Mechanical Valve Replacement (Option B)
For a patient with symptomatic bicuspid aortic regurgitation, surgical aortic valve replacement is the definitive management—TAVR should NOT be performed, and follow-up alone is inadequate once symptoms develop. 1
Why Surgical Valve Replacement is Mandatory
The European Society of Cardiology gives surgical aortic valve replacement a Class I, Level B recommendation for all symptomatic patients with severe aortic regurgitation, regardless of left ventricular systolic function or dimensions 1
Surgery is indicated for any symptoms including dyspnea (NYHA class II-IV) or angina 1
Operative mortality is acceptably low at 3-7% in symptomatic patients, making the risk-benefit ratio strongly favor intervention 1
Once symptoms develop, mortality without surgery increases dramatically from 6% per year to 25% per year, with 75% of patients dying or requiring valve replacement within 10 years 1
Delaying surgery after symptom onset leads to irreversible LV dysfunction and reduced long-term survival 1
Why NOT TAVR (Option A)?
The European Society of Cardiology explicitly recommends that TAVR should NOT be performed in patients with isolated severe AR who are surgical candidates 1
TAVR is contraindicated in pure aortic regurgitation because the calcified landing zone is lacking, removing anatomical landmarks for proper valve alignment and causing malposition 1
When TAVR has been attempted for AR, more than mild residual AR doubles mortality at 1 year (22% vs 46%) 1
The single case report of TAVR for bicuspid AR in a 17-year-old with complex congenital heart disease required valve-in-valve procedure for severe paravalvular leak and represents an extreme exception, not standard practice 2
Why NOT Follow-Up Alone (Option C)?
Follow-up is only appropriate for asymptomatic patients—the presence of symptoms is an absolute indication for intervention 1
The natural history of symptomatic severe AR is dismal, with rapid progression to death or irreversible ventricular dysfunction 1
Waiting leads to worse postoperative outcomes including persistent LV dysfunction that may not recover after surgery 1
Valve Choice: Mechanical vs Bioprosthetic
While the question asks about mechanical valve specifically, the choice between mechanical and bioprosthetic depends on:
Patient age: Younger patients with bicuspid valves (mean age 42 years in repair series) may benefit from mechanical valves to avoid multiple reoperations 3
Anticoagulation tolerance: Mechanical valves require lifelong anticoagulation
Repair consideration: At experienced centers, valve repair may be considered when aortic root/ascending aorta replacement is performed, though reintervention rates are approximately 20% at 10 years 1, 4, 5
Concomitant Aortic Management
If the aortic root diameter is ≥45 mm in bicuspid valve patients, replacement of the aortic sinuses and/or ascending aorta should be performed simultaneously 1
For bicuspid valve patients with risk factors (family history of dissection, rapid growth >2mm/year), aortic surgery should be considered at ≥50 mm 1
All bicuspid valve patients should have aortic imaging with MRI or CT at some point, as 50% have aortic root involvement 6