Percutaneous therapy for valvular heart disease: a huge advance and a huge challenge to do it right.

In this week’s Circulation , Webb and colleagues1 report on the use of percutaneous “valve-in-valve” rereplacement in the treatment of 24 ill patients with prosthetic valve failure under compassionate-use protocols. Ten procedures addressed the aortic valve; 7, the mitral valve; 6, the pulmonary valve; and 1, the tricuspid valve. The 30-day survival rate was 96%. Clinically, the results were excellent, with 88% of these highly symptomatic patients returning to New York Heart Association class I or II. Hemodynamically, the results were more modest, with an average postprocedure transaortic gradient of 20 mm Hg and a transmitral gradient of 8 mm Hg. Article see p 1848 Although the above results are gratifying, they go far beyond the fact that 24 ill patients received valve-in-valve replacement. They focus on the next step in the therapy of valvular heart disease (VHD) ushered in by the advent of percutaneous devices. Where exactly this group of therapies will lead is uncertain, but what is certain is that each step of the way will be an exciting one with many successes and some failures. All severe symptomatic VHD is eventually fatal if left untreated, and the only effective treatment is restoration of valve function toward normal. No medical therapies significantly alter the course of VHD; only mechanical relief of the pressure or volume overload created …