Mitral valve replacement in young patients: review and current challenges

Abstract

Mitral valve repair is the ideal intervention for mitral valve disease with excellent long-term survival comparable to the age-matched general population. When the mitral valve is not repairable, mechanical prostheses may be associated with improved survival as compared with biological prostheses. Newer mechanical and biological valve prostheses have the potential to improve outcomes following mitral valve replacement in young patients. Patients presenting for mitral valve surgery after failed transcatheter mitral valve-in-valve have high rates of postoperative mortality and morbidity, exceeding those seen with reoperative mitral valve surgery, which poses issues in young patients who have a higher cumulative incidence of reintervention.

Plain Language Summary

Patients presenting with mitral valve disease, the most common type of heart valve disease, have a survival advantage when they undergo mitral valve repair as opposed to replacement, and this is particularly true for young patients. When the mitral valve is not repairable, mechanical prostheses (prosthetic implants) may be associated with improved survival as compared with biological prostheses, and this difference is mostly observed until the age of 70 years. Newer techniques of treating mitral valve disease without requiring open heart surgery have not yet been shown to be superior or even equivalent to traditional open heart surgery in the general population. Patients presenting for mitral valve surgery after failure of these newer techniques have high rates of death, exceeding those seen with mitral valve reoperation, which has important implications for young patients with mitral valve disease.

Plain language summary

Article highlights.

• Patients presenting with mitral valve disease have a survival advantage when they undergo mitral valve repair as opposed to replacement, and this is particularly true for young patients.

• Most young patients with degenerative mitral disease can be successfully repaired but those with nondegenerative etiology pose a greater challenge, including patients with infective endocarditis and advanced rheumatic disease.

• When the mitral valve is not repairable, mechanical prostheses may be associated with improved survival as compared with biological prostheses, and this difference in survival is mostly observed until the age of 70 years.

• Newer mechanical and biological valve prostheses have the potential to improve outcomes following mitral valve replacement in young patients.

• As compared with primary mitral valve surgery, reoperation is associated with significantly higher mortality and morbidity. Patients presenting for redo mitral surgery might benefit from a right mini-thoracotomy approach as opposed to a median resternotomy.

• While transcatheter mitral valve-in-valve is a less invasive and appealing option, there are multiple concerns about exponentially increasing transvalvular gradients with each subsequent valve-in-valve, which may limit its durability and success in young patients.

1. Background

Mitral valve repair (MVr) remains the ideal intervention to restore normal valvular function and provide long-term survival comparable to the general population. When the mitral valve is not repairable because of unfavorable anatomical features, the optimal mitral valve substitute is still a subject of debate, particularly in younger patients. These patients carry a unique challenge because of their anticipated long-life expectancy, their active lifestyle and prerequisite need for optimal hemodynamics, and their higher cumulative lifetime risk of prosthesis-related complications. As opposed to the aortic valve, where the Ross procedure provides a living substitute when the valve is nonrepairable, a similar living valve option does not exist for the mitral valve, and the currently available valve replacement options include conventional mechanical or biological prostheses. Strategic valve selection is critical in young patients when considering the lifetime management of their nonrepairable mitral valve disease.

2. Mitral valve replacement impairs survival

A large body of evidence has demonstrated that patients undergoing MVr have a long-term survival comparable to that of the age-matched general population, and this is irrespective of the patient's age (Supplementary Table S1). In a very large, longitudinal study interrogating the Medicare database, Vassileva and colleagues found that MVr resulted in survival comparable to that of the age- and sex-matched US population, even when stratified by age (<75 years and ≥75 years) [1]. In fact, at 10 years postsurgery, the survival of patients having had an MVr was comparable to that of the general population, with a survival of about 70% for those <75 years old at the time of surgery and a survival of about 40% for those ≥75 years old at the time of surgery [1].

As for the survival of patients undergoing MVr compared with those having mitral valve replacement (MVR), the survival advantage in favor of repair was demonstrated for degenerative disease and was magnified in younger patients. In the same study by Vassileva and colleagues, in patients <75 years of age, MVR resulted in a survival of <50% at 10 years (compared with about 70% for MVr patients and the general population). As for patients ≥75 years old, MVR resulted in survival of <30% at 10 years (compared with about 40% for MVr patients and the general population) [1].

