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The optimal timing of valve replacement surgery in chronic severe aortic regurgitation (AR) has remained a major clinical problem in the management of these patients. Although the onset of symptoms is the generally accepted indication for aortic valve replacement (AVR), the unpredictable development of pre-symptomatic left ventricular (LV) dysfunction as a result of prolonged volume overload has resulted in numerous reports attempting to formulate a risk profile for these patients. Although aortic root and LV cineangiography have been the "gold standard" for defining the severity of AR and its effect on LV performance, serial follow-up by these means is impractical. More recently numerous non-invasive measures of LV size (echocardiogram) and function both at rest and on exercise (echocardiogram and equilibrium radionuclide angiocardiography., ERNA) have been serially utilised~ In these endeavours, the thinking has been clouded by a tendency to equate these two measures and failing to appreciate that apparent preoperative LV dysfunction (particularly on exercise) may be rapidly reversible by AVR and the consequent changes in LV loading conditions. This study was a prospective, sequential evaluation of left ventricular function using both non-invasive and invasive techniques in symptomatic and asymptomatic patients with isolated chronic, severe (4+) AR at cardiac catheterisation. The aims of the study were to (I) Identify differences in the clinical, echocardiographic, resting and exercise haemodynamic and I radionuclide measures of left ventricular function in symptomatic and asymptomatic patients with chronic severe A.R. with particular reference to the incidence of presymptomatic development of left ventricular dysfunction. (II) Critically evaluate the role of exercise stress (both isotonic and isometric) in the assessment of patients with chronic severe A.R. (III) Evaluate the influence of time (sequential studies) on the haemodynamic burden in asymptomatic patients. (IV) Study the impact of successful aortic valve replacement on the reversibility of abnormal pre-operative LV function in an attempt to predict which patients would benefit from this therapeutic intervention and whether operation for symptoms alone is the correct clinical practice.

Aortic stenosis is a life-threatening valvular heart disease. At the onset of symptoms, a patient’s prognosis becomes poor and the risk of death rapidly increases. Aortic valve replacement surgery remains the gold standard in treatment for aortic stenosis. However, in the total population of patients with severe aortic stenosis, about one third are deemed inoperable due to their high surgical risk. In recent years, the development of transcatheter aortic valve implantation (TAVI), a non-invasive heart valve replacement procedure brought hope for the elderly, high-risk and inoperable aortic stenosis patient population pool. A literature review was performed to examine the safety, efficacy and effectiveness evidence for transcatheter aortic valve treatment option. The results showed that TAVI is a safe treatment option, however the effectiveness for the whole patient population is unknown. The adoption of this alternative treatment option is certainly coupled with multiple dimension of impact from a public health perspective. It remains inconclusive whether TAVI is an effective treatment option to be adopted. / published_or_final_version / Public Health / Master / Master of Public Health

Aneurysms of the aortic root and ascending aorta often require surgical correction. Currently, two common alternatives exist: The Bentall procedure has traditionally been used successfully for many decades, utilising an aortic valve prosthesis to replace the aortic valve and a conduit to replace the aneurysmic aorta. The more recent approach has been to reimplant suitable aortic valves utilising a dacron graft as well as replacing the affected aortic segment. The most widely used technique thereof is the David procedure. The decision for either operation depends greatly on patient circumstance and preference, as well as the recommendation of the operating surgeon. This is due to the associated features and disadvantages of the procedures at hand that make the careful choice of technique vital. Previous research has shown promising results for the equivalence, if not superiority, of the David procedure in certain patient groups, as well as in comparison to the Bentall procedure overall. At the same time, there are concerns about the David approach regarding the durability, perioperative risk, and long-term outcomes, among others. Regardless, avoidance of anticoagulation postoperatively has made it an attractive choice for patients who do not want to or cannot receive anticoagulants. While the David procedure has shown these beneficial properties, it has been widely limited