Management Of Valvular Heart Disease Research Articles

TAVI : histoire et perspectives

Nearly 20 years have passed from the concept to clinical development of percutaneous aortic valve replacement, starting from an idea considered "stupid" of Professor Alain Cribier in Rouen. After a first phase of compassionate implantation, large randomized trials PARTNER and COREVALVE US have allowed TAVI to impose itself in the European and American recommendations in patients inoperable or considered with high surgical risk. Next European recommendations on the management of valvular heart diseases expected in 2017 should take into account the positive results observed in intermediate risk patients in the PARTNER 2 and SURTAVI studies, recently adopted in the US recommendations. Randomized trials in "all coming" patients are already on their way, and the future of TAVI is to be the reference treatment for a vast majority of patients with aortic stenosis.

Valvular Heart Disease in Heart Failure

Structural valvular heart disease may be the cause of heart failure or may worsen the clinical status of patients with heart failure. Heart failure may also develop in patients treated with valve surgery. Patients with heart failure with valvular heart disease are at increased risk of events including sudden cardiac death. Before considering intervention (surgical or percutaneous) all patients should receive appropriate medical and device therapy taking into account that vasodilators must be used with caution in patients with severe aortic stenosis. Numerous percutaneous and/or hybrid procedures have been introduced in the past few years and they are changing the management of valvular heart disease. In patients with heart failure and valvular heart disease, either primary or functional, the whole process of decision-making should be staged through a comprehensive evaluation of the risk– benefit ratio of different treatment strategies and should be made by a multidisciplinary ‘heart team’ with a particular expertise in valvular heart disease. The heart team should include heart failure cardiologists, cardiac surgeons/structural valve interventionists, imaging specialists, anaesthetists, geriatricians and intensive care specialists. This article will review recent developments and distill practical guidance in the management of this important heart failure co-morbidity.

The implications of HIV infection on the management of valvular heart disease in Southern Africa

There is very limited information on the disease profile and treatment approaches in HIV patients with valvular heart disease (VHD) in developing countries. HIV infection impacts on patients with VHD in three settings: HIV/Aids as a comorbid disease in patients with underlying valve disease, infective endocarditis secondary to immunosuppression, and non-infective valve involvement from myocardial failure or from marantic endocarditis. The clinical presentation of infective endocarditis does not differ between HIV and non-HIV patients, with the exception that intravenous drug abuse is a common cause in specific populations. While peri-operative mortality and morbidity is high in acute infective endocarditis, surgical interventions do not increase the postoperative risk for complications or death and should therefore not be withheld. There is also little evidence to suggest that HIV or antiretroviral drugs increase the rate of cardiac-related pregnancy complications or that pregnancy may alter the course of HIV infection. Since antiretroviral therapy has been associated with considerable improvement in clinical status prior to surgery, as well as in long term outcomes, all patients with valve disease in whom intervention is likely should undergo HIV testing and staging so that highly active antiretroviral treatment (HAART) may be instituted timeously. Conclusion: The high prevalence of HIV in our population makes consideration of this comorbidity an essential facet in the routine evaluation and management of patients with VHD. There is solid evidence that these patients do no worse than non-HIV patients undergoing medical treatment or percutaneous/surgical intervention – open-heart surgery may be offered safely to patients with HIV if proper precautions are taken.

Characteristics, aetiological spectrum and management of valvular heart disease in a Tunisian cardiovascular centre

