EDITORIAL COMMENT “Prophylactic” Valve Replacement for Mild Aortic Valve Disease at Time of Surgery for Other

Mild aortic valve disease. RHEUMATIC MITRAL VALVE DISEASE. Sir William Broadbent (4) stated 100 years ago that “The age of the patient at the time when the lesion is acquired is the most important consideration in prognosis. . . .” This was confirmed in the study of Goldschlager et al. (5) and also in the current era by the seminal study of Bonow et al. (6). More recently, Spagnuolo et al. (7) reported on 174 “young” patients with rheumatic heart disease from Irvington House and Bellevue Hospitals, New York, who were entered into the registry from 1952 through 1966. Patients in the “low-risk” group (probably those with less than severe AR) (Table 1) had an outcome that was better than that of a patient with a prosthetic heart valve (please see following section). In this issue of the Journal, Vaturi et al. (8) report on the natural history of mild AVD in 131 patients aged 61 6 12 years, and followed from 1975 to 1992 for 13 6 7 years (range 1 to 33 years, median 13 years) after surgery for rheumatic mitral valve disease. Of 131 patients, 59 (42%) had AVD (mild in all); 52 of the 59 (88%) had AR, 1 had AS and 6 (10%) had mixed AS/AR. At the end of follow up, 96 (73%) of the patients had AVD; 63 of the 96 (66%) had AR, 6 (6%) had AS and 27 (28%) had AS/AR. Severe AS or AR was present in only 2 and 1 patients, respectively; all 3 initially were in the AS/AR group. It is of interest that of the 6 patients who required surgery on follow up, 4 were primarily for re-operation of the mitral valve and only 2 for severe AS. There are limitations to the study of Vaturi et al. (8). Of 424 patients with rheumatic mitral valve disease, 83 patients died during the first year (64 in-hospital deaths and 19 died during one year follow-up) and 200 patients had inadequate follow-up, leaving 131 patients in the study who were a select group. Nevertheless, the study of Vaturi et al. (8) is useful; it confirms that even in the current era, and even in older patients with rheumatic mitral valve disease, AR and not AS is the more common lesion, and mild aortic valve disease (AVD) rarely progresses to severe AVD over a long follow-up period. Therefore, patients with mild AVD at time of surgery for rheumatic mitral valve disease should not have surgery for the AVD.