Transcatheter aortic valve replacement (TAVR) has not been systematically studied as an alternative to surgical aortic valve replacement (SAVR) in young (age <65 years), low-risk patients with severe aortic stenosis (AS); and current guidelines recommend shared decision making. Unanswered questions about TAVR in this population include the safety and effectiveness of TAVR among patients with bicuspid aortic valve (BAV); future coronary access; the durability of TAVR; considerations for surgical explantation of TAVR; management of concomitant conditions including aortopathy, mitral valve disease, and coronary disease (CAD); and the safety and feasibility of future valve-in-valve TAVR.

This state-of-the-art review addresses these questions, and discusses risks and benefits of theoretical treatment strategies in the lifetime management of young patients with severe AS. The following are points to remember:

1. Current evidence on TAVR in low-risk patients: Three randomized clinical trials and three nonrandomized prospective studies have evaluated TAVR in low-risk patients. In these trials, mean patient age was between 68 and 79 years; Sievers type 0 BAV was under-represented; and all-cause mortality was consistently lower with TAVR than SAVR at 30 days, 1 year, and 2 years.
2. BAV: Although randomized trials of TAVR in low-risk patients excluded patients with BAV, results recently were presented for two nonrandomized studies and preliminary results for another registry. Patients with Sievers 0 BAV were under-represented. Significant paravalvular leak was less common than in earlier trials involving earlier-generation TAVR devices, but stroke risk was higher than that seen after TAVR for trileaflet AS.
3. Coronary access after TAVR: Coronary artery access after TAVR is of increased concern among younger patients who might develop future coronary disease; access can be impeded by obstruction from the displaced native aortic valve leaflets, the TAVR stent, or TAVR suture posts. Certain TAVR orientations and newer devices that allow commissural alignment might help facilitate future coronary access after TAVR.
4. Durability after TAVR: Data on TAVR durability are less extensive than for bioprosthetic SAVR durability. However, available data so far do not suggest early TAVR degeneration, and might suggest that freedom from structural valve degeneration is at least as good for TAVR as for SAVR.
5. Risk for coronary obstruction with TAVR-in-TAVR: Coronary obstruction is a risk during valve-in-valve TAVR, and the risk might be higher following self-expanding TAVR owing to the supra-annular leaflet position. This should be considered if TAVR is offered to younger patients who might need multiple subsequent procedures during their lifetime.
6. Surgical explantation of TAVR: Surgical explantation of a TAVR can be technically challenging, especially if the valve has been in place for several years. Complex aortic root and ascending aorta reconstruction often are required, especially in the setting of a self-expanding TAVR. The authors suggest that explantation procedures should be performed at experienced aortic centers.
7. Concomitant pathology: Current guidelines recommend SAVR as the preferred treatment for patients with BAV and aorta diameter >4.5 cm, patients with multivessel CAD with high SYNTAX score or left main disease, or patients with severe mitral valve degeneration. The authors recommend a multidisciplinary heart team approach to decision making for young patients with AS, especially when concomitant pathology does not meet guideline criteria for surgical intervention.
8. Lifetime management of severe AS in young patients: Young patients with severe AS may require multiple lifetime interventions. The authors discuss the relative anticipated risks and benefits of three scenarios: initial SAVR followed by two TAVR-in-SAVR procedures (SAVR-TAVR-TAVR), TAVR followed by SAVR followed by TAVR-in-SAVR (TAVR-SAVR-TAVR), and TAVR followed by two TAVR-in-TAVR procedures (TAVR-TAVR-TAVR). The authors recommend tailoring strategies to individual patient anatomy, and lifetime priorities and expectations; along with discussion of newer surgical approaches (including rapid-deployment valves, resilient valves, and mechanical SAVR with lower-intensity anticoagulation requirements).

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Coronary Artery Disease, Interventions and Structural Heart Disease, Mitral Regurgitation

Keywords: Aortic Valve Stenosis, Cardiac Surgical Procedures, Coronary Artery Disease, Heart Valve Diseases, Heart Valve Prosthesis, Mitral Valve Insufficiency, Risk Assessment, Secondary Prevention, Stents, Stroke, Transcatheter Aortic Valve Replacement

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