Well, this depends on a lot more factors than You mentioned here. First, I´ll assume, that the stenosis is high grade and responsible for intolerable symptoms (like Dyspnea/shortness of breath, chest pain, sudden loss of consciousness). Overall, there are 4 main possibilities to manage aortic stenosis:

1) conservative / medical, which is essentially b-Blockers (minimize symptoms), statins (minimize progression), careful ACE-Inhibitors/Aldosterone-Inhibitors (limit progression), nitrates (lower LVEDP and limit dyspnea).

2) catheter based valve implant; there are certain criteria - most echocardiographically - that determinate, if this is doable. You have to determine the distance of the coronary arteries to the valve plane, the access route (good arteries) and calcification of the valve.

3) operative reconstruction; the valve can be repaired operatively. But in a bicuspid valve this is rarely an acceptable option.

4) artificial valve implantation; this means implantation of either an biological or mechanical heart valve. Usually, biological valves are preferred due to better haemodynamics and no need for anticoagulation. The downside is, that they sometimes are not as durable as mechanical valves. Therefore, re-operation in a couple of years might be necessary with increased risk (previous operation).

In some cases, a ross procedure might be feasible, meaning, that the pulmonary valve is used as aortic valve and a prothesis is used in the low-pressure pulmonary position.

In short, reconstruction and medical treatment are no final options here. If the patient is symptomatic and with a bicuspid valve, it should be replaced either by catheter or surgically. The choice is made usually by the comorbidity profile of the patient. Pulmonary function, atherosclerosis, previous stroke, above mentioned parameters for minimally invasive procedures of the aortic valve, renal function etc. Some of them are determined by the EuroScore, giving a success probability/ risk of thoracic surgery.

As the patient is young, a ross procedure should be discussed wit the surgeon, but in general I´d recommend surgical valve replacement (biological valve).

Aside of that, hyperthyroidism should be addressed. Possibly, atrial fibrillation might convert after valve replacement and in euthyroidism. But this again depends on various factors (including left atrial diameter). And in this setting, atrial fibrillation (together with valve disease) means lifelong oral anticoagulation (warfarin, no NOAC). This pushes the decision for a biological valve more to a mechanical valve, because there are multiple reasons for oral anticoagulation and mechanical valves tend to function longer, reducing the need for re-operation.

still aortic valvereplacement with mechanical valve is the choice. size is generally preferable is 21. if not fitting in go for root enlargement

Bi-leaflet mechanical heart valve (ATS or St Jude).  Should be able to implant 21 mm valve either by supra annular placement technique or by posterior annular enlargement technique (Nicks or Manougian). Biological valve inappropriate (unless there is strong contra-indication for lifelong anticoagulation), and TAVI and Ross also inappropriate.

She recieved  size 20 AP  ATS  with effective orifice area of 2,5 which I think  is  the best choice for her . If not available or not fitting ,I would  ve used size18 AP with EOA of 1.85. My third choice is St J ude regent 19  EOA 1.65.

I found nowadays special design valves ,supraanulat tech have minimised the need for ANNULAR ENLARGING PROCEDURES  

Dear Dr Alebrahim,

I woud not consider TAVI in such a young patient.

On the other hand, the patient is quite obese and has some comorbidities. I would therefore pursue a less invasive strategy - avoiding a full sternotomy could be advantageous, and avoiding sternotomy at all would be ideal.

I would go for a right anterior minithoracotomy (http://mmcts.oxfordjournals.org/content/2006/1110/mmcts.2005.001826.full). This has been the preferred approach at our instiutution during the last 10 years, and thanks to the recent improvement in techniques and technologies, has become safe, simple and fast in almost all patients.

A preoperative Chest CT scan is essential. If you could upload the images somehow, I would be glad to give you my opinion about the feasibility of the procedure.

Finally, I would consider using a bioprosthesis:  this lady is definitively too young for a TAVI now, but with some luck she'll be old enough for valve in valve implantation when the bioprosthesis will degenerate.

Best regards,

Alfredo Giuseppe Cerillo

UO Cardiochirurgia

Ospedale del Cuore G. Pasquinucci

Fondazione Toscana Gabriele Monasterio

Via Aurelia Sud 54100 Massa, Italy

Tel. 00390585493643

Fax. 00390585493614

email: [email protected]; [email protected]

I appreciate the considerations of Dr Cerillo. There is another point that needs to be carefully mentioned in a 52 y old lady with moderate mitral regurgitation and AF. The presence of AF induce me to think that MR will not disappear after the aortic replacement. A concomitant procedure of mitral annuloplasty and AF ablation does not increase the surgical risk but can surely improve the quality of life and survival of such a young patient. If the patient needs in any case oral anticoagulation a mechanical valve still remains an excellent option. Right thoracotomy is safe but only in expert hands and can be done also in combined procedures (AVR+mitral+ablation).

