When is it Too Late for Aortic Valve Surgery

Determining operability in patients with aortic valve disease is dependent on two major factors: The extent of damage induced by strain on the myocardium from stenotic and regurgitant lesions and technical and anatomical considerations related to the surgical procedure itself. The decision to operate can be a delicate balance of the risk/benefit outcome expected from the surgical intervention. Indications recommend performing corrective procedures before establishment of severe myocardial damage. Thus the treating physician may believe that it is too late to refer a patient for surgical intervention due to advanced age, in the presence of significant and serious co-morbidities, and when myocardial contractile reserve is poor.On the other hand, the surgeon may be reluctant to perform the intervention in the presence of technical challenges. In either case, management of valve disease has witnessed major advances permitting surgical intervention in these high-risk patients. Anaesthetic care has improved with perioperative and intensive care protocols allowing better preparation of patients for the surgicalprocedure and smoother postoperative periods. Surgical techniques have become less aggressive with objectives to deminish the inflammatory syndrome of the heart-lung machine and provide better myocardial protection. Recently, transcatheter techniques allowing endovascular access precluding the need for cardiopulmonary bypass and aortic cross clamping altogether have openednew horizons in patients for whom technical complexity would contraindicate the procedure or the risk of conventional surgery would be unacceptable. The final decision on operability depends on centre experience, available technology and should be taken by a heart team including surgeons, cardiologists and anaesthesiologists