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Journal of Thoracic Disease logoLink to Journal of Thoracic Disease
. 2026 May 27;18(6):612. doi: 10.21037/jtd-2026-1-0490

A single-center study on prosthesis selection strategy in aortic valve replacement for patients aged 50–65 years

Jia Sun 1,#, Yuqiu He 1,#, Xinyi Mao 1,#, Xiaofei Han 2, Junyi Hu 1, Ziang Zhou 1, Yuming Huang 3, Yongfeng Shao 4,✉, Yefan Jiang 4,✉
PMCID: PMC13358481  PMID: 42444919

Abstract

Background

The optimal valve type for middle-aged AVR patients remains debated with inconsistent guideline recommendations. To explore valve selection strategy for 50- to 65-year-old undergoing aortic valve replacement (AVR) by comparing long-term outcomes of mechanical vs. biological artificial valves, with age stratification (≤60/>60 years) to guide clinical decisions.

Methods

A retrospective cohort study analyzed 341 patients (2009–2016) undergoing valve replacement surgery, categorized into mechanical valve (n=155) and biological valve (n=186) groups. Propensity score matching (PSM) (1:1) was performed in the overall cohort, as well as in the <60- and ≥60-year subgroups to balance baselines confouders. We regarded all-cause mortality as the primary endpoint while major adverse cardiovascular events (MACEs) served as the secondary endpoint. Univariate and multivariate analyses identified prognostic factors.

Results

After PSM, In the overall cohort, mechanical valve recipients had significantly longer MACE-free survival [hazard ratio (HR) =2.007, P=0.004] vs. bioprosthetic recipients, driven by lower new-onset arrhythmia (HR =1.822, P=0.02). No significant difference in overall survival was observed. Notably, the incidence of MACE showed an increasing trend with age in the bioprosthetic valve group, whereas no such trend was observed in the mechanical valve group. For patients <60 years, overall survival did not differ pre-/after-PSM. Mechanical recipients had superior MACE-free survival (after-PSM HR =2.025, P=0.04), mainly due to fewer new-onset arrhythmias (HR =1.904, P=0.03). For patients ≥60 years, no significant differences were found in overall survival, MACE-free survival, or reoperation-free survival between groups.

Conclusions

For patients aged 50- to 65-years-old who require AVR, overall and MACE-free survival is comparable between mechanical and biological valves. Mechanical valves are associated with more favorable MACE-free survival in those under 60 years of age, but individualized selection remains crucial.

Keywords: Aortic valve replacement (AVR), mechanical valve, bioprosthetic valve, 50–65 years

Highlight box.

Key findings

• After 1:1 propensity score matching (PSM) and long-term follow-up, all-cause mortality was similar between mechanical and bioprosthetic valves in 50–65-year-old aortic valve replacement (AVR) patients. Mechanical valves yielded superior major adverse cardiovascular event (MACE)-free survival in patients under 60 years mainly due to lower arrhythmia risk, while no intergroup outcome difference was found in patients aged 60–65 years.

What is known and what is new?

• Current clinical guidelines have inconsistent recommendations on valve selection for middle-aged patients receiving AVR, and most previous studies lack age-stratified long-term outcome analysis.

• This study eliminated baseline confounding factors via PSM and performed subgroup analysis split at age 60 years, providing stratified long-term survival evidence to fill the research gap.

What is the implication, and what should change now?

• Clinicians should adopt age-individualized prosthesis strategies: mechanical valves are preferred for patients younger than 60 years, whereas bioprosthetic valves are a reasonable choice for patients aged 60–65 years.

Introduction

Aortic valve replacement (AVR) is an important surgical method for the treatment of aortic valve diseases, but the selection of mechanical valves and biological valves in the patient population aged 50–65 years still has great clinical controversy. Mechanical valves have the advantage of excellent durability, but patients need lifelong anticoagulant therapy, which can increase the risk of bleeding and stroke; although biological valves avoid the burden of long-term anticoagulant therapy, they face the risk of reoperation caused by structural valve degeneration (SVD) in young patients. Current international guidelines exhibit significant controversy regarding optimal valve selection for patients aged 50–65 years undergoing AVR. The European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS) guidelines advocate mechanical valves for patients <60 years, biological valves for those >65 years, and individualized selection for the 60–65-year age group. Meanwhile, the 2024 updated American Heart Association/American College of Cardiology (AHA/ACC) guidelines recommend mechanical valves for patients <50 years of age, bioprosthetic valves for patients >65 years of age, and shared decision-making for those aged 50–65 years (1).

Previous related studies have demonstrated the following limitations: First, the follow-up duration was less than 10 years, whereas bioprosthetic valve degeneration requiring reoperation typically occurs 10–15 years postoperatively (2). This insufficient follow-up period compromises accurate comparisons of reoperation rates, major adverse cardiovascular event (MACE) and other outcomes (3). Secondly, the age range of enrolled patients (commonly 50–65 or 50–70 years) exhibited significant heterogeneity without stratified subgroup analysis. Since the timing of bioprosthetic valve degeneration correlates with patient age—older patients experience delayed degeneration—this omission limits the precision of age-specific outcome predictions. Thirdly, for elderly patients with comorbidities, clinicians tend to recommend the use of bioprosthetic valves, which introduces a discrepancy. Based on these observations, our study focuses on patients aged 50–65 years undergoing AVR, with follow-up exceeding 10 years and stratified age subgroup analysis, aiming to provide evidence-based guidance for clinical valve selection (4). We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0490/rc).

