The availability of TAVI has changed the dynamics of the discussion of the trade-offs be- tween mechanical and bioprosthetic valves in younger (Table 22). Recommendation-Specific Supportive Text 1. The choice of valve prosthesis in each patient is based on consideration of several factors, includ- ing valve durability, expected hemodynamics for valve type and size, surgical or interventional risk, the potential need for long-term anticoagulation, and patient values and preferences. The trade-off between the risk of reintervention for biopros- thetic valve deterioration and the risk of long- term anticoagulation should be discussed. Some patients prefer to avoid repeat surgery and are willing to accept the risks and inconvenience of lifelong anticoagulant therapy. Other patients are unwilling to consider long-term anticoagulation because of the inconvenience of monitoring, the attendant dietary and medication interactions, and the need to restrict participation in some types of physical activity. The incidence of structural dete- rioration of a bioprosthesis is greater in younger patients, but the risk of bleeding from anticoagu- lation is higher in older patients. In patients with shortened longevity and/or multiple comorbidi- ties, a bioprosthesis might be more appropriate. In women who desire subsequent pregnancy, the issue of anticoagulation during pregnancy is an additional consideration (see pregnancy-related issues in Section 13.5).20,21 2. Anticoagulant therapy with VKA is necessary in all patients with a mechanical valve to prevent valve thrombosis and thromboembolic events. If anti- coagulation is contraindicated or if the patient refuses VKA therapy, an alternative valve choice is appropriate. Newer anticoagulant agents have not been shown to be safe or effective in patients with mechanical heart valves. 3. 