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(Circulation. 1998;97:518-520.)
© 1998 American Heart Association, Inc.

Editorial

Finding `Just the Right Moment' for Operative Intervention in the Asymptomatic Patient With Moderate to Severe Aortic Regurgitation

Melvin D. Cheitlin, MD

From the Cardiology Division, San Francisco General Hospital, San Francisco, Calif.

Correspondence to Melvin D. Cheitlin, MD, Emeritus Professor of Medicine, Cardiology Division, Room 5G1, San Francisco General Hospital, 1001 Potrero Ave, San Francisco, CA 94110.

Key Words: Editorials • regurgitation • valves • follow-up studies

The decision to recommend operative intervention to the patient with valve disease is the most difficult when the valve disease is severe chronic aortic regurgitation and the patient is asymptomatic or minimally symptomatic. Because aortic valve replacement is almost always necessary and because the biological and mechanical valves still have problems resulting in significant mortality and morbidity, the decision to recommend surgery in an asymptomatic patient must wait until there are indications that changes are occurring that will predict an increased risk of death or congestive heart failure even after valve replacement.

The goals of operative intervention in valve disease are to (1) decrease or diminish symptomatology and thus to improve the quality of life for the patient; (2) prevent "catastrophes" or problems that are irreversible, such as myocardial infarction, left ventricular (LV) fibrosis, decreasing myocardial contractility, thromboemboli, and sudden death; and (3) prolong life. There is little doubt that the first goal is achievable, that of decreasing symptomatology. Every study reported of aortic valve replacement succeeds in that goal. If the patient survives, the chances of improvement in symptoms and functional classification are excellent.

Success of the third goal, that of prolonging life, is difficult to prove. The problem is that the mortality rate in patients with aortic regurgitation, especially those who are asymptomatic or only mildly symptomatic, is very low, and it would take large numbers of patients followed for a long period of time to randomize for study. This is not likely to be done. To randomize . . . [Full Text of this Article]

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