Methods

Ethical statement

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board (Ethics Committee) of The First Affiliated Hospital with Nanjing Medical University (approval number: 2024-SR-403) and individual consent for this retrospective analysis was waived. All enrolled patients were aged 50–65 years (no minors were included).

Study objects

A retrospective study was conducted on 341 patients aged 50–65 years who received AVR treatment in our hospital from 2009 to 2016. Inclusion criteria: (I) undergoing AVR due to aortic valve diseases; (II) aged 50–65 years; (III) complete follow-up data. Exclusion criteria: (II) with non-aortic valve diseases as the primary surgical indication; (II) missing key data of baseline data, surgical information or outcome indicators; (III) implanting specially designed valves (such as stentless bioprostheses, allogeneic valves); stentless bioprostheses were excluded due to higher surgical complexity that may introduce technical bias (5); (IV) patients receiving transcatheter aortic valve implantation treatment; (V) The patient has poor medication/treatment compliance and cannot receive treatment as instructed. They were divided into the mechanical valve group (n=155) and the biological valve group (n=186) according to the type of implanted valves (Figure 1).

Figure 1.

Figure 1

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Flow-chart reporting patient selection criteria. AVR, aortic valve replacement.

Follow-up and outcome indicators

Follow-up was carried out through a combination of outpatient service, telephone and electronic medical record system review. The follow-up time ranged from 8 to 15 years. The primary endpoint was all-cause mortality. Secondary endpoints comprised MACE (6), defined as follows: new-onset arrhythmia: postoperative arrhythmia diagnosed via postoperative electrocardiography (ECG); cardiac insufficiency: characterized by New York Heart Association (NYHA) functional class III–IV; major bleeding and stroke events (composite of stroke, bleeding, and reintervention), according to international criteria and a validated MACE definition in accordance with current clinical studies (7-10); valve-related reoperations encompass complications such as thrombosis, paravalvular leakage, valve degeneration and etc. This category includes both patients who underwent reoperations and those for whom surgery was recommended following clinical re-evaluation but ultimately declined by the patient. Patients with prior cardiac surgery or AVR before the index operation were considered to have baseline comorbidities and were not counted as reoperation events in the analysis.

Statistical analysis

SPSS 26.0 software was used for data analysis. Measurement data were expressed as mean ± standard deviation, and independent sample t-test was used for comparison between groups; count data were expressed as cases (%), and χ2 test was used for comparison between groups. 1:1 PSM was performed in the overall cohort, and separately in the <60- and ≥60-year subgroups to balance the matching variables included age, gender, body mass index (BMI), arrhythmia, left ventricular ejection fraction (LVEF), aortic valve lesion type (AS/AR/mixed) and comorbidities (such as hypertension, diabetes, cerebrovascular diseases, etc.) Matching tolerance was set at 0.1. P<0.05 was considered statistically significant. For the analysis of preoperative baseline and periprocedural data, statistical methodology was rigorously selected based on variable type: Continuous variables were evaluated using independent samples t-test while categorical variables were analyzed using Pearson χ2 test (or Fisher’s exact test for expected frequencies <5). Survival analysis was performed using the Kaplan-Meier method to draw survival curves, and the log-rank test was used to compare the differences in survival curves between groups. In screening independent risk factors affecting prognosis, variables with P<0.1 in univariate analysis were included in the Cox proportional hazard regression model for multivariate prognostic analysis.

Results

Patients characteristics

The baseline characteristics of the patients are presented in Table 1. After 1:1 PSM, a total of 222 patients were included in the overall cohort (111 biological vs. 111 mechanical), 154 in the <60-year subgroup (77 vs. 77), and 60 in the ≥60-year subgroup (30 vs. 30). All baseline characteristics were well balanced (all P>0.05, standardized variance <10% for all variables), including age, gender, BMI, comorbidities, preoperative arrhythmia, and aortic valve lesion types [aortic stenosis (AS), aortic regurgitation (AR), mixed AS/AR]. No significant intergroup differences were observed in the distribution of surgical indications for AVR in any cohort (all P>0.05), eliminating confounding from hereditary aortopathy related to predominant AR. The in-hospital mortality rate was 1.1% in patients with biological valves and 0 in patients with mechanical valves.

Table 1. Baseline characteristics after PSM in the overall cohort, <60- and ≥60-year subgroups.

