Is there a risk in avoiding risk for younger patients with aortic valve disease?

Around 30 000 patients in the UK and Ireland had open heart surgery to replace the aortic valve in the five years up to March 2008, 40% of whom also had coronary bypass grafts. The annual number of replacements steadily increased, reaching 7000 in the last recorded year.1 Valve replacement is highly effective in averting the risk of sudden death and fatal deterioration in cardiac function, and the risk of perioperative death is now below 2.5% for all patients under 80 years old and 1% in patients under 40 years.2 Nevertheless, patients living with a replacement valve face a time related accrual of life threatening and disabling events.3 Tissue valves fail over time, and recipients of mechanical valves must take anticoagulants for life, which reduces but does not entirely prevent thrombosis and embolism and increases the risk of bleeding. We pose the question whether in ensuring that surgeons’ and institutional death rates are brought to the lowest possible levels, as they have been superbly well for older patients, insufficient consideration may have been given to younger patients.