Assessment of the patient with valvular heart disease: An integrative approach

In managing the patient with valvular heart disease (VHD), three major issues must be addressed: (1) assessment of the severity of disease, (2) the effect the disease is having or is likely to have on the patient and his/her cardiovascular system, and (3) the timing and type of intervention to be used to correct the lesion. Existing guidelines are helpful in addressing these tenets in many cases, often using quantifiable parameters to aid the clinician in making key clinical decisions. Many times these guidelines allow the physician and patient to arrive easily at a management strategy. However, in other cases it may take every piece of available data to develop a management plan that is still only a best guess at the proper course to take. Overall, the indications for intervention in VHD are straightforward: valvotomy (in mitral stenosis), or valve repair or valve replacement is indicated when severe VHD causes symptoms or cardiac dysfunction. In some cases, low-risk intervention such as mitral valve repair may be undertaken in the absence of symptoms or dysfunction when it seems inevitable that deterioration will occur because of markedly severe disease. These assessments are rarely made using one test and usually require the integration of all the clinical acumen that can be summoned to address the issues above. The following will summarize the general approach to the assessment of VHD severity, impact, and timing of intervention, with attention paid to the specifics of each individual disease.