This poll asked readers to consider the appropriate aortic valve intervention for a young patient expected to live an additional 20 years who is at low risk for mortality and morbidity from surgical aortic valve replacement (SAVR) but who may be at risk for patient-prosthesis mismatch in the setting of obesity and has slightly unfavorable anatomy for transcatheter aortic valve replacement (TAVR).

A total of 42% of respondents opted for mechanical SAVR while 11% opted for bioprosthetic SAVR. The frequency of SAVR with a bioprosthesis has increased over time, partly related to patients' increasing unwillingness to take warfarin and also more recently related to the option of future valve-in-valve (ViV) TAVR. In a retrospective multi-center study, Goldstone et al. found no significant difference in mortality when comparing bioprosthetic and mechanical aortic valve replacement in patients 55-64 years of age.¹ The mechanical SAVR group had higher cumulative incidence of bleeding complications, and the hazard for reoperation was higher in the bioprosthetic SAVR group.¹ SAVR without annular enlargement in this patient with smaller annular diameter and larger body surface area may result in patient-prosthesis mismatch or earlier re-operation for structural valve degeneration.

A total of 22% chose annular enlargement with bioprosthetic SAVR (likely with a stented rather than stentless valve in mind), looking to future ViV TAVR at the time of structural valve degeneration of the surgical valve. For a 55-year-old patient with a bioprosthetic surgical valve, re-operation would be anticipated in her late 60s to early 70s. In patients who underwent ViV TAVR, smaller failed bioprosthesis was associated with worse survival at 8 years compared to those with a larger failed bioprosthesis.² Newer techniques for annular enlargement (e.g., "Y" incision/rectangular patch enlargement as described by Yang and Naeem³) may allow for upsizing by 2-3 sizes of the surgical bioprosthetic valve. In this patient, that may be the difference between a 21-mm prosthesis and a 25- or 27-mm prosthesis. TAVR valve durability of 5 to 10 years⁴ will reasonably get this patient to her late 70s or early 80s.

A total of 14% opted for upfront TAVR, perhaps anticipating a series of procedures over the patient's lifetime that includes TAVR, SAVR, redo SAVR, ViV TAVR after SAVR, and ViV TAVR after TAVR (not necessarily in that order). The appropriate sequence that maximizes long-term survival with acceptable mortality has not yet been determined. There are several potential factors that will influence success with a TAVR-first approach, including but not limited to the following:

• Long-term durability of TAVR valves beyond 10 years
• Increased complexity of SAVR after previous TAVR⁵
• Implications of TAVR, SAVR, and ViV procedures in small annuli and prostheses
• Development of native coronary artery disease and future need to access the coronary ostia

Further studies and longitudinal follow-up are needed.

Few chose aortic root replacement (5%) or the Ross procedure (7%). The Ross procedure remains a durable option by experienced surgeons and centers with high volume but a technically complex procedure (both the first operation and any re-operation) that adds long-term management of the pulmonary valve to the patient's course. This is usually considered more for younger patients, especially female patients of child-bearing age, in whom anticoagulation is less than desirable and durability of a bioprosthetic valve is relatively short compared to the anticipated life span.

References

1. Goldstone AB, Chiu P, Baiocchi M, et al. Mechanical or Biologic Prostheses for Aortic-Valve and Mitral-Valve Replacement. N Engl J Med 2017;377:1847-57.
2. Bleiziffer S, Simonato M, Webb JG, et al. Long-term outcomes after transcatheter aortic valve implantation in failed bioprosthetic valves. Eur Heart J 2020;41:2731-42.
3. Yang B, Naeem A. A "Y" Incision/Rectangular Patch to Enlarge the Aortic Annulus by 3 Valve Sizes. Ann Thorac Surg 2021;Mar 5:[Epub ahead of print].
4. Blackman DJ, Saraf S, MacCarthy PA, et al. Long-Term Durability of Transcatheter Aortic Valve Prostheses. J Am Coll Cardiol 2019;73:537-45.
5. Fukuhara S, Brescia AA, Shiomi S, et al. Surgical explantation of transcatheter aortic bioprostheses: Results and clinical implications. J Thorac Cardiovasc Surg 2020;Jan 12:[Epub ahead of print].

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Interventions and Coronary Artery Disease

Keywords: Transcatheter Aortic Valve Replacement, Aortic Valve, Warfarin, Bioprosthesis, Pulmonary Valve, Retrospective Studies, Coronary Artery Disease, Body Surface Area, Follow-Up Studies, Heart Valve Prosthesis, Prosthesis Failure, Surgical Instruments, Obesity, Anticoagulants

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