Variable Overall cohort (PSM, n=222) <60 years (PSM, n=154) ≥60 years (PSM, n=60)
Biological (n=111) Mechanical (n=111) P value Biological (n=77) Mechanical (n=77) P value Biological (n=30) Mechanical (n=30) P value
Age, years 58.27±4.22 57.30±4.31 0.09 55.96±3.01 55.52±3.14 0.37 68.35±5.16 67.92±4.83 0.65
Male 63 (56.8) 70 (63.1) 0.34 50 (64.9) 48 (62.3) 0.74 25 (60.0) 28 (65.1) 0.59
BMI, kg/m2 24.56±3.59 24.84±4.03 0.71 25.41±3.75 25.00±4.81 0.70 25.02±3.86 25.27±4.11 0.77
Hypertension 53 (47.7) 54 (48.6) 0.89 35 (45.5) 37 (48.1) 0.75 21 (51.2) 24 (55.8) 0.65
Diabetes 11 (9.9) 10 (9.0) 0.82 11 (14.3) 7 (9.1) 0.32 4 (10.3) 5 (11.6) 0.82
Hyperlipidaemia 9 (8.1) 7 (6.3) 0.60 6 (8.0) 5 (6.5) 0.72 3 (7.3) 3 (7.0) 0.94
Cerebrovascular disease 12 (10.8) 11 (9.9) 0.83 9 (11.7) 6 (7.8) 0.42 7 (14.6) 7 (16.3) 0.79
Peripheral vascular disease 8 (7.2) 4 (3.6) 0.24 4 (5.2) 3 (3.9) 0.70 5 (12.2) 2 (4.7) 0.11
Renal dialysis 7 (6.3) 5 (4.5) 0.55 4 (5.3) 3 (4.1) 0.71 5 (12.2) 4 (9.3) 0.63
Valve size, mm 21.70±2.293 22.69±7.515 0.18 22.24±2.11 23.06±2.32 0.13 23.11±8.90 22.03±2.12 0.19
Preoperative arrhythmia 52 (46.8) 50 (45.0) 0.79 34 (44.2) 38 (49.4) 0.52 23 (56.1) 23 (53.5) 0.80
AS 10 (9.0) 9 (8.1) 0.61 6 (8.6) 5 (7.1) 0.77 4 (9.8) 4 (9.3) 0.92
AR 59 (53.1) 65 (58.6) 0.56 34 (48.6) 39 (55.7) 0.41 25 (61.0) 26 (60.5) 0.95
Mixed AS/AR 42 (37.8) 37 (33.3) 0.98 25 (35.7) 22 (31.4) 0.59 17 (41.5) 15 (34.9) 0.45
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Data are presented as mean ± standard deviation or n (%). AR, aortic regurgitation; AS, aortic stenosis; BMI, body mass index; PSM, propensity score matching.

No significant differences were observed in prosthetic valve size between groups (P>0.05) and no patient-prosthesis mismatch existed. All implanted valves were mainstream models with standardized hemodynamic performance. For mechanical valve patients, standardized anticoagulation management and regular INR monitoring were applied, with good anticoagulation control indicated by low bleeding and thromboembolism rates.

Table S1 summarizes the baseline characteristics of the total cohort and stratified analysis by age group before propensity score matching. Before matching, significant imbalances in age, hypertension, diabetes, hyperlipidemia, and smoking history were observed between the biological and mechanical valve groups in the age ≤60 years subgroup, which were balanced after propensity score matching (Table 1).

Long-term survival

After propensity PAM, no significant differences in overall survival were observed between the biological and mechanical valve groups in the overall cohort, <60-year subgroup, or ≥60-year subgroup (all Log-rank P>0.05).

The mean overall survival time was comparable between groups in all cohorts, with no statistically significant differences detected after balancing baseline characteristics.

MACE

Overall analysis

After PSM, patients in the mechanical valve group were with better MACE-free survival [hazard ratio (HR) =2.007, P=0.004]. In detail, a significantly lower risk of stroke and bleeding events was observed in the mechanical valve cohort [HR =0.219, 95% confidence interval (CI): 0.057–0.839, P=0.03]. No statistically significant difference in cardiac insufficiency was detected between the two groups (HR =2.714, 95% CI: 0.765–9.632, P=0.10). In addition, patients receiving bioprosthetic valves had a significantly higher risk of postoperative new-onset arrhythmia compared with those receiving mechanical valves (HR =1.822, 95% CI: 1.112–2.985, P=0.02). Valve-related reoperations: subgroup analysis revealed that this difference was primarily driven by new-onset arrhythmia (e.g., atrial fibrillation), rather than fatal endpoints such as mortality or stroke (Figure 2). Notably, MACE incidence exhibited an age-related increasing trend among patients receiving bioprosthetic valves, while no similar association was found in those with mechanical valves (Figure 3).

Figure 2.

Figure 2

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MACE‑free survival and components in the overall PSM cohort. HR, hazard ratio; MACE, major adverse cardiovascular event; PSM, propensity score matching.

Figure 3.

Figure 3

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Incidence of MACE in patients of different ages. MACE, major adverse cardiovascular event.

Subgroup analysis

≤60-year subgroup

In the <60-year subgroup after propensity score matching, mechanical valves still yielded significantly superior MACE-free survival outcomes (HR =2.025, 95% CI: 1.029–3.985, P=0.04). In detail, no statistically significant difference was found in cardiac insufficiency (HR =1.951, 95% CI: 0.462–8.233, P=0.38) and stroke and bleeding events (HR =0.228, 95% CI: 0.026–1.992, P=0.15) between the two groups. Meanwhile, the risk of postoperative new-onset arrhythmia remained significantly higher in the bioprosthetic valve group (HR =2.155, 95% CI: 1.032–4.498, P=0.04). Valve-related reoperations: The trend toward increased reoperation in bioprosthetic patients dissipated post-matching (HR =59.830, 95% CI: 0.181–1.980×104, P=0.18) (Figure 4).