Valvular heart diseases occur frequently in Tunisia, but no precise statistics are available. To analyse the characteristics of patients with abnormal valvular structure and function, and to identify the aetiological spectrum, treatment and outcomes of valvular heart disease in a single cardiovascular centre in Tunisia. This retrospective study included patients with abnormal valvular structure and function, who were screened by transthoracic echocardiography at a single cardiology department between January 2010 and December 2013. Data on baseline characteristics, potential aetiology, treatment strategies and discharge outcomes were collected from medical records. There were 959 patients with a significant valvular heart disease (mean age 53±17years; female/male ratio 0.57). Valvular heart disease was native in 77% of patients. Mitral stenosis was the most frequent lesion (44.1%), followed by multiple valve disease (22.3%). Rheumatic origin (66.6%) was the most frequent aetiology, followed by degenerative (17.2%) or ischaemic (8.1%) causes, endocarditis (1.4%) and congenital (0.9%) causes. Native valve disease was severe in 589 patients (61.4%). Percutaneous mitral balloon valvuloplasty was performed in 36.9% of patients with mitral stenosis. Among patients with severe valvular heart disease, surgical treatment was indicated for 446 (75.7%) patients. Only 161 (36.1%) patients were finally operated. Postoperative mortality was 13.6% for all valvular heart diseases. This retrospective study has shown that the main cause of valvular heart disease in Tunisia is rheumatic fever. Mitral stenosis and multiple valve disease are the most frequent valvular heart diseases in Tunisia. Percutaneous mitral balloon valvuloplasty and prosthetic valve replacement are the preferred treatment methods for valvular heart disease.

Minimally Invasive Surgical Mitral Valve Repair: State of the Art Review.

Minimally invasive surgical mitral valve repair (MVRepair) has become routine for the treatment of mitral valve regurgitation, and indications have been expanded to include reoperations. Current European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines for the management of valvular heart disease recommended standards in terms of mitral valve disease differentiation, timing of intervention and surgical techniques to improve patient care. Numerous minimally invasive techniques to lessen the invasiveness have been described, such as the minimal-access J-sternotomy (ministernotomy), the parasternal incision, the port-access technique and the right minithoracotomy. Despite the development of catheter-based techniques, surgical repair remains the gold standard today for nearly all patients with degenerative valvular diseases and the majority of patients with other types of valvular diseases. Techniques include resection of the prolapsed segment, neo-chordae implantation and ring annuloplasty. In this review, the current indications for mitral valve surgery are summarised and state-of-the-art MVRepair techniques are highlighted.

Transcatheter aortic valve implantation in 2015.

The last decade has seen transcatheter aortic valve implantation (TAVI) emerge as the standard of care for patients with severe symptomatic aortic stenosis deemed to be either at excessive- or high-risk for surgical aortic valve replacement (SAVR). This position is supported by three important multicentre randomized trials comparing TAVI to the historical gold standard therapies: (1) The Placement of AoRTic TraNscathetER Valve Trial Edwards SAPIEN Transcatheter Heart Valve (PARTNER) IB Trial compared TAVI (Edwards SAPIEN, Edwards Lifesciences Inc., Irvine, CA) to optimal medical therapy in patients at excessive surgical risk, and demonstrated an absolute mortality reduction of > 20% at 1-year, an effect that was maintained out to 5-year follow-up;[1] (2) The PARTNER 1A Trial compared TAVI (Edwards SAPIEN, Edwards Lifesciences Inc., Irvine, CA) and SAVR in patients at high operative risk, and found no significant differences in either clinical outcomes or valve function at five years;[2] (3) The CoreValve (CoreValve, Medtronic Inc., Minneapolis, MN) U.S. Pivotal Trial compared TAVI and SAVR, and demonstrated significantly reduced mortality among patients treated percutaneously (22.2%), compared to those treated with SAVR (28.6%; log-rank test P < 0.05) at two years.[3] These strong data have resulted in TAVI being used in hundreds of thousands of patients worldwide,[4] and incorporated into the guidelines for the management of valvular heart disease from both the European Society of Cardiology and the American Heart Association / American College of Cardiology.[5],[6]

Morphology, Clinicopathologic Correlations, and Mechanisms in Heart Valve Health and Disease.

The clinical and pathological features of the most frequent intrinsic structural diseases that affect the heart valves are well established, but heart valve disease mechanisms are poorly understood, and effective treatment options are evolving. Major advances in the understanding of the structure, function and biology of native valves and the pathobiology, biomaterials and biomedical engineering, and the clinical management of valvular heart disease have occurred over the past several decades. This communication reviews contemporary considerations relative to the pathology of valvular heart disease, including (1) clinical significance and epidemiology of valvular heart disease; (2) functional and dynamic valvular macro-, micro- and ultrastructure; (3) causes, morphology and mechanisms of human valvular heart disease; and (4) pathologic considerations in valve replacement, repair and, potentially, regeneration of the heart valves.

