Similar long-term survival after isolated bioprosthetic versus mechanical aortic valve replacement: A propensity-matched analysis

Objectives: Improved durability and preference to avoid anticoagulation have led to increasing use of bioprostheses in younger patients despite the need for eventual reoperation. Therefore, we compared in-hospital complications, reoperation, and survival after bioprosthetic and mechanical aortic valve replacement. Methods: From January 1990 to January 2020, 6143 patients underwent isolated aortic valve replacement at Cleveland Clinic; 637 patients received a mechanical prosthesis and 5506 a bioprosthesis. Propensity matching identified 527 well-matched pairs (83% of possible matches) for comparison of perioperative outcomes. The average age of patients was 54 years in the bioprosthesis group and 55 years in the mechanical prosthesis group. Random Forest machine-learning analysis was performed to compare survival using the entire cohort of 6143 patients. Results: Among matched patients, major in-hospital complications, including stroke, deep sternal wound infection, and reoperation for bleeding, were similar, as was in-hospital mortality (2 in the bioprosthesis group [0.38%] vs 3 in the mechanical prosthesis group [0.57%]; P > .9). Patients receiving a bioprosthesis had shorter hospital stays (median 6 vs 7 days, P < .0001). Fifty-one patients (32% at 14 years) in the bioprosthesis group and 17 patients in the mechanical prosthesis group (8% at 14 years) underwent reoperation (P [log-rank] < .0001); 5-year survival after reoperation was 85% versus 82% (P = .6). Risk-adjusted Random Forest prediction of 18-year survival was 60% in the bioprosthetic group and 58% in the mechanical prosthesis group. Conclusions: Aortic valve bioprostheses are associated with excellent short-term outcomes and 18-year survival similar to that of patients receiving mechanical valves. Reoperation does not adversely affect survival. These results suggest that risk for reoperation alone should not deter the use of bioprostheses in younger patients.