What is the best alternative if the aortic valve cannot be repaired?

Aortic valve repair is the preferred treatment for aortic insufficiency. When the valve is not repairable, options for valve substitutes include bioprosthetic valves, mechanical valves, aortic valve homografts and a pulmonary autograft (Ross procedure). The choice of an aortic valve substitute must be made judiciously, as each of these options has benefits and drawbacks that significantly impact long-term prognosis and quality of life. Current guidelines recommend the use of a mechanical valve in patients less than 50 years and a bioprosthetic valve in patients more than 70 years (1). Nonetheless, with the advent of transcatheter aortic valve replacement—and the promise of valve-in-valve therapy—bioprosthetic valves are increasingly being implanted in young patients (2). Several contemporary studies have shown that both bioprosthetic and mechanical valves are associated with excess mortality when implanted in young and middle-aged adults. All the more, this excess mortality is inversely proportional to patient age at the time of surgery (i.e., the youngest patients have the largest excess mortality) (3,4)