Redo Aortic Valve Replacement Research Articles

Surgical explantation for a rapid deployment valve: the 'shave-and-hook technique'.

An 80-year-old female patient underwent redo aortic valve replacement for haemolysis caused by moderate paravalvular leakage 1 year after a 21-mm Intuity Elite valve implantation. The elevatorium passed at the segment with paravalvular leakage. The frame was then bent inward using a hook and the peel around the sawing ring was shaved by an elevatorium. After explantation of the Intuity Elite valve, endoscopic examination showed no sign of annular or sub-annular damage. Conventional aortic valve replacement using a biological valve was performed. We introduce a safe alternative technique for explantation of a rapid deployed valve.

REDO AORTIC VALVE REPLACEMENT WITH ROOT ENLARGEMENT IN THE MANAGEMENT OF PATIENT PROSTHESIS MISMATCH

REDO AORTIC VALVE REPLACEMENT WITH ROOT ENLARGEMENT IN THE MANAGEMENT OF PATIENT PROSTHESIS MISMATCH

Aortic Regurgitation, Time to Aortic Valve Reintervention, and Mortality in Degenerated Trifecta Versus Non-Trifecta Bioprosthesis

On July 31, 2023, the Trifecta valve was withdrawn from the market after concerns regarding early (≤5 years) structural valve deterioration (SVD), mainly as aortic regurgitation (AR). Our aim was to determine the timing, mechanism, and impact of bioprosthetic SVD in patients who underwent redo aortic valve replacement (redo-AVR) with either redo-SAVR or valve-in-valve transcatheter aortic valve replacement (TAVR) using Trifecta versus other bioprosthetic valves. Patients who underwent redo-AVR for SVD at our institution were categorized into 2 groups based on the valve type: Trifecta versus non-Trifecta. Multivariate Cox proportional hazard model and Kaplan-Meier curves were used to compare mortality. A total of 171 patients were included; 58 (34%) had previous SAVR with a Trifecta valve and 113 (66%) with non-Trifecta valve. A total of 103 patients (60%) underwent valve-in-valve TAVR and 68 redo-SAVR (40%). The age, gender, and Society of Thoracic Surgeons score were similar between Trifecta and non-Trifecta groups. In patients with bioprosthetic valves requiring redo-AVR, Trifecta valves had an earlier onset of greater than moderate AR (4.5 vs 11.9 years, p <0.001) and earlier time to redo-AVR (5.5 vs 12 years, p <0.001). AR was more common as the mechanism of SVD in Trifecta versus non-Trifecta valves (55.2% vs 30.1%, p = 0.006). All-cause adjusted mortality from index SAVR was higher in the Trifecta than in non-Trifecta group (hazard ratio 4.1, 95% confidence interval 1.5 to 11.5, p = 0.007). In conclusion, compared with non-Trifecta valves, Trifecta valves exhibit early SVD primarily as AR and progress rapidly to significant SVD requiring redo-AVR. Mortality is significantly higher with Trifecta than in non-Trifecta valves, potentially impacting the results of SAVR versus TAVR studies.

Recent outcomes of surgical redo aortic valve replacement in prosthetic valve failure.

As redo surgical aortic valve replacement(AVR) is relatively high risk, valve-in-valve transcatheter AVR has emerged as an alternative for failed prostheses. However, the majority of studies are outdated. This study assessed the current clinical outcomes of redo AVR. This study enrolled 324 patients who underwent redo AVR due to prosthetic valve failure from 2010 to 2021 in four tertiary centers. The primary outcome was operative mortality. The secondary outcomes were overall survival, cardiac death, and aortic valve-related events. Logistic regression analysis, clustered Cox proportional hazards models, and competing risk analysis were used to evaluate the independent risk factors. Redo AVR was performed in 242 patients without endocarditis and 82 patients with endocarditis. Overall operative mortality was 4.6% (15 deaths). Excluding patients with endocarditis, the operative mortality of redo AVR decreased to 2.5%. Multivariate analyses demonstrated that endocarditis (HR 3.990, P=0.014), longer cardiopulmonary bypass time (HR 1.006, P=0.037) and lower left ventricular ejection fraction (LVEF) (HR 0.956, P=0.034) were risk factors of operative mortality. Endocarditis and lower LVEF were independent predictors of overall survival. The relatively high risk of redo AVR was due to reoperation for prosthetic valve endocarditis. The outcomes of redo AVR for non-endocarditis are excellent. Our findings suggest that patients without endocarditis, especially with acceptable LVEF, can be treated safely with redo AVR.