I fully agree with my dear friend Mattia Glauber and would also recommend to consider a combined intervention of AVR, MVRec and Afib-Ablation.  If the annulus is too small for a 21 mm valve, I would even take a root enlargement into consideration. A mechanical valve is indeed still an excellent option and the discussion about a biological valve as first choice and lateron a valve in valve procedure seems somewhat unrealistic to me.

First, we are propably talking about a 19 mm or a 21 mm prosthesis. There is currently no option for the first one except a risky off label use of one device and there are few mediocre options for the latter one, As to my experience, the results in these small sizes are less than satisfying! Second, the life expectancy for women goes towards 80 years. What about a "valve in valve in valve" and how much orifice area would you expect at the end? 

A TAVI in such a young lady seems contraindicated to me, however, a minimally invasive approach is an option in experienced hands. 

I fully agree with my dear friend Mattia Glauber and would also recommend to consider a combined intervention of AVR, MVRec and Afib-Ablation.  If the annulus is too small for a 21 mm valve, I would even take a root enlargement into consideration. A mechanical valve is indeed still an excellent option and the discussion about a biological valve as first choice and lateron a valve in valve procedure seems somewhat unrealistic to me.

First, we are propably talking about a 19 mm or a 21 mm prosthesis. There is currently no option for the first one except a risky off label use of one device and there are few mediocre options for the latter one, As to my experience, the results in these small sizes are less than satisfying! Second, the life expectancy for women goes towards 80 years. What about a "valve in valve in valve" and how much orifice area would you expect at the end? 

A TAVI in such a young lady seems contraindicated to me, however, a minimally invasive approach is an option in experienced hands. 

I fully agree with my dear friend Mattia Glauber and would also recommend to consider a combined intervention of AVR, MVRec and Afib-Ablation.  If the annulus is too small for a 21 mm valve, I would even take a root enlargement into consideration. A mechanical valve is indeed still an excellent option and the discussion about a biological valve as first choice and lateron a valve in valve procedure seems somewhat unrealistic to me.

First, we are propably talking about a 19 mm or a 21 mm prosthesis. There is currently no option for the first one except a risky off label use of one device and there are few mediocre options for the latter one, As to my experience, the results in these small sizes are less than satisfying! Second, the life expectancy for women goes towards 80 years. What about a "valve in valve in valve" and how much orifice area would you expect at the end? 

A TAVI in such a young lady seems contraindicated to me, however, a minimally invasive approach is an option in experienced hands. 

I thank both my "Old" Maestro Mattia and Dr Moosdorf for their important comments.

If the patient has chronic, permanent AF, a mechanical prosthesis should probably be preferred. However, the patient has hyperthyroidism, and the aetiology of the valve disease is not rheumatic: hopefully the afib could be treated medically. If this is the case, I would still consider a bioprosthesis: only an in-depth evaluation of the patient condition and desire can lead to the right decision.

Infact, it is true that life expectancy for healty women goes beyond 80 years -in Europe! However, is the picture the same for a 52 yo obese patient with valvular heart disease, LV dysfunction and afib??? And hasn't coumadin therapy any impact on the survival and quality of life? Even keeping the target INR to a lower range could, in my opinion, help.

Concerning the future valve-in-valve procedure, to my knowledge the results of the VIVID registry are not that bad- and we're in 2015! The 1st transfemoral TAVI has been reported only 10 years ago, and looking at what is happening now, especially in the Dr Moosdorf home Country, I'm sure that in 2025 the number of on-pump redo AVR procedures will be extremely limited...

Finally, with some "Technological aid", isolated AVR through a right anterior minithoracotomy can really be performed in a safe, easy and fast way by any average surgeon like me: it has become a standard procedure here, mostly thanks to Dr Glauber...

I think the first option should be for mechanical aortic valves. Size shouldn't be less than 21 otherwise enlarge the aortic root.

Moderate mitral and tricuspid regurge should be addressed and repairing both valves would be my first choice. 

AF can be managed concomitantly with ablation.

AVR by mechanical valve (St.Jude Regent), MAZE procedure (kryo or radiofr.) For decision to perform  MVP and TVP itś necessary to know more data TEE.

I think that the age of the patient recommend valve replacement with a mechanical prosthesis. The ring diameter 20mm, considering the weight, would recommend to enlarge the annulus and to place a valve size 23 mm.The FA must be converted to RS with a Maze procedure to improve the FE. The real problem is the evaluation of the degree of insufficiency of the mitral valve and tricuspid valve. A valve repair is recommended.

Thank you all for this interesting discussion