Bioprosthetic versus mechanical surgical aortic valve replacement in patients ≥65 years of age

Shared decision-making of prosthesis selection for aortic valve replacement (AVR) weighs patient-specific valve durability with oral anticoagulation requirements. Given evolving strategies of lifetime management, we evaluated contemporary longitudinal outcomes of patients aged 65 years or greater undergoing bioprosthetic versus mechanical AVR.

Patients aged 65-85 who underwent isolated surgical AVR (2018-2022) were identified in the United States Centers for Medicare and Medicaid Services database and stratified by valve type as bioprosthetic (bAVR) or mechanical (mAVR). Doubly robust risk adjustment of variables including frailty was performed using inverse probability weighting of propensity scores, multivariable logistic regression, and time-to-event analysis with competing risks. The primary outcome was the composite of all-cause mortality, valve reintervention, stroke, and bleeding.

The study cohort included a total of 69,423 patients (62,925 bAVR and 6498 mAVR). After comprehensive risk adjustment was performed, bAVR versus mAVR was associated with superior freedom from the primary composite outcome over the 5-year study period (hazard ratio [HR], 0.82; P < .001), as well as reduction in longitudinal mortality (HR, 0.78; P < .001), all-cause readmissions (HR, 0.89; P < .001), and readmissions for bleeding (HR, 0.47, P < .001) and heart failure (HR, 0.86; P < .001). No difference in aortic valve reintervention was observed between groups (HR, 0.93; P = .65). Similar trends favoring bAVR were observed in subanalyses of patients aged 65 to 69 years. For patients with preoperative end-stage renal disease, there was no difference in the longitudinal primary outcome between bAVR or mAVR.

In Medicare beneficiaries, bAVR was associated with superior risk-adjusted survival, fewer bleeding complications, and fewer readmissions with no difference in valve reintervention compared with mAVR.