Pulmonary insufficiency: preparing the patient with ventricular dysfunction for surgeryBased, with permission, on the chapter by Bouzas-Zubeldia B and Gatzoulis MA. “Valvular Insufficiency and Heart Failure” to be published in Chang AC and Towbin JA (eds). Heart Failure in Children and Young Adults: From Molecular Mechanisms to Medical and Surgical Strategies. In press.

Insufficiency of any of the four cardiac valves is a common cause of heart failure in children. Progression of ventricular dysfunction can be predictable, but requires thorough understanding of valvar disease. In valvar regurgitation, the heart has to cope with an increased volume of blood. The pathophysiological sequence is similar for both the right and the left heart. There is initially an increase in end-diastolic volume, followed by an increase in end-systolic volume, and at the end, a decrease in the shortening and ejection fractions. Different compensatory mechanisms and pathophysiologic adaptations develop to maintain the stroke volume for each type of valvar insufficiency, but heart failure eventually ensues. When symptoms of heart failure develop, irreversible ventricular dysfunction is often established, and outcome after surgery may ultimately be compromised. Discerning the optimal time for intervention, before irreversible ventricular dysfunction develops, is a key point in the management of regurgitant valvar heart disease.