Intervention indication – Part I

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.

We will divide into the specific valve diseases and their etiologies to bring a summary of the intervention indication. Each valve disease will be addressed specifically and in greater detail in specific posts.

Primary mitral valve disease

In this case, both stenosis and regurgitation, patients in stage D have a class I indication for intervention. In this case, conventional intervention has more evidence of long-term benefit, with percutaneous intervention being restricted to isolated cases.

Stage C patients are indicated for intervention in cases of significant hemodynamic repercussion, such as a drop in the ejection fraction, the appearance of recent atrial fibrillation or the appearance/worsening of pulmonary arterial hypertension. Important cavitary dilations may also indicate intervention, even without a drop in the ejection fraction, but with less evidence of benefit.

Secondary or functional mitral valve disease

In this case, we have only functional mitral regurgitation and the indication for conventional intervention alone in these cases is very weak, regardless of whether Stage C or D. This means that if the patient has functional mitral regurgitation (secondary to left ventricular dilation), absence of another reason for sternotomy, we only thought about intervening in cases refractory to clinical treatment and even so, with little evidence of benefit.

Practically, we hardly indicate a correction of isolated functional mitral regurgitation. Recently, the discussion regarding percutaneous intervention in this group of patients has intensified, but with very specific criteria for intervention that will be better addressed in a specific post.

Suggested literature:

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

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