Heart valve health, disease, replacement, and repair: a 25-year cardiovascular pathology perspective.

The past several decades have witnessed major advances in the understanding of the structure, function, and biology of native valves and the pathobiology and clinical management of valvular heart disease. These improvements have enabled earlier and more precise diagnosis, assessment of the proper timing of surgical and interventional procedures, improved prosthetic and biologic valve replacements and repairs, recognition of postoperative complications and their management, and the introduction of minimally invasive approaches that have enabled definitive and durable treatment for patients who were previously considered inoperable. This review summarizes the current state of our understanding of the mechanisms of heart valve health and disease arrived at through innovative research on the cell and molecular biology of valves, clinical and pathological features of the most frequent intrinsic structural diseases that affect the valves, and the status and pathological considerations in the technological advances in valvular surgery and interventions. The contributions of many cardiovascular pathologists and other scientists, engineers, and clinicians are emphasized, and potentially fruitful areas for research are highlighted.

2012 European guidelines on the management of valvular heart disease: what's new?

2012 European guidelines on the management of valvular heart disease: what's new?

Guidelines on the management of valvular heart disease (version 2012). 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)

Guidelines on the management of valvular heart disease (version 2012). 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)

Role of Imaging Techniques in Percutaneous Treatment of Mitral Regurgitation

Mitral regurgitation is the most prevalent valvular heart disease in the United States and the second most prevalent in Europe. Patients with severe mitral regurgitation have a poor prognosis with medical therapy once they become symptomatic or develop signs of significant cardiac dysfunction. However, as many as half of these patients are inoperable because of advanced age, ventricular dysfunction, or other comorbidities. Studies have shown that surgery increases survival in patients with organic mitral regurgitation due to valve prolapse but has no clinical benefit in those with functional mitral regurgitation. In this scenario, percutaneous repair for mitral regurgitation in native valves provides alternative management of valvular heart disease in patients at high surgical risk. Percutaneous repair for mitral regurgitation is a growing field that relies heavily on imaging techniques to diagnose functional anatomy and guide repair procedures.

Papel de las técnicas de imagen en el tratamiento percutáneo de la insuficiencia mitral

Mitral regurgitation is the most prevalent valvular heart disease in the United States and the second most prevalent in Europe. Patients with severe mitral regurgitation have a poor prognosis with medical therapy once they become symptomatic or develop signs of significant cardiac dysfunction. However, as many as half of these patients are inoperable because of advanced age, ventricular dysfunction, or other comorbidities. Studies have shown that surgery increases survival in patients with organic mitral regurgitation due to valve prolapse but has no clinical benefit in those with functional mitral regurgitation. In this scenario, percutaneous repair for mitral regurgitation in native valves provides alternative management of valvular heart disease in patients at high surgical risk. Percutaneous repair for mitral regurgitation is a growing field that relies heavily on imaging techniques to diagnose functional anatomy and guide repair procedures.Full English text available from:www.revespcardiol.org/en

Proportion of patients in the Uganda rheumatic heart disease registry with advanced disease requiring urgent surgical interventions.

Since the establishment of the Uganda Rheumatic Heart Registry, over 900 patients have been enrolled. We sought to stratify the patients in the registry according to disease severity and optimal management strategy. We reviewed data of 618 patients who had enrolled in the Registry between March 2010 and February 2013. The 67 patients who had died were excluded leaving 551 patients who were recruited. The optimum management strategy was determined according to the 2012 European Society of Cardiology guidelines on the management of valvular heart disease. Out of the 551 patient's records evaluated, 398 (72.3%) required invasive intervention, with 332(60.3%) patients requiring surgery and 66 (12.0%) requiring percutaneous mitral commissurotomy (PMC). This leaves only 27.7% of patients who required only medical management. Currently, majority of the patients (498, 90.4%) in the registry are on medical treatment. Of the 60.3% requiring surgical intervention, only 8.0% (44 patients) underwent valvular surgery and 5(1.0%) patients of the 66 (12.0%) underwent PMC successfully. There is a high proportion of patients with severe disease that require surgical treatment yet they cannot access this therapy due to absence of local expertise.

Transition to palliative care when transcatheter aortic valve implantation is not an option: opportunities and recommendations.

Purpose of reviewTranscatheter aortic valve implantation (TAVI) is the recommended treatment for most patients with symptomatic aortic stenosis at high surgical risk. However, TAVI may be clinically futile for patients who have multiple comorbidities and excessive frailty. This group benefits from transition to palliative care to maximize quality of life, improve symptoms, and ensure continuity of health services. We discuss the clinical determination of utility and futility, explore the current evidence guiding the integration of palliative care in procedure-focused cardiac programs, and outline recommendations for TAVI programs.Recent findingsThe determination of futility of treatment in elderly patients with aortic stenosis is challenging. There is a paucity of research available to guide best practices when TAVI is not an option. Opportunities exist to build on the evidence gained in the management of end of life and heart failure. TAVI programs and primary care providers can facilitate improved communication and processes of care to provide decision support and transition to palliative care.SummaryThe increased availability of transcatheter options for the management of valvular heart disease will increase the assessment of people with life-limiting conditions for whom treatment may not be an option. It is pivotal to bridge cardiac innovation and palliation to optimize patient outcomes.

The role of biomarkers as an alternative and completion of the diagnostic and therapeutic pathway in patients with aortic stenosis

Aortic stenosis (AS) is the most frequent type of valvular heart disease. Clinically, it presents as calcific and congenital AS. Calcific AS is often age dependent and affects 2–7% of people over 65 years of age. Many clinical studies proved high correlation between age and the prevalence of calcific aortic stenosis. According to todays’ knowledge, AS presents not only as simple degenerative disease of the valve, but as an active inflammatory and proliferative process. Better control and evaluation of risk factors might decelerate progression of the disease. It is necessary to increase the knowledge about risk factors and early markers of AS. Echocardiography is the method of choice in the diagnostic course and evaluation of stenosis grade and disease progression, but the role of biomarkers is becoming more and more significant among the clinical evaluation of patients and has been already mentioned in The European Society of Cardiology (ESC) guidelines on the management of valvular heart disease in patients qualified for Aortic Valve Replacement (AVR) with severe, asymptomatic AS, preserved ejection fraction and normal exercise stress test results. The natriuretic peptides level increase at the follow-up measurements is an important co-factor in decision-making. This review article analyses and summarizes the most important research and correlation between calcific aortic valve disease and the biomarkers. The potential clinical implementation of fourteen biomarkers has been reviewed. Echocardiography depends on the operator experience and imaging quality, therefore biomarkers could contribute important information to patients’ diagnosis and follow-up.

0325: Prognosis of cardiac valve interventions among indigenous populations: a retrospective cohort study in New Caledonia

Data on the management of valvular heart disease is scarce in the Pacific, a region where rheumatic heart disease remains endemic. Were included patients presenting to the single tertiary centre in New Caledonia and who underwent heart valve surgery for the first time (2005-2010). Clinical, echocardiographic, surgical data and outcomes were collected in 2013. We explored potential factors associated with major cardiovascular events as a composite endpoint. Among the 180 patients included, 95 (52.8%) were male; mean age was 48.2 years (±19.3). 124 (78.9%) were Pacific islanders, 122 (70.9%) presented in heart failure (70.9%) and 125 (69.4%) had rheumatic heart disease. 84 patients (46.7%) received a mechanical prosthetic valve. Median follow-up was 4.7 years (IQR 3.5-6.7). Early postoperative mortality rate was of 2.8%. The incidence of annual mortality was 31.75‰ (95% CI 19.77-43.72) (including 25.78‰ cardiovascular death; 95 CI 15.01-36.55). The annual incidences of stroke and severe bleeding were 38.23‰ (95% CI 24.07-52.39) and 36.54‰ (95% CI 22.49-50.58), respectively. We did not identify factors associated with outcomes according to the aetiology (rheumatic heart disease versus other) or the procedure (mechanical prosthetic valve versus other). In the Pacific heart valve interventions are mainly performed in young patients with underlying rheumatic heart disease. Post-operative mortality is low but morbidity remains high

