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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 February 2, 2021 e141 CLINICAL STATEMENTS AND GUIDELINES

bioprosthetic valve replacement for all patients, but especially for those between 50 and 65 years of age, should be made in a shared decision-making process that must account for the trade-offs between durability (and the need for reintervention), bleeding, and thromboembolism.1 5.	 In patients >65 years of age at the time of bioprosthetic AVR, the likelihood of primary structural deterioration at 15 to 20 years is only about 10%.28–31 In addition, older patients are at higher risk of bleeding complications related to VKA therapy and more often require interruption of VKA therapy for noncardiac surgical and interventional procedures. It is reasonable to use a bioprosthetic valve in patients >65 years of age to avoid the risks of anticoagulation because the durability of the valve exceeds the expected years of life. 6.	 In general, patients with mechanical valve replacement experience a higher risk of bleeding because of anticoagulation, whereas individuals who receive a bioprosthetic valve replacement incur a higher risk of repeat intervention attributable to structural valve deterioration. In patients <65 years of age, observational data suggest better long-term outcomes with a mechanical mitral valve replacement, even when the risks and inconvenience of long-term VKA anticoagulation are considered. In a propensity-matched analysis from New York’s Statewide Planning and Research Cooperative System (SPARCS), although there was no survival difference for patients 50 to 69 years of age undergoing mechanical versus bioprosthetic mitral valve replacement,7 the rates of reoperation were lower (HR: 0.59) with a mechanical valve, though stroke risk (HR: 1.62) was higher. In the 2017 report from the California Office of Statewide Health Planning and Development,1 for patients who underwent mitral-valve replacement and were 40 to 69 years of age, receipt of a biological prosthesis was associated with a mortality rate significantly higher than that seen with receipt of a mechanical prosthesis.1 The choice of a mechanical mitral valve in patients <65 years of age who are good candidates for anticoagulation should account for these observational, nonrandomized data and abide by the principles of shared decision-making.1,7,10

7.	 Hazards associated with anticoagulation increase with age, and rates of structural valve deterioration decline significantly. In patients >65 years of age, the ratio of valve durability to life expectancy supports the use of a bioprosthetic mitral valve replacement, which allows avoidance of the risks of long-term VKA anticoagulation in these older patients. In 1

Figure 11. Prosthetic valves: choice of bioprosthetic versus mechanical valve type. Colors correspond to Table 2. *Approximate ages, based on US Actuarial Life Expectancy tables, are provided for guidance. The balance between expected patient longevity and valve durability varies continuously across the age range, with more durable valves preferred for patients with a longer life expectancy. Bioprosthetic valve durability is finite (with shorter durability for younger patients), whereas mechanical valves are very durable but require lifelong anticoagulation. Long-term (20-y) data on outcomes with surgical bioprosthetic valves are available; robust data on transcatheter bioprosthetic valves extend to only 5 y, leading to uncertainty about longer-term outcomes. The decision about valve type should be individualized on the basis of patient-specific factors that might affect expected longevity. †See Section 3.2.4.2 for a discussion of the choice of TAVI versus SAVR. AVR indicates aortic valve replacement; CVC, Comprehensive Valve Center; VKA, vitamin K antagonist; SAVR, surgical aortic valve replacement; and TAVI, transcatheter aortic valve implantation.

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