Robert Ogden Bonow

In his seminal treatise on aortic stenosis in 1958, Paul Wood, MD, noted that “aortic stenosis is a simple mechanical fault which, if severe enough,

Importance The management of aortic valve disease, including aortic stenosis and aortic regurgitation (AR), in younger adult patients (age <65 years) is complex, and the optimal strategy is often unclear, contingent on multiple anatomic and holistic factors. Observations Traditional surgical approaches carry significant considerations, including compulsory lifelong anticoagulation for patients who receive a mechanical aortic valve replacement (AVR) and the risk of structural valvular deterioration and need for subsequent valve intervention in those who receive a bioprosthetic AVR. These factors are magnified in young adults who are considering pregnancy, for whom issues of anticoagulation and valve longevity are heightened. The Ross procedure has emerged as a promising alternative; however, its adoption is limited to highly specialized centers. Valve repair is an option for selected patients with AR. These treatment options offer varying degrees of durability and are associated with different risks and complications, especially for younger adult patients. Patient-centered care from a multidisciplinary valve team allows for discussion of the optimal timing of intervention and the advantages and disadvantages of the various treatment options. Conclusions and Relevance The management of severe aortic valve disease in adults younger than 65 years is complex, and there are numerous considerations with each management decision. While mechanical AVR and bioprosthetic AVR have historically been the standards of care, other options are emerging for selected patients but are not yet generalizable beyond specialized surgical centers. A detailed discussion by members of the multidisciplinary heart team and the patient is an integral part of the shared decision-making process.

Left ventricular (LV) remodeling in response to the volume overload imposed by chronic severe aortic regurgitation creates a dilemma for cardiologists in the treatment of asymptomatic patients. Compensatory increases in LV volume allow maintenance of LV systolic function and normal forward output, but determining the threshold of LV dilation beyond which irreversible myocardial damage is likely to develop remains an inexact science. If timed right, aortic valve replacement results in normalization of LV size and function, but there is a risk that delaying too long can lead to progressive LV dysfunction and chronic heart failure after otherwise successful aortic valve replacement. On the other hand, early surgery in asymptomatic patients places them at risk of anticoagulation-related complications associated with a mechanical prosthesis or structural valve deterioration with a bioprosthesis when they might have done well for many years with their native valve.

Article Abstract Resurgence of the Ross procedure Robert O. Bonow

There is no perfect prosthetic valve substitute for young and middle-aged patients requiring aortic valve replacement (AVR). The long-term risks of anticoagulation with a mechanical prosthesis must be weighed against the risks of structural valve deterioration of a bioprosthetic valve. In patients aged 20 to 40 years, the decision almost always leads to the selection of a mechanical valve and lifelong anticoagulation. Unfortunately, aortic valve repair is an option for only a small number of patients who are highly selected.

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