to cases where the aortic valve is deemed suitable. Over the last decade, several studies have assessed the usage of David procedure for cases that did not previously seem to be a fit, such as patients with bicuspid aortic valves, who are now deemed suitable. With the David procedure becoming more widely applied and the application of the operation being extended, the question arises, whether the Bentall procedure remains the gold standard for correction of aortic root pathology. Several studies have been conducted over the years, but because cases are comparatively few, evidence is still lacking. For this, we conducted a study into the short and long-term outcomes of patients who underwent either Bentall or David procedures at the Leipzig Heart Centre between 2000 and 2015. Pre-operative, operative and post-operative data was gathered, and a follow-up was conducted through questionnaires, reports by physicians and telephone surveys. Statistical analysis was performed to gain data on perioperative mortality, adverse outcomes and long-term effects, such as bleeding incidents, reoperation rates and overall mortality, among others. This resulted in two publications that form the basis of this dissertation: Publication A sought to compare the outcomes of David cases with those who received correction with the Bentall procedure, including both mechanical valve prostheses and biological replacements. Publication B compared David cases to biological Bentall replacements. This subgroup analysis was done because both procedures avoid long term-anticoagulation. We found that both the David and Bentall operation had excellent early and long-term results, with comparable outcomes for early and late mortality among others. Furthermore, we did not see an increased risk of reoperation for the David procedure during our observational period. We recorded a higher incidence of serious bleeding events in the Bentall group (Publication A). The comparison of bioprosthetic Bentall cases to the David group showed equivalent outcomes for both procedures without significant difference in endpoints. While patient preferences and circumstances should still be considered, our investigations showed clear advantages for the David procedure in the analysed patient group. We concluded that the David operation is the preferable operation in patients with appropriate pathoanatomy, because long-term complications associated with prosthetic heart valves remain a major concern and it has shown to mitigate said complications.

In the United States alone, there are nearly 49,000 aortic valvular repairs or replacements each year, and this number is expected to rise. Unlike atherosclerosis, the molecular mechanisms contributing to this side-dependent disease development are limited, which contributes to the lack of therapeutic treatments. Once clinically manifested, options for treatment are limited to valvular replacement or repair. Therefore understanding the mechanobiology and cellular responses in aortic valves may provide important information for disease development and possible biomarkers or therapeutic treatments. Aortic valve disease occurs on one side of the valvular leaflet. The fibrosa side, which faces the aorta, is prone to disease development, while the ventricularis remains relatively unaffected. The hemodynamics is hypothesized to play a role in side dependent disease formation. The fibrosa endothelium is exposed to oscillatory flow while the ventricularis endothelium is exposed to a pulsatile unidirectional flow. Previous work by our group has shown that bone morphogenic protein-4 is a mechanosensitve inflammatory cytokine in the vasculature. In the following study, we proposed that mechanosensitive bone morphogenic proteins play a role in side specific aortic valve disease. Recently, the bone morphogenic proteins (BMPs) have been found in calcified human aortic valves. Furthermore, BMP-4 in vascular endothelial cells is increased by oscillatory shear stress. However, the role of the BMPs in aortic valve endothelial cells and their contribution to aortic valve calcification remains unstudied. Therefore, the overall objective of this dissertation was to investigate how disease and hemodynamics affects the BMP pathway and inflammation in human aortic valvular endothelial cells. By understanding how the bone morphogenic proteins are regulated and what roles they play in aortic valve disease, we will have better insight into endothelial cell regulation and contribution in aortic valve pathology. The central hypothesis of this project was that oscillatory flow conditions on the fibrosa side of the aortic valve stimulate endothelial cells to produce BMP-4, which then activates an inflammatory response leading to accumulation of inflammatory cells, calcification, and ultimately valve impairment. This hypothesis was tested through three specific aims using calcified human aortic