Bioprosthetic Aortic Valve Replacement in the Young

It has sometimes been observed that if there are many solutions to a problem, then it is probable that none is exactly correct. Such is the circumstance for young, adult-sized patients facing surgical aortic valve replacement (AVR). For their much younger and smaller counterparts, in whom somatic growth is incomplete, the pulmonary autograft (Ross procedure) is certainly the correct solution.1 At the other end of the age spectrum, for patients >70 years of age, a stented bioprosthesis is virtually always the best choice unless high surgical risk would favor transcatheter AVR.2 For patients <60 years of age, a mechanical prosthesis is appropriate, although current American College of Cardiology/American Heart Association guidelines of the management of patients with valvular heart disease include the following hedge: “A bioprosthesis is recommended in patients of any age for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired.”1 Therein lies the rub: Virtually no young adult desires anticoagulation, and adherence to complex medication regimens in this age group is notoriously poor, rendering the “appropriate” management of vitamin K antagonist (VKA) medication dosage problematic.3 Furthermore, a substantial number of young, adult-sized patients facing AVR are female and may wish to avoid VKA during childbearing years, despite recent reports describing favorable outcomes in women with carefully supervised VKA-based anticoagulation during pregnancy.4 Thus, for young, adult-sized patients (and their parents), the contemplation of which valve is the best, or least worst, choice is based on multiple factors, as shown in the Table, with the final selection based on the combination of risk assessment and lifestyle preferences unique to each young patient. (For the sake of completeness, the Table includes the option of stentless bioprostheses, either allograft or xenograft, although they are rarely used except in unusual forms of …