Lazam and colleagues compared the 20-year survival of MVr versus MVR in patients with severe degenerative mitral regurgitation (MR). They utilized the Mitral Regurgitation International Database with about 2000 patients; using propensity score matching and inverse probability of treatment weighting, they demonstrated that MVr patients have lower operative mortality (1.3% vs 4.7%; p < 0.001) and better 20-year survival (46% vs 23%; p < 0.001), and these results were not influenced by the statistical method of adjustment or by subgroup analyses by age or sex. The authors also showed that MVr resulted in a lower incidence of reoperations and valve-related complications [2].

Looking at patients presenting with ischemic MR, the CTSN trial, which randomized 251 patients with severe MR to either mitral valve replacement or repair, showed that at 2 year-follow-up there was no significant difference in survival or left ventricular remodeling between the two groups (despite the study's not being powered to assess survival). However, the repair group had higher rates of recurrent moderate or severe MR, along with heart failure-related adverse events and cardiovascular admissions [3]. On the other side, Vassileva and colleagues performed a meta-analysis of short- and long-term outcomes comparing MVr to MVR [4]. They found that MVR resulted in a higher likelihood of both short-term mortality (pooled odds ratio: 2.7; 95% CI: 1.9–3.8) and long-term mortality (pooled hazard ratio [HR]: 1.4; 95% CI: 1.1–1.6).

3. Reasons for nonrepairable mitral valve disease

In general, the vast majority of adults presenting with mitral valve disease have either myxomatous degeneration, an ischemic etiology, an infectious cause, or rheumatic disease [5]. In young patients, most with degenerative MR can be successfully repaired but those patients presenting with nondegenerative etiology remain a challenge, including patients with ischemic disease, infective endocarditis, advanced rheumatic disease, radiation-induced heart disease, severe mitral annular calcification, congenital disease, and inflammatory conditions.

Gillinov and colleagues examined 3286 patients who underwent mitral valve surgery and the authors reported successful MV repair in 93% of the patients [6]. Regarding the characteristics of those who underwent MVR, these patients were older (70 years vs 57 years; p < 0.0001), more likely to be female (49% vs 32%; p < 0.0001), more symptomatic (New York Heart Association ≥3: 29% vs 13.8%; p < 0.0001), had more anterior (22% vs 7.6%; p < 0.0001) and bileaflet prolapse (35% vs 9.4%; p < 0.0001), had more mitral valve (MV) calcification (48% vs 22%; p < 0.0001), and had lower left ventricular ejection fraction and more comorbidities.

In the case of severe ischemic MR, a debate still exists on whether MVr or MVR is the preferred option, and the results of the various studies that addressed this question are not consistent [3,7–9]. One of the main reasons for this inconsistency of results is the vast heterogeneity of the patients included in these studies. Regarding the predictors of failed MVr in the setting of ischemic MR, several risk factors have been identified, including an MV annular diameter larger than 3.7 cm and a tenting area greater than 1.6 cm² [5], left ventricular sphericity index at end-systole [10], and severe leaflet tethering [11]. Overall, patients with ischemic MR, even when young, have a limited life expectancy that is more likely related to the underlying ischemic heart disease and left ventricular dysfunction rather than the mitral disease in itself [3].

For patients presenting with MV endocarditis, MVr is preferred, but in many cases, when the free margin of the valve leaflets is destroyed or when infection invades the central fibrous trigones, MVR is often required. Therefore, it is not the ‘infective endocarditis’ per se that is a contraindication for MVr but rather the amount of destruction and the quality of the remaining tissue that often limit the possibility of MVr. When possible in the setting of infective endocarditis, MVr yields superior outcomes over MVR [12]. In a meta-analysis by Feringa and colleagues comparing 470 patients with MVr with 724 patients with MVR after presenting with infective endocarditis, MVr resulted in lower in-hospital mortality (relative risk: 0.15; p < 0.0001) and long-term mortality (relative risk: 0.19; p < 0.0001), along with lower rates of early and late reoperation, early and late cerebrovascular events, and late recurrent endocarditis [12]. Young adults with intravenous drug use are a particularly challenging population with high risks of recidivism, prosthetic valve endocarditis, and noncompliance. This group of patients has a poor long-term life expectancy secondary to an ongoing risk of infection, and surgery does not seem to alter the long-term prognosis [13].

