Asymptomatic Valvular Heart Disease: Can Earlier Intervention Be Justified?

Abstract

Advances in cardiac surgical techniques and peri-operative management over the past 2 decades have led to improved patient outcomes and frame-shifted the timing of operation to an earlier stage in the natural history of valvular heart disease. Both US and European guidelines recommend valve replacement surgery for asymptomatic patients with left ventricular systolic dysfunction as defined by the specific valve lesion. The debate regarding the optimal approach to the patient with severe valvular heart disease and preserved systolic function has yet to be informed by prospective randomized trials, performance of which is challenged by lack of equipoise, cost, and funding. Individual considerations in the older population are particularly challenging, given the trade-offs between surgical risk and the desire to maximize the time over which a full, functional recovery might be enjoyed. A mandate that surgery for the asymptomatic patient be performed in centers of excellence cannot be enforced in the absence of clear and transparent definitions. Lastly, the excitement surrounding trans-catheter valve intervention poses a risk for its application in increasingly healthier patient populations. It is hoped that the heart team approach will enable balanced decision-making in collaboration with an informed patient, until properly designed randomized prospective studies are completed. A national effort will be required to reach this goal.