Long-term prognosis in patients undergoing redo-isolated aortic valve replacement

Aim: To evaluate clinical outcomes after redo aortic valve replacement (AVR) with sutured valves, versus valve-in-valve transcatheter aortic valve replacement (ViV-TAVR), versus sutureless valves. Methods: We identified 113 consecutive patients undergoing redo AVR with either ViV-TAVR, redo-sutured and redo-sutureless valves between August 2010 to March 2020. Heart-team made the decision whether patient should undergo redo-sutureless versus ViV-TAVR, versus redo-sutured AVR. Results: Preoperatively, redo-sutured (n = 57), ViV-TAVR (n = 31) and redo-sutureless (n = 25) patients were compared. Postoperatively, after propensity-adjustment analysis, the redo SAVR group had a higher incidence of new postoperative atrial fibrillation (POAF; p = 0.04) compared with redo-sutureless group. Follow-up outcomes analysis did not show differences among groups. Conclusion: Patients undergoing redo-sutureless AVR experienced a higher incidence of POAF compared with patients undergoing redo-sutured.

Transventricular Cardioscopic Release of a Trapped Prosthetic Mitral Valve Leaflet.

Trapped prosthetic valve leaflets are a rare but challenging complication. A 68-year-old male patient had previously undergone redo aortic valve replacement. Postoperatively, he decompensated with severe mitral regurgitation, requiring extracorporeal membrane oxygenation and a salvage mitral valve replacement via right thoracotomy with very difficult access. This procedure was complicated by a trapped valve leaflet. He recovered well initially but presented 2 years later with worsening heart failure due to mitral stenosis and rising pulmonary artery pressures. Due to the high risk of sternotomy and right thoracotomy, a transventricular cardioscopic release of the trapped mitral valve leaflet was undertaken by left minithoracotomy. The procedure was successful, and the patient was discharged home on day 12. This novel minimally invasive approach, which does not require myocardial preservation, is ideal for high-risk patients with this rare complication and has not previously been described. We hope that by sharing our experience, others will consider this innovative approach.

11-Year Durability of a Perceval Sutureless Aortic Valve Implanted Inside a Hostile Calcified Homograft Root

Perceval valves are sutureless bioprosthetic surgical valves designed for the aortic position. The full breadth of indications for implanting Perceval valves is still unknown. Furthermore, the longer-term durability of the Perceval valve is also unclear. We report the long-term outcomes of a Perceval valve utilised for redo aortic valve replacement inside a heavily calcified homograft root in a patient with Klippel-Trenaunay-Weber syndrome.

Use of the Perceval Sutureless Valve for Redo Aortic Valve Replacement Inside a Patch-Reconstructed Neo-Aortic Root

This study highlights the novel use of the Perceval sutureless bioprosthesis in a new context, that is: for redo aortic valve replacement inside a reconstructed neo-aortic root following debridement of an infected root abscess.

Aortic root enlargement during redo Aortic valve replacement for prosthetic aortic valve dysfunction; A Case Report

Introduction: A variety of procedures for enlarging the aortic root have been described. The aim of the current study is to report a case of redo aortic valve replacement that underwent aortic root enlargement using a novel method. Case report: A 32-year-old female with a history of severely stenotic aortic valve prothesis developed recurrent attacks of syncope and dyspnea with minimal effort. She had a past surgical history of aortic valve repair. Under general anesthesia in the supine position, a re-sternotomy was done. The newly developed technique was used for aortic root enlargement. There were no significant intraoperative complications. The patient remained two days in the cardiac intensive care unit and 15 days in the ward. Conclusion: Modification of aortic root enlargement can increase the root by three times even in redo valve replacement. 

Interventional versus Surgical Treatment of Degenerated Freestyle Prosthesis.

