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. CLINICAL STATEMENTS AND GUIDELINES bioprosthetic valve replacement for all patients, but especially for those between 50 and 65 years of age, should be made in a shared decision-mak- ing process that must account for the trade-offs between durability (and the need for reinterven- tion), bleeding, and thromboembolism.1 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 risk of bleeding complications related to VKA ther- apy and more often require interruption of VKA therapy for noncardiac surgical and interventional procedures. 