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Management Challenges in Patients Younger Than 65 Years With Severe Aortic Valve DiseaseA Review

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Importance  The management of aortic valve disease, including aortic stenosis and aortic regurgitation (AR), in younger adult patients (age <65 years) is complex, and the optimal strategy is often unclear, contingent on multiple anatomic and holistic factors.

Observations  Traditional surgical approaches carry significant considerations, including compulsory lifelong anticoagulation for patients who receive a mechanical aortic valve replacement (AVR) and the risk of structural valvular deterioration and need for subsequent valve intervention in those who receive a bioprosthetic AVR. These factors are magnified in young adults who are considering pregnancy, for whom issues of anticoagulation and valve longevity are heightened. The Ross procedure has emerged as a promising alternative; however, its adoption is limited to highly specialized centers. Valve repair is an option for selected patients with AR. These treatment options offer varying degrees of durability and are associated with different risks and complications, especially for younger adult patients. Patient-centered care from a multidisciplinary valve team allows for discussion of the optimal timing of intervention and the advantages and disadvantages of the various treatment options.

Conclusions and Relevance  The management of severe aortic valve disease in adults younger than 65 years is complex, and there are numerous considerations with each management decision. While mechanical AVR and bioprosthetic AVR have historically been the standards of care, other options are emerging for selected patients but are not yet generalizable beyond specialized surgical centers. A detailed discussion by members of the multidisciplinary heart team and the patient is an integral part of the shared decision-making process.

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Article Information

Accepted for Publication: October 26, 2022.

Published Online: December 21, 2022. doi:10.1001/jamacardio.2022.4770

Corresponding Author: Robert O. Bonow, MD, MS, Northwestern University Feinberg School of Medicine, 676 N St Clair St, Ste 600, Chicago, IL 60611 (r-bonow@northwestern.edu).

Conflict of Interest Disclosures: Dr Malaisrie reported receiving grant support and serving as consultant for Artivion, Terumo Aortic, Edwards Lifesciences, and Medtronic outside the submitted work. Dr McCarthy reported royalties and/or honorarium from Edwards Lifesciences, Medtronic, and Atricure; serving as a member of the advisory board for Egnite; and serving as the principal investigator of the REPAIR MR trial outside the submitted work. Dr Davidson reported receiving grant support and serving as a consultant for Edwards Lifesciences. No other disclosures were reported.

Disclaimer: Dr Bonow is Editor of JAMA Cardiology, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.

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