Alternatively, large retrospective observational studies have shown similar long- term survival rates in patients 50 to 69 years of age undergoing mechanical versus bioprosthetic In general, patients with mechanical valves experience a higher risk of bleeding because of anticoagulation, whereas individuals who receive bioprosthetic valves expe- rience a higher rate of reoperation attributable to structural deterioration of the prosthesis, as well as perhaps a decrease in survival rate.6,25 27 Several other factors should be considered in the choice of type of valve prosthesis (see Section 11.1). Ultimately, the choice of mechanical versus Table 22. Selected Factors That May Impact Shared Decision-Making for the Choice of Prosthetic Valve Favor Mechanical Prosthesis Favor Bioprosthesis Age <50 y Increased incidence of structural deterioration with bioprosthesis 50% for age 20 y) Lower risk of anticoagulation complications Age >65 y Low incidence of structural for age >70 y) Higher risk of anticoagulation complications Patient preference (avoid risk of reintervention) Patient preference (avoid risk and inconvenience of anticoagulation) Low risk of long-term anticoagulation High risk of long-term anticoagulation Compliant patient with either home monitoring or close access to INR monitoring Limited access to medical care or inability to regulate VKA Other indication for long-term anticoagulation (eg, AF) Access to surgical centers with low reoperation mortality rate High-risk reintervention (eg, porcelain aorta, prior radiation therapy) Access to transcatheter ViV replacement Small aortic root size for AVR (may preclude ViV procedure in future) TAVI valves have larger effective orifice areas for smaller valve sizes (avoid patient prosthesis mismatch) AF indicates atrial fibrillation; AVR, aortic valve replacement; INR, international normalized ratio; TAVI, transcatheter aortic valve implantation; ViV, valve-in-valve; and VKA, vitamin K antagonist. 