A “Watchful Surgery” Approach: Timing and Valve Choice for Mildly Symptomatic Mitral and Aortic Valve Disease

Author(s): Shaanali Mukadam, Chang Kon Kim, and Devendra K. Agrawal

The timing of surgical intervention and prosthesis selection in mildly symptomatic aortic and mitral valve disease remain an area of clinical uncertainty. Symptom-based referral often occurs after the onset of adverse ventricular remodeling, whereas earlier surgery may improve long-term outcomes but introduces procedural risk. This article synthesized contemporary evidence to delineate optimal strategies in this intermediate-risk population. In aortic stenosis, randomized trials including RECOVERY and AVATAR demonstrate that early surgical aortic valve replacement reduces heart failure events and may improve survival. In aortic and mitral regurgitation, observational data associate early intervention, triggered by mild symptoms or subclinical ventricular dysfunction, with improved survival and preservation of cardiac function. Emerging modalities such as global longitudinal strain and natriuretic peptide biomarkers enhance risk stratification in asymptomatic individuals. Prosthesis selection is primarily informed by patient age, comorbidity burden, and anticoagulation tolerance. Mechanical valves confer superior durability and lower reoperation risk in younger patients. Bioprosthetic valves are increasingly favored in older adults due to compatibility with transcatheter valve-in-valve reintervention and avoidance of lifelong anticoagulation. Comparative cohort studies and meta-analyses suggest a survival benefit for mechanical valves up to approximately 65-to-70 years of age, beyond which the benefit diminishes due to competing mortality risks. Evidence supports timely surgical referral in mildly symptomatic patients, particularly in the presence of early imaging or biomarker evidence of ventricular dysfunction. Individualized decision-making through multidisciplinary heart team evaluation remains essential. Further investigations are warranted to define long-term prosthetic durability and the role of early surgery in valvular regurgitation.