Clinical Treatment

The clinical treatment of valvular heart disease should never delay an indication for intervention and I start this post saying this, due to the importance it brings. If at any time a patient has a symptom secondary to any valve disease, it is classified as stage D and as will be discussed below, this is the point of greatest evidence for indication.

That said, when you meet a patient with significant valve disease and symptoms, you initially indicate the intervention and at that point you can associate with clinical treatment. Never start clinical treatment to assess whether the patient improves symptoms and gives up on recommending the intervention.

For symptoms of heart failure, such as dyspnea, we have the use of loop diuretics and in the presence of a drop in the ejection fraction, the use of medications that are proven to increase survival is imperative. Here I mention ACE inhibitors or angiotensin receptor blockers, cardioselective beta-blockers and spironolactone when indicated.

Complaints such as palpitation can be addressed with the use of beta-blockers as well as other complaints with the respective classes of symptomatic treatment.

Intervention indication

Each patient with valvular heart disease is almost an internal medicine book, given the various associated comorbidities that they may have. Therefore, there is no general basic rule to be applied in all cases.

To help this rationale, the American Heart Association’s classification by A-D stages brings some interesting points to discuss and help the reader to have a guide in the handling of cases.

Regardless of the affected valve, patients in stages A and B have no indication for isolated indication and the symptoms they may present almost certainly do not come from the valve disease in question. Exception is made in cases of any other intervention, for example, a conventional myocardial revascularization and the patient has a moderate valve lesion. In these cases, we can find a concomitant approach, but with low evidence of benefits and further discussion is still needed.

The main indications are in stages C and D, because it is an important valve disease and what differentiates both stages is the presence (stage D) or not (stage C) of symptoms.

Types of intervention

Traditionally, interventions in valvular heart disease occur through conventional surgery after sternotomy and the need for cardiopulmonary bypass. These are deeply studied procedures, with follow-up from cohorts over 50 years old, therefore, very well experienced in terms of complications and evolutionary patterns.

Recently, more specifically after 2002 with the advent of TAVR, we started a race to develop percutaneous interventions in heart valve diseases, with aortic stenosis being the most advanced stage of technical maturity.

However, the reader is mistaken if he believes that percutaneous procedures did not exist before 2002. Long before that, we had already established the approach to rheumatic mitral stenosis through a balloon catheter with excellent results.

A balloon catheter was inserted intravenously into the femoral vein and after transfection of the interatrial septum, the catheter was positioned in the topography of the stenotic mitral valve. With balloon insufflation, mitral valve commissurotomy occurred, with commissural fusion, typical of rheumatic involvement.

With excellent results both in the short and long term, percutaneous mitral valve replacement by balloon catheter, or simply VMP, is the treatment of choice for important rheumatic mitral stenosis, without any anatomical indications that will be discussed in the specific post of mitral stenosis.

Currently, there is a great discussion in the scientific community about the percutaneous approach to functional mitral regurgitation through the implantation of a clip that simulates the Alfieri technique, the mitraclip. Recent publications have placed this pathology at the center of the table with possible reclassification of the severity of this etiology. To read more about this subject, click here.

Given the above, we currently find, in a very simplistic way, two forms of intervention, the conventional one through sternotomy, extracorporeal circulation and implantation of valve prosthesis or valve repair and percutaneous intervention with implantation of prostheses, clips or devices for annuloplasty.

Suggested literature:

1 – Braunwald, Eugene. Cardiovascular medicine treaty. 10th ed. São Paulo: roca, 2017. v.1 and v.2.

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