Surgical Implications of the 2025 ESC/EACTS Guidelines for the Management of Valvular Heart Disease: Key Recommendations Bridging Guidelines and Clinical Practice.

ACC/AHA 2008 Guideline Update on Valvular Heart Disease: Focused Update on Infective Endocarditis

2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: A proposal to optimize care for patients with valvular heart disease: A joint report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons

2019 AATS/ACC/ASE/SCAI/STS Expert Consensus Systems of Care Document: A Proposal to Optimize Care for Patients With Valvular Heart Disease: A Joint Report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and The Society of Thoracic Surgeons

Coronary Computed Tomographic Angiography Often Allows for the Avoidance of Invasive Coronary Angiography Before Transcatheter Aortic Valve Implantation.

Fool me once, shame on you; fool me twice, shame on me! A perspective on the emerging world of percutaneous heart valve therapy

Valvular Heart Disease in Pregnancy: Anticoagulation and the Role of Percutaneous Treatment

Introduction: Evidence for the gender gap in valvular heart disease (VHD) has been mixed. This study aimed to investigate the potential gender differences concerning distribution patterns, clinical characteristics, management and in-hospital outcomes of noteworthy VHD in the elderly Chinese population. Hypothesis: Gender disparities exist across the spectrum and management of valvular heart disease in elderly Chinese patients. Methods: The China Degenerative Valve Disease (China DVD) Cohort Study was conducted from October 2016 to December 2017 in 72 centers from China. It included prospectively 8923 patients aged ≥60 years with moderate to severe native VHD, infective endocarditis, or previous valve intervention. In-hospital outcomes after invasive treatments were evaluated by composite endpoint consisting of death, major bleeding and nonfatal stroke. Results: Of all the 8923 VHD patients, men accounted for 52.48%, with aortic regurgitation (AR; 13.2% vs. 6.5%) and aortic stenosis (AS; 5.8% vs. 3.8%) contributing more of the VHD diagnosis than women. By contrast, the proportion of women with mitral stenosis (MS; 4.8% vs. 1.8%) was much higher than men. While the rheumatic causes stayed significant in MS, a growing predominance of degenerative causes was detected regardless of gender in patients with aortic VHD and MR. Body mass index, history of smoking, hypertension, CHD, cardiomyopathy, aortic diseases and previous intervention were significantly higher in men whereas women were more frequently complicated with atrial fibrillation or atrial flutter. Concerning medical intervention, coronary angiography was used in 51.5% of male patients compared to 47.3% of female patients (p=0.01). Among the 2188 patients received invasive treatments, the prosthetic replacement was performed in 61% of women with AS in comparison to 47.2% of men with AS (p=0.006). Conversely, men with AR were more likely to receive prosthetic replacement than women (29.8% vs. 21.3%, p=0.008). No significant differences were found in patients with mitral VHD. Operative mortality was < 5% for single VHD. Multivariate regression analysis revealed an association between in-hospital outcomes and higher BMI as well as concomitant aortic disease regardless of gender. Conclusions: This study provides sex-specific data on characteristics and management of elderly Chinese patients with VHD. Pronounced sex-specific patterns were observed for aortic VHD and MS.

2012 ACCF/AATS/SCAI/STS Expert Consensus Document on Transcatheter Aortic Valve Replacement: Developed in collaboration with the American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Failure Society of America, Mended Hearts, Society of Cardiovascular Anesthesiologists, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance

