Management of valvular stenosis.

The management of valvular stenosis has changed dramatically over the past 15 years, largely due to interventional cardiology. At the beginning of the 1980s, balloon valvuloplasty was thought by many to represent a definitive new treatment for calcific aortic stenosis in the elderly infirm. Before the end of the decade, this treatment had gone out of favor, but by that time we had learned that many of those same patients could undergo aortic valve replacement relatively safely and with excellent results. Unlike aortic stenosis, mitral stenosis is a disabling rather than a lethal disease, so the timing of intervention is much more difficult, particularly as there are treatment choices. Mortality, morbidity, and the possible bonus from proceeding earlier rather than later all need to be taken into consideration. Much to many people's surprise, mitral balloon valvuloplasty has grown and prospered, especially since the introduction of the Inoue balloon. It is the treatment of choice for young patients with mobile, noncalcified, stenosed valves, although still offering worthwhile palliation for older patients with higher echocardiographically determined valve scores. Echocardiography has gradually usurped cardiac catheterization for the assessment of valve stenosis and left ventricular function, but in patients with concomitant coronary disease that will be treated at the same time, the need for coronary angiography remains almost unchallenged.