AMD's architecture is better per watt, this is undisputed. If NV wants to beat the 6990 with their 590, they can't artificially cap their TDP to some predefined limit. As we can already see from the reviews, 2x 580s is around 10-15% faster than 1x6990 at 2560 res and around 10% faster at 3 monitor res. 2 x 580s also pull ~200W more than a 6990 [hardocp]. If NV lower the 590 core clocks too much to fit in the 375W "limit", they won't have a chance of matching the 6990. It will be interesting to see their approach.
As for noise, people who buy these cards are the top end of the enthusiast market, they will often water cool their rigs, so reference cooling isn't important as long as its sufficient.
One 6990 is overkill even at 2560 res in most games, including Metro if ppl turn off DoF. Don't even waste time with CF 6990 unless you eyeinfinity, IMO.