Current management of valvular heart disease (VHD) seeks to optimize
long-term outcome by timely intervention. Recommendations for treatment
of patients with symptoms due to severe valvular disease are based on a
foundation of solid evidence. However, when to intervene in asymptomatic
patients remains controversial and decision requires careful individual
weighing of the potential benefits against the risk of intervention and
its long-term consequences. The primary rationale for earlier
intervention is prevention of irreversible left ventricular (LV)
myocardial changes that might result in later clinical symptoms and
adverse cardiac events. A number of outcome predictors have been
identified that facilitate decision-making. This review summarizes
current recommendations and discusses recently published data that
challenge them suggesting even earlier intervention. In adults with
asymptomatic aortic stenosis (AS), emerging risk markers include very
severe valve obstruction, elevated serum natriuretic peptide levels, and
imaging evidence of myocardial fibrosis or increased extracellular
myocardial volume. Currently, transcatheter aortic valve implantation
(TAVI) is not recommended for treatment of asymptomatic severe AS
although this may change in the future. In patients with aortic
regurgitation (AR), the potential benefit of early intervention in
preventing LV dilation and dysfunction must be balanced against the
long-term risk of a prosthetic valve, a particular concern because
severe AR often occurs in younger patients with a congenital bicuspid
valve. In patients with mitral stenosis, the option of transcatheter
mitral balloon valvotomy tilts the balance towards earlier intervention
to prevent atrial fibrillation, embolic events, and pulmonary
hypertension. When chronic severe mitral regurgitation is due to mitral
valve prolapse, anatomic features consistent with a high likelihood of a
successful and durable valve repair favour early intervention. The
optimal timing of intervention in adults with VHD is a constantly
changing threshold that depends not only on the severity of valve
disease but also on the safety, efficacy, and long-term durability of
our treatment options.
