Asymptomatic valvular disease: who benefits from surgery?

Routine physical examination and noninvasive imaging frequently lead to the diagnosis of valvular heart disease in asymptomatic patients. The decision to proceed to surgical repair or replacement is based on an informed evaluation of the risks of surgery versus those encountered with a nonoperative course. In determining whether symptoms are present, stress testing may be helpful, as many patients with significant valvular lesions have a tendency to limit their daily physical exertion to levels that do not provoke symptoms. The two most feared consequences of conservative management, sudden death and permanent myocardial damage, are rare in asymptomatic patients with severe aortic stenosis or regurgitation. Surgery for asymptomatic aortic stenosis is performed only for certain high-risk subsets of patients, including those with left ventricular dysfunction, ventricular arrhythmia, and critically small valves. Asymptomatic patients with aortic regurgitation and mitral regurgitation should undergo surgery if they have systolic dysfunction or marked ventricular enlargement.

A syndrome of transient left ventricular apical wall motion abnormality in the absence of coronary disease: a perspective from the United States.

BACKGROUND: The syndrome of chest pain associated with characteristic anterior electrocardiographic changes, moderate increases in cardiac enzymes, and a reversible apical wall motion abnormality in the absence of coronary artery disease has been documented in Japan, but has received relatively little attention in other countries. METHODS: The clinical and echocardiographic data of 12 patients (11 women, mean age 64 +/-14 years) who presented with chest symptoms, electrocardiographic (ECG) changes indicative of an acute anteroapical myocardial infarction, abnormal cardiac enzyme levels and echocardiography showing an apical wall motion abnormality were collected. Coronary angiography was performed in 10 patients. A follow-up echocardiogram was obtained within 2 weeks of the initial diagnosis in most cases. RESULTS: An identifiable, precipitating ("trigger") event could be identified in all 12 individuals. Respiratory distress was present in 7, the death of a relative in 3, in 4 a surgical or medical procedure had been performed, and in 1 a panic disorder was diagnosed. The echocardiograms showed a characteristic wall motion pattern of significant apical dysfunction. All of the patients who underwent coronary arteriography had noncritical coronary artery disease. Follow-up echocardiography showed normalization of the LV dysfunction in all instances. CONCLUSION: We identified a syndrome of chest pain, dyspnea, ECG and enzyme changes mimicking acute myocardial infarction, similar to the "Takotsubo" syndrome described in Japan. It is likely that the widespread use of echocardiography, coupled with increased recognition of this syndrome, will result in this diagnosis being made more commonly.