Several studies have shown a survival advantage with a mechanical prosthesis in this age group. Alternatively, large retrospec- tive observational studies have shown similar long-term survival rates in patients 50 to 69 years of age undergoing mechanical versus biopros- thetic valve replacement.22 24 In general, patients with mechanical valves experience a higher risk of bleeding caused by anticoagulation, whereas individuals who receive bioprosthetic valves expe- rience a higher rate of reoperation because of structural deterioration of the prosthesis, as well as perhaps a decrease in survival rate.6,25 27 There are several other factors to consider in the choice of type of valve prosthesis (see Section 11.1). Ultimately, the choice of mechanical versus bio- prosthetic valve replacement for all patients, but especially for those between 50 and 65 years of age, is a shared decision-making process that must account for the trade-offs between dura- bility (and the need for reintervention), bleeding, 5. In patients >65 years of age at the time of bio- prosthetic AVR, the likelihood of primary struc- tural deterioration at 15 to 20 years is only about In addition, older patients are at higher CLINICAL STATEMENTS AND GUIDELINES risk of bleeding complications related to VKA therapy and more often require interruption of VKA therapy for noncardiac surgical and inter- ventional procedures. It is reasonable to use a bioprosthetic valve in patients >65 years of age to avoid the risks of anticoagulation because the durability of the valve exceeds the expected years of life. 6. Replacement of the aortic valve with a pulmo- nary autograft (the Ross procedure) is a complex operation involving replacement of the aortic valve by the patient s own pulmonic valve, along with placement of a pulmonic valve homograft. 