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.
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 http://dx.doi.org/10.21037/atm-20-7581). The authors have no conflicts of interest to declare.
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- Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2017;38:2739-91. [Crossref] [PubMed]
- Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017;135:e1159-95. [Crossref] [PubMed]
- Lin M, Gan N, Chen J, et al. A single-center 14-year follow-up study of the BalMedic® bovine pericardial bioprosthetic valve. Ann Transl Med 2020;8:692. [Crossref] [PubMed]
- Goldstone AB, Chiu P, Baiocchi M, et al. Mechanical or Biologic Prostheses for Aortic-Valve and Mitral-Valve Replacement. N Engl J Med 2017;377:1847-57. [Crossref] [PubMed]
- Guo H, Lu C, Huang H, et al. Long-Term Clinical Outcomes of the Carpentier-Edwards Perimount Pericardial Bioprosthesis in Chinese Patients with Single or Multiple Valve Replacement in Aortic, Mitral, or Tricuspid Positions. Cardiology 2017;138:97-106. [Crossref] [PubMed]
- Rodriguez-Gabella T, Voisine P, Puri R, et al. Aortic Bioprosthetic Valve Durability: Incidence, Mechanisms, Predictors, and Management of Surgical and Transcatheter Valve Degeneration. J Am Coll Cardiol 2017;70:1013-28. [Crossref] [PubMed]