Use of the BalMedic bovine pericardial bioprosthetic valve in China: a new light on the horizon?

Use of the BalMedic bovine pericardial bioprosthetic valve in China: a new light on the horizon?

Maximilian Luehr^, Thorsten Wahlers^

Department of Cardiothoracic Surgery, Heart Center Cologne, University of Cologne, Cologne, Germany

^ORCID: Maximilian Luehr, 0000-0002-0645-1764; Thorsten Wahlers, 0000-0002-8437-4119.

Correspondence to: Maximilian Luehr, MD, PhD. Department of Cardio-Thoracic Surgery, Heart Center Cologne, University of Cologne, Cologne, Germany. Email:

Submitted Dec 28, 2020. Accepted for publication Jan 21, 2021.

doi: 10.21037/atm-20-7581

Since the early beginnings in the 1960s, bioprosthetic valves have been largely improved with regard to the continuous developments in tissue fixation, graft materials and chemical treatment (1). Despite the recent advances of trans-catheter based techniques for valve replacement, stented bioprosthetic valves remain the Gold standard for most patients with valvular heart disease in aortic, mitral and tricuspid position worldwide (2,3).

The present study by Lin et al. reports on 299 patients with a mean age of 53.5 years who received a BalMedic bovine pericardial bioprosthesis to treat mainly rheumatic and degenerative heart valve disease at a single institution. The overall perioperative mortality was very acceptable with 3% only (4).

Treatment of patients with bioprosthetic valves at a younger age is currently supported in the revised guidelines of the AHA/ACC and ESC/EACTS (2,3). However, the recommended age cutoff for a mechanical rather than a bioprosthetic valve differs between both guidelines. While the AHA/ACC guideline recommends a general age cutoff of <50 years, the ESC/EACTS guideline distinguishes between recommendations for mechanical aortic (<60 years) and mitral (<65 years) valve replacement.

The general use of the BalMedic bovine bioprosthetic valve for patients with rheumatic heart valve disease, especially for younger patients, might appear rather arbitrary due to a clear survival advantage with mechanical prostheses in aortic (<55 years) and mitral (<70 years) position that has been shown more recently (5). However, the level of the existing healthcare system with off-the-shelf availability for foreign products, patient compliance and general economic differences in China have to be taken into account.

Direct comparison with a similar Chinese cohort (n=225; mean age 61.2 years), treated with the Carpentier-Edwards Perimount (CE-P) bovine pericardial prosthesis, shows very similar results after 5 years (6). But after 10 years, the survival rates seem to favor the BalMedic bioprosthesis for aortic (80.6% vs. 66.2%) and double valve (82.9% vs. 55.9%) replacement. However, the structural valve deterioration (SVD) rates at 10 years were lower after mitral (58.9% vs. 83.9%) and double valve (53.8% vs. 68.2%) replacement using the CE-P bioprosthesis.

The indications for surgical and trans-catheter heart valve replacement with bioprostheses are likely to further expand in the future (2,7). Therefore, the current study by Lin et al. in this issue of the Annals of Translational Medicine adds important information with regard to postoperative mid- and long-term outcome after valve replacement with a bovine bioprosthestic heart valve.

The BalMedic bioprosthetic valve may indeed become a very valuable tool in the armamentarium of cardiac surgeons for the treatment of structural valve disease, however, more homogenous cohorts and larger patient numbers are required in future analyses.


Funding: None.


Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Translational Medicine. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at The authors have no conflicts of interest to declare.

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Cite this article as: Luehr M, Wahlers T. Use of the BalMedic bovine pericardial bioprosthetic valve in China: a new light on the horizon? Ann Transl Med 2021;9(6):444. doi: 10.21037/atm-20-7581