valves, non-calcified human aortic valves, and side-specific human aortic valve endothelial cells. We first worked to establish the importance of the BMPs in the aortic valvular endothelium by looking at two populations of aortic valves: 1) calcified human aortic valves were obtained from patients undergoing valve replacement, and 2) non-calcified valves were obtained from recipient hearts of patients undergoing heart transplantation. Using immunohistochemical techniques, we examined the BMPs, BMP antagonists, and SMADs. Surprisingly, we identified that the ventricularis endothelium had higher BMP expression in both calcified and non-calcified human aortic valves. Furthermore, no disease-dependent BMP expression was detected. Next, we examined the BMP antagonists and found that there was robust BMP antagonist expression in the ventricularis endothelium and very low expression in the fibrosa endothelium. Finally, to determine if the BMP pathway was activated, we stained for the canonical BMP signaling molecule phosphorylated-SMAD 1/5/8 and found increased staining in the endothelium of calcified human aortic valves. Furthermore, a significant increase in SMAD 1/5/8 phosphorylation was seen in the endothelium of calcified fibrosa when compared to the non-calcified fibrosa. Finally, inhibitory SMAD 6 was significantly increased in the ventricularis endothelium of non-calcified human aortic valves. These findings suggest that preferential activation of BMP pathways, controlled by the balance between the BMPs and their inhibitors, play an important role in side-dependent calcification of human AVs. We next wanted to examine the role of shear stress in BMP regulation, but before doing so, we needed to examine the endothelial response to fluid shear stress to validate the phenotype of our isolated human aortic valve endothelial cells. KLF2 and eNOS expression in vascular endothelial cells has been shown to be increased by laminar flow and to have anti-inflammatory effects by decreasing VCAM-1 levels. Conversely, oscillatory shear stress has been shown to increase NF-kappa B translocation and increase ICAM-1 and E-selectin. We found laminar shear stress causes human aortic valve endothelial cells align parallel to flow and have robust increases of KLF2 and eNOS and decreases in VCAM-1 levels; however, laminar shear-treated cells had similar levels of NF-kappa B activation as oscillatory treated cells while ICAM-1 and E-selectin was not affected by shear stress. In contrast, oscillatory shear had higher levels of monocytes bound which may be due to eNOS's protective effects under laminar shear and robust VCAM-1 expression in oscillatory shear. These studies suggest differential regulation of human aortic valvular endothelial cells than published reports on human aortic endothelial cells which adds to the growing evidence that valvular endothelial cells are phenotypically different than vascular endothelial cells. After verifying the shear response of our endothelial cells, we next determined the shear response of the BMPs and BMP antagonists and described BMPs' effect on inflammation. Previously, BMP-4 has been shown in vitro and in vivo to be increased in endothelial cells exposed to oscillatory flow, while the closely-related BMP-2 has not been shown to be shear sensitive. In this study we have found that BMPs -2 and -4 are shear sensitive while BMP-6 is not. Furthermore, we have found that follistatin is decreased by laminar flow only in the ventricularis, while MGP1 is decreased in the fibrosa valvular endothelial cells under both oscillatory and laminar flow. Finally, incubation with noggin did not affect monocyte adhesion after shear, suggesting differential regulation of inflammation in human aortic valvular endothelial cells. By addressing the specific aims of this project, we have investigate disease- and side-dependent valvular endothelial BMP expression in vivo, shear regulation of valvular endothelial inflammation in vitro, and shear regulation of valvular endothelial BMP expression in vitro. Our results suggest that the BMP pathway is playing a role in side specific aortic valve disease development; however, regulation of the BMPs does not appear to be shear regulated in vivo. Other factors that may be affecting BMP production include including pulsatile pressures, bending stresses, cyclic stretch, and humeral stimuli present in the blood of the patients. However, in vitro we have found BMPs -2 and -4 to be shear-regulated in human aortic valvular endothelial cells. Shear-induced inflammation in human aortic valve endothelial cells seems to be VCAM-1-dependent, and BMP-independent. Finally, by identifying factors that are modulated in calcific- and shear-dependent processes, new targets for the early detection of aortic valve disease can be determined and new therapeutics to slow or stop the progression of aortic valve disease may be discovered.

