Cardiologic aspects of aortic valve surgery--who? when? what?

The title invites a discussion of a patient (age, lesion, physical condition, compliance, and other organ pathology) with aortic valve disease in the context of proposed surgical management. It further seeks clarification on the timing of such surgical contribution and on which operation is optimal. Without reviewing all the vast and somewhat conflicting literature, these aspects are addressed by a clinical cardiologist based principally on his own experience. Among the principal conclusions are the following: a) Surgery can safely be delayed in hemodynamically significant congenital aortic stenosis in children or young adults provided that the patients are nearly asymptomatic and that submaximal or maximal stress testing shows minimal or no ST-T changes. b) Prognosis after successful valve surgery for critically tight aortic stenosis in middle-aged and elderly patients differs from that for aortic regurgitation in that left ventricular myocardial dysfunction, however severe, will always improve postoperatively in the former condition. There is, therefore, never a cardiac contraindication to surgical management of symptomatic patients with tight aortic stenosis. c) Certain features in cases of chronic severe aortic regurgitation, such as diminished ejection fraction, increased end-systolic left ventricular diameter, electrocardiographic repolarization abnormalities, marked cardiomegaly on radiologic examination, and NYHA class III or IV symptoms, reflect a higher operative mortality and poorer long-term prognosis. Nevertheless, none of these features, alone or combined, can to date justify a definite contraindication to surgery in a specific patient. d) There is little uniformity or agreement among surgeons, including their cardiologists if or when that is pertinent, on the type of operation for patients of any age requiring aortic valve surgery. For example, a patient aged 40 years and depending on the "whims and fancies" of a Department or indeed those of an individual surgeon, which include his own judgement of his technical ability, may be subjected to a repair, a Ross procedure, insertion of a homograft or replacement with one of a variety of bioprosthetic and mechanical valves. The reasons, logic or motives behind these different choices are sometimes difficult, certainly for this author, to comprehend. Hopefully, ongoing international experience and research endeavors will, at least partially, clarify the current confusion. There is presumably an "optimal" way to hold a golf club or to kick a football?! The skill and judgement of the operators will, inevitably and sometimes regrettably, always vary.