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 risk of bleeding complications related to VKA ther- apy and more often require interruption of VKA therapy for noncardiac surgical and interventional 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. In general, patients with mechanical valve replace- ment experience a higher risk of bleeding because of anticoagulation, whereas individuals who receive a bioprosthetic valve replacement incur a higher risk of repeat intervention attributable to structural valve deterioration. In patients <65 years of age, observational data suggest better long-term outcomes with a mechanical mitral valve replace- ment, even when the risks and inconvenience of long-term VKA anticoagulation are considered. In a propensity-matched analysis from New York s Statewide Planning and Research Cooperative System (SPARCS), although there was no survival difference for patients 50 to 69 years of age under- going mechanical versus bioprosthetic mitral valve the rates of reoperation were lower (HR: 0.59) with a mechanical valve, though stroke risk (HR: 1.62) was higher. In the 2017 report from the California Office of Statewide Health Planning for patients who underwent mitral-valve replacement and were 40 to 69 years of age, receipt of a biological prosthesis was associ- ated with a mortality rate significantly higher than that seen with receipt of a mechanical prosthesis.1 The choice of a mechanical mitral valve in patients <65 years of age who are good candidates for anticoagulation should account for these observa- tional, nonrandomized data and abide by the prin- ciples of shared decision-making.1,7,10 7. 