Systolic BP Targets Should Probably Be Higher in Early Aortic Stenosis

ORLANDO — Optimal blood pressure in patients with asymptomatic mild to moderate aortic stenosis is 140–159 mm Hg for systolic and 70–89 mm Hg for diastolic, according to an analysis of all-cause mortality in the world's largest data set of such patients with longitudinal follow-up and endpoint evaluation. Within those target blood pressure ranges, the nadir in terms of all-cause mortality is about 145/82 mm Hg, Kristian Wachtell, MD, PhD, reported at the American Heart Association scientific sessions. He presented an analysis of 1,873 asymptomatic patients with mild to moderate aortic stenosis (AS) and a peak aortic-jet velocity of 2.5–4.0 m/s upon enrollment in the Simvastatin Ezetimibe in Aortic Stenosis (SEAS) trial. SEAS was a double-blind, multicenter study in which participants were randomized to 40 mg of simvastatin plus 10 mg of ezetimibe per day or placebo and followed for a mean of 4.3 years. Half of them had a history of hypertension at baseline. As previously reported (N Engl J Med 2008;359:1343–56), SEAS was a negative trial. Lipid-lowering therapy didn't affect AS progression or aortic valve–related outcomes. On the plus side, the SEAS cohort is the world's largest population of patients with asymptomatic AS followed prospectively for clinical endpoints, noted Dr. Wachtell of Oslo University. 'I think it's most likely that for blood pressure, one size does not fit all. ... The extent of target organ damage ... warrants a different level of blood pressure.' He and his coinvestigators decided to plot all-cause mortality vs. average blood pressure in the SEAS cohort because of the paucity of data regarding blood pressure and antihypertensive therapy in patients with asymptomatic AS. Neither the 2014 ACC/AHA guidelines for management of valvular heart disease (Circulation 2014;129[23]:e521–643) nor the European guidelines provide recommendations for optimal blood pressure targets in patients with asymptomatic AS, even though AS is the third most common cardiac disease, behind hypertension and coronary artery disease. Moreover, nearly 100,000 aortic valve replacements are done per year in the United States as a consequence of AS. And AS and hypertension go hand in hand, with the prevalence of hypertension among patients with AS cited as 50% or more in multiple studies, the cardiologist continued. In a multivariate analysis adjusted for aortic valve area index and peak velocity, heart failure, myocardial infarction, and aortic valve replacement during follow-up, all-cause mortality showed a U-shaped relationship with blood pressure. A systolic blood pressure below 120 mm Hg was associated with a 5-fold increased risk of mortality, a systolic of 120–139 mm Hg carried a 1.5-fold increased risk, and a diastolic blood pressure of 90 mm Hg or more was associated with a 1.9-fold increased risk. “Patients with low systolic blood pressure had an increased mortality risk and should probably undertake individual clinical assessment for blood pressure control and evaluation of their AS,” Dr. Wachtell said. The first question audience members asked was, “What about SPRINT?” The SPRINT trial, presented elsewhere at the meeting, was a practice-changing study that was the talk of the conference. It redefined the systolic blood pressure treatment target as less than 120 mm Hg instead of less than 140 mm Hg in hypertensive patients (N Engl J Med 2015;373:2103–16). “I think it's most likely that for blood pressure, one size does not fit all,” Dr. Wachtell replied. “The extent of target organ damage — and you could say that aortic stenosis is actually target organ damage, like atrial fibrillation or left ventricular hypertrophy — warrants a different level of blood pressure.” He added, however, that the SEAS analysis was based on observational data, and that's a limitation. “This is a qualified guess as to what blood pressures should be in patients with aortic stenosis,” he cautioned. Dr. Wachtell reported having no conflicts of interest regarding his presentation. Bruce Jancinis with the Denver bureau of Frontline Medical News.

