Mechanical Versus Bioprosthetic Aortic Valve Replacement in Middle-Aged Adults: A Systematic Review and Meta-Analysis Dong Fang Zhao, BA, Michael Seco,

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Mechanical Versus Bioprosthetic Aortic Valve Replacement in Middle-Aged Adults: A Systematic Review and Meta-Analysis Dong Fang Zhao, BA, Michael Seco, BMedSc, MBBS, James J. Wu, BMusStudies, James B. Edelman, MBBS(Hons), PhD, Michael K. Wilson, MBBS, Michael P. Vallely, MBBS, PhD, Michael J. Byrom, MBChB, PhD, Paul G. Bannon, MBBS, PhD The Annals of Thoracic Surgery Volume 102, Issue 1, Pages 315-327 (July 2016) DOI: 10.1016/j.athoracsur.2015.10.092 Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart of search strategy. The Annals of Thoracic Surgery 2016 102, 315-327DOI: (10.1016/j.athoracsur.2015.10.092) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Forest plot of overall long-term mortality risk associated with bioprosthetic valve (BV) compared with mechanical valve (MV) after surgical aortic valve replacement. (CI = confidence interval; IV = inverse variance; Random = random effects model.) The Annals of Thoracic Surgery 2016 102, 315-327DOI: (10.1016/j.athoracsur.2015.10.092) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Forest plot of overall long-term risk of developing valve-related morbidity, including major adverse prosthesis-related event (MAPE), anticoagulant-related events, major bleeding, reoperation, and structural valve degeneration (SVD), with bioprosthetic valve (BV) compared with mechanical valve (MV) after surgical aortic valve replacement. (CI = confidence interval; IV = inverse variance; Random = random effects model.) The Annals of Thoracic Surgery 2016 102, 315-327DOI: (10.1016/j.athoracsur.2015.10.092) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Overall Kaplan-Meier survival curves based on reconstructed individual study data. (A) Aggregated survival curves for bioprosthetic valve (BV [blue line]) compared with mechanical valve (MV [red line]). (B) Long-term survival of the BV cohort after aortic valve replacement, reconstructed from 4,072 patients. (C) Long-term survival of the MV cohort after aortic valve replacement, reconstructed from 4,589 patients. (CI = confidence interval; HR = hazard ratio.) The Annals of Thoracic Surgery 2016 102, 315-327DOI: (10.1016/j.athoracsur.2015.10.092) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Overall Kaplan-Meier survival curves based on reconstructed individual study data. Aggregated survival curves for bioprosthetic valve (blue lines) compared with mechanical valve (red lines) after aortic valve replacement in patients aged (A) 50 to 70 years; (B) 60 to 70 years; and (C) less than 65 years. (CI = confidence interval; HR = hazard ratio.) The Annals of Thoracic Surgery 2016 102, 315-327DOI: (10.1016/j.athoracsur.2015.10.092) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Overall Kaplan-Meier survival curves based on reconstructed individual study data. Aggregated survival curves for (A) bioprosthetic valve compared with (B) mechanical valve after aortic valve replacement in patients aged 50 to 70 years (green lines), 60 to 70 years (blue lines), and less than 65 years (red lines). The Annals of Thoracic Surgery 2016 102, 315-327DOI: (10.1016/j.athoracsur.2015.10.092) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions