Which is the optimal operation for the young adult patient with aortic valve disease

Professor Elisabeth Stahle questions the Ross operation in her editorial comments (1) on Koul et al.’s article “Ross operation for bicuspid aortic valve disease in adults: Is it a valid surgical option?” (2). Concerns about the safety and longevity of the Ross operation are well justi ed based on the data in the Ross registry (3). The editorial strongly promoted replacement with a mechanical valve prosthesis and anticoagulation for the young adult with aortic valve disease. In my present world the arguments weigh differently. How the choice of prosthesis has varied over time at The Cleveland Clinic is shown in Fig. 1. In the year 2001 aortic valve replacements totaled 964 at The Cleveland Clinic with mechanical valves accounting for 11%, bioprosthesis 76%, allografts 13% and Ross 0.5%. In addition 86 aortic valve repairs were performed. The choice of operation by age is shown in Fig. 2. Sixty-one percent of all isolated aortic valve procedures were performed through a ministernotomy. During the period 1990–2000 the choice of valve in the STS (The Society of Thoracic Surgeons) registry for patients less than 60 years of age with aortic valve disease was mechanical valve in 77%, bioprosthesis in 13%, allograft in 5%, and Ross in 5%. The issues to consider are operative risks and long-term survival, risk of thromboembolism, risk of anticoagulation-related bleeding complications, risk of endocarditis, other valve-related morbidities, valve durability and risk of reoperation(s). Operative risks are related to primary procedure and reoperations while other risks are continuous and cumulative. Long-term survival is the result of valveand non-valve-related morbidities, including reoperations. Although the best and larger series show very low mortality with any alternative operation including the Ross operation, the operative risk has to be higher for the more complex operations involving manipulations of the coronary arteries like the allograft, Ross or composite graft root replacements. The higher mortality in the Ross registry compared with other published larger single surgeon Ross series con rms that the operative risk of complex operations is surgeon dependent. Aortic valve repair is less often possible and technically more dif cult than mitral valve repair, the exception being repair of noncalci ed bicuspid valves with pure regurgitation. The majority of leaking bicuspid valves can be repaired with good intermediate term results (4). The long-term durability and durability of repairs of other valve pathologies are yet to be proven. An increasing number of surgeons are adopting aortic valve preservation in cases of aortic dissection or aortic root aneurysm. In meta analyses the only certain differences between mechanical and tissue valves are more anticoagulationrelated bleeding complications and better durability/ freedom from reoperation for mechanical valves. For bioprosthesis and allografts valve durability dependent on patient age is available, being worse in younger patients. Second generation bioprostheses perform better than  rst generation. Allografts and autografts seem to be better than any prosthetic valve with regard to risk of endocarditis and thromboembolism and, considering the cumulative risk, this is increasingly important the younger the patient is