Beta-blockade for mitral regurgitation: could the management of valvular heart disease actually be moving into the 21st century?

Severe valvular heart disease comprises a group of lesions that impose a hemodynamic burden on potentially all 4 cardiac chambers. This burden is eventually fatal if left untreated by timely valve repair or valve replacement. However, defining the word timely is fraught with uncertainty. Ideally, the procedure should occur early enough to spare the patient from irreversible left or right ventricular (and atrial) dysfunction, or both, and certainly from sudden death, but should be delayed long enough to reduce timedependent complications inherent to valve prostheses if valve repair is impossible to perform. Remarkably, in 2012, in the midst of a wealth of scientific tools available in other medical realms, deciding on the “golden moment” for valvular intervention rests on tools that are at least 50 years old: the presence of cardiac symptoms, increased heart size, ejection performance, evidence of pulmonary hypertension, or a combination thereof (1). To be sure, modern imaging techniques can give us precise measurements of lesion severity, of the size and function of the cardiac chambers, of pulmonary pressure, and of regional and global wall motion.