Bioprosthetic stentless aortic valves may degenerate over time and will require replacement. This study aimed to evaluate early- and mid-term outcomes after isolated surgical redo aortic valve replacement (redo-SAVR) and transcatheter valve-in-valve implantation (TAVI-VIV) for degenerated stentless Freestyle bioprostheses. We reviewed records of 56 patients at a single center. Overall, 37 patients (66.1%) received TAVI-VIV and 19 (33.9%) received redo-SAVR. Thirty-day survival was similar in both groups (100%). One-year survival was comparable between groups (97.3% in TAVI-VIV and 100% in redo-SAVR, p = 1.0). The difference in mid-term survival after adjusting for age and EuroScore II was not significant (p = 0.41). The incidence of pacemaker implantation after TAVI-VIV was higher than after redo-SAVR (19.4% vs. 0%, p = 0.08). The 30-day and 1-year survival rates after both procedures were outstanding, irrespective of baseline characteristics. Isolated redo-SAVR should be favored in young patients, as the pacemaker implantation rate is lower. TAVI-VIV for degenerated Freestyle prosthesis can be a method of choice in elderly patients and those with high operative risk.

Candida endocarditis in a transcatheter aortic valve.

A 74-year-old male presented to the emergency room with fever and lethargy. His past medical history includes severe aortic stenosis status post transfemoral aortic valve replacement (TAVR) with #34 Evolute valve 10 months prior, and coronary artery disease. One month prior to presentation, he started developing symptoms of dry cough, night sweat, intermittent fever, and generalized weakness. Laboratory data significant for pancytopenia: white blood cell count 2.3 K/µL, hemoglobin 10.7 g/dL, platelet 75 K/µL. Blood culture drawn on admission positive for pan-sensitive Candida Parapsilosius; it remained positive on five sets of repeat cultures. Transesophageal echo showed preserved left ventricular systolic function, a 2-cm echodensity on the left ventricular side of the bioprosthesis with severe functional aortic stenosis, para-aortic abscess, and small to moderate pericardial effusion. Patient underwent successful re-do aortic valve replacement with #25 Inspiris valve, explant of TAVR valve, and repair of aortic wall abscess with pericardial patch on hospital day #7. Culture of the excised Evolute valve was positive for C. Parapsilosius. Patient was treated with intravenous micafungin 150 mg for 42 days and lifelong suppression with oral fluconazole. Pancytopenia was thought to be as a result of the candida infection. Hospital course was complicated by multiple small bilateral cortical and subcortical infarcts, consistent with thromboembolic phenomenon. Patient was discharged to rehabilitation facility on hospital day #21. At the time of writing this case, patient is 2-month post-hospital discharge and has been discharged home. Fungal endocarditis of the TAVR valve is an extremely rare entity. We describe a successfully treated case with surgical interventions.

Reply from authors: Sutureless valves-expanding the surgeon's toolbox.

The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. Currently, most patient with degenerated bioprosthetic valves are referred for valve-in-valve transcatheter aortic valve replacement (ViV TAVR). Although feasible for most, patients with small prosthetic valves (<23 mm internal diameter) are more prone to have higher residual gradients, patient–prosthesis mismatch (25%), and higher periprocedural mortality (10%).1Dvir D. Webb J.G. Bleiziffer S. Pasic M. Waksman R. Kodali S. et al.Transcatheter aortic valve implantation in failed bioprosthetic surgical valves.JAMA. 2014; 312: 162-170https://doi.org/10.1001/jama.2014.7246Crossref PubMed Scopus (656) Google Scholar In our article on sutureless valve use in reoperative AVRs, we present an alternative for patients deemed as inappropriate candidates for ViV TAVR by a heart team.2Dhanekula A.S. Nishath T. Aldea G.S. Burke C.R. Use of a sutureless aortic valve in reoperative aortic valve replacement.J Thorac Cardiovasc Surg Tech. 2022; 13: 31-39https://doi.org/10.1016/j.xjtc.2022.02.025Abstract Full Text Full Text PDF Scopus (1) Google Scholar Our data revealed a significant improvement in hemodynamic parameters, minimal postoperative morbidity, and an objectively larger internal diameter in nearly all patients compared with if ViV TAVR was performed in their existing bioprosthesis. However, we recognize the concerns brought up by Grimm and Sultan3Grimm J.C. Sultan I. Commentary: sutureless valves or futureless valves?.J Thorac Cardiovasc Surg Tech. 2022; 13: 40-41https://doi.org/10.1016/j.xjtc.2022.04.004Abstract Full Text Full Text PDF Scopus (0) Google Scholar in their commentary, and we agree that currently this strategy is of most utility in specific populations. Certainly, we hold reservation with sutureless valve use in patients younger than age 60 years, due to durability concerns with bioprostheses compared with mechanical valves in this population, yet-to-be-defined long-term outcomes of sutureless valves (although current 10-year data appear promising), and growing enthusiasm for alternative valve operations in this population (such as Ross, valve repair, and root enlargement procedures).4Goldstone A.B. Chiu P. Baiocchi M. Lingala B. Patrick W.L. Fischbein M.P. et al.Mechanical or biologic prostheses for aortic-valve and mitral-valve replacement.N Engl J Med. 2017; 377: 1847-1857https://doi.org/10.1056/NEJMoa1613792Crossref PubMed Scopus (315) Google Scholar, 5El-Hamamsy I. Toyoda N. Itagaki S. Stelzer P. Varghese R. Williams E.E. et al.Propensity-matched comparison of the ross procedure and prosthetic aortic valve replacement in adults.J Am Coll Cardiol. 2022; 79: 805-815https://doi.org/10.1016/j.jacc.2021.11.057Crossref PubMed Scopus (18) Google Scholar, 6Szecel D. Meuris B. Long-term outcome with sutureless valves: 12 years of Perceval experience.Ann Cardiothorac Surg. 2020; 9: 322-324https://doi.org/10.21037/acs.2020.04.03Crossref PubMed Google Scholar We also recognize that root replacement and annular enlargement provide a well-established strategy managing for small annuli, while also creating a scaffold for future ViV. However, there are still specific populations that can benefit from sutureless valve placement. Root replacement, annular enlargement, concomitant procedures, re-do traditional surgical AVR, and surgery after failed TAVR in older individuals with small, calcified annuli can be challenging and risky, especially in centers with limited experience in such procedures. Beyond limiting crossclamp and bypass times, this valve class also offers excellent gradients across valve sizes.6Szecel D. Meuris B. Long-term outcome with sutureless valves: 12 years of Perceval experience.Ann Cardiothorac Surg. 2020; 9: 322-324https://doi.org/10.21037/acs.2020.04.03Crossref PubMed Google Scholar Although the data on ViV TAVR into sutureless valves is limited, early reports indicate favorable hemodynamic parameters and no episodes of coronary obstruction, offering a significant advantage over smaller stented valves in patients with small sinuses, low native coronary artery heights, and short predicted valve-to-coronary distances.7Landes U. Dvir D. Schoels W. Tron C. Ensminger S. Simonato M. et al.Transcatheter aortic valve-in-valve implantation in degenerative rapid deployment bioprostheses.EuroIntervention. 2019; 15: 37-43https://doi.org/10.4244/EIJ-D-18-00752Crossref PubMed Scopus (19) Google Scholar Travel to a trout stream with an avid fly angler, and you will likely see them cycle through box after box filled with various flies to accommodate differing conditions. A carpenter would never show up to a job site with a single hammer. Contemporary aortic valve surgeons should be no different. Management of aortic valve disease is increasingly nuanced, and is no longer limited to traditional surgical AVR. Primary TAVR, ViV TAVR, and TAVR in TAVR continue to increase in prevalence with improving outcomes and evolving technologies, whereas alternative operations—such as the Ross procedure and valve-sparing techniques—continue to grow in popularity. These are all essential components within the heart team construct and critical elements to the modern aortic valve surgeon's toolbox, and we certainly believe sutureless valves merit space here. Our experience with these valves provides another solution that is well suited for certain cohorts and should be considered by heart valve teams, along with other conventional therapies, in patients with primary aortic stenosis as well as those with prosthetic valve dysfunction. Sutureless bioprostheses for aortic valve reoperations: How to get out of troublesJTCVS TechniquesVol. 16PreviewSutureless bioprostheses have the well known advantage of a rapid implantation with significant reduction of the ischemic times during surgical aortic valve replacement (AVR).1 This is particular beneficial in high-risk, elderly patients in whom surgical AVR might be indicated. Full-Text PDF Open Access

A Case of Commando Procedure for Paravalvular Leakage after Redo Aortic Valve Replacement and Mitral Valve Replacement

A Case of Commando Procedure for Paravalvular Leakage after Redo Aortic Valve Replacement and Mitral Valve Replacement

Abstract 13294: Role of Retrospective Cardiac Computed Tomography Angiography in the Detection of Prosthetic Valve Endocarditis

Case presentation A 47-year-old man was readmitted for evaluation of recurrent fevers, night sweats, and weight loss over a 3 month period. He had a history of bioprosthetic aortic and mitral valve replacements for rheumatic valve disease and heart failure with reduced ejection fraction due to non-ischemic cardiomyopathy. Physical examination was remarkable for a[LMD1] grade II/VI systolic murmur. Laboratory notable for neutrophilic leukocytosis elevated C-reactive protein and erythrocyte sedimentation rate. Blood cultures demonstrated Staphylococcus epidermidis . On transthoracic echocardiogram (TTE) performed in the current admission and transesophageal echocardiogram (TEE) done 2 months prior the prosthetic valves were not clearly visualized, but there was no regurgitation, stenosis or vegetation noted. Due to a high index of suspicion for prosthetic valve endocarditis (PVE), a retrospectively gated cardiac computed tomography angiography (CCTA) of the entire cardiac cycle was performed. It revealed a 13 mm mobile vegetation attached to the ventricular side of the left coronary cusp (Figure 1). Subsequently, the patient underwent a redo aortic valve replacement. Blood cultures cleared and the patient was discharged on hospital day 16 to complete 6 weeks of Cefazolin and Rifampin. Discussion: The modified Duke criteria play an important role in the diagnosis of native valve infective endocarditis (IE) (~ 80% sensitive), but it carries a lower diagnostic yield in the detection of PVE. While TEE carries high accuracy in the diagnosis of native valve endocarditis, approximately 30% of patients with PVE and/or intra-cardiac devices have inconclusive or normal echocardiographic findings. Inability to recognize IE in a timely fashion (&lt;4 days) leads to greater embolic events. We showed how CCTA can be used to expedite the diagnosis of PVE.

Transcatheter Release of a Stuck Mechanical Valve in Aortic Position With Cerebral Embolic Protection

A 69-year-old man underwent aortic valve replacement (AVR) in 2000 with a 21-mm tilting disc valve. Nineteen years later, he underwent redo AVR with a 20-mm ATS AP360 valve (Medtronic) for a pannus ingrowth and an increased gradient. Three years after the second surgery, the patient presented with subacute onset of dyspnea on exertion. The international normalized ratio was 2.1. A transthoracic echocardiogram showed a mean gradient of 91 mm Hg with grade II valvular leak across the aortic mechanical valve without a thrombus.

Ten-year clinical and echocardiographic follow-up of third-generation biological prostheses in the aortic position

ObjectivesPERIMOUNT Magna Ease (Carpentier-Edwards; PME) prostheses have been widely implanted during the past decade for aortic valve replacement (AVR). Although promising results at midterm follow-up were reported, long-term outcome has yet to be confirmed. On this study we aimed to evaluate long-term results in terms of structural valve degeneration (SVD), major clinical outcomes, long-term hemodynamic valve performance, and left ventricular remodeling. MethodsFrom 2010 to 2012, 689 consecutive patients underwent AVR with PME. Complete clinical 10-year follow-up was obtained. The degree of SVD was categorized on the basis of the latest guidelines. Echocardiographic data were analyzed at 1, 5, and 10 years. Competing risk analysis was performed for major events. Cumulative incidence of SVD, reoperation, and endocarditis were also assessed according to prosthetic sizes (19-21-23 mm vs 25-27-29 mm) and age (<65 vs 65-75 vs >75 years old). ResultsThe overall cumulative incidence reported for SVD ≥2 and reoperation were 3.6% and 1.9% at 10 years, respectively. An early left ventricular reverse remodeling was noted after implantation and confirmed at follow-up. Patients younger than 65 years showed higher cumulative incidence of SVD ≥2 at 10 years compared with patients aged 65 to 75 and older than 75 years (9.7% vs 2.6% vs 2.7%; P = .013), as well as of redo AVR (7.8% vs 3.3% vs 0.4%; P = .002). There was no difference in terms of SVD and redo AVR for different prosthetic size categories (P > .05). The risk of endocarditis was similar among age and size groups. ConclusionsPME provides very good durability at long-term and could be considered one of the high performing third-generation bioprostheses for AVR.

Redo aortic valve surgery in a case of dextrocardia with situs inversus totalis

IntroductionDextrocardia is a rare congenital cardiac anomaly where the base-apex axis of the heart is directed to the right side. It may be associated with situs solitus, situs inversus, or situs ambiguous. Such cases are technically challenging when heart surgery is needed.Presentation of caseWe presented a case of a patient with dextrocardia and situs inversus totalis, who had severe aortic bioprosthetic valve degeneration needing a redo aortic valve replacement. Our operative strategy was to change the position of the main surgeon to the left side of the patient to perform most surgical steps.DiscussionA meticulous pre-operative surgical plan involving the whole team was very important for a smooth intra-operative course and a favourable outcome. Regarding the position of the main surgeon standing on the left side of the patient, we believed this surgical team arrangement added much to the technical ease for the procedure, since the anatomy was opposite to what our minds are used to. Also, computed tomography scan played a crucial role for a proper preoperative anatomical evaluation and surgical planning.ConclusionOur approach with the surgeon on the left side provided excellent exposure for redo aortic valve replacement in dextrocardia with situs inversus totalis. This surgical management played an important role for the good result in this technically challenging scenario.

Completely detached mechanical aortic valve prosthesis stuck to the aortic arch in a patient with Behçet’s disease

BackgroundAlthough detachment of the implanted valve prosthesis was a well-known complication in patients with Behçet’s disease, complete detachment of an aortic bileaflet valve prosthesis has never been reported.Case presentationAn 18-year-old boy with Behçet’s disease (HLA-A26 positive) who had previously undergone aortic valve replacement with an 18-mm ATS-Advanced Performance (ATS-AP) valve (ATS Medical, Inc., Minneapolis, MN) at the age of 12 years, presented sudden-onset general fatigue and was emergently transferred to the regional hospital. Chest X-ray showed displacement of the implanted mechanical valve. An echocardiogram revealed mobile valve prosthesis and severe aortic regurgitation. Just before leaving for our hospital for surgical treatment, a completely detached valve prosthesis was floating in the ascending aorta. On arrival, the valve prosthesis was stuck to the transverse arch. Emergent removal of the previous mechanical valve from the aortic arch and redo aortic valve replacement with a 24-mm ATS-AP valve were performed under total circulatory arrest. Infectious endocarditis was denied by histopathological examination. The patient was back to the intensive care unit with extracorporeal membrane oxygenation support, which was successfully decannulated 5 days later.ConclusionsThis was the first report of a patient with Behçet’s disease who encountered a complete detachment of implanted aortic valve prosthesis. The patient could be rescued by emergent surgery.

Impact of postoperative patient-prosthesis mismatch as a risk factor for early structural valve deterioration after aortic valve replacement with Trifecta bioprosthesis

BackgroundSeveral studies have reported high rates of structural valve deterioration (SVD) in the Trifecta valves. Herein, we analyzed the midterm results of the Trifecta valve and risk factors for early SVD.MethodsWe retrospectively reviewed the records of 110 patients who had undergone Trifecta implantation between January 2012 and December 2017.ResultsWe encountered seven cases of Trifecta valve failure. We performed a redo aortic valve replacement in five patients and a transcatheter aortic valve replacement in two patients. The SVD rate was 4.8% at 5 years and 6.6% at 7 years. The mean pressure gradient and peak velocity on the first postoperative echocardiogram in patients with SVD were higher than those in patients without SVD. The SVD rates with and without patient-prosthesis mismatch (PPM) were 2.8% and 12.6% at 5 years and 2.8% and 20.0% at 7 years. PPM is a risk factor for SVD. Noncoronary cusp tears were observed in all patients who had undergone redo surgery.ConclusionsThe most common cause of SVD was noncoronary cusp tear. Patients with PPM are at high risk of developing SVD.

Technical Details of Redo Aortic Valve Replacement Using St. Jude Medical Mechanical Prosthesis in a Patient with Thrombosed Aortic Mechanical Prosthesis: A Video Presentation

AbstractCurrent consensus guidelines of the American Heart Association and European Society of Cardiology uniformly recommend either type of prosthetic valve for patients aged between 60 and 70 years and mechanical prosthesis for patients aged less than 60 years. These recommendations are based on the results of randomized controlled trials that demonstrated no significant difference in late survival. Two of these trials compared mechanical and bioprosthetic valve models implanted in 1970s and 1980s. The other two trials included patients undergoing aortic valve replacement. Contemporary data are limited to small single-center studies