The ideal aortic valve substitute remains elusive. Bioprosthetic valves are the replacement option of choice in elderly patients undergoing aortic valve replacement (AVR). When implanted in young and middle-aged adults, both bioprosthetic and mechanical valves are associated with excess mortality compared with the age- and sex-matched general population. The Ross procedure is the only operation that can restore normal life expectancy in young and middle-aged adults undergoing AVR. In this article, the authors review the various options for surgical AVR and examine their contemporary applications and outcomes.

Key points

• Although in elderly patients, bioprosthetic valves are durable and associated with low rates of valve-related complications, in non-elderly adults, they are associated with reduced durability and lower than expected survival, both of which are worsened by the presence of patient-prosthesis mismatch.
• In young adults, mechanical valves are associated with lower rates of prosthesis degeneration and need for reoperation compared with bioprosthetic valves, at the cost of higher rates of anticoagulation-related bleeding and thromboembolic events.
• Nevertheless, both mechanical and bioprosthetic valves are associated with excess mortality compared with the general population when implanted in non-elderly patients.
• The Ross procedure is the only operation that can restore a normal life expectancy in young and middle-aged adults undergoing aortic valve replacement.