Valvular heart disease: Patient needs and practice guidelines

Major advances in the evaluation and management of valvular heart disease, occurring principally over the past four decades, have resulted in marked improvement in the outcomes of patients with these conditions throughout the world. These advances have developed on several fronts, including development of imaging modalities (most notable ultrasound) that have provided essential data on natural history and predictors of outcome after operative intervention. This information provides cardiologists with the necessary clinical data, along with symptomatic status, to make informed decisions regarding frequency of repeat evaluations and ultimately timing of surgery. At that same time, the steady significant advances in cardiac surgery, including improved prosthetic valve design, evolution of valve repair and valve-sparing techniques, and enhanced methods for intraoperative myocardial preservation, have expanded operative windows to include surgery on both older patients and younger patients, and even patients who are asymptomatic. Rather than waiting to operate on patients when they are severely symptomatic and have impaired left ventricular function, which was the paradigm 50 years ago, the current clinical strategies are now moving toward earlier intervention before the onset of severe symptoms, left ventricular dysfunction and other adverse endpoints such as atrial fibrillation and pulmonary hypertension.