The ever-increasing choices for aortic valve replacement: which one will win in the marketplace?

S ymptomatic aortic stenosis (AS) is a fatal disease unless treated by transcatheter aortic valve replacement (TAVR). During the latter half of the 20th century, aortic valve replacement (AVR) was accomplished in the operating room using a variety of replacement valves, both mechanical and bioprosthetic, the choice of which steadily evolved over time. Bioprostheses avoid the need for vitamin K antagonist anticoagulation (VKA) but are subject to structural valve deterioration that occurs more rapidly when they are implanted in younger versus older patients (1). Mechanical prostheses are more durable but require VKA and its attendant risks of thromboembolism related to underanticoagulation versus hemorrhage in cases of overanticoagulation. It is fair to add that mechanical valves are not entirely free of structural deterioration, and bioprostheses are not entirely free of thromboembolism. However, irrespective of data that show similar survival with mechanical and biologic valves (2–4), most patients prefer to avoid the risks of VKA, shifting their preference toward bioprostheses. A bioprosthesis is also made more attractive by a persistently decreasing risk of reoperation if required for a failed valve and also by the unproven but possible long-term strategy of inserting a valve percutaneously inside a failed bioprosthesis, avoiding reoperation. Pulmonary autografting (Ross procedure) offers the advantages of both durability in