Re-evaluation of the indications for cardiac valve replacement.

We re-evaluated the indications for mitral valve replacement and reconstruction, and attempted to determine the optimal time for aortic valve replacement. (1) The actuarial event-free survival rate in patients undergoing open mitral commissurotomy for mitral stenosis with far-advanced subvalvular deformities was 78 per cent at 11 years after surgery and similar in patients undergoing mitral valve replacement for mitral stenosis. Postoperative clinical improvements compared favorably with those in patients undergoing mitral valve replacement. If quality of postoperative life in patients not requiring anticoagulants is borne in mind, open mitral commissurotomy should be given strong consideration as the procedure of choice for the majority of patients with mitral stenosis. (2) The long-term results of reconstructive procedures for mitral regurgitation largely depend upon the pathological anatomies contributing to the development of mitral regurgitation. The results were less satisfactory in patients with fibrotic changes of valvular and subvalvular tissue than in patients undergoing mitral valve replacement for mitral regurgitation. (3) In aortic valve replacement, the postoperative prognosis was poor in patients with a preoperative left ventricular end-systolic volume index exceeding 200 ml/m2 and left ventricular ejection fraction less than 0.35. Operative management of patients with aortic valve disease should be considered, before severe left ventricular systolic dysfunction is evident.