An approach to the diagnosis and management of valvular heart disease.

Valvular heart disease poses a common yet difficult problem in everyday clinical practice. A thorough clinical evaluation with basic common investigations such as an electrocardiogram (ECG) and a chest radiograph (CXR) remains the cornerstone of diagnosis. Echocardiography and more invasive testing, if needed, are usually performed at specialist level to confirm the diagnosis, assess severity and assist in definitive decision-making.The causes and clinical, ECG and CXR features of the common valve lesions are described. Patients with symptomatic valve lesions should be referred for specialist assessment. In most cases, medical therapy serves as a bridge to definitive mechanical or surgical therapy.

Tips and tricks to implant a MitraClip in a patient with previous surgical closure of atrial septal defect

Percutaneous edge-to-edge mitral valve repair using the MitraClipdevicehasevolvedasanewtoolfortreatmentofmitralvalveregurgita-tion (MVR). The first randomized controlled trial (EVEREST II) com-pared the standard surgical repair/replacement of mitral valve versuspercutaneous repair by MitraClip and demonstrated its superior safetycomparedtosurgicalprocedure,withinferiorefficacyinMVRreduction,but similar improvements in clinical outcomes at 4 years follow-up [1].The guidelines [2,3] on the management of valvular heart disease, pub-lished in 2012 and 2014, suggested to consider percutaneous edge-to-edge mitral valve repair in patients with symptomatic severe MR, con-sidered inoperable or at high surgical risk by “heart team” and thathave a reasonable life expectancy (Class IIb). Percutaneous edge-to-edge mitral valve repair by MitraClip device using trans-septal leftheartcatheterization[4] isbecomingafirst-line treatmentfor function-alMR,whenanatomicalfeaturesaresuitable.Infact,thesepatientsusu-ally show a higher surgical risk and hospital mortality and a longerhospital stay than degenerative MR [5].We describea rarecaseof a61-year-oldmanwithsevere functionalMR, idiopathic dilatative cardiomyopathy and low ejection fraction(30%), in which the MitraClip implantation was very demanding. Healso had arterial hypertension, chronic renal failure on dialysis, moder-ate pulmonary hypertension and previous surgical closure of atrialseptum defect with direct suture. He underwent to automatedcardioverter defibrillator implantation in primary prevention and wasreferred to our hospital for a severe MVR in functional Class IV NYHA.The patient's anterior chest wall revealed a well healed sternotomyscar. The results of his laboratory analysis, including metabolic profileand complete blood count, were normal, with the exception of serumcreatinineandpro-BNPlevelsthatwereelevated.TheECGshowednor-mal sinus rhythm at 78 bpm. The trans-thoracic echocardiogramshowedanincreased diameter of theleft atrium and ventricle with dif-fuse hypokinesia and severe reduction of left ventricular systolic func-tion (Simpson ejection fraction 30%); thickening of the mitral valveleaflets, annulus and subvalvular apparatus and increased diameters oftherightsectionswithslightreductionofrightventricularsystolicfunc-tion (TAPSE 14mm). The color-Doppler demonstrated a severe MR (jetarea 11 cm

Management of valvular disease in pregnancy: a global perspective.

Valvular heart disease (VHD) in pregnant women, whether due to congenital or acquired aetiologies, poses a challenge to clinicians and their patients. Significant valve disease, which can affect a single valve or several valves, increases the risk of pregnancy to the mother and foetus and requires a careful preconception risk assessment and, subsequently during pregnancy, specialized care to minimize maternal and foetal morbidity and mortality. The goal of this paper is to provide a guide to risk assessment and to give an overview of the optimal cardiac and obstetric management, including surgical intervention, taking into consideration the resources available in higher and lower-to-middle income countries. This manuscript provides a practical approach and is not replacing comprehensive guidelines on the management of VHD or cardiovascular disease in pregnancy. It focuses on common valvular diseases and does not cover the large variety of aortic disease with and without valve disease or complex congenital heart disease in detail.