Shared decision making is an emerging physician-patient interaction model for clinical practice [1]. Essentially, shared decision making implies that both the physician and the patient contribute to and bear responsibility for the clinical decision to be taken. It offers an alternative for the paternalistic model, in which it is the physician who informs the patient and proposes the decision to be made. Shared decision making emphasizes patient’s autonomy and recognizes the argumentation and preferences of the informed patient as valid elements in the decision process. Thus, it can dramatically influence the physician-patient relationship. E.g., in a given case, the choice for doing nothing as an alternative for pharmacotherapy could be considered as an acceptable outcome of the shared decision making process, while it could be considered as disobedient behavior of the patient in the paternalistic model. Clinical practice guidelines usually define a single best option in a given case [2]. Seen from this perspective, guidelines leave little freedom for the patient and reinforce the paternalistic model rather than shared decision making. Moreover, the shared decision making model is not universally preferred; numerous situations can be mentioned in which either patient or physician would prefer the paternalistic model [1]. Shared decision making is, however, particularly important when trade-offs between options strongly depend on individual preferences. This includes recommendations within guidelines for which the evidence is scarce or conflicting or for which there is more than one relevant treatment option that different individuals may value differently [2]. This explains why more and more recommendations for shared decision making appear in new guidelines. One of these guidelines is the 2012 version of the Guidelines on the Management of Valvular Heart Disease, by the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) [3], that reads, on page S9: “Finally, a decision should be reached through the process of shared decision-making, first by a multidisciplinary ‘heart team’ discussion, then by informing the patient thoroughly, and finally by deciding with the patient and family which treatment option is optimal”. Also the new 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease [4] mentions shared decision making several times. Amongst others, this guideline gives the following class I, level of evidence C recommendation: “The choice of valve intervention, that is, repair or replacement, as well as type of prosthetic heart valve, should be a shared decisionmaking process that accounts for the patient’s values and preferences, with full disclosure of the indications for and risks of anticoagulant therapy and the potential need for and risk of reoperation.” Also, in the AHA/ACC guideline, discussion of individual cases in a multidisciplinary ‘heart valve team’ is considered essential. Indeed, extra complexity in shared decision making can arise if multidisciplinary expertise is involved, e.g., cardiology and thoracic sugery in the case of cardiac valve disease. In the current issue of the Netherlands Heart Journal, Korteland and colleagues [5] present a survey among Dutch cardiologists and cardiac surgeons regarding their opinion on decision making in prosthetic aortic valve selection. A total of 117 physicians participated, 54 cardiothoracic surgeons (11 in training) and 63 cardiologists (7 in training), representing 38 % and 6 % of the Dutch cardiothoracic/cardiologist population, respectively. Most respondents agreed that patients should be involved in decision making, with surgeons leaning more toward patient involvement than cardiologists. Most respondents found that patients and doctors should decide together, with cardiologists leaning more toward taking the lead than surgeons. Physicians working in a centre with cardiac surgery were more inclined to decide together with the patient while physicians working in a centre without a cardiac surgery program more often preferred to take the lead in decision making. Shared decision making may not fit all forms of clinical practice, but it seems an appropriate approach in valve intervention, as underscored by the guidelines [3, 4]. It is not sure how much the study results of Korteland and colleagues [5] were influenced by selection bias. Assuming that selection bias is limited, their study suggests that shared decision making in prosthetic aortic valve selection is quite commonly performed in the Netherlands. The difference between the cardiologists’ and surgeons’ responses to the questionnaire remains puzzling. At the same time it is one main raison d'etre for the multidisciplinary heart team as recommended in the guidelines [3, 4].

Pregnancy heart team: A lesion-specific approach

Objective:To evaluate the evidence for common therapeutic controversies in the medical management of valvular heart disease (VHD).Data Sources:A literature search of PubMed (inception to December 2020) was performed using the terms angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and aortic stenosis (AS); and adrenergic β-antagonists and aortic valve regurgitation (AR) or mitral stenosis (MS).Study Selection and Data Extraction:Randomized controlled trials (RCTs) and meta-analyses conducted in humans and published in English that reported ≥1 clinical outcome were included.Data Synthesis:Nine articles were included: 3 RCTs and 1 meta-analysis for ACE inhibitors/ARBs in AS, 1 RCT for β-blockers in AR, and 4 RCTs for β-blockers in MS. Evidence suggests that ACE inhibitors/ARBs do not increase the risk of adverse outcomes in patients with AS but may delay valve replacement. β-Blockers do not appear to worsen outcomes in patients with chronic AR and may improve left-ventricular function in patients with a reduced ejection fraction. β-Blockers do not improve and may actually worsen exercise tolerance in patients with MS in sinus rhythm.Relevance to Patient Care and Clinical Practice:ACE inhibitors/ARBs and β-blockers can likely be safely used in patients with AS or AR, respectively, who have a compelling indication. There is insufficient evidence to recommend routine use of β-blockers in patients with MS without atrial fibrillation.Conclusions:Common beliefs about the medical treatment of VHD are not supported by high-quality data. There remains a need for larger-scale RCTs in the medical management of VHD.

Valvular heart disease (VHD) is the next epidemic in the cardiovascular field, affecting millions of people worldwide and having a major impact on health care systems. With aging of the population, the incidence and prevalence of VHD will continue to increase. However, VHD has not received the attention it deserves from both the public and policymakers. Despite important advances in the pathophysiology, natural history, management, and treatment of VHD including the development of transcatheter therapies, VHD remains underdiagnosed, identified late, and often undertreated with inequality in access to care and treatment options, and there is no medication that can prevent disease progression. The present review article discusses these gaps in the management of VHD and potential actions to undertake to improve the outcome of patients with VHD.

