Circulation Topic Review

Survival in young adult patients after mechanical aortic valve replacement is reported to be significantly reduced compared with the general ageand gender-matched population, whereas survival after the Ross procedure is excellent and comparable to that in the general population. There is ongoing debate about whether the excellent survival rates observed in Ross patients are a consequence of a hemodynamically superior valve and low valve-related complication rates or of patient selection. This is the first study to compare survival in young adult patients after mechanical aortic valve replacement and the Ross procedure using propensity score matching. In comparable patients, there was no late survival advantage in the first postoperative decade for the Ross procedure over mechanical aortic valve implantation with optimal anticoagulation selfmanagement. In contrast to older reports, the relative survival in these selected young adult patients closely resembles that of the general population, possibly a result of better timing of surgery, improved patient selection, and highly specialized self-management anticoagulation treatment in more recent years. In the absence of late mortality differences between comparable patients who received either a mechanical prosthesis or the Ross procedure, the weight of the prosthetic valve selection decision making process shifts toward quality of life and patient preference. Clinicians are therefore encouraged to systematically elicit patient preferences when discussing prosthetic valve selection in this young adult population.