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Patients with mitral or aortic valve disease constitute an important part of patients in cardiology practice. General practitioners and internists have an important role in the long-term care of these patients. We review current knowledge and recommendations for follow-up, medical therapy and indications for surgery in patients with aortic and mitral valve disease. Asymptomatic patients with valve disease need a clinical and echocardiographic follow-up at specific time intervals. Most patients with mild or moderate valve disease do not need medical or surgical therapy. However, once a patient becomes symptomatic, he needs a non-invasive and likely an invasive evaluation for surgical valve repair or replacement. In case the valve disease progresses without the development of clinical symptoms, the indication for surgery must be derived from hemodynamic parameters, the onset of arrhythmias (atrial fibrillation), and pulmonary hypertension. In symptomatic and asymptomatic severe valve disease specific medical therapy can be very beneficial. However, improvement under medical therapy should not delay a prognostically necessary surgical valve repair or replacement.

Rupture of the left ventricular myocardium during the course of an acute myocardial infarction may affect the free wall, the interventricular septum, or the papillary muscles. When a rupture occurs, it is referred to as a mechanical complication of acute myocardial infarction. All mechanical complications may lead to cardiogenic shock. However, the location of the rupture can often be suspected clinically. To confirm the diagnosis, echocardiography must be performed. Since the advent of thrombolytic therapy and percutaneous coronary intervention, the incidence of mechanical complications has declined. Even though mortality remains high, their recognition is important since survivors may have an excellent long-term prognosis. The cases convey two main messages: 1) Mechanical complications must be carefully searched for in any patient with an acute coronary syndrome and signs of cardiogenic shock and/or a systolic murmur. 2) Aggressive and timely medical and surgical treatment should be provided even though in a substantial proportion of these patients prognosis may be dismal.

Percutaneous transvenous mitral valvuloplasty using the double-balloon technique has been attempted in 25 patients (mean age 39 +/- 10 years; 17 women, 8 men) with severe, non-calcified (20 patients) or only slightly calcified (5 patients) mitral stenosis. Valvuloplasty was successful in 22 of the 25 patients. The procedure resulted in a marked increase in mitral valve area from 1.0 +/- 0.2 to 1.9 +/- 0.5 cm2 (p0.001) whereas the diastolic transmitral gradient decreased from 11 +/- 4 to 4 +/- 2 mm Hg (p0.001). Functional classification according to the New York Heart Association improved from 2.4 +/- 0.6 to 1.7 +/- 0.5 (p0.001) and physical working capacity increased from 64 +/- 20 to 76 +/- 17% (p0.01). In 3 patients the procedure was not successful: cardiac tamponade and ventricular perforation occurred in 1 patient each and in the third valvuloplasty had to be ended because of lack of cooperation. Follow-up examination was performed 24 +/- 17 months after successful valvuloplasty. In all patients an electrocardiogram, an exercise test and an echocardiogram were obtained after 3, 12, 26 and 40 months. Sinus rhythm was found in 13 and atrial fibrillation in 9 patients before valvuloplasty. After the procedure 3 additional patients could be converted into sinus rhythm. Physical exercise capacity did not change during the follow-up. Mitral valve area determined by Doppler-echocardiography increased from 1.0 +/- 0.1 to 1.7 +/- 0.3 cm2 (p0.001) after valvuloplasty and decreased slightly to 1.5 +/- 0.2 cm2 (NS) during the follow-up. Left atrial chamber diameter did not change significantly after the procedure (5.2 vs. 5.0 cm). It is concluded that percutaneous mitral valvuloplasty is successful in 88% of all patients with severe, non calcified mitral stenosis. The clinical result seems to be beneficial and almost all patients had a stable follow-up for two years. Several complications during the procedure occurred in two patients (8%).

To assess the value of late potential recordings in predicting complex ventricular arrhythmias in chronic coronary heart disease, signal-averaged ECG and 24-h Holter were performed in 101 consecutive patients following coronary arteriography. In 69 of 101 patients, non-sustained ventricular tachycardia (VT) (22 patients) or monotopic or polytopic ventricular premature beats (VPB) (47 patients) were detected. When the different patient groups (VT, VPB, no arrhythmias) were compared, the parameters defining the late potentials demonstrated broad variability. Patients with non-sustained ventricular tachycardia showed a tendency to increased late potentials, though this tendency was not significant. In patients with pathologic late potentials the predictability of non-sustained ventricular tachycardia was only 38%. - It is therefore concluded that late potentials in patients with chronic coronary heart disease are not directly linked to the extent and severity of arrhythmias recorded in the ambulatory 24-h Holter.