4B.3 Management of valvular heart disease in pregnancy

Valvular heart disease is a prevalent and clinically significant condition with potential complications and adverse outcomes if left untreated or poorly managed. Accurate assessment of valve structure, function and hemodynamics is crucial for effective evaluation and management of valvular heart disease. In this systematic review, we provide a comprehensive overview and comparison of imaging modalities used in the assessment of valvular heart disease. The introduction highlights the background and significance of valvular heart disease, emphasizing its impact on cardiovascular health, global prevalence, and associated complications. Furthermore, it emphasizes the importance of imaging modalities in the evaluation and management of valvular heart disease, discussing their role in providing crucial information for accurate diagnosis, risk stratification, treatment planning, and monitoring. The objective of this review article is to summarize the strengths, limitations and diagnostic accuracy of different imaging modalities in valvular heart disease assessment. We present detailed discussions on echocardiography, computed tomography (CT) imaging, nuclear imaging techniques and emerging imaging modalities, such as 3D echocardiography, strain imaging and fusion imaging. Each section explores the specific role of the imaging modality, its advantages, limitations and diagnostic accuracy in the evaluation of valvular heart disease. Additionally, we provide a comparative analysis of these imaging modalities, highlighting their strengths, weaknesses and specific indications. The integration of multiple imaging modalities for a comprehensive evaluation in specific scenarios is also discussed, emphasizing the complementary roles of different modalities in optimizing diagnostic accuracy and treatment planning. The review concludes with implications for clinical practice and future research directions. It underscores the importance of selecting the appropriate imaging modality or combination of modalities based on individual patient characteristics and clinical needs. Furthermore, it highlights the potential clinical impact of emerging imaging techniques and the need for standardization, cost-effectiveness studies, and further research to optimize the utilization of imaging modalities in valvular heart disease management. Bangladesh Heart Journal 2023; 39(1): 49–56

The assessment of myocardial function in the context of valvular heart disease (VHD) remains highly challenging (Galli et al. 2014). The myocardium deforms simultaneously in three-dimensions, and global left ventricular (LV) function parameters such as volume and ejection fraction may remain compensated despite alterations in myocardial deformation properties (Galli et al. 2014). In VHD, the decline in myocardial deformation parameters precedes the onset of symptoms and portends a poor outcome. Nevertheless, it has not been demonstrated that LV global longitudinal strain (GLS) has independent prognostic value in patients with VHD (Joint Task Force on the Management of Valvular Heart Disease, 2012) and GLS does not figure in current recommendations for the management of these patients (Joint Task Force on the Management of Valvular Heart Disease, 2012; Nishimura et al. 2014). The advent of novel tissue-tracking echocardiography techniques offers new opportunities for clinical identification of early abnormalities in LV function. In this issue of The Journal of Physiology, Hulshof et al. (2017) propose a new non-invasive measure of LV performance based on electrocardiographic estimates of simultaneous LV longitudinal deformation and volume. They present strain–volume loops evaluated throughout the cardiac cycle and have tested the value of this elegant index of LV function in 27 patients with aortic valve stenosis (AS) or aortic regurgitation (AR). These volume–strain loops were able to distinguish the haemodynamic cardiac impact of AS and AR. As yet, these results are preliminary only and much work remains to be done in order to demonstrate the advantages of this new approach over the assessment of LV longitudinal strain on its own (Russell et al. 2013; Vecera et al. 2016). LV pressure–strain loops (PSLs) are another interesting and closely related approach. Clinical use of the PSL has been limited by the need for instantaneous LV pressure recordings. However, non-invasive methods for acquiring these data have been developed (Russell et al. 2013; Boe et al. 2015). The reliability of PLS as an index of LV function has been validated in animal models and confirmed in preliminary studies conducted in cardiac resynchronization therapy (CRT) candidates and in patients with ischaemic heart disease (Urheim et al. 2005; Russell et al. 2012, 2013; Boe et al. 2015). An advantage of LV pressure–strain analysis is that it allows the estimation of regional and global LV work (quantified by calculating the rate of segmental shortening (strain rate) and multiplying it by instantaneous LV pressure). During LV ejection, work performed during segmental elongation represents energy loss, defined as negative work (NW), while work performed during segmental shortening represents positive work (PW). The dispersion of cardiac work may be expressed as a work wasted ratio (WWR) and calculated as NW/PW. Work efficiency (WE) evaluates the proportion of total work dissipated during systole and can be estimated as: (1 − NW)/(PW + NW) × 100% (Russell et al. 2012, 2013). This is a simple index of LV mechanical dispersion that is highly reproducible and has already been tested in several conditions (Haugaa et al. 2009, 2015). We have recently completed a preliminary assessment of PLS as an index of LV myocardial function in patients with severe AS and preserved LV ejection fraction (LVEF) undergoing aortic valve replacement (AVR) using echocardiographic data recorded at baseline and 1 year after the aortic valve replacement. LV pressure was estimated from an empiric, normalized reference curve adjusted according to the duration of the isovolumic and ejection phases, defined by mitral and aortic valve opening and closure times. Our preliminary results are consistent with those presented here by Hulshof et al. In marked contrast to LVEF, both strain–volume and strain–pressure-derived parameters distinguish the LV systolic properties of AS and AR patients clearly, and describe the changes of LV performances before and after AVR. Heart failure (HF) with preserved ejection fraction (a condition frequently found in patients who remain breathless following AVR) may be another interesting field of application of these newly introduced parameters. GLS alone has not proved to be an effective prognostic index in HF with preserved ejection fraction (Kraigher-Krainer et al. 2014; Shah et al. 2015), but it seems probable that strain–volume loops and/or pressure–volume loops could better describe intrinsic myocardial function in this setting. The findings presented by Hulshof et al. (2017) are very preliminary, but they encourage further research to determine the extent to which these promising new indices can be translated to everyday clinical practice. None declared. E.D. received a research grant from General Electric Healthcare.