The new ESC Guidelines, 726001.
Vienna, Austria, 2 September 2007:
Today valve disease still represents an important health problem; valve patients are getting older and older with more and more comorbities, which contribute to increased operative risk and render the decision-making process more difficult. The recent ESC Guidelines on the management of valvular heart disease are the first European guidelines on this topic.
The guidelines consider successively general comments on the evaluation of the patients with the management of native valve disease and that of the important group of patients who have undergone previous cardiac intervention.
Nowadays, we are more and more often faced with patients with severe valve disease but with no symptoms. In such cases the performance of a stress test should be encouraged, particularly in aortic stenosis, if it can be carried out in an appropriate setting.
Echocardiography is today the key examination to assessing valve disease. Echocardiographic examination should always integrate quantitative parameters, with the assessment of the mechanism of valve lesions and its consequences, as well as clinical findings.
Catheterisation to evaluate valve function should be indicated only in the rare cases of discordance between clinical and echocardiographic findings. On the other hand, the indication for pre-operative coronary angiography should be wide. Finally, the decision for early intervention should take into account the surgical risk related to the type of surgery, and the general condition and life expectancy of the patient.
At the other end of the spectrum, in patients with very advanced valve disease surgery should still be considered after careful evaluation of the risk-to-benefit ratio. In this high-risk population, the decision will depend on three major parameters: Spontaneous prognosis; surgical risk, which should be evaluated using quantative scores such as the EuroScore and, finally, the evaluation of life expectancy. This evaluation should be multi-disciplinary, including cardiologists, surgeons, and anaesthesiologists, and should take into account the wishes of the well-informed patient.
Intervention in valve disease should be performed promptly, trying wherever possible to use the less invasive techniques. In mitral regurgitation, surgical repair is the treatment of choice and should be discussed in all patients. The decision to perform conservative surgery or valve replacement will take into account valve anatomy and also the experience of the surgical team. The good results of mitral valve repair apply also to tricuspid regurgitation, which should be looked for and repaired during surgery on the left heart valve disease to avoid re-intervention at higher risk. For mitral stenosis, the efficacy of percutaneous mitral commissurotomy has been well established. Today, this technique represents a complement of mitral valve replacement.
The choice of the most appropriate valve prosthesis is a matter of debate. It should be based on the integration of several factors. First and foremost, are the wishes of the well-informed patient. Second, it should take into account the feasibility and the risk of anticoagulation in mechanical prosthesis, and the risk of re-intervention for bioprostheses. It is arbitrary to base the decision on age alone, which should be integrated with other factors.
The publication of these new recommendations, together with those from the United States hopefully represents an important aid for decision-making in of the management of patients with valve disease. However, it should be emphasised that they rely only on a relatively low level of evidence. This should be an incitation to perform more well-controlled studies on this topic to, thus, improve the level of our knowledge.