Structural valve degeneration (SVD) of surgical bioprostheses (BP) is increasingly diagnosed. We aimed to reappraise aortic BP SVD mode, determinants, effect of treatment and outcome.

A total of 262 SVD patients (78±9 years, 53.4% males) were enrolled. The mode and determinants of SVD were investigated by echocardiography, surgical and macroscopic evaluation. Mortality and the effect of treatment were assessed.

The predominant mode of SVD was stenosis (58%). The annualized rate of increase in mean gradient was 4.6±3.2mmHg/year in stenotic SVD. In multivariable analysis, predictive factors of an earlier SVD were age (P<0.001), creatinine clearance (P<0.0001), early post-operative effective orifice area (P=0.011) and mean gradient (P<0.0001), BP type (Stentless/Stented porcine/Stented pericardial, P=0.009) and a specific type of BP (P<0.0001). Seventy (26.7%) patients underwent exclusive medical care (Medical), 79 VinV (30.1%) and 113 (43.1%) Redo-Surgery. In explanted BP (n=113) moderate to severe calcifications was found in 83.2%. Leaflet fibrosis, as a component of SVD, was found in 23.9% of BP. Out of 19 (16.8%) BP with no or minimal calcification (NoCalcif) 7 had fibrotic stenosis (36.8%). At 4 years, overall survival was improved by invasive management (74.0±6.6% vs. 55.7±6.9%, P=0.01). In multivariable analysis predictors of overall survival were Redo-S (HR 0.47, P=0.028), VinV (HR 0.37, P=0.014), and Nt-pro-BNP>3000 (HR 2.22, P=0.004).

The rate of SVD progression is 4 to 5mmHg/year on average. BP type and post-operative hemodynamic are predictors of faster SVD. NoCalcif accounts for>15% of SVD. Leaflet fibrosis is a component of SVD. Redo-surgery and VinV are associated with a better outcome, independently of failure mode, and should be considered in most SVD patients.