Treatment strategies for mixed aortic valve disease in nonelderly patients

ABSTRACT

Introduction: Mixed aortic valve disease (MAVD) is defined by simultaneous occurrence of aortic stenosis (AS) and aortic regurgitation (AR). In our review, we focus on treatment options for nonelderly MAVD patients (age<55 years), who suffer from congenital aortic valve disease (unicuspid/bicuspid aortic valves).

Areas covered: A systematic literature search was performed on PubMed and Embase databases using the following terms: mixed aortic valve disease, aortic stenosis/regurgitation, bicuspid/unicuspid aortic valve, mechanical/bioprosthetic aortic valve replacement, TAVR, Ross procedure. After preselection of title and abstracts, two authors (M.S. and E.G.) assessed the methodological quality of the full-text articles prior to final inclusion in the manuscript.

Expert opinion: Currently, no ideal valvular substitutes are available in the treatment of nonelderly MAVD patients. Mechanical valves are associated with a reduced life expectancy due to a combination of prothesis-associated factors, mainly thrombotic and bleeding complications. Bioprostheses degenerate in the second decade and re-operations are inevitable, which also limit life expectancy. Long-term outcomes and durability of transcatheter aortic valve replacement are currently unknown. Finally, only Ross procedure is a therapeutic option with excellent long-term outcomes comparable to the healthy population. However, the Ross procedure has some important drawbacks and should therefore be only performed in expert centers and in well-selected patients.

KEYWORDS:

• Mixed aortic valve disease
• congenital
• Ross procedure
• mechanical aortic valve replacement
• valve-in-valve transcatheter aortic valve replacement

Article highlights

• Due to lacking data about MAVD, an explicit indication for aortic valve surgery remains currently unaddressed. Generally, surgical treatment should be considered based on the symptoms, changes of LV geometry and/or worsening of diastolic LV dysfunction.

• Currently, there are no ideal prosthetic valvular substitutes available in the treatment of nonelderly MAVD patients. Mechanical valves are associated with a reduced survival due to bleeding and thromboembolic complications. Bioprosthetic valves are prone to structural valve degeneration.

• Using native cusp tissue (i.e. Ross procedure), favorable hemodynamics, and excellent long-term outcome are well documented. Therefore, the Ross operation should currently be considered the best option in the young MAVD entity. Though, due to its technical complexity, high-volume centers and appropriately trained Ross surgeons are required.

• In the end, the choice of most appropriate treatment must be tailored to the individual needs of the young patient.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.