Figure 4.

Figure 4

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MACE‑free survival and components in the <60-year PSM cohort. HR, hazard ratio; MACE, major adverse cardiovascular event; PSM, propensity score matching.

In the ≥60-year subgroup after propensity score matching, no statistically significant difference in MACE-free survival was identified between the biological and mechanical valve groups (HR =1.312, 95% CI: 0.741–2.322, P=0.11). Similarly, there were no significant intergroup differences in stroke and bleeding events (HR =0.667, 95% CI: 0.048–1.312, P=0.41), cardiac insufficiency (HR =1.526, 95% CI: 0.443–5.257, P=0.10), or postoperative new-onset arrhythmia (HR =1.187, 95% CI: 0.632–2.228, P=0.38). Due to the very low number of valve-related reoperation events in this subgroup, a valid Kaplan-Meier survival analysis and log-rank test could not be performed, and no formal comparison is presented for this endpoint (Figure 5).

Figure 5.

Figure 5

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MACE‑free survival and components in the ≥60-year PSM cohort. HR, hazard ratio; MACE, major adverse cardiovascular event; PSM, propensity score matching.

Subgroup analysis revealed that this difference was primarily among patients younger than 60-year-old. And the Figure S1 shows the overall MACE-free survival curves for the overall cohort and predefined subgroups following AVR with biological or mechanical valves before PSM.

Univariate and multivariate analysis results

Univariate analysis of factors related to long-term survival and MACE in the overall cohort and patients ≤60 years old showed: long-term survival: gender, age, BMI, hypertension, diabetes, hyperlipidemia, cerebrovascular diseases, peripheral vascular diseases, renal dialysis, AS/AR, arrhythmia and valve type were not significantly correlated with long-term survival. The survival curve showed that the cumulative survival rate curves of each factor stratified decreased in a similar trend, with no statistical difference (Table S2). MACE: in the overall PSM cohort (n=222), univariate analysis showed that arrhythmia (P<0.001) and valve type (P=0.004) were significantly associated with the occurrence of MACE. No significant correlations were observed for other variables, including gender, age, BMI, hypertension, diabetes, hyperlipidemia, cerebrovascular disease, peripheral vascular disease, renal dialysis, and AS/AR (all P>0.10). Multivariate Cox regression confirmed that both arrhythmia (HR =2.674, 95% CI: 1.489–4.803, P=0.001) and valve type (biological vs. mechanical valves, HR =0.421, 95% CI: 0.230–0.771, P=0.007) remained independent predictors of MACE.

In the age ≤60 PSM subgroup (n=154), similar results were observed: univariate analysis showed that arrhythmia (P=0.04) and valve type (P=0.04) were significantly associated with MACE. Multivariate analysis further confirmed both as independent predictors of MACE in this subgroup (arrhythmia: HR =0.491, P=0.04; valve type: HR =1.972, P=0.04).

The detailed results of the univariate and multivariate analyses are presented in Table 2.

Table 2. Predictors of major adverse cardiovascular events in patients after PSM.

Variable Overall cohort (PSM, n=222) <60 years cohort (PSM, n=154)
One-way analysis of variance (P value) Multi-factor analysis (P value) Specific value ratio One-way analysis of variance (P value) Multi-factor analysis (P value) Specific value ratio
Sex (male) 0.31 0.80
Age 0.19 0.25 0.96 0.96
BMI 0.73 0.18
Hypertensive 0.81 0.78
Diabetes 0.27 0.77
Hyperlipidaemia 0.73 0.92
Cerebrovascular disease 0.47 0.92
Peripheral vascular disease 0.29 0.48
Renal dialysis 0.94 0.43
AS/AR 0.35 0.38
Arrhythmia <0.001 0.001 2.67 0.04 0.04 0.49
Biological valves or mechanical valves 0.004 0.007 0.42 0.04 0.04 1.97
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AR, aortic regurgitation; AS, aortic stenosis; BMI, body mass index; PSM, propensity score matching.

Discussion

The selection between mechanical and biological prostheses for AVR in patients aged 50–65 years remains a controversial issue. The primary points of controversy lie in the unpredictable nature of both patient life expectancy and the durability period of biological valves. Patients neither wish to endure the hemorrhagic and thrombotic risks associated with lifelong warfarin therapy after mechanical valve implantation, nor the pain and risks of reoperation due to biological valve degeneration. As we have stated in the introduction, previous studies exhibited bias in follow-up duration and subgroup analysis, leading to biased conclusions in their follow-up results. To address this issue, in our study, we extended the follow-up duration to cover the period when biological valves begin to degenerate, and further conducted age-stratified subgroup analysis for patients aged 50–65 years.

