Indications for heart valve replacement.

Proper evaluation of the patient with valvular heart disease begins with a thorough history and physical examination. Today, sophisticated noninvasive tests--especially echocardiography with color flow Doppler imaging--complement the information gained at cardiac catheterization. Information previously available only through cardiac catheterization can now be obtained from these noninvasive techniques. Serial evaluations can be performed, which are important in managing lesions of borderline hemodynamic significance and in avoiding subclinical deterioration of left ventricular contractility. Improvements in surgical expertise and intraoperative myocardial preservation allow postoperative improvement for patients with aortic stenosis and aortic insufficiency despite the presence of left ventricular systolic dysfunction. Many traditional indicators of a poor operative result in aortic insufficiency appear less reliable today. Consequently, these indicators should never be viewed in isolation or be given preeminence over clinical judgment. The long-term results following aortic valvuloplasty have been disappointing. However, mitral valvuloplasty--for technically suitable types of mitral stenosis--is an attractive alternative to surgery. Echocardiography may be helpful in selecting patients best suited for this technique. The timing of valve replacement in mitral insufficiency is made difficult by the altered loading conditions which can mask underlying contractile dysfunction. In this regard, the use of end-systolic measurements (e.g., end-systolic stress-volume ratio) more accurately characterized left ventricular contractility. When mitral insufficiency patients with left ventricular systolic dysfunction require surgery, valve repair appears superior to traditional mitral valve replacement. With valve repair, the postoperative left ventricular ejection fraction is usually higher, as left ventricular contractile reserve is better maintained.