Pre‐operative detection of valvular heart disease

I read with interest the recent article on pre-operative detection of valvular heart disease by anaesthetists [1]. It is suggested that pre-operative cardiac auscultation by anaesthetists is only reasonable in patients over 40 years of age, and that murmurs in patients under the age of 40 never reflect valvular heart disease. I do not find this to be the case. Recently a 16-year-old girl presented for dental extractions under general anaesthesia. She was well and had a normal exercise tolerance but on cardiac auscultation had a loud systolic murmur. The echocardiogram confirmed moderate mitral regurgitation. Although this patient does not require valve surgery now, it is likely that she will in the future and she will now be followed up annually by the cardiologists. More importantly, she requires antibiotic prophylaxis for dental procedures. If I had failed to listen, I would not have routinely given antibiotics, and the current guidelines insist on their administration for prophylaxis of endocarditis. Anyone who has seen bacterial endocarditis in a young person is reminded of the devastation it can cause. Valvular heart disease is not the only cause of murmurs in young patients. Other cardiac lesions such as ventricular septal defects are just as important to diagnose and also require prophylaxis against endocardits. One's choice of anaesthetic agents may not be affected by identifying a murmur in an asymptomatic patient and it may not be necessary to delay surgery. However, antibiotic prophylaxis is relevant and cardiology follow-up for patients with cardiac lesions is important. I am a clinician, not a technician, and I will continue to listen to all my patients prior to surgery!