Biological valves are primarily formed from bovine pericardium or porcine aortic valves processed through specialized techniques. Immune responses within the body constitute a significant cause of degeneration in these valves, and such responses are closely correlated with age. Discussing patients aged 50–65 years as a single cohort would likely introduce age-related bias in outcomes. Our results also reveal inconsistencies between conclusions drawn when treating all patients aged 50–65 years as a unified group versus stratifying them using 60 years as a demographic boundary—highlighting the importance of age-specific subgroup analysis for this population. During preprocessing, we initially analyzed three subgroups (50–55, 55–60, and 60–65 years), but limited sample sizes in each subgroup introduced bias, precluding the use of 5-year intervals for subgroup analysis. The age of 60 years serves as a critical immunological threshold in human, as people under 60 years exhibit more vigorous secretion of pro-inflammatory cytokines such as IL-6 and TNF-alpha (11). Therefore, 60 years was selected as the demarcation point for age-stratified subgroup analysis (12). This stratification is fully supported by clinical evidence: Nishida et al. demonstrated that long-term survival and bleeding outcomes differ significantly between mechanical and bioprosthetic aortic valves, with distinct risk profiles observed in patients aged <60 years versus those ≥60 years (1). This conclusion also confirms the necessity of our subgroup analysis of patients based on the age of 60.

During follow-up, we observed no significant difference in long-term survival between different prosthesis groups. However, the incidence of MACE showed significant variation. Further categorization of MACE components revealed that differences were primarily manifested in new-onset arrhythmias, predominantly driven by atrial fibrillation, a non-fatal but clinically relevant event, which should be distinguished from severe adverse events. Notably, new-onset atrial fibrillation after AVR is clinically relevant and cannot be ignored. Postoperative atrial fibrillation can increase the risk of intracranial hemorrhage and thromboembolism, impair cardiac systolic and diastolic function, and increase frequent palpitations and discomfort, thereby reducing long-term quality of life even in the absence of mortality. While patients under 60 years receiving biological valves exhibited a trend toward increased reoperation rates, this trend disappeared after PSM to eliminate baseline differences in patients under 60 years. Björn et al. also found the similar conclusion in a multicenter study that among patients after AVR, the incidence of postoperative in-hospital and long-term out-of-hospital AF was higher in those receiving biological valves compared to the mechanical valve group; however, the enrolled patients were aged 60 years and older (13). Axtell et al. found that increased age and preoperative significantly enlarged left atrium increase the probability of postoperative new-onset persistent AF in patients. Although this conclusion was derived from univariate and multivariate analyses, the age of patients who developed persistent AF postoperatively was significantly higher than that of those who did not develop atrial fibrillation (14). However, in patients with preoperative left atrial enlargement, ongoing vigilance for postoperative AF remains clinically imperative, and prophylactic antiarrhythmic therapy demonstrates measurable therapeutic value (15).

The absence of significant differences in stroke and bleeding events, as well as cardiac insufficiency events, may be attributed to the increasingly accessible coagulation monitoring and cardiac ultrasound follow-up in the postoperative period. These diagnostic modalities have progressively transitioned from tertiary hospitals to community healthcare centers, with many community hospitals now capable of performing such assessments. Automated coagulation testing systems deployed in community settings yield results comparable to those from large tertiary centers, thereby reducing the logistical complexity and inconvenience associated with frequent hospital visits for follow-up. Concurrently, the enhanced accessibility of community healthcare services has increased the frequency of cardiac function evaluations, enabling timely pharmacological adjustments that mitigate the occurrence of cardiac insufficiency (16,17). The absence of significant differences in reoperation rates constitutes a particularly noteworthy observation. For patients ≥60 years, attenuated systemic inflammatory responses and delayed valve degeneration contribute to no significant increase in reoperation risk during standard follow-up intervals. While extended follow-up duration may uncover higher reoperation rates, this holds limited clinical utility given potential exceedance of patient life expectancy. Among patients <60 years, pre-PSM (propensity score matching) analysis revealed a trend toward increased reoperation that dissipated post-PSM. This phenomenon is primarily ascribed to pre-PSM biological valve recipients exhibiting older age, elevated comorbidity burden (diabetes, hypertension, hyperlipidemia, smoking history), and heightened immune activity linked to these comorbidities—factors that collectively accelerate valve degeneration. These findings indicate that for patients <60 years with multiple comorbidities, biological valve selection may be clinically preferable (18-20).