As for rheumatic MV disease, the long-term durability of MVr has been affected by the extent of the disease, the pliability of the leaflets, and the extent of the involvement of the subvalvular apparatus. In addition, many of these patients present late, have severe pulmonary hypertension, have atrial fibrillation, and are already on anticoagulation, all of which negatively alter the long-term prognosis. Additionally, rheumatic heart disease is usually a progressive disease, and in the young population, pancarditis may result in progressive fibrosis, resulting in repair failure, and recurrent episodes of rheumatic fever may predispose them to valve deterioration. An additional challenge stems from the difficulty in preoperative surgical planning in rheumatic mitral disease, given that many elements of the morphology and pathology of the diseased valve are revealed gradually as the commissural fusion and chordal restriction are released. Data from the Society of Thoracic Surgeons Database show that the repair rate in rheumatic MV disease patients remains low (10%) and remains associated with relatively high surgical mortality (4%) [14]. So far, standardized repair techniques are still lacking for this disease entity and long-term results are suboptimal. Kim and colleagues examined 193 patients (mean age: 39 years) who underwent MVr for rheumatic valve disease and showed that at 10 years, the incidence of ≥moderate MR was about 33% [15]. In an effort to improve rheumatic MVr in a very young cohort of patients (<18 years), Ananthanarayanan and colleagues presented their promising data with actuarial survival and freedom from reoperation at 2.5 years of 96.2% and 97.1%, respectively [16]. Their approach focused on careful examination and correction of multiple components of the valve, which included leaflet thinning (peeling with or without shaving), leaflet augmentation, commissurotomy, and papillary muscle splitting, especially for stenotic lesions, and chordal procedures, especially for nonstenotic lesions. Pericardial augmentation of the leaflets using glutaraldehyde-treated autologous pericardium was done in a third of patients when there was significant leaflet tissue deficit (from leaflet retraction) and all the repairs were supported by an annuloplasty. The authors recommended reinforcing the leaflet augmentation suture lines with additional interrupted sutures to prevent dehiscence of the patch if it becomes inflamed by subsequent episodes of rheumatic fever.

4. Options for MV replacement

Gammie and colleagues interrogated the Society of Thoracic Surgeons Adult Cardiac Surgery Database and looked at all patients who underwent isolated primary MV surgeries between the years 2011 and 2016 [17]. In their analysis, about 61% of all cases were for degenerative MV disease, and of these, 82.5% were repaired. Overall, MVr had a lower unadjusted operative mortality (1.1% vs 3.7%). About 34% of all the interrogated patients underwent MVR, and of these, 16.2% had an MVr attempt before converting to an MVR. Therefore, still to this day, about a third of all patients requiring MV surgery undergo MVR, therefore highlighting the relevance of MVR in today's practice. The authors observed a significant increase in the frequency of bioprosthetic valves, from 65.4% in the year 2011 to 75.8% in 2016 [17].

Young patients undergoing MV replacement deserve special consideration. These patients are active, often participate in contact sports, are of child-bearing age, and have unpredictable diets and lifestyles, which complicate their internal normalized ratio (INR) management and stability. In the current era, the available options for MV replacement include the use of either a mechanical prosthesis, a biological prosthesis, or an MV homograft. The largest study to date to compare the outcomes of mechanical versus biological prosthesis for MV (and aortic valve) replacement demonstrated differential outcomes based on patients' ages [18]. Goldstone and colleagues examined the data from California between the years 1996 and 2013 and evaluated the effect of prosthesis type (mechanical vs biological) on mortality, rate of reoperation, stroke, and bleeding. The authors found that the use of biological prostheses increased significantly during the study period (16.8% to 53.7%) [18], which is consistent with the data from Gammie and colleagues [17]. Interestingly, regarding the long-term mortality (median follow-up: 4.6 years for patients with a biological prosthesis and 7.6 years for patients with a mechanical prosthesis), the use of a biological prosthesis was associated with higher mortality in patients aged 40–49 years (HR: 1.9 at 15 years of follow-up; 95% CI: 1.4–2.6) and in patients aged 50–69 years (HR: 1.2 at 15 years of follow-up; 95% CI: 1.04–1.3). There was no difference in patients aged 70–79 years. The use of a biological prosthesis was found to be associated with a lower cumulative incidence of stroke only in patients aged 50–69 years and a lower cumulative incidence of bleeding in patients aged 50–69 years and 70–79 years. However, the use of a biological prosthesis resulted in a much higher cumulative incidence of reoperations, particularly among younger patients, and the 30-day mortality of these reoperations were about 14% [18]. Schnittman and colleagues examined the long-term outcomes after MV replacement in patients aged 18–50 years who underwent isolated mitral replacement in California and New York from 1997 to 2006 and analyzed the data on 2727 patients using propensity score matching [19]. They found that actuarial 15-year survival was 74.3% after bioprosthetic versus 80.8% after mechanical valve replacement (HR: 1.67; 95% CI: 1.21–2.32). At 15 years after MV replacement, the cumulative incidence of stroke and that of major bleeding events were similar but the cumulative incidence of reoperation after bioprosthetic valve replacement was greater. The result of this study suggested the inferiority of bioprosthetic valves in young patients with a greater risk of reoperation, which is not mitigated by a reduction in stroke and major bleeding rates, compared with mechanical valves in patients younger than 50 years. The significant survival and reoperation benefit that was observed with mechanical MV replacement in the Goldstone and Schnittman studies could be due to accelerated structural degeneration in mitral bioprostheses in younger patients.

