Valvular heart surgery: evaluating the past to enlighten the future.

Unlike the steady decline observed in coronary artery bypass graft (CABG) surgery rates over the last couple of decades [1], there has been a rise in non-congenital [2] and congenital heart valve operations through the last 10–15 years [3]. This upsurge can firstly attributed to the increasing prevalence of degenerative valvular heart disease due to the rising age of the population worldwide. Secondly, improved surgical outcomes in asymptomatic patients [4, 5] and performance of surgery based on echocardiographic parameters, in addition to symptomatology, have led to more patients undergoing surgery in earlier stages of the disease [6], preventing progression to irreversible ventricular dysfunction that would, otherwise, have rendered them inoperable, thus indirectly contributing to growth in surgical volumes. Finally, the improvements in perioperative care of older and sicker patients with multiple comorbidities, better surgical techniques and the development of newer minimally invasive and transcatheter technologies in valve repair and replacement have enabled surgeons to treat patients who were previously considered to be prohibitively high risk for conventional surgical procedures. This alteration in patterns in valve surgery, observed globally, has been elegantly presented by Siregar et al. [7] in this edition of the journal through a comprehensive study involving a compilation of extensive data of 56 397 patients undergoing valve operations (excluding transcatheter procedures) derived by linking four nationalized databases developed at different periods during the last two decades in the Netherlands. The authors noted that the annual volumes of valve operations doubled from 20/100 000 Dutch adults in 1995 to 43/100 000 in 2010 with similar trends also observed for isolated aortic valve (AV) and mitral valve (MV) surgeries. More than half of these surgeries were AV operations with or without CABG. A comparable trend in isolated valve procedures was observed in the voluntary registry of the German Society for Thoracic and Cardiovascular Surgery (GSTCVS) and the Society of Thoracic Surgeons (STS) database [2, 8]. In the current study, the authors reported an absolute reduction of 41 and 30% in the use of mechanical aortic and mitral pros-theses, respectively, over the 16-year study-period. Similar observations were also described by Hamm et al. [9] on behalf of the German AV registry executive board. This enormous increase in implantation of bioprostheses is due to the lower incidence of thromboembolism and anticoagulation-related haemorrhage and improved durability due to technological advances in the manufacture of newer generation valves. The recent surge in transcatheter valve …