Timing of surgery in valvular heart disease: prophylactic surgery vs watchful waiting in the asymptomatic patient

Abstract

In the absence of randomized controlled trial data, the management of patients with severe valvular heart disease without symptoms, ventricular dysfunction, or other identified triggers for surgery is controversial. In this review, we frame the debate between prophylactic surgery vs close follow-up until triggers occur (watchful waiting) for severe aortic stenosis and degenerative mitral regurgitation (MR), the 2 conditions for which the pros and cons of these approaches are best articulated. Classic high-gradient severe aortic stenosis is generally accurately diagnosed. In asymptomatic patients, stress testing can be used to confirm asymptomatic status and identify high-risk features including reduced exercise tolerance, exercise-induced symptoms, and absolute or relative hypotension. Resting echocardiographic predictors of disease progression and/or adverse events include very high gradients, rapid progression, and extensive calcification. Surgical risk calculators can help estimate perioperative morbidity/mortality with the ultimate choice of a medical vs a prophylactic surgical approach to be made after discussion with the patient. With degenerative MR, severity can be inaccurately estimated. Stress testing might clarify whether the patient is truly asymptomatic and identify features associated with worse prognosis and symptom onset. Selecting patients with high probability of repair can be challenging. Perioperative risk and postoperative risks including those of unanticipated valve replacement and recurrent MR after repair are also considerations. In aggregate, management of patients with valvular disease who are asymptomatic and who have no clear trigger for surgery is complex, requires individualization, and should be carried out by or in collaboration with a heart valve centre of excellence.