Advancements in technology have concurrently enhanced the clinical utility of mechanical valve prostheses through iterative design improvements. Firstly, the popularization of INR monitoring in community hospitals coupled with the convenience brought by online medical consultation has effectively reduced the risks of bleeding and embolism in patients with mechanical valves. Traditional anticoagulation management requires patients to regularly visit hospitals for INR monitoring, which often involves long waiting times, travel costs, and disruptions to daily work and life. However, online medical consultation platforms now allow patients to access professional medical services remotely. A multicenter, randomized controlled trial involving 721 patients with mechanical heart valves showed that internet - based anticoagulation management, through remote INR result upload, medication reminders, and real-time dosage adjustment guidance, significantly improved the time in therapeutic range (TTR) and reduced the incidence of anticoagulation-related bleeding and embolism compared with traditional offline management (21). Recent studies have also demonstrated that point-of-care testing (POCT) combined with mobile remote management (MRM) significantly improves anticoagulation efficacy by shortening the time to achieve target INR, increasing the TTR, and reducing the incidence of bleeding and thromboembolic complications compared with conventional hospital-based monitoring (22). Furthermore, portable coagulometers and remote patient monitoring (RPM) systems have been validated to enhance postoperative anticoagulation safety and patient satisfaction, with higher TTR levels and fewer hypocoagulation events observed in remotely managed patients (23).Secondly, upgrades in mechanical valve materials reduce anticoagulation requirements, thereby reducing the risk of bleeding and thromboembolism in patients. ATS Open Pivot valves use pure pyrolytic carbon + cobalt-chromium alloy reinforcement rings, with a valve body 40% thinner reducing thrombus accumulation under low anticoagulation (INR 1.5–2.5); Bicarbon valves use titanium alloy valve bodies and carbon film coating, arc-shaped valve leaflets optimize blood flow, rolling hinges reduce friction, and the incidence of thrombus is reduced by 15–20%; On-X valves use silicon-free pure pyrolytic carbon, 90° fully open valve leaflets reduce turbulence, and low anticoagulation (INR 1.5–2.0) combined with aspirin reduces bleeding events by 30% (24). In terms of biological valves, new products enhance durability via material processing innovations including: removal of free aldehydes with dry preservation design; stentless valves utilizing a double bovine pericardial structure; and integration of AOA anti-calcification treatment with PEEK polymer stents (24-26); In addition, transcatheter valve-in-valve technology (TAVR-in-valve) has matured, and patients with biological valve failure can avoid re-thoracotomy, with the 30-day mortality rate of reoperations reduced to less than 5% (27), which may change the concerns of young patients in selection.

Notably, the management of bioprosthetic valve dysfunction following surgical bioprosthesis implantation is no longer confined to conservative therapy or redo sternotomy; transcatheter valve-in-valve (ViV) intervention has emerged as a valid therapeutic option. Compared with redo open-heart surgery and primary transcatheter aortic valve replacement (TAVR), ViV-TAVR is associated with lower in-hospital mortality and a reduced incidence of postoperative complications (10,28). The 14-year survival of a patient who underwent initial ViV-TAVI for bioprosthesis failure and subsequently received a second ViV-TAVI further corroborates the technique’s relative safety (29). However, this requires that the initially implanted bioprosthesis be of adequate size; in patients with a small aortic annulus, aortic annular enlargement is therefore necessary (30). This procedure demands considerable surgical expertise and clinical experience and is only feasible at a limited number of high-volume centers, creating additional challenges for the widespread application of ViV intervention. Although an undersized primary surgical bioprosthesis imposes inherent limitations and increases procedural risk for ViV-TAVI, the clinical application of bioprosthetic valve fracture technology may mitigate this issue to a degree (31). Nevertheless, the broad clinical implementation of such interventional strategies still has a long path forward (32). Importantly, in the contemporary TAVR era, surgical AVR remains advantageous due to its lower risk of conduction disorders (e.g., permanent pacemaker implantation rate ~5% vs. ~15% with TAVR) and comparable incidence of new-onset atrial fibrillation, both of which impact long-term quality of life (33).

With the advancement of science, the previously noted disadvantages of mechanical valves and biological valves have gradually diminished, as discussed in our prior context. The short-term and long-term clinical outcomes of both valve types are becoming increasingly comparable. For patients, the choice between valve types now often revolves around a trade-off between lifelong anticoagulant therapy and potential reoperation. This decision is particularly tied to patients’ expectations regarding quality of life.

Limitations

This study also has certain limitations: (I) retrospective design is prone to introduce selection bias. Despite PSM balanced baseline characteristics, selection bias could not be fully eliminated in this retrospective study. Unmeasured confounders including frailty, patient preference, and surgeon decision-making might influence the results, which is a common limitation of retrospective research; (II) single-center data may limit the extrapolation of results, and differences in surgical techniques and postoperative management in different centers may affect the prognosis; (III) the sample size of the ≥60-year was relatively small (n=30 per group), which may reduce statistical efficiency. This is a single-center retrospective study with long-term enrollment, which is limited by sample size; (IV) details such as valve size and anticoagulant intensity are not included, and their impact on bleeding or thrombus events needs further analysis.

Conclusions

This study reveals that the prognosis of mechanical and biological valves in patients aged 50–65 years undergoing AVR is age-dependent. Overall survival is comparable between mechanical and biological valves after PSM. But Mechanical valves are associated with more favorable MACE-free survival for patients under 60 years, mainly due to a lower risk of new-onset arrhythmia, while biological valves are preferred for those over 60 years, with individualized considerations essential in clinical decision-making.

Supplementary

The article’s supplementary files as

jtd-18-06-612-rc.pdf (89.4KB, pdf)
DOI: 10.21037/jtd-2026-1-0490
jtd-18-06-612-coif.pdf (694.9KB, pdf)
DOI: 10.21037/jtd-2026-1-0490
jtd-18-06-612-supplementary.pdf (260.3KB, pdf)
DOI: 10.21037/jtd-2026-1-0490

Acknowledgments

None.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board (Ethics Committee) of The First Affiliated Hospital with Nanjing Medical University (approval number: 2024-SR-403) and individual consent for this retrospective analysis was waived.