Die vorliegende Arbeit untersucht, inwieweit sich minimalinvasive Zugangswege gegenüber der medianen Sternotomie bei isolierten Aortenklappeneingriffen positiv auf die postoperative Schultergelenks- und Schultergürtelmobilität auswirken. Die Beurteilung erfolgt dabei postoperativ primär durch Anwendung des Constant-Murley-Score (CMS). Weiterhin werden der Disabilities of the Arm, Shoulder and Hand Fragebogen (DASH) sowie Untersuchungen von Gelenkbeweglichkeiten und Muskelfunktion (Verlängerbarkeit und Kraft) durchgeführt. Bis dato existiert kein gesondertes Testinstrument zur Beurteilung der funktionellen Einheit Schultergürtel / Schultergelenk in der Herzchirurgie. Existierende Untersuchungen deuten jedoch darauf hin, dass größere, insbesondere herzchirurgische Eingriffe sowohl lokal als auch systemisch Einfluss auf die Funktionalität von Muskulatur haben. Sei es durch direkte Affektion oder aufgrund postoperativer Immobilisation. Für den DASH gibt es ebenfalls bereits veröffentlichte Ergebnisse, die eine Verschlechterung der Funktion der oberen Extremität nach einer Herz-OP zeigen. Bei Betrachtung der Ergebnisse des CMS in dieser Arbeit haben die Patienten nach minimalinvasivem Aortenklappenersatz sowohl rechts (78,9±10,4 minimalinvasiv vs. 60,8±8,6 konventionell, p<0,01) als auch links (80,0±8,0 minimalinvasiv vs. 61,8±5,6 konventionell, p<0,01) eine signifikant bessere Schulterfunktion als nach medianer Sternotomie. Auch die Ergebnisse des DASH zeigen nach minimalinvasiver Operation eine signifikant bessere Funktion der oberen Extremität (40,9±13,6 minimalinvasiv vs. 62,5±22,1 konventionell, p=0,02). Die Beweglichkeitsuntersuchungen lassen bessere postoperative Ergebnisse bei den minimalinvasiv Operierten, insbesondere für nach vorne gerichteten Bewegungen, wie der Protraktion links (20±2,9° minimalinvasiv vs. 13±5,7° konventionell, p<0,01) und der horizontalen Adduktion rechts (115±9,8° minimalinvasiv vs. 103±9,7° konventionell, p=0,03), erkennen. Muskelverlängerbarkeit und -kraft hingegen offenbaren in diesem Setting keine signifikanten Unterschiede zwischen minimalinvasiver und konventioneller Gruppe. Ein Grund dafür kann unter anderem das lange Untersuchungsintervall postoperativ sein. Aufgrund der kleinen Anzahl eingeschlossener Patienten ist die statistische Aussagekraft dieser Arbeit eingeschränkt. Insgesamt wird jedoch die Annahme unterstützt, dass minimalinvasive Verfahren in der Aortenklappenchirurgie eine bessere Funktion der Schulter postoperativ ermöglichen, als dies durch die mediane Sternotomie der Fall ist. Diese bessere Funktion lässt sich durch etablierte Instrumente wie den Constant-Murley-Score sowie den DASH-Fragebogen darstellen.

Este estudo avalia mortalidade, eventos hemorrágicos e reoperação em pacientes submetidos à cirurgia para troca valvar aórtica utilizando substituto biológico ou mecânico, com poder de relevância na seleção do tipo da prótese. Foram selecionados, randomicamente, 301 pacientes submetidos à cirurgia para troca valvar aórtica entre 1990 e 2005, com seguimento máximo de 20 anos. A sobrevivência em 5, 10 e 15 anos após cirurgia utilizando substituto mecânico foi de 83,9%, 75,4% e 60,2% e, para substituto biológico, foi de 89,3%, 70,4% e 58,4%, respectivamente (p=0,939). Os fatores associados com o óbito foram: idade, obesidade, doença pulmonar, arritmias, eventos hemorrágicos e insuficiência valvar aórtica. A probabilidade livre de reoperação desses pacientes em 5, 10 e 15 anos após cirurgia utilizando substituto mecânico foi de 97,9%, 95,8% e 95,8% e, para bioprótese, foi de 94,6%, 91,0% e 83,3%, respectivamente (p=0,057). Os fatores associados com reoperação foram: insuficiência renal, endocardite de prótese e idade. A probabilidade livre de eventos hemorrágicos em 5, 10 e 15 anos após cirurgia utilizando substituto mecânico foi de 94,5%, 91,7% e 91,7% e, para bioprótese, foi de 98,6%, 97,8% e 97,8%, respectivamente (p=0,047). Os fatores associados com eventos hemorrágicos foram: insuficiência renal e prótese mecânica. Os autores concluíram que: 1) a mortalidade foi estatisticamente semelhante entre os grupos; 2) as características basais dos pacientes foram os maiores determinantes de mortalidade tardia após a cirurgia; 3) houve uma tendência à reoperação para o grupo com bioprótese; 4) pacientes com prótese mecânica tiveram mais eventos hemorrágicos ao longo do tempo; 5) os dados encontrados no presente estudo são concordantes com a literatura atual. / This paper evaluates mortality, bleeding events and reoperation in patients subjected to surgery for replacement of the aortic valve using a biological or a mechanical substitute, where selection of the type of prosthesis is relevant. Three hundred and one patients who had been subjected to aortic valve replacement surgery between 1990 and 2005, with a maximum follow-up period of 20 years, have been randomly