Valvular heart disease

An appreciation of the natural history of acquired valvular heart disease is a prerequisite to an understanding of how surgical intervention has altered the natural outlook. The prognosis for a patient with valvular heart disease treated medically is dependent on the stage of the disease at which he is first seen. Therefore, assessment for surgery requires evaluation of the pathophysiologic consequences that have resulted from the hemodynamic alterations. Survival statistics for patients seen at the University of California Medical Center at San Francisco are presented and compared with the data of others. Stenotic lesions appear to have a poorer prognosis than chronic regurgitant lesions and generally warrant surgical intervention at an earlier functional stage of the disease. However, valvular insufficiency produced acutely is poorly tolerated and many constitute a surgical emergency. The selection of patients with mitral or aortic valve disease for surgery obviously requires an appreciation of the natural history of valvular heart disease. One must weigh the expected surgical morbidity and mortality against the anticipated outcome of medical management alone. Therefore, one must know not only the early and late results of surgical procedures for various valvular lesions, but also the pathophysiologic consequences of valvular heart disease at various stages in its natural history. Simple awareness of average survival statistics is inadequate. For example, the prognosis of asymptomatic mitral stenosis differs greatly from that of mitral stenosis that has led to severe pulmonary vascular disease with resultant pulmonary hypertension and cardiac decompensation. The purpose of this review is to examine the major valvular lesions in terms of their pathophysiologic consequences and their natural history in the absence of surgical intervention.