There are almost 100 000 heart valve replacement surgeries in the United States every year. This includes the most common which are mitral valve replacement and aortic valve replacement. In general there are 2 choices for type of surgical heart valve replacement, mechanical valves or bioprosthetic valves. When choosing the valve type its important to consider the advantages and disadvantages of mechanical and bioprosthetic heart valves.
Heart Valve Replacement Surgery – Artificial or Bioprosthetic Heart Valves
When heart valves are severely diseased the treatment is valve replacement surgery with artificial or bioprosthetic heart valves. As things stand there is no medicines that can reverse heart valve disease and so valve replacement or valve repair is required. Artificial heart valves are often known as mechanical heart valves and made from metallic alloys or plastic materials. In bioprosthetic heart valves, the valve tissue is typically from an animal species and mounted on a frame, known as a bioprosthesis.
Mechanic vs. Bioprosthetic Heart Valve Replacement – Which is Best?
There is a wide range of options for surgeons to choose from when it comes to heart valve replacement surgery. The most appealing part of a mechanical heart valve replacement is the fact that it typically has lifelong durability. The biggest drawback of mechanical heart valve replacement is the need for lifelong blood thinning medication (anticoagulation). Blood-thinning treatment comes with risk of bleeding complications. The most appealing part of a bioprosthetic heart valve is that it does not typically require blood-thinning medication. The biggest drawback of a bioprosthetic heart valve is that it will inevitably degenerate over time and fail, therefore requiring repeat procedures in those who survive long enough to warrant it.
Mechanical Heart Valves
What Are The Common Mechanical Heart Valves?
The 2 most common mechanical valves used are tilting disc valves and bileaflet valves. They both require lifelong blood thinning medication and have comparable durability and outcomes.
What Are The Advantages of Mechanical Heart Valves?
The major advantage of a mechanical heart valve is its durability. Mechanical heart valves would be expected to last > 20-30 years whereas bioprosthetic heart valves may only last 10-15 years before degenerating. This means that patients with mechanical heart valves are less likely to need a reoperation or repeat valve procedure.
What Are The Disadvantages of Mechanical Heart Valves?
Mechanical heart valves also have disadvantages. The blood flow around a mechanical heart valve is at higher stress then a bioprosthetic valve that can lead to blood clotting abnormality and potentially development of clot on the valve. For this reason, patients undergoing mechanical heart valve replacement require life long blood thinning medicine. The typical medication used for this is Warfarin. Of course this required life long monitoring, possible diet modification and a higher risk of bleeding. When compared to patients undergoing bioprosthetic valve replacement, those with a mechanical valve have a several fold increase in risk of bleeding. This stands particularly true for older patient, which is why with increasing age, a bioprosthetic heart valve is more often favored.
Factors To Consider Regarding Blood Thinning Medication
As mentioned above, those on life long blood thinning medication need to make significant lifestyle adjustment. There is the need for potentially frequent visits to healthcare facilities to have the blood thickness levels monitored. Dietary modifications may be required to maintain consistent levels of vitamin K. Patients will also need to avoid activities with more than an ordinary risk of bleeding such as contact sports.
Other Important Factors Regarding The Use Of Mechanical Heart Valves
It is also important to consider existing conditions and patient factors. Even though they may be young, a woman wishing to get pregnant may necessitate a bioprosthetic valve replacement so as to avoid blood-thinning medications that may be harmful during pregnancy. Similarly, younger patients that already have issues with bleeding may opt for a bioprosthetic heart valve replacement. Some patients may already have conditions that require the use of blood thinning medication such as atrial fibrillation of a history of blood clots. In these patients it may make more sense to use a mechanical heart valve since they are already taking the blood thinning medication.
Bioprosthetic Heart Valves
What Are The Common Bioprosthetic Heart Valves?
Bioprosthetic heart valves are most commonly either made of bovine (cow) or porcine (pig) tissue. Of course the main advantage of a bioprosthetic valve is that there is not typically the need for life long blood thinning medication and therefore a significantly lower risk of bleeding.
What Are The Disadvantages of Bioprosthetic Heart Valves?
Although the bioprosthetic heart valves have a lower risk of bleeding they don’t last as long. The tissue of the valve itself undergoes degeneration and over time the valve fails. The structural deterioration begins typically after around 5 years and by 10-15 years a significant number of patients have deterioration that interferes with acceptable valve function. At 15 years this is up to 40% of patients.
Increased deterioration means an increased risk of reoperation or repeat procedure. In patients with a bioprosthetic valve, the risk of needing a reoperation is around 25%. In patients over the age of 60, a bioprosthetic valve is often used, as the expected lifespan of the patient may be less than the valve.
