Timing of surgical therapy for aortic valve stenosis. Goals of therapy.

In patients with aortic stenosis, delineation of the optimal timing of surgery is of particular importance since inappropriately early surgery subjects the patient to the risk of prosthetic heart valve disease for a longer time than is necessary (Figure 1) and inappropriately late surgery can result in prolonged untreated symptoms and irreversible myocardial changes or systemic complications. A valve orifice area less than 1.0 cm2 or less than 0.7 cm2/m2, respectively, is indicative of critical stenosis. The indication for surgery should be established mainly on the basis of compromise of the valve orifice area equal to or in excess of the latter. In young patients surgical intervention should be carried out as soon as a critical stenosis is documented. Aortic stenosis can lead to symptoms such as fatigue, dyspnea, chest pain or syncope which surgery can eliminate and the incidence of sudden death may exceed 10% per year in symptomatic patients and can approach 2% per year in asymptomatic patients. In the younger age group, since the surgery required is almost exclusively commissurotomy rather than valve replacement, the operative mortality is less than 2% and the patient is not subjected to prosthetic heart valve disease. In adult patients with symptomatic, documented critical aortic stenosis, surgery should not be delayed. The symptoms can be ameliorated through surgery. The prognosis without surgery is poor with a five-year survival rate less than 50%, while after aortic valve replacement survival at five years is approximately 75 to 80%.(ABSTRACT TRUNCATED AT 250 WORDS)