MANAGEMENT OF VALVULAR REGURGITATION

The principles of the management of left-sided valvular regurgitation, which weigh watchful waiting against surgery, have crystallized over the past 15 years. While the timing of surgery once was enigmatic, it is now clear that surgery must be done prior to the development of pro longed left ventricular dysfunction. Fortunately, satisfactory indexes have been developed that allow the clinician to detect and avoid such dysfunction. Therefore, patients now undergo surgery sooner, resultin g in reduced operative mortality and better long-term survival. Howeve r, there are still several unresolved issues regarding the management of valvular regurgitation. For instance, operations for mitral regurgi tation that preserve the mitral apparatus improve postoperative left v entricular performance compared with conventional mitral valve replace ment. However, the proper timing for these operations is still being e xamined. Another issue is whether vasodilators, which reduce the regur gitant overload, can delay the onset of ventricular dysfunction and th us also delay surgery. In contemplating vasodilator use there is a par adox between the principle of early surgery to prevent dysfunction and use of medical therapy to delay surgery. Several studies which have a ppeared in the literature in the past year help resolve some of these issues.