Current Recommendations Regarding Choice Of Heart Valve Replacement
Currently, the general recommendation regarding valve choice favors a bioprosthetic valve in those over 60-65, and a mechanical valve in those younger than 60-65 years. Medical factors may influence this decision however. Those with conditions that significantly decrease life expectancy and possibly increase bleeding such as dialysis dependent kidney disease may be better off with a bioprosthetic valve. Those with conditions such as hyperparathyroidism that may accelerate valve deterioration may be better off with a mechanical valve.
Surgical Factors
Of course the risk of a heart operation and a possible reoperation itself influences the decision. Patients may also need additional procedures at the same time such as replacement of the aortic root that may influence the valve selection. The coexistent conditions that a patient may have, as mentioned above, also play an important role.
Patient Decision Making
When I discuss valve choices with patients I carefully go through the factors that underlie the general recommendations so that they have a decent understanding of the decision-making. The choice of valve replacement is as much a lifestyle decision as it is a medical decision.
I ask the following questions and discuss the factors that may influence them.
- What are your thoughts on possibly needing an operation again one day vs. the risk of a bleed?
- What are your thoughts on lifestyle modification that ay accompany a mechanical valve replacement and blood thinner?
- In female patients, the potential for pregnancy and the impact of that on valve choice is discussed.
In my opinion it is critical that the patient is educated on these factors and has a role in the decision making process.
Is New Valve Replacement Technology Changing The Way We Think?
The most striking example of this is the TAVR procedure short for transcatheter aortic valve replacement. In this procedure the aortic valve is replaced without the need for open-heart surgery, usually through the vessels of the leg. The procedure has been the biggest advance of the last several decades in valve replacement. While it was initially used for only very high-risk patients the TAVR procedure is now being used in lower and lower risk subsets of patients. The TAVR procedure can be performed as a valve in valve procedure whereby a TAVR valve is placed inside an existing bioprosthetic valve, thus avoiding the need for repeat open-heart surgery. Before firm recommendation can be made, further studies will be required however the TAVR procedure will almost certainly be a strong influence in the decision to use a bioprosthetic valve in younger subsets of patients in the coming years.
I just found out about a year ago, that my aortic valve is bicuspid with increasing stenosis from mild to moderate in that year. I am hooked up to very good cardiologist who will hook me up with the right surgeon as needed. I am 66 and have multiple comorbidities, ie., HTN, Type 2 diab, obesity. I have been researching on line at the best medical sources(I am RN) My card is great gives me a lot of info but after all I have read and heard THIS ARTICLE IS THE MOST COMPREHENSIVE I HAVE READ!! I feel so much more prepared for my next appointment in a couple weeks. I think the doc will want cardiac angiocath. My echos are not always great due to my thickness of soft tissue. Thank you so much for such complete info which is making my decisions from a more informed place!!!!!
My husband is 55 years old and needs to have aortic valve replacement. After doing so much research on mechanical vs bioprosthetic, this helped make up our minds. I’m grateful for your website.
Has your Husband had the surgery yet? I will be having mine soon and have not made this decision yet.
Brent where are you located, what state? I was just curious. What is your age? What are some of your determining factors on which way you will go with your surgery?
My husband who is 58 has just found out he will need a valve replacement ….he will have to do this soon. I am trying to read up on all of the info I can. I found this article (page) to be very helpful.
hi vj
iam 47 had a
MV bioprosthetic” valve replacement in 2012 but remain wit afib so far everything fair to fine but quite challenging i wud hav my good and bad days
sometimes am afraid of any out come for later on cuz i cant afford of another surgery…i have 2 kids my husband support
Hello.
A few years ago, at 60, I found out that I had a Bicuspid Aortic Valve, with considerable Stenosis, whilst undergoing a pre op for a Robotically Assisted Partial Nephrectomy. It was a pretty interesting period! The heart had to be treated before the kidney.
Because of my age I was on the borderline for a mechanical valve, but there was concern that this could cause complications due to Warfrin during my Kidney op, and so I chose a bioprosthetic valve, in my case a Cows.
Every now and then I wonder if I made the right choice – your article has convinced me I did.
Thank you
Glad you found it useful.
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i have to have 2 values put in..Aortic and mirtal ..iam 55 the dr says i need 2 mechnical …is this right
Not really possible to comment without knowing the full situation.
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I am 58 and have a tricuspid aortic valve with well compensated moderate aortic regurgitation 2-3/4 which is stable. I am asymtomatic.
