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Prosthetic valve type for patients undergoing aortic valve replacement: a decision analysis.
N J Birkmeyer1, J D Birkmeyer, A N Tosteson
1Department of Surgery and the Center For the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, New Hampshire, USA. nancyj.birkmeyer@dartmouth.edu
The Annals of Thoracic Surgery
|January 13, 2001
Summary
For patients over 60 undergoing aortic valve replacement (AVR), tissue valves offer greater life expectancy than mechanical valves. This is due to lower rates of major bleeding complications outweighing reoperation risks for tissue valve degeneration.
Area of Science:
- Cardiovascular Surgery
- Biomaterials Science
- Clinical Decision Analysis
Background:
- Long-term survival after aortic valve replacement (AVR) showed similar outcomes for tissue and mechanical valves in prior trials.
- Mechanical valves have higher bleeding risks due to anticoagulation, while tissue valves face reoperation for degeneration.
- Patient demographics and clinical practices have evolved since initial AVR trials.
Purpose of the Study:
- To reassess the optimal prosthetic valve type for aortic valve replacement (AVR) in contemporary patient populations.
- To compare the long-term outcomes of tissue versus mechanical aortic heart valve prostheses using decision analysis.
Main Methods:
- A Markov state-transition model was employed to simulate AVR-related events and life expectancy.
- Probabilities for clinical events and mortality were sourced from pivotal randomized clinical trials and extensive follow-up studies.
Main Results:
- In 70-year-old patients (current mean AVR age), tissue valves provided greater life expectancy (11.1 years) than mechanical valves (10.7 years).
- Major bleeding complications (24%) with mechanical valves significantly outweighed reoperation for tissue valve failure (12%) at 12 years for 70-year-olds.
- The choice of valve type was most sensitive to anticoagulation bleeding rates; rates would need to be 68% lower for mechanical valves to be favored in 70-year-olds.
Conclusions:
- For patients under 60 undergoing AVR, mechanical valves remain the preferred choice.
- For the current elderly AVR patient population (mean age 70), tissue valves are associated with better life expectancy and outcomes.