The use of mitral homograft has been investigated but yielded poor results [20]. Ali and colleagues looked at 104 patients who underwent mitral homograft replacement, with the most common indication being rheumatic disease. Hospital mortality was about 4%. Five patients required early reoperation (<3 months) and ten patients needed late reoperations. Among patients who had a total homograft, freedom from major cardiac events was only about 60% at 6 years of follow-up in patients younger than 40 years [20].

5. Prosthesis outcomes after MVR

Various mechanical and biological prostheses are currently available for use, and many of them have demonstrated excellent durability at long-term follow-up. It is well known that bioprosthetic valves have a higher rate of structural valve degeneration when implanted in the mitral position, as compared with the aortic position [21]. It is, however, still debatable whether a porcine prosthesis performs better than a pericardial valve in the mitral position, which is not the case after aortic valve replacement, where both prostheses demonstrate similar rates of structural valve degeneration [22,23]. In a meta-analysis of long-term follow-up studies, Malvindi and colleagues found that porcine prostheses are associated with higher freedom from structural valve degeneration at long-term follow-up [24]. There have been, however, some critiques regarding the methodology of the aforementioned meta-analysis [25]. On the other hand, Beute and colleagues published their long-term comparison of porcine MVs with bovine pericardial MVs in a large cohort of 940 patients. This study was published after the Malvindi meta-analysis and showed that for patients younger than 65 years, structural valve deterioration at 15 years was 15.8% versus 30.2% for porcine and pericardial valves, respectively (p = 0.009) [26]. Although many surgeon biases and preferences predominate the choice of tissue prosthesis for the mitral position, the authors of the current study believe this topic would be best answered with a randomized trial.

Celiento and colleagues reported the outcomes of the Mosaic MV bioprosthesis [27]. At 15 years, actuarial freedom from valve-related deaths was about 86%, freedom from structural valve deterioration was about 93%, and freedom from overall valve-related complications was about 82% [27]. Loor and colleagues reported the outcomes of the Carpentier-Edwards Perimount Magna mitral bioprothesis, and at 5 years, freedom from structural valve degeneration was about 90% [28]. Jamieson and colleagues examined the results of the St. Jude Medical Epic porcine prosthesis [29]. At 4 years, freedom from valve-related mortality was about 97%, freedom from major thromboembolic events was about 91%, freedom from thrombosis was about 98%, and freedom from reoperation due to structural valve degeneration was 100% [29].

In terms of mechanical prostheses, Remadi and colleagues reported their 19-year follow-up of the St. Jude medical mitral mechanical prosthesis [30]. They reported freedom from valve-related mortality of about 92% at 10 years and 84% at 19 years. At late follow-up, freedom from endocarditis was about 99%, and freedom from reoperation was about 90%. Freedom from thromboembolic or hemorrhagic events was about 80% [30]. Murana and colleagues reported their 10-year experience with the On-X mechanical valve in 318 patients [31]. At 10 years, survival rates were about 71%, freedom from reoperation was about 93%, and freedom from thromboembolic or hemorrhagic events was about 89% [31].

