, Spampinato N, et al. Aortic valve replacement: a prospective randomized evaluation of mechanical versus biological valves in patients ages 55 to 70 years. J Am Coll Cardiol 2009;54:1862–8. https://doi.org/10.1016/j.jacc.2009.07.032.

8. Vankayalapati DK, Segun-Omosehin O, El Ghazal N, Suresh Daniel R, El Haddad J, Mansour R, et al. Long-Term Outcomes of Mechanical Versus Bioprosthetic Aortic Valve Replacement: A Systematic Review and Meta-Analysis. Cureus 2024;16:1–24. https://doi.org/10.7759/cureus.52550.

9. Goldstone AB, Chiu P, Baiocchi M, Lingala B, Patrick WL, Fischbein MP, et al. Mechanical or Biologic Prostheses for Aortic-Valve and Mitral-Valve Replacement. N Engl J Med 2017;377:1847–57. https://doi.org/10.1056/NEJMoa1613792.

10. Iribarne A, Leavitt BJ, Robich MP, Sardella GL, Gelb DJ, Baribeau YR, et al. Tissue versus mechanical aortic valve replacement in younger patients: A multicenter analysis. J Thorac Cardiovasc Surg 2019;158:1529-1538.e2. https://doi.org/10.1016/j.jtcvs.2019.02.076.

11. Tillquist MN, Maddox TM. Cardiac crossroads: deciding between mechanical or bioprosthetic heart valve replacement. Patient Prefer Adherence 2011;5:91–9. https://doi.org/10.2147/PPA.S16420.

12. Korteland NM, Bras FJ, van Hout FMA, Kluin J, Klautz RJM, Bogers AJJC, et al. Prosthetic aortic valve selection: current patient experience, preferences and knowledge. Open Hear 2015;2:e000237. https://doi.org/10.1136/openhrt-2015-000237.

13. Chiang YP, Chikwe J, Moskowitz AJ, Itagaki S, Adams DH, Egorova NN. Survival and long-term outcomes following bioprosthetic vs mechanical aortic valve replacement in patients aged 50 to 69 years. JAMA 2014;312:1323–9. https://doi.org/10.1001/jama.2014.12679.

14. Jiang Y, Wang S, Bian J, Chen S, Shao Y. Mechanical versus Bioprosthetic Aortic Valve Replacement in Middle-Aged Adults: A Systematic Review and Meta-Analysis. J Cardiovasc Dev Dis 2023;10. https://doi.org/10.3390/jcdd10020090.

15. Nguyen DT, Delahaye F, Obadia J-F, Duval X, Selton-Suty C, Carteaux J-P, et al. Aortic valve replacement for active infective endocarditis: 5-year survival comparison of bioprostheses, homografts and mechanical prostheses. Eur J Cardio-Thoracic Surg Off J Eur Assoc Cardio-Thoracic Surg 2010;37:1025–32. https://doi.org/10.1016/j.ejcts.2009.11.035.

16. Flynn CD, Curran NP, Chan S, Zegri-Reiriz I, Tauron M, Tian DH, et al. Systematic review and meta-analysis of surgical outcomes comparing mechanical valve replacement and bioprosthetic valve replacement in infective endocarditis. Ann Cardiothorac Surg 2019;8:587–99. https://doi.org/10.21037/acs.2019.10.03.

17.