I have low normal systolic function – EJ of 50-55 (my EJ was 65 two years ago).
My left ventricle is slightly enlarged -LVEDD of 155 mls (up from 132 mls last year); IVS d 0.9cm; LVPW d 1.0 cm; LVID d 5.6 cm.
There is no evidence of adverse remodelled of left ventricle
My left and right atria are slightly enlarged.
Normal right ventricular size and systolic function
My aortic root is mildly dilated 4.1 cm and stable for 3 years now.
Other than moderate regurgitate murmur my clinical exam was normal: BP 130-80; lungs clear, carotid pulse volume on upstroke normal; pulse not collapsing.
Based on these findings my cardiologist just wants to see me in a year.
Just a couple of questions:
(1) no one can give me definitive advice on why my EF has been reduced. He said it is still in the normal range so don’t worry. Can you think of any other reason for the drop.
(2) Is there the possibility I might not need a new or repair of the aortic valve?
(3) my original diagnosis 30 years ago was a bicuspid aortic valve which has recently been changed to a tricuspid valve with prolapse of the right coronary cusp. Given the very slow deterioration of valve function is this clinically significant?
1) Im not sure without seeing the scans from prior, its important to ensure the same method and a quantitative one at that is used each time, or consideration of MRI with volume analysis.
2) With volume enlargement it is important surveillance is watertight, it is likely to need intervention one day although depends on a number of factors
3) Its either always been bicuspid or tricuspid, it is significant with regards to the potential for aortic dilation and timing of intervention.
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Thank you. My 28 year old son has a damaged aortic valve due to a blood infection. We are weighing the two options. First surgeon is gung ho on mechanical. He downplayed the effects of coumadin.
Getting a second opinion shortly.
Dr. Ahmad, I am at present in a difficult position to make a decision on my son, who was born with a bicuspid valve. He is 40 and recent cardiograms in India show reduced LVEF of 45 to 50% (varying per each echo cardio). Each surgeon here is recommending an open surgery. My son does not like the idea of the tick tick with the mechanical valve. We have no insurance for him in US. Yet my thought would be to have the surgery done in US. I would appreciate your thoughts doctor and an approximate idea of the total cost with no insurance. If you e-mail back I could send the reports by e-mail and or WhatsApp. Many thanks.
I’m 29 M with mechanical AVR. The ticking is there, but it’s not really that bad. There are ways to get away from it, and even a slightly noisy room covers it up. For me, if I lay slightly on my left side, the noise stops. Its kinda annoying to deal with, but I can tell I’m already getting use to it.
Let’s put it this way, do you really want to get another open heart operation every 10 years just because you can’t learn to deal with a sound? Trust me, living through the experience is something you only want to do once
Very Interesting and informative. Born with Bicuspid valve, affected by rheumatic fever during childhood that caused severe stenosis in the Aortic valve which was accidentally diagnosed while doing a routine ECHO in 2014, I will be 53 years this October and now I am not only sure but definite that I will settle with tissue valve as my doctor suggested for valve replacement. But, the last para says it all that “………….further studies will be required however the TAVR procedure will almost certainly be a strong influence in the decision to use a bioprosthetic valve in younger subsets of patients in the coming years.”
And, I think that in the next ten years or so with advanced medicine and technology including the cost effectiveness across the world, TAVR would be the final choice over conventional open heart surgeries.
I am a 65 yr old woman who had the mitral mechanical valve replaced in 1999. Blood infection did my old one in. In 2009 I had to have the mechanical one replaced as its sheath had a hole in it the size of a pencil, and many old clots were hanging around the valve. I replaced it with the pig valve, ( not on the killer Warfarin since getting rid of the mech valve!) the rat poison is what ruins your life and health. The 2009 surgery was successful and my health regained. Now in 2019 the leaflets have turned hard like leather, causing me trouble again. But they want to do it via artery surgery. If there are blockages how do they fix those?
I am a 65 yr old woman who had the mitral valve replaced in 1999, with the mechanical valve. Blood infection did my old one in. In 2009 I had to have the mechanical one replaced as its sheath had a hole in it the size of a pencil, and many old clots were hanging around the valve. I replaced it with the pig valve, ( not on the killer Warfarin since getting rid of the mech valve!) the rat poison is what ruins your life and health. The 2009 surgery was successful and my health regained. Now in 2019 the leaflets have turned hard like leather, causing me trouble again. But they want to do it via artery surgery. If there are blockages how do they fix those?
My father is 90 years old. Why would the Doctors recommend an artificial as to a tissue. You think they would do tissue. He bleeds like crazy and only takes an aspirin a day. Won’t he be worse on blood thinners?
Very comprehensive article regarding mechanical vs biotissue valves.Thank you!
I have a 15 year old son who was borne with TOF. Heart repaired was performed at 2 months by Dr. Hanley and Stanford Children’s Hospital. Today, we are having to decide what type of valve (Pulmonary Valve) to go with. Currently, the folks at UCSF are pushing for the Sapien valve. However I am weighing all options. Have reached out to Spencer Heart doctor, whom performed his TOF repair and expect to hear from them in a few weeks as to there recommendation. Our son does not want his chest cracked yet I am concerned over the life expectancy of the valve. The mechanical valve sure has its advantages however, given our sons position not to have his chest cracked, the Sapien valve seems like a good choice. But the life expectancy of the Sapien is where I am concerned.
I have a 15 year old son who was borne with TOF. Heart repaired was performed at 2 months by Dr. Hanley and Stanford Children’s Hospital. Today, we are having to decide what type of valve (Pulmonary Valve) to go with. Currently, the folks at UCSF are pushing for the Sapien valve. However I am weighing all options. Have reached out to Spencer Heart doctor, whom performed his TOF repair and expect to hear from them in a few weeks as to their recommendation. Our son does not want his chest cracked yet I am concerned over the life expectancy of the valve. The mechanical valve sure has its advantages however, given our sons position not to have his chest cracked, the Sapien valve seems like a good choice. But the life expectancy of the Sapien is where I am concerned.
I am 40 years old and i have to have my aortic valve replaced i am on the fence of which one to get i am going in for surgery next week to have it done i have to have open heart done I’m not to thrilled about it but it is what it is and i just don’t know what valve to get.
I am a 40 year old momma and Mimi who is needing to make a choice on pig valve or mechanical. The thought of being on comudin scares me bc I had gastric sleeve surgery almost 2 years ago and don’t want to gain weight. My youngest kids are 5 and 9 so I need to feel good and be able to play with my kids. I currently already take 6 medications daily and don’t want to add another pill to my list. Which choice is best for me!!!???
A 77 year old man. Aortic valve replaced at 70 with Bioprosthetic & age 75 bio. mitral valve replaced. Now with CRT pacemaker at age 75. Many Marfan issues but still living!!
Valve life – aortic maximum say 15 years & was suggested mitral perhaps 10 years (same surgeon). I may be mistaken re life spans of replaced valves as with advancing age my short term memory is poor. A comment re lifespan of Bios in aortic & mitral position would be apprreciated. Thanks.
Usually 10-15 years in those positions at that age.
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Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
Hello Dr. Mustafa Ahmed,
I was wondering if you could advise on which heart valve to choose in following situation:
59 years old, height 167, weight 67; pancreatitis and gastritis. Had hepatitis, chronic hepatitis (30 years); eye surgery Lasik; cerebrovascular accident with loss of consciousness. Heredity is burdened with oncological diseases (lungs, stomach, blood).
If you could give your opinion it would be highly appreciated.
Thank you a lot in advance,
Anastasia
In 2017 I had a mital valve replacement with a mechanical one. I was 55 Years old. In the article they do not mention the ticking noise of the mechanical valve. It took me sometime to get use to it but eventually did. I am on a blood thinner for life and I am okay with that. I have Afib and two years later had to have a ablation done. Since then I have had no problems with my. I did not know about the ticking but I believe even if I did I would not change my mind. I prefer not to go through that surgery again.
My husband is 63. He has an aortic aneurysm and also needs his valves replaced. The surgeon said he could wait a bit on the valve but the aneurysm is on the cusp of needing surgery. We think getting the surgery sooner makes sense (we fear the rupture of the aneurysm) and going with the mechanical so he hopefully won’t need another surgery. Any thoughts?
I was 50 when it was discovered that I had a bicuspid aortic valve, very calcified. I chose a bio-prosthetic valve due to my career as a machinist. 8+ years now and doing fine. Hoping TAVR will be the replacement method, when the time comes…
Hi, I am 57. I have bicuspid valve, serious aortic stenosis. I don’t want to be on blood thinners or countless doctor visits.i may need a pace maker but that decision has not been clarified. Can it be my choice to choose mechanical or tissue valve and when tissue valve may need replacement can A TAVR be done. Thank you for reading my post.
The most appealing part of a bioprosthetic heart valve is that it does typically require blood-thinning medication.
Should that be “does NOT typically require blood thiner?”
Thanks for pointing that out, Jessica! We’ve updated our article.