In terms of the newer-generation prostheses, the PROACT mitral randomized, controlled trial examined the use of lower INR targets in patients with an On-X MV [32]. This was a high-quality, randomized trial investigating the best available evidence for INR targets in mechanical MV replacement with robust scientific quality for the conduct, monitoring, auditing, analysis, and reporting of clinical results. The On-X MV (Artivion, GA, USA) was introduced to the market in the early 2000s with the proposed benefits of improved hemodynamics and reduced thrombogenicity because of the wide opening angle and the taller and flared housing, which may reduce the risk of pannus ingrowth (Figure 1). The PROACT mitral study confirmed excellent clinical outcomes with the On-X MV. At a median follow-up of 4.1 years, survival was 94% in the low-dose group and 91% in the standard warfarin group. The On-X MV also showed excellent hemodynamics, as evidenced by the low rates of regurgitation, low paravalvular leak rates, and low-pressure gradients, as well as sustained improvement in symptoms. The study found that at a mean follow-up of 4.1 years, a lower INR target did not achieve noninferiority compared with a standard INR target in terms of a composite primary end point of thromboembolism, valve thrombosis, or bleeding, largely driven by the unexplainably higher bleeding rate in the low-INR group.

Figure 1.

Implantation of the On-X mitral heart valve mechanical prosthesis. (A) Picture of the On-X mitral heart valve (used with the permission of Artivion, Inc.). (B) On-X valve seated onto the mitral annulus. (C) Minimally invasive approach to implantation of the mechanical mitral valve through left anterior mini-thoracotomy. (D) Postoperative transesophageal echocardiographic image of the implanted On-X valve.

As for newer-generation bioprosthetic valves, the Edwards MITRIS RESILIA mitral tissue valve is a new bovine pericardial prosthesis that builds on the Carpentier-Edwards Perimount valve platform (Edwards Lifesciences, CA, USA) by incorporating a low-profile design and a saddle-shaped sewing cuff in addition to a special integrity preservation technology and enhanced anti-calcification treatment that could increase its durability (Figure 2) [33]. Another proposed benefit is the incorporation of a radiopaque frame for ease of use in the case of potential subsequent valve-in-valve interventions. The COMMENCE trial was recently published and showed a good safety profile and stable hemodynamic performance with the RESILIA valve. The 5-year event-free probabilities for all-cause mortality, structural valve deterioration, and reoperation were 79.9%, 98.7%, and 97.1%, respectively [34].

Figure 2.

Implantation of the MITRIS RESILIA biological mitral valve prosthesis. (A) Picture of the MITRIS RESILIA biological mitral valve (used with the permission of Edwards Lifesciences LLC, Irvine, CA, USA). (B) MITRIS RESILIA valve seated onto the mitral annulus. (C) Minimally invasive approach to implantation of the biological mitral valve through left anterior mini-thoracotomy. (D) Postoperative transthoracic echocardiographic image of the implanted MITRIS RESILIA valve.

In the authors' opinion, performing an MV replacement is trading one disease for another disease. In fact, as described above, most of the observational available data reflect a highly selected patient population, which limits the generalizability of the findings. What is certain, however, is that prosthetic valves do not perform as well in the mitral position as in the aortic position; they have much higher transvalvular forces, with limited durability and a much higher valve-related complication rate.

6. Redo MV surgery

Patients with a previous MV intervention (an MVr, an MVR, or transcatheter edge-to-edge repair) presenting with an indication for MV surgery will undergo either an open redo MV surgery (either MV re-repair or MVR) or a valve-in-valve transcatheter MV replacement. A previous failed MVr should not exclude these patients from undergoing a repeat MVr if the etiology of the failure is clearly identified and can be corrected and/or prevented at the time of the second repair.

As compared with primary MV surgery (MVS), reoperative MVS is associated with significantly higher mortality and morbidity. In a large Society of Thoracic Surgeons regional database analysis, Mehaffey and colleagues compared the outcomes of primary MVS (10,145 patients) to redo MVS (1096 patients) between the years of 2002 and 2016 [35]. Redo MVS was associated with higher 30-day mortality (11.1% vs 6.5%; p < 0.0001) and higher morbidity, including reoperation, renal failure, and stroke. Although the outcomes of redo MVS have not been directly compared with those of redo aortic valve surgery, extrapolation from existing data shows that redo MVS is associated with higher 30-day mortality and higher rates of reoperation, renal failure, and stroke [36].

An increasing number of patients are presenting for MVS after having a failed transcatheter edge-to-edge repair (TEER), and their postoperative outcomes have been worse than most other redo MVS (i.e., when the primary intervention was not a TEER) series [37–39]. Kaneko and colleagues reported the midterm outcomes of MVS after TEER from the CUTTING-EDGE international registry [39]. They looked at 332 patients from the years 2009–2020. The mean age was about 74 years, 84% of them were deemed to have ≥intermediate surgical risk for TEER, 47% of them were deemed frail, and 27% of them had had prior cardiac surgery. Among the included patients, 21.2% had aborted TEER, 17.6% required acute MVS, and 61.2% needed delayed MVS. The median interval from TEER to MVS was 3.5 months and the primary indication for MVS was recurrent MR. The vast majority (>92%) of these patients underwent MVR (68% through a sternotomy and 31% through a right thoracotomy). 30-day outcomes included a mortality rate of 16.6%, a stroke rate of 2.8%, and a readmission rate of 5%. Actuarial mortality was 24% at 1 year and 32% at 3 years. When stratified by the timing relative to index TEER, there was no significant difference in the cumulative mortality among the three groups [39].