selected. Survival at 5, 10 and 15 years after surgery using a mechanical substitute was 83.9%, 75.4% and 60.2% and, for a biological substitute, was 89.3%, 70.4% and 58.4%, respectively (p=0.939). Factors associated with death were: age, obesity, pulmonary disease, arrhythmia, bleeding and aortic valve failure. The probability free of reoperation for these patients at 5, 10 and 15 years after surgery using a mechanical substitute was 97.9%, 95.8% and 95.8% and, for those using bioprostheses, was 94.6%, 91.0% and 83.3%, respectively (p=0.057). Factors associated with reoperation were: renal failure, prosthesis endocarditis and age. The probability free of bleeding events at 5, 10 and 15 years after surgery using the mechanical substitute was 94.5%, 91.7% and 91.7% and, for bioprostheses, was 98.6%, 97.8% and 97.8%, respectively (p=0.047). Factors associated with bleeding events were: renal failure and mechanical prostheses. The authors have concluded that: 1) mortality was statistically similar in the groups; 2) patient characteristics at baseline were a major determinant of late mortality after surgery; 3) there was a tendency toward reoperation in the bioprostheses group; 4) patients using a mechanical prosthesis had more bleeding events as time passed; 5) the data presented in this paper is in accordance with current literature.

Este estudo avalia mortalidade, eventos hemorrágicos e reoperação em pacientes submetidos à cirurgia para troca valvar aórtica utilizando substituto biológico ou mecânico, com poder de relevância na seleção do tipo da prótese. Foram selecionados, randomicamente, 301 pacientes submetidos à cirurgia para troca valvar aórtica entre 1990 e 2005, com seguimento máximo de 20 anos. A sobrevivência em 5, 10 e 15 anos após cirurgia utilizando substituto mecânico foi de 83,9%, 75,4% e 60,2% e, para substituto biológico, foi de 89,3%, 70,4% e 58,4%, respectivamente (p=0,939). Os fatores associados com o óbito foram: idade, obesidade, doença pulmonar, arritmias, eventos hemorrágicos e insuficiência valvar aórtica. A probabilidade livre de reoperação desses pacientes em 5, 10 e 15 anos após cirurgia utilizando substituto mecânico foi de 97,9%, 95,8% e 95,8% e, para bioprótese, foi de 94,6%, 91,0% e 83,3%, respectivamente (p=0,057). Os fatores associados com reoperação foram: insuficiência renal, endocardite de prótese e idade. A probabilidade livre de eventos hemorrágicos em 5, 10 e 15 anos após cirurgia utilizando substituto mecânico foi de 94,5%, 91,7% e 91,7% e, para bioprótese, foi de 98,6%, 97,8% e 97,8%, respectivamente (p=0,047). Os fatores associados com eventos hemorrágicos foram: insuficiência renal e prótese mecânica. Os autores concluíram que: 1) a mortalidade foi estatisticamente semelhante entre os grupos; 2) as características basais dos pacientes foram os maiores determinantes de mortalidade tardia após a cirurgia; 3) houve uma tendência à reoperação para o grupo com bioprótese; 4) pacientes com prótese mecânica tiveram mais eventos hemorrágicos ao longo do tempo; 5) os dados encontrados no presente estudo são concordantes com a literatura atual. / This paper evaluates mortality, bleeding events and reoperation in patients subjected to surgery for replacement of the aortic valve using a biological or a mechanical substitute, where selection of the type of prosthesis is relevant. Three hundred and one patients who had been subjected to aortic valve replacement surgery between 1990 and 2005, with a maximum follow-up period of 20 years, have been randomly selected. Survival at 5, 10 and 15 years after surgery using a mechanical substitute was 83.9%, 75.4% and 60.2% and, for a biological substitute, was 89.3%, 70.4% and 58.4%, respectively (p=0.939). Factors associated with death were: age, obesity, pulmonary disease, arrhythmia, bleeding and aortic valve failure. The probability free of reoperation for these patients at 5, 10 and 15 years after surgery using a mechanical substitute was 97.9%, 95.8% and 95.8% and, for those using bioprostheses, was 94.6%, 91.0% and 83.3%, respectively (p=0.057). Factors associated with reoperation were: renal failure, prosthesis endocarditis and age. The probability free of bleeding events at 5, 10 and 15 years after surgery using the mechanical substitute was 94.5%, 91.7% and 91.7% and, for bioprostheses, was 98.6%, 97.8% and 97.8%, respectively (p=0.047). Factors associated with bleeding events were: renal failure and mechanical prostheses. The authors have concluded that: 1) mortality was statistically similar in the groups; 2) patient characteristics at baseline were a major determinant of late mortality after surgery; 3) there was a tendency toward reoperation in the bioprostheses group; 4) patients using a mechanical prosthesis had more bleeding events as time passed; 5) the data presented in this paper is in accordance with current literature.

