Table 4.

Decision Making Algorithm. m-AVR for middle-aged patients.

Supported by EACTS/ESC Guidelines from 2021 [6]	Supported by ACC/AHA Guidelines from 2020 [5]
-Class I SAVR for patients with STS-PROM/EuroSCORE II <4 %, who ask for this type of valve, no contraindication for anticoagulation or high risk for accelerated SVD -Class IIa for patient already anticoagulated for another mechanical valve, for <60 years, high risks of reoperation or TAVI (if appropriate) -Class IIb for patient on long-term anticoagulation.	-Class 1 SAVR for symptomatic, well-informed patients who ask for this type of valve, no contraindication for anticoagulation, >20 years of life expectancy, -Class 1 SAVR for asymptomatic patients, <50% LVEF, >20 years life expectancy or rapid progression\urgency (abnormal exercise test, elevated BNP) -Class 2a for patients younger than <50 years -Class 2a for patients 50–65 years, informed shared decision, depending on patient characteristics
Pros	Cons
-All previously mentioned benefits for mAVR -available option for well-informed patients, compliant to the treatment and socially supported -May be “once in a lifetime procedure” in this category of age	-all the previously mentioned risks for a mechanical valve in young population.
-Good option for patients who experience fear of any other intervention