Heart valve disorders encompass a range of conditions affecting the function of the heart’s four valves—mitral, aortic, tricuspid, and pulmonary.
These valves ensure unidirectional blood flow through the heart chambers.
When valves become stenotic (narrowed) or regurgitant (leaky), the heart must work harder to maintain adequate circulation, potentially leading to heart failure, arrhythmias, and other complications. Common valve disorders include aortic stenosis (AS), aortic regurgitation (AR), mitral regurgitation (MR), and tricuspid regurgitation (TR).
Indications for Surgery: Guidelines and Clinical Decision-Making
Established clinical guidelines outline clear criteria for when surgical treatment is appropriate. In cases of severe aortic stenosis, surgery is strongly recommended for patients who exhibit symptoms, have a left ventricular ejection fraction (LVEF) below 50%, or show signs of very advanced disease, such as a peak aortic jet velocity of 5 m/s or higher.
Surgical intervention is also advised for asymptomatic individuals if they are undergoing other cardiac procedures or if the condition is rapidly worsening, indicated by a velocity increase of more than 0.3 m/s per year.
In aortic regurgitation, surgery is indicated for symptomatic patients with severe AR or asymptomatic patients who show signs of left ventricular overload, such as an end-systolic diameter (LVESD) >50 mm or reduced LVEF ≤50%. Both guidelines emphasize early intervention to prevent irreversible myocardial damage.
Surgical Options: Repair, Replacement, and Transcatheter Techniques
Surgical approaches vary depending on valve pathology, patient risk profile, and anatomical considerations. Valve repair is favored for mitral and tricuspid valves due to better preservation of cardiac function and lower risk of prosthesis-related complications.
Surgical aortic valve replacement (SAVR) remains the gold standard for many patients with aortic valve disease, especially younger individuals (<65 years per ACC/AHA, <75 years per ESC/EACTS) with low surgical risk.
For older patients or those with significant comorbidities, transcatheter aortic valve replacement (TAVR) offers a less invasive alternative with comparable outcomes. Guidelines recommend shared decision-making to tailor the choice between SAVR and TAVR based on patient-specific factors.
Emerging Considerations and Future Directions
Advanced imaging modalities, including 3D echocardiography and cardiac magnetic resonance imaging, are increasingly utilized to assess myocardial remodeling and guide timing of surgery. These technologies enhance risk stratification and help detect subtle ventricular dysfunction before symptoms develop.
The role of valve repair in aortic regurgitation is gaining attention, especially in experienced centers where durable outcomes are achievable. Ongoing research explores expanding TAVR indications to patients with AR, although current guidelines advise caution in low-risk patients.
Expert Perspective
Dr. Michael A. Borger, a renowned cardiothoracic surgeon, emphasizes, "Timely surgical intervention in heart valve disease is critical to prevent irreversible cardiac damage and improve long-term survival. Advances in minimally invasive and transcatheter techniques have broadened treatment options, allowing us to tailor therapy to individual patient profiles."
Surgery becomes necessary in heart valve disorders when valve dysfunction leads to symptoms, ventricular impairment, or progressive cardiac remodeling. Adhering to guideline-based criteria ensures optimal timing of intervention, balancing risks and benefits. With evolving surgical and transcatheter technologies, personalized care strategies are enhancing outcomes and quality of life for patients with valvular heart disease.
Multidisciplinary heart teams play a pivotal role in decision-making, integrating clinical, imaging, and patient preferences to achieve the best results.
