Obstruction to left ventricular outflow: Current criteria for the selection of patients for operation ∗

Abstract

The current criteria for the selection for operation of patients with the various forms of obstruction to left ventricular outflow are reviewed. In children or adolescents with congenital valvular or discrete subvalvular stenosis, left heart catheterization should be performed whenever the clinical examinations indicate or suggest the possibility that severe stenosis is present. Operation is recommended in children with peak systolic pressure gradients between the left ventricle and brachial artery which exceed 50 mm. Hg or with an effective orifice less than 0.7 cm 2./M 2. BSA. It is now quite clear that the outlook for survival is limited in the adult with symptoms resulting from aortic stenosis, and operation is recommended when the peak systolic left ventricular-arterial pressure gradient exceeds 50 mm. Hg. In many adult patients with calcific aortic stenosis, effective debridement cannot be accomplished without the destruction of valvular tissue, and excision and prosthetic replacement of at least a portion of the valve is frequently necessary. Accordingly, surgical consideration is postponed in the totally asymptomatic adult. The surgical treatment of supravalvular aortic stenosis and of idiopathic hypertrophic subaortic stenosis is usually more difficult and less effective than the surgical relief of congenital valvular or discrete subvalvular stenosis. The criteria for the selection for operation of patients with these less common forms of obstruction to left ventricular outflow are stricter than for those with the more common forms of obstruction; the combination of severe narrowing and serious or progressive symptoms are required before operation is recommended.