Footnotes

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0490/rc

Funding: This work was supported by the National Natural Science Foundation of China (grant No. 82370376 and 82200409), the Nanjing Medical University Education Research Project (grant No. 2023ZC042), and the Youth Fund of Jiangsu Provincial Basic Research Program (grant No. BK20230732).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0490/coif). The authors have no conflicts of interest to declare.

Data Sharing Statement

Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0490/dss

jtd-18-06-612-dss.pdf (70.2KB, pdf)
DOI: 10.21037/jtd-2026-1-0490
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References

  • 1.Thompson A, Fleischmann KE, Smilowitz NR, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024;150:e351-442. 10.1161/CIR.0000000000001285 [DOI] [PubMed] [Google Scholar]
  • 2.Sakamoto Y, Yoshitake M, Matsumura Y, et al. Choice of Aortic Valve Prosthesis in a Rapidly Aging and Long-Living Society. Ann Thorac Cardiovasc Surg 2016;22:333-9. 10.5761/atcs.oa.16-00104 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Carrier M, Pellerin M, Perrault LP, et al. Aortic valve replacement with mechanical and biologic prosthesis in middle-aged patients. Ann Thorac Surg 2001;71:S253-6. 10.1016/s0003-4975(01)02512-7 [DOI] [PubMed] [Google Scholar]
  • 4.Huckaby LV, Sultan I, Gleason TG, et al. Outcomes of tissue versus mechanical aortic valve replacement in patients 50 to 70 years of age. J Card Surg 2020;35:2589-97. 10.1111/jocs.14844 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Isselbacher EM, Preventza O, Hamilton Black J, 3rd, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022;146:e334-482. 10.1161/CIR.0000000000001106 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Rodríguez-Caulo EA, Otero-Forero JJ, Sánchez-Espín G, et al. 15 years outcomes following bioprosthetic versus mechanical aortic valve replacement in patients aged 50–65 years with isolated aortic stenosis. Cirugía Cardiovascular 2018;25:135-40. [Google Scholar]
  • 7.Kappetein AP, Head SJ, Généreux P, et al. Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document (VARC-2). Eur J Cardiothorac Surg 2012;42:S45-60. 10.1093/ejcts/ezs533 [DOI] [PubMed] [Google Scholar]
  • 8.Bosco E, Hsueh L, McConeghy KW, et al. Major adverse cardiovascular event definitions used in observational analysis of administrative databases: a systematic review. BMC Med Res Methodol 2021;21:241. 10.1186/s12874-021-01440-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Deanfield J, Lincoff AM, Kahn SE, et al. Semaglutide and cardiovascular outcomes by baseline and changes in adiposity measurements: a prespecified analysis of the SELECT trial. Lancet 2025;406:2257-68. 10.1016/S0140-6736(25)01375-3 [DOI] [PubMed] [Google Scholar]
  • 10.Majmundar M, Doshi R, Kumar A, et al. Valve-in-valve transcatheter aortic valve implantation versus repeat surgical aortic valve replacement in patients with a failed aortic bioprosthesis. EuroIntervention 2022;17:1227-37. 10.4244/EIJ-D-21-00472 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Coorens THH, Collord G, Jung H, et al. The somatic mutation landscape of normal gastric epithelium. Nature 2025;640:418-26. 10.1038/s41586-025-08708-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Keirns BH, Keirns NG, Sciarrillo CM, et al. Postprandial inflammation across the aging spectrum. J Nutr Health Aging 2025;29:100468. 10.1016/j.jnha.2024.100468 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Björn R, Nissinen M, Lehto J, et al. Late incidence and recurrence of new-onset atrial fibrillation after isolated surgical aortic valve replacement. J Thorac Cardiovasc Surg 2022;164:1833-1843.e4. 10.1016/j.jtcvs.2021.03.101 [DOI] [PubMed] [Google Scholar]
  • 14.Axtell AL, Moonsamy P, Melnitchouk S, et al. Preoperative predictors of new-onset prolonged atrial fibrillation after surgical aortic valve replacement. J Thorac Cardiovasc Surg 2020;159:1407-14. 10.1016/j.jtcvs.2019.04.077 [DOI] [PubMed] [Google Scholar]
  • 15.Gillinov M, Soltesz EG. Commentary: Atrial fibrillation after aortic valve replacement: Predict, prevent, protect. J Thorac Cardiovasc Surg 2020;159:1415-6. 10.1016/j.jtcvs.2019.05.080 [DOI] [PubMed] [Google Scholar]
  • 16.Akay M, Salas de Armas I, Patarroyo-Aponte M, et al. Inter-Institutional Collaboration Between Quaternary and Tertiary Hospitals: Cardiac Surgery Impact. Heart Surg Forum 2022;25:E525-9. 10.1532/hsf.4723 [DOI] [PubMed] [Google Scholar]
  • 17.Chambers JB, Lancellotti P. Heart Valve Clinics, Centers, and Networks. Cardiol Clin 2020;38:65-74. 10.1016/j.ccl.2019.09.006 [DOI] [PubMed] [Google Scholar]