In another analysis, by Chikwe and colleagues, also looking at MVS after TEER through the Society of Thoracic Surgeons database, 463 patients were examined. About 95% of these patients underwent MVR and only 4.8% had MVr (6.8% in degenerative cases). In those undergoing isolated MVS, the rate of operative mortality was 10.6%, 13.4% required reoperation after their surgery, and 12% of them needed a permanent pacemaker or device. The authors performed a volume-outcome analysis and showed that in centers that had performed more than ten cases, operative mortality was 2.6% compared with 12.4% in centers with fewer than ten cases [37].

Patients presenting for redo MVS might benefit from a right mini-thoracotomy approach as opposed to a median resternotomy. In a systematic review and meta-analysis of observational studies, Daemen and colleagues compared these two approaches in a pooled analysis of 777 patients. Mini-thoracotomy was associated with reduced mortality (odds ratio: 0.4; 95% CI: 0.18–0.96; p = 0.04), along with lower reoperation for bleeding and a comparable risk of stroke [40].

7. Transcatheter mitral valve-in-valve

Transcatheter mitral valve-in-valve (TMViV) has been proposed as an alternative to redo MVS in patients with prohibitive surgical risks. It has also been proposed as a viable strategy in young patients who desire a tissue MVR when the biological valve degenerates. In a study by Khan and colleagues, the authors interrogated the National Inpatient Sample between the years 2015 and 2019 and used propensity score matching to compare 395 patients with TMViV with 395 patients with redo MVR [41]. After matching, the mean age of the redo MVR group was 75 years, 65% of them had atrial fibrillation, 81% of them had congestive heart failure, 28% had chronic obstructive lung disease, 63% had coronary artery disease, and 6% had the cerebrovascular disease (as opposed to <2.8% in the TMViV group). They observed that the proportion of redo MVR decreased from 88% to 78% over the study period, and this was parallel with an increase in TMViV. Redo MVR was associated with higher adjusted mortality (7.6% vs 2.8%); the factors that were associated with higher mortality in redo MVR were age older than 75 years, liver disease, renal failure, and peripheral vascular disease [41]. Although TMViV is a less invasive and appealing option, there are multiple concerns about exponentially increasing transvalvular gradients with each subsequent valve-in-valve, which may limit its durability and success in young patients.

8. Conclusion

Patients presenting with MV disease have a survival advantage when they undergo an MVr as opposed to replacement, and this is particularly true for young patients. When the MV is not repairable, mechanical prostheses may be associated with improved survival as compared with biological prostheses. The choice of the appropriate tissue valve is of great debate, which requires further study with long-term comparative datasets. Current trends suggest that younger patients are undergoing TEER, where there has been no evidence of its superiority or even equivalence to standard MVr or replacement. What is clear, however, is that patients presenting for MVS after failed TEER have high rates of postoperative mortality and morbidity, exceeding those seen with reoperative MVS, which has important implications for young patients with nonrepairable MV disease.

9. Future perspective

Contemporary data suggest a survival advantage in young patients with mechanical mitral prostheses; however, shared decision-making often raises issues of quality-of-life benefit and durability with newer-generation biological prostheses. As MV replacement technology continues to evolve, we might soon witness the development of more durable biological prostheses or the advent of newer classes of anticoagulants for mechanical mitral prostheses, which could be a game changer for young patients with MV disease.

Supplemental material

Supplemental data for this article can be accessed at https://doi.org/10.1080/14796678.2024.2343592

Financial disclosure

The authors have no financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Competing interests disclosure

MWA Chu has received a speaker's honorarium from Medtronic, Edwards Lifesciences, Terumo Aortic, Abbott Vascular, and Boston Scientific. The authors have no other competing interests or relevant affiliations with any organization or entity with the subject matter or materials discussed in the manuscript apart from those disclosed. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Writing disclosure

No writing assistance was utilized in the production of this manuscript.