What is the best valve option for aortic valve replacement (AVR) and ascending aortic aneurysm repair in a 65-year-old patient with severe bicuspid aortic stenosis?

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Last updated: March 23, 2025 • View editorial policy

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From the Guidelines

For a 65-year-old patient with severe bicuspid aortic stenosis and ascending aortic aneurysm requiring AVR, a bioprosthetic valve is the preferred option due to the avoidance of lifelong anticoagulation and its associated risks. According to the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1, the choice of valve prosthesis should be based on several factors, including valve durability, expected hemodynamics, surgical or interventional risk, and patient values and preferences.

In this case, the patient's age of 65 is a significant factor, as the incidence of structural deterioration of a bioprosthesis is lower in older patients, while the risk of bleeding from anticoagulation is higher 1. The guideline suggests that in patients with shortened longevity and/or multiple comorbidities, a bioprosthesis might be more appropriate 1.

Some key considerations for this patient include:

  • The potential need for long-term anticoagulation with a mechanical valve, which may be a significant burden for an older patient 1
  • The risk of valve thrombosis and thromboembolic events with a mechanical valve, which requires anticoagulant therapy with VKA 1
  • The improved durability of newer generation bioprosthetic valves, which may reduce the need for future valve degeneration 1
  • The availability of valve-in-valve TAVR as a less invasive option for future valve degeneration 1

Given these considerations, a bioprosthetic valve, such as a bovine pericardial valve, combined with ascending aortic replacement using a Dacron graft, is the recommended approach for this patient. This approach would avoid the need for lifelong anticoagulation with warfarin, reduce the risk of bleeding and thromboembolic events, and provide a durable and effective solution for the patient's aortic valve disease and ascending aortic aneurysm. Postoperatively, the patient would require aspirin 81mg daily and regular echocardiographic follow-up to monitor valve function and aortic dimensions.

From the Research

Valve Options for Aortic Valve Replacement (AVR) and Ascending Aortic Aneurysm Repair

  • The choice of valve for AVR in a 65-year-old patient with severe bicuspid aortic stenosis depends on several factors, including the patient's age, lifestyle, and preferences, as well as the clinical judgement of the heart team 2.
  • Bioprosthetic valves are gaining favor over mechanical valves to avoid anticoagulation with warfarin, but the decision between the two types of valves requires thorough consideration of the potential need for future valve-in-valve interventions 2.
  • Transcatheter aortic valve replacement (TAVR) is a viable option for patients with severe aortic stenosis, but its use in patients with bicuspid aortic valve (BAV) is still uncertain due to technical challenges and limited clinical evidence 3.
  • Surgical aortic valve replacement (SAVR) is still the preferred treatment for younger patients, but TAVR may be considered for older patients or those with high operative risks 4, 5.

Considerations for Bicuspid Aortic Valve (BAV) Patients

  • BAV patients are at higher risk of ascending aorta dilatation and rupture, and simultaneous replacement of the ascending aorta may be necessary during AVR 6.
  • The use of TAVR in BAV patients is still evolving, and more research is needed to determine its safety and efficacy in this population 3.
  • Computed tomography scans play a critical role in the diagnosis, classification, and treatment planning of BAV patients undergoing TAVR 3.

Comparison of TAVR and SAVR

  • TAVR may reduce the risk of certain side effects, such as major bleeding and acute kidney injury, but may increase the risk of others, such as major vascular complications and permanent pacemaker implantation 4.
  • SAVR may reduce the risk of certain side effects, such as paravalvular leaks and aortic regurgitation, but may increase the risk of others, such as stroke and myocardial infarction 4, 5.
  • The choice between TAVR and SAVR should be made on a case-by-case basis, taking into account the individual patient's characteristics, preferences, and clinical indicators 2, 4, 5.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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