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J Thorac Cardiovasc Surg 2009;137:881-886
© 2009 The American Association for Thoracic Surgery

Acquired Cardiovascular Disease

Patient outcome after aortic valve replacement with a mechanical or biological prosthesis: Weighing lifetime anticoagulant-related event risk against reoperation risk

^a Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
^b Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
^c University of British Columbia, Vancouver, Canada
^d Providence Health System, Portland, Oregon

Received for publication February 26, 2008; revisions received August 5, 2008; accepted for publication September 11, 2008.

^_* Address for reprints: Martijn W. A. van Geldorp, MD, MSc, Department of Cardiothoracic Surgery, Erasmus Medical Center, Room Bd 575, PO Box 2040, 3000 CA Rotterdam, The Netherlands. (Email: m.vangeldorp{at}erasmusmc.nl).

Objective: Although the results of aortic valve replacement with different valve prostheses are well documented in terms of survival, the risks of (valve-related) events are less well explored.

Methods: We used a dataset of 3934 patients who underwent aortic valve replacement with either a bioprosthesis (73%) or a mechanical prosthesis (27%) between 1982 and 2003 to simulate the outcome of patients after aortic valve replacement with either valve type. With the use of microsimulation, we compared total age and gender-specific life expectancy, event-free life expectancy, reoperation-free life expectancy, lifetime risks of reoperation, and valve-related events for both valve types.

Results: The total follow-up was 26,467 patient-years. The mean follow-up was 6.1 years in the biological arm and 8.5 years in the mechanical arm. The mean age at implantation was 70 and 58 years for biological and mechanical prostheses, respectively, and the percentage of concomitant coronary artery bypass grafting was 47% and 28%, respectively. For a 60-year-old man, simulated life expectancy in years for biological versus mechanical prostheses was 11.9 versus 12.2, event-free life expectancy was 9.8 versus 9.3, and reoperation-free life expectancy was 10.5 versus 11.9. Lifetime risk of reoperation was 25% versus 3%. Lifetime risk of bleeding was 12% versus 41%.

Conclusion: Even for patients aged 60 years, event-free life expectancy is better with a bioprosthesis. Although the chance of reoperation is higher, the lifetime risk of bleeding is lower compared with a mechanical prosthesis. Comparing lifetime event risks between different types of valve prostheses provides more insight into patient outcome after aortic valve replacement and aids patient selection and counseling.