Surgical options in young adults with aortic valve disease

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Definition of young and middle-aged adult patients

For the purposes of this discussion, young and middle-aged adult patients are defined as those between the ages of 20 and 60 years. The reasons for this range are the generally accepted valve procedure selections for both patients aged < 20 years (Ross pulmonary autograft procedure or aortoventriculoplasty plus allograft for congenital aortic valve stenosis) and those aged > 60 years (biological valves, particularly bovine pericardial, and separate valve plus associated graft repairs of aortic

Procedures

Surgical procedures, durability, risks, and morbidity are summarized below.

Aortic valve disease associated with coronary artery disease

Clearly, one of the most common and important variables in selecting a valve prosthesis is presence of concurrent coronary artery disease. Patients with coronary artery disease and who need concurrent valve replacement have reduced long-term survival.101, 102, 103, 103a

There are 2 relevant arguments that can be debated. The first is that use of a mechanical valve, with warfarin for anticoagulation, may reduce the risk of subsequent reoperation from progression of coronary disease. However,

Comparisons

To better understand which valves are used in young adults in the United States, Fig 22 shows the types of valve used by age group. Data from the STS database show increasing use of allografts, but mechanical valves are still most frequently used. With increasing patient age, biological valves are increasingly used. Centers performing the Ross procedure routinely are few. Selection of the valve procedure thus must be predicated on whether the procedure of choice is available where the patient

Allografts versus pericardial valves

In an evaluation of 629 allograft replacements and 267 pericardial valve replacements with 99% complete follow-up, structural valve deterioration was similar for both valve types, although the absolute deterioration was greater in patients with pericardial valves at only an age < 45 years (see Figures below). This suggests that for middle-aged patients without endocarditis, a pericardial valve is a reasonable option when avoiding anticoagulation is important.

Multi-institutional study of mortality after aortic valve replacement

In a previous study139, 140, 141, 142

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