Cardiac valve prosthesis choice for left-sided infective endocarditis in Medicare patients

Objective: To compare the outcomes between bioprosthetic and mechanical prosthesis choice for aortic valve and mitral valve infective endocarditis (IE) in patients >65 years old. Methods: Medicare Provider Analysis and Review files from 2011 to 2019 were queried for adult patients >65 years old with de novo IE who underwent isolated bioprosthetic aortic valve replacement (bAVR), mechanical aortic valve replacement (mAVR), bioprosthetic mitral valve replacement (bMVR), or mechanical mitral valve replacement (mMVR). Patients with preoperative ischemic or hemorrhagic stroke were excluded. Analyses were conducted separately for the aortic and mitral position: bAVR versus mAVR, and bMVR versus mMVR. Propensity score matching was used to account for measured confounders. The primary outcome was 5-year overall survival analyzed using restricted mean survival time; secondary outcomes were the 5-year cumulative incidences of valve reoperation, heart failure readmission, recurrent IE, bleeding, and ischemic stroke analyzed using Fine-Gray regression with death as a competing risk. Results: Matching yielded 330 patients in each AVR group and 250 patients in each MVR group. Five-year survival favored bAVR over mAVR (66.1% vs 56.7%, RMST: 3.96 years vs 3.46 years, P = .001), whereas 5-year survival was similar for bMVR versus mMVR (53.1% vs 53.1%, RMST: 3.50 years vs 3.35 years, P = .451). There were no significant differences in the cumulative incidences of secondary outcomes. Conclusions: This analysis of patients >65 years old with left-sided IE demonstrated that mechanical valves were associated with worse early mortality, no 5-year survival advantage over bioprosthetic valves, and provide no benefit in this population.