Management of valvular regurgitation.

The principles of the management of left-sided valvular regurgitation, which weigh watchful waiting against surgery, have crystallized over the past 15 years. While the timing of surgery once was enigmatic, it is now clear that surgery must be done prior to the development of prolonged left ventricular dysfunction. Fortunately, satisfactory indexes have been developed that allow the clinician to detect and avoid such dysfunction. Therefore, patients now undergo surgery sooner, resulting in reduced operative mortality and better long-term survival. However, there are still several unresolved issues regarding the management of valvular regurgitation. For instance, operations for mitral regurgitation that preserve the mitral apparatus improve postoperative left ventricular performance compared with conventional mitral valve replacement. However, the proper timing for these operations is still being examined. Another issue is whether vasodilators, which reduce the regurgitant overload, can delay the onset of ventricular dysfunction and thus also delay surgery. In contemplating vasodilator use there is a paradox between the principle of early surgery to prevent dysfunction and use of medical therapy to delay surgery. Several studies which have appeared in the literature in the past year help resolve some of these issues.