• Aortic Diseases

In older adults with severe aortic valve disease, aortic valve replacement (AVR) with a bioprosthetic valve has survival advantage over a mechanical valve because there is no need for warfarin anticoagulation and repeat intervention is unlikely given the balance between bioprosthetic valve durability and longevity in these patients. The proven value of transcatheter aortic valve implantation (TAVI) in older adults, and in those at high risk of surgical intervention, further supports use of a bioprosthetic valve in these patients. However, valve durability is inversely proportional to age; thus, younger patients not only live longer but bioprosthetic valves deteriorate more quickly. Thus, the optimal intervention for younger adults (age 18–60 years) with aortic valve disease remains unclear.

In this issue of Heart, Stoica and colleagues1 present a consensus approach based on appropriateness ratings for a list of 75 clinical scenarios in younger adults, using a Likert scale, before and after an in-person meeting of 12 clinicians, with support from a patient advisory group. As a percentage of all clinical scenarios, appropriate interventions were a mechanical AVR in 57%, bioprosthetic AVR in 68%, the Ross (pulmonic autograft) procedure in 39% and the aortic valve neocuspidisation (Ozaki) procedure in 3% of adults aged 18 to 60 years. TAVI was considered appropriate in only 7%, specifically in scenarios characterised by frailty, prohibitive surgery risk or very limited life expectancy. This consensus approach allows a nuanced exploration of the many factors involved in clinical decision making, including anatomic details, clinical presentation, cardiac and non-cardiac comorbidities, concurrent treatments and lifestyle considerations. However, this approach …