  • 18.Gan L, Ye D, Feng Y, et al. Immune cells and hypertension. Immunol Res 2024;72:1-13. 10.1007/s12026-023-09414-z [DOI] [PubMed] [Google Scholar]
  • 19.Chen Y, Zheng J, Ni D, et al. The correlation between periodontitis and uncontrolled hypertension is mediated by inflammatory markers: results from a cross-sectional study of urban elderly population in southeast China. BMC Oral Health 2023;23:919. 10.1186/s12903-023-03680-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Lin K, Lan Y, Wang A, et al. The association between a novel inflammatory biomarker, systemic inflammatory response index and the risk of diabetic cardiovascular complications. Nutr Metab Cardiovasc Dis 2023;33:1389-97. 10.1016/j.numecd.2023.03.013 [DOI] [PubMed] [Google Scholar]
  • 21.Zhu Z, Li C, Shen J, et al. New Internet-Based Warfarin Anticoagulation Management Approach After Mechanical Heart Valve Replacement: Prospective, Multicenter, Randomized Controlled Trial. J Med Internet Res 2021;23:e29529. 10.2196/29529 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Huang L, Ouyang C, Ye X, et al. Anticoagulation monitoring using point-of-care testing combined with mobile remote management in postoperative cardiac valve replacement patients receiving warfarin therapy: A single-center cross-sectional study. Medicine (Baltimore) 2026;105:e47395. 10.1097/MD.0000000000047395 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Guede-Fernández F, Silva Pinto T, Semedo H, et al. Enhancing postoperative anticoagulation therapy with remote patient monitoring: A pilot crossover trial study to evaluate portable coagulometers and chatbots in cardiac surgery follow-up. Digit Health 2024;10:20552076241269515. 10.1177/20552076241269515 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Tayama E, Saku K, Anegawa T, et al. Prosthetic cardiac valves: history and review of cardiac prostheses clinically available in Japan. Surg Today 2022;52:521-31. 10.1007/s00595-021-02361-y [DOI] [PubMed] [Google Scholar]
  • 25.Ternacle J, Hecht S, Eltchaninoff H, et al. Durability of transcatheter aortic valve implantation. EuroIntervention 2024;20:e845-64. 10.4244/EIJ-D-23-01050 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Gillinov M, Malas T, Desai MY, et al. Heart Valve Replacement: Time for a 3-Party System? J Am Coll Cardiol 2025;86:527-9. 10.1016/j.jacc.2025.06.016 [DOI] [PubMed] [Google Scholar]
  • 27.Sotade OT, Falster MO, Pearson SA, et al. Comparison of long-term outcomes of bioprosthetic and mechanical aortic valve replacement in patients younger than 65 years. J Thorac Cardiovasc Surg 2023;166:728-737.e13. 10.1016/j.jtcvs.2022.01.016 [DOI] [PubMed] [Google Scholar]
  • 28.Tuzcu EM, Kapadia SR, Vemulapalli S, et al. Transcatheter Aortic Valve Replacement of Failed Surgically Implanted Bioprostheses: The STS/ACC Registry. J Am Coll Cardiol 2018;72:370-82. 10.1016/j.jacc.2018.04.074 [DOI] [PubMed] [Google Scholar]
  • 29.Salizzoni S, La Torre M, Vairo A, et al. 14-Year Journey Culminating in Valve-in-Valve-in-TAVI: The Longest Reported Follow-Up of Tricuspid Valve-in-Valve Therapy. JACC Cardiovasc Interv 2025;18:2946-8. 10.1016/j.jcin.2025.09.042 [DOI] [PubMed] [Google Scholar]
  • 30.Baldus S, Mauri V. Valve-in-valve TAVI: the new standard therapy for failing bioprosthetic valves? EuroIntervention 2022;17:1197-8. 10.4244/EIJ-E-21-00006 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Kitamura H, Fukumoto Y, Imamura Y, et al. Transcatheter aortic valve implantation in small surgical aortic prosthesis for small body size patients. Asian Cardiovasc Thorac Ann 2025;33:269-74. 10.1177/02184923251331338 [DOI] [PubMed] [Google Scholar]
  • 32.Nuche J, Ellenbogen KA, Mittal S, et al. Conduction Disturbances After Transcatheter Aortic Valve Replacement: An Update on Epidemiology, Preventive Strategies, and Management. JACC Cardiovasc Interv 2024;17:2575-95. 10.1016/j.jcin.2024.07.032 [DOI] [PubMed] [Google Scholar]
  • 33.Lim GB. MicroRNA-directed cardiac repair after myocardial infarction in pigs. Nat Rev Cardiol 2019;16:454-5. 10.1038/s41569-019-0216-z [DOI] [PubMed] [Google Scholar]

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    Supplementary Materials

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    jtd-18-06-612-rc.pdf (89.4KB, pdf)
    DOI: 10.21037/jtd-2026-1-0490
    jtd-18-06-612-coif.pdf (694.9KB, pdf)
    DOI: 10.21037/jtd-2026-1-0490
    jtd-18-06-612-supplementary.pdf (260.3KB, pdf)
    DOI: 10.21037/jtd-2026-1-0490

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    jtd-18-06-612-dss.pdf (70.2KB, pdf)
    DOI: 10.21037/jtd-2026-1-0490
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