Aortic valve surgery: time to be open-minded and to rethink

Successful treatment strategies for cardiovascular diseases have often been initiated and driven by surgeons, which is true for both coronary artery and valvular heart diseases. Radical excision of diseased tissue, repair and replacement strategies lead to long-term successful treatment of the underlying diseases and clearly improved patient outcome. For many surgeons it was and may still be hard to understand that balloon dilation and stenting of severely diseased arteriosclerotic coronary arteries could be competitive for bypass surgery. The impact of all interventional strategies was underestimated by the surgeons, which lead to the overwhelming development of a new discipline of interventional cardiology. They further developed and steadily improved such strategies, heavily supported by medical industry, which lead to a steady growth of PCI, by far surpassing CABG surgery worldwide. Right now interventional cardiologists supported by some cardiac surgeons are on their way to transform some conventional open surgical procedures into catheter-based less invasive interventions, such as valve repair and replacement. Most of the surgeons react very conservatively and some get themselves involved to evaluate such techniques in order to have a fair comparison and control. Conventional aortic and mitral valve replacement is a routineprocedure thathas beenperformed safely for decades. Themajority ofpatientspresentwith severely calcifyingaortic valve stenosis, accounting for approximately 10—30% of cardiac surgical workload. Resection of all calcified tissue with subsequent prosthetic heart valve implantation using a standard suturing technique has been the only definitive therapy. Excellent haemodynamic outcome and functional results are achieved, and good long-term performance of conventional prostheses has beenprovenbynumerous studies. Can similar results ever be accomplished by balloon dilation and stent based valve implantation without complete resection of the heavily calcified cusps? This is hard to believe for most surgeons since balloon dilation of aortic valve stenosis alone did not lead to any convincing data. Also, it is of interest to note that there obviously is a major cohort of patients with both severe aortic and mitral valve disease who are not being referred to surgery usually for the reason that the operative risks are considered to be too high. According to a recent survey of the European Society of Cardiology in 2003, only one-third of these patients underwent surgery.