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Deciding who should receive maximal technological treatment options and who should not represents an ethical, moral, psychological and medico-legal challenge for health care providers. Especially in patients with chronic heart failure, the ethical and medico-legal issues associated with providing maximal possible care or withholding the same are coming to the forefront. Procedures, such as cardiac transplantation, have strict criteria for adequate candidacy. These criteria for subsequent listing are based on clinical outcome data but also reflect the reality of organ shortage. Lack of compliance and non-adherence to lifestyle changes represent relative contraindications to heart transplant candidacy. Mechanical circulatory support therapy using ventricular assist devices is becoming a more prominent therapeutic option for patients with end-stage heart failure who are not candidates for transplantation, which also requires strict criteria to enable beneficial outcome for the patient. Physicians need to critically reflect that in many cases, the patient’s best interest might not always mean pursuing maximal technological options available. This article reflects on the multitude of critical issues that health care providers have to face while caring for patients with end-stage heart failure.

This chapter will address the question: Does the presence of coronary atherosclerosis (CAD) affect the outcome of valvular replacement surgery, and if so, how and why?

Compared to single valve replacement, combined aortic and mitral replacement represents a major technical challenge, as it theoretically increases the possibility of early and late valve-related complications and is usually performed in the setting of the myocardial dysfunction of chronic multivalvular heart disease. The entire experience with 121 patients undergoing double valve replacement (DVR) at Cedars-Sinai Medical Center between 1969 and 1982 forms the basis of this report.

Use of the ST. JUDE MEDICAL® cardiac valve was begun as a limited trial in high-risk subsets of valve recipients in March 1978. As of March 1984, we have implanted 442 valves in 382 patients. There has been increasing clinical utilization of this prosthesis in many other centers since the valve’s FDA approval. However, the responsibility of the original clinical investigators is to continually review and analyze the experience with the earliest recipients of this prosthesis to address the as yet unanswered question about its long-term durability. Accordingly, we recently analyzed the clinical results of our patients with a maximum of 5 years follow-up and a minimum of one year follow-up.