Este estudo avalia mortalidade, eventos hemorrágicos e reoperação em pacientes submetidos à cirurgia para troca valvar aórtica utilizando substituto biológico ou mecânico, com poder de relevância na seleção do tipo da prótese. Foram selecionados, randomicamente, 301 pacientes submetidos à cirurgia para troca valvar aórtica entre 1990 e 2005, com seguimento máximo de 20 anos. A sobrevivência em 5, 10 e 15 anos após cirurgia utilizando substituto mecânico foi de 83,9%, 75,4% e 60,2% e, para substituto biológico, foi de 89,3%, 70,4% e 58,4%, respectivamente (p=0,939). Os fatores associados com o óbito foram: idade, obesidade, doença pulmonar, arritmias, eventos hemorrágicos e insuficiência valvar aórtica. A probabilidade livre de reoperação desses pacientes em 5, 10 e 15 anos após cirurgia utilizando substituto mecânico foi de 97,9%, 95,8% e 95,8% e, para bioprótese, foi de 94,6%, 91,0% e 83,3%, respectivamente (p=0,057). Os fatores associados com reoperação foram: insuficiência renal, endocardite de prótese e idade. A probabilidade livre de eventos hemorrágicos em 5, 10 e 15 anos após cirurgia utilizando substituto mecânico foi de 94,5%, 91,7% e 91,7% e, para bioprótese, foi de 98,6%, 97,8% e 97,8%, respectivamente (p=0,047). Os fatores associados com eventos hemorrágicos foram: insuficiência renal e prótese mecânica. Os autores concluíram que: 1) a mortalidade foi estatisticamente semelhante entre os grupos; 2) as características basais dos pacientes foram os maiores determinantes de mortalidade tardia após a cirurgia; 3) houve uma tendência à reoperação para o grupo com bioprótese; 4) pacientes com prótese mecânica tiveram mais eventos hemorrágicos ao longo do tempo; 5) os dados encontrados no presente estudo são concordantes com a literatura atual. / This paper evaluates mortality, bleeding events and reoperation in patients subjected to surgery for replacement of the aortic valve using a biological or a mechanical substitute, where selection of the type of prosthesis is relevant. Three hundred and one patients who had been subjected to aortic valve replacement surgery between 1990 and 2005, with a maximum follow-up period of 20 years, have been randomly selected. Survival at 5, 10 and 15 years after surgery using a mechanical substitute was 83.9%, 75.4% and 60.2% and, for a biological substitute, was 89.3%, 70.4% and 58.4%, respectively (p=0.939). Factors associated with death were: age, obesity, pulmonary disease, arrhythmia, bleeding and aortic valve failure. The probability free of reoperation for these patients at 5, 10 and 15 years after surgery using a mechanical substitute was 97.9%, 95.8% and 95.8% and, for those using bioprostheses, was 94.6%, 91.0% and 83.3%, respectively (p=0.057). Factors associated with reoperation were: renal failure, prosthesis endocarditis and age. The probability free of bleeding events at 5, 10 and 15 years after surgery using the mechanical substitute was 94.5%, 91.7% and 91.7% and, for bioprostheses, was 98.6%, 97.8% and 97.8%, respectively (p=0.047). Factors associated with bleeding events were: renal failure and mechanical prostheses. The authors have concluded that: 1) mortality was statistically similar in the groups; 2) patient characteristics at baseline were a major determinant of late mortality after surgery; 3) there was a tendency toward reoperation in the bioprostheses group; 4) patients using a mechanical prosthesis had more bleeding events as time passed; 5) the data presented in this paper is in accordance with current literature.