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VALVULAR DISEASE IN 2018

Informed decision-making in patients with valvular disease

Nature Reviews Cardiology volume 16, pages 81–82 (2019)Cite this article

Subjects

A number of papers published in 2018 have provided important information expected to influence clinical practice, particularly for the management of functional mitral regurgitation in patients with heart failure caused by ischaemic or non-ischaemic cardiomyopathy and for the treatment of severe aortic stenosis in patients at low surgical risk.

Key advances

  • Functional mitral regurgitation (MR) should not be regarded merely as a marker of severity of heart failure (HF), but also as having an active role in the progression of HF1.

  • The most relevant adverse prognostic effect of severe MR seems to be in a subcohort of patients with intermediate HF phenotype; in patients with advanced remodelling, functional MR is no longer of prognostic relevance1.

  • The results of the MITRA-FR and COAPT trials should be interpreted as being complementary rather than contradictory2,3.

  • The prognostic benefit of the MitraClip procedure is clearly apparent in patients with moderate-to-severe or severe MR in whom the left ventricle is not too dilated2,3.

  • In patients at low surgical risk with severe aortic stenosis, TAVR seems to be associated with increased mortality; SAVR should for now remain the treatment of choice for these patients4.

The combination of heart failure (HF) and secondary or functional mitral regurgitation (MR) is not uncommon in patients with ischaemic or non-ischaemic cardiomyopathy. The prevalence of this combination is expected to grow in the future with the ageing of the population. In this clinical context, MR is not related to the abnormal morphology of the valve but to changes in the geometry and function of the left ventricle, resulting in progressive dilatation with dislocation of the papillary muscles, tethering of the mitral leaflets, dilatation and/or flattening of the mitral annulus, dyssynchrony in contraction and reduced closing forces. According to previous studies, functional MR in patients with HF is associated with increased symptoms of HF and hospitalization rates, as well as worse long-term prognosis. The unfavourable prognostic effect of MR is stronger when the incompetence of the valve is severe. However, whether functional MR is a driving force for the progression of HF or instead a bystander reflecting the severity of the disease remains debated. Considering the substantial efforts currently being undertaken to reduce functional MR in patients with chronic HF in the hope of improving prognosis, this question is clearly of great relevance. Given the lack of solid data, the 2017 European and US guidelines for the management of valvular heart disease are both rather tepid in recommending correction of severe functional MR when concomitant coronary revascularization is not indicated (recommendation class IIb).

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Fig. 1: Long-term mortality according to severity of mitral regurgitation.

References

  1. Goliasch, G. et al. Refining the prognostic impact of functional mitral regurgitation in chronic heart failure. Eur. Heart J. 39, 39–46 (2018).

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  2. Obadia, J. F. et al. Percutaneous repair or medical treatment for secondary mitral regurgitation. N. Engl. J. Med. https://doi.org/10.1056/NEJMoa1805374 (2018).

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  3. Stone, G. W. