Is Aortic Valve Replacement with Bileaflet Prostheses Still Contraindicated in the Elderly?

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Abstract
Background: Prolonged survival in the Western world has increased the number of elderly patients referred for open-heart surgery during the last decade. Aortic valve disease is the most common heart valve disease in aged patients. Which aortic valve substitute is best employed in the elderly is still a debated matter. The main concern is about the thromboembolic and hemorrhagic risks related to mechanical valves and anticoagulation. Objective: The study aimed at reviewing clinical results after isolated aortic valve replacement with bileaflet prostheses in patients over 70 years and at retrospectively comparing them with those of a group of otherwise comparable patients under 50 years of age who underwent isolated aortic valve replacement with a mechanical device. Methods: The study population included 118 consecutive elderly patients (group A) operated on between January 1988 and January 1999 and 122 young patients (group B) who underwent aortic valve replacement during the same time period. Patients with associated coronary artery disease, mitral stenosis or regurgitation, type A aortic dissection, and infective endocarditis were excluded from the study. Preoperative clinical data, early and late postoperative mortality, all valve-related complications, and all data concerning the anticoagulation status – including the mean international normalized ratio (INR) and the mean time interval between each INR assay – were compared between the two groups. Results: The hospital mortality was significantly lower in group B (2.45%) than in group A (9.3%; p = 0.022). The mean follow-up period was 50.98 ± 2.23 months. The 12-year actuarial survival was significantly lower (69.6 ± 0.08%) in group A than in group B (94.4 ± 0.02%; p < 0.001). No significant difference was found in terms of valve-related and anticoagulation-related complication rates and actuarial freedom as well as mean interval between consecutive INR checks (p = 0.219) and mean INR value (p = 0.914). Conclusions: Bileaflet prostheses in elderly patients can achieve excellent early and late clinical results, with a low incidence of anticoagulation-related complications and an extremely low risk of a reoperation. Older age can no longer be considered a contraindication to bileaflet prosthesis implantation in the aortic position.