Ann Thorac Surg 2003;76:680
© 2003 The Society of Thoracic Surgeons
Invited commentary
Robert A. Dion, MDa
a Department of Cardiothoracic Surgery, Leids Universitair Medisch Centrum, Thoraxchirurgie K6S, Albinusdreef 2-Leiden, PB 9600 NL-2300 RC Leiden, Netherlands
e-mail: r.a.e.dion{at}lumc.nl
This work addresses a clinical situation, which, in view of the increasing age and comorbid disorders of the surgical candidate, is not infrequently met in our present practice. It is true that, in most instances, and certainly in patients with concomitant coronary artery disease, heart catheterization will remain mandatory before the first operation. However, noninvasive techniques like echocardiography and probably very soon MRI will get preeminence in preoperative diagnosis, especially if the necessity of selective coronary angiography decreases with time. As detailed by the authors in their answer to the reviewer's comments, adequately performed echocardiographic assessment of aortic stenosis may result in identical or at least comparable findings, provided that the degree of valvular calcification is evaluated as well. Another important point is the ability to detect early exhaustion of myocardial adaptation. Early stages of left ventricle maladaptation to chronic pressure overload are characterized by a reduced contractility reserve that manifests only during a stress test. In order to assess myocardial adaptation in clinically asymptomatic patients with suspected moderate aortic stenosis, exercise examination such as radionuclid ventriculography or stress echocardiography is necessary.
It is quite interesting that the authors have been able to determine that the etiology of aortic stenosis and the age of the patient at first catheterization yield no significant influence on the progression of aortic stenosis.
The conclusion of this remarkable work certainly will enable the surgeon to make a more clear-cut choice when facing such a patient. Personally, I would certainly agree to apply these rules even it might result in a few "unnecessary" concomitant aortic valve replacements. As stressed by the authors, the increased risk of a concomitant aortic valve replacement simply cannot be compared with that of a reoperation for aortic valve replacement later.
I congratulate the authors for their contribution to clarify a most controversial medical indication. In the few borderline cases where the decision still will remain difficult, I shall certainly think of measuring the potentially reduced contractility reserve via an exercise test using MRI or echocardiography.
