Is it ever too late to operate on the patient with valvular heart disease?
Blase A. Carabello, MD, FACC*,*
* Medical Care Line, Department of Veterans Affairs, Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Figure 1 The natural history of aortic stenosis. Survival is nearly normal until the symptoms of angina, syncope, or heart failure develop, after which survival abruptly declines. Reprinted from Ross and Braunwald (4) with permission.
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Figure 2 Survival following surgery for aortic stenosis patients with low gradient and low ejection fraction. Operative mortality was 21%, and less than half of the patients survived four years. Reprinted from Connolly et al. (10) with permission.
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Figure 3 Ejection fraction plotted against afterload (mean systolic wall stress) for aortic stenosis patients demonstrates and excellent inverse correlation. Reprinted from Gunther and Grossman (11) with permission.
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Figure 4 A relationship similar to that shown in Figure 3 is plotted for aortic stenosis patients with low ejection fraction. Four patients (Xs) had depressed ejection fraction out of proportion to afterload and had a poor outcome following AVR. These patients had a mean aortic gradients of <30 mm Hg. Reprinted from Carabello et al. (8) with permission.
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Figure 5 Survival for aortic stenosis patients with low gradient and low ejection fraction. Group I patients demonstrated inotropic reserve and had a better outcome with AVR than did similar patients treated medically, and better than group II patients who lacked inotropic reserve. Reprinted from Monin et al. (22) with permission.
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Figure 6 Left ventricular (LV) ejection fraction is shown pre- and postoperatively for patients who had mitral apparatus preservation versus those with apparatus removal. Reprinted from Rozich et al. (37) with permission.
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Figure 7 Postoperative outcome is shown for mitral stenosis patients with pulmonary hypertension. Long-term outcome was good but followed a high (12%) operative mortality. Reprinted from Vincens et al. (41) with permission.
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Figure 8 Ejection fraction is plotted against afterload for aortic regurgitation patients before and after aortic valve replacement for patients with preserved and patients with depressed preoperative ejection fraction. In both groups, afterload decreased and ejection fraction increased following surgery. Triangles = Group 1 (n = 23); squares = Group 2 (n = 6); circles = normal subjects. Reprinted from Taniguchi et al. (45) with permission.
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