Aortic Valve Disease Particularly Challenging to Manage Before Age 65: Review

With many more potential years of life left compared with their older counterparts, patients younger than 65 present challenges when it comes to the management of severe aortic valve disease, a review published online recently in JAMA Cardiology highlights.

Choice of procedure and prosthetic valve, intervention timing, the need for lifelong anticoagulation, pregnancy considerations, and other issues take on even greater importance in the shared decision-making process for younger patients with aortic stenosis and/or regurgitation, lead author Jayson Baman, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), and colleagues indicate.

Navigating these choices is complicated, they note, because much of the work that’s been done in terms of randomized trials of treatments for severe aortic valve disease—which include surgical and transcatheter aortic valve replacement, the Ross procedure, and aortic valve repair—has focused on older patients, with limited data on those younger than 65.

“The management of aortic valve disease has been revolutionized over the past couple of decades with the advent of TAVR, as well as the reemergence of the Ross procedure,” Baman told TCTMD. “And when we think about aortic valve disease, many of us consider the management of aortic valve disease in older patients, [many of whom] may only need one valve to last them the rest of their lifetime.”

But there is also a sizeable proportion of patients who are younger and who may have aortic valve disease related to endocarditis or a congenital abnormality like a bicuspid or unicuspid valve, he added.

“The discussions in those patients are a little bit different in the sense that there are more considerations as far as the longevity of the valve itself, as far as weighing the risks and benefits of a mechanical or bioprosthetic valve versus a Ross procedure if it’s available, or aortic valve repair if that’s available,” Baman said.

The key takeaway from looking into this issue is that there “is not a one-size-fits-all approach” and that various factors come into play when making decisions, he said.

Reviewing the Evidence

The reviewers start out by discussing surgical aortic valve replacement (AVR) with either mechanical or bioprosthetic valves, with a table of selected studies comparing the valve types. Mechanical valves are more durable, but come with the need for lifelong anticoagulation. Bioprosthetic valves avoid chronic anticoagulation but break down faster, with the highest rates of structural valve deterioration seen in the youngest patients. Guidelines tend to favor mechanical AVR in younger patients, although anticoagulation—with its heightened bleeding risks and lifestyle limitations—is a major consideration.

Some of these issues are magnified in women of reproductive age, as prior studies have shown that pregnant women with valve disease have worse outcomes with mechanical versus biological prostheses. Moreover, use of vitamin K antagonists has been associated with worse pregnancy outcomes. “A practical alternative approach for young adults who are considering pregnancy is to discuss the use of a bioprosthetic [surgical] AVR at the index procedure,” Baman et al say.

TAVI is a possible option for younger patients, particularly in the presence of other conditions that make it unlikely the patient will outlive the implanted valve, although there are limited randomized data on the procedure in patients younger than 65. Even in the low-risk TAVI trials, the authors note, average patient age was roughly 73 years and follow-up lasted only a few years. In addition, there are no randomized trials evaluating TAVI in patients with non-tricuspid valve morphologies.

“We don’t necessarily think TAVR is a strong option in this population for several different reasons,” Baman said, pointing to the underrepresentation of younger patients in the pivotal trials and the lack of long-term data on the durability of the procedural result. “For many younger patients, many of whom are low surgical risk, we think that a surgical AVR . . . would be more appropriate than TAVR based on what the data presents right now.”

The authors also take a look at evidence regarding selected surgical approaches, including less-invasive options and the Ross procedure. There has been revived enthusiasm for the Ross procedure for the treatment of aortic stenosis and/or regurgitation in recent years, particularly for younger patients looking to avoid chronic anticoagulation. It’s more challenging than TAVI, Baman et al note. “However,” they add, “when performed in highly specialized centers with experienced surgical teams and in carefully selected patients, the long-term outcomes related to the Ross procedure are encouraging.”

Finally, the review touches on special considerations for the treatment of chronic aortic regurgitation in younger patients. Most patients who meet criteria for aortic valve surgery without other indications for cardiac surgery will undergo AVR with a mechanical or biological prosthesis, although aortic repair is also in option for some. As for transcatheter treatment, “there is limited utility of off-label use of TAVR in the management of native chronic severe AR with current commercially available technologies,” the authors say.

A Focus on Lifetime Management, Patient Preference

For patients younger than 65, lifetime management takes on a greater role in management decisions because there is a greater likelihood of needing a repeat intervention, and the review includes both a box discussing important factors when it comes to valve-in-valve TAVI for a deteriorated surgical valve and a figure highlighting the advantages and disadvantages of various approaches for initial treatment of severe aortic stenosis and/or regurgitation.

“Given the cumulative risk of structural valve deterioration for patients who undergo bioprosthetic SAVR or TAVR, and the cumulative risk of bleeding while taking anticoagulation in those who undergo mechanical SAVR, the timing of valve intervention is paramount in the young adult population,” Baman et al write.

They underscore the value of a multidisciplinary care team, and preferences of the patients themselves, when it comes to making choices about aortic valve disease treatment in younger age groups.

“The patients are the most important part of the decision-making process. In many aspects of medicine, we have clear guidelines as far as what to recommend in various clinical situations, and when it comes to management of aortic valve disease in these younger adults, that just isn’t out there,” Baman said.

“And so the purpose of this paper was to actually empower clinicians to have discussions with patients in as informed a way as possible, and really kind of empower the shared decision-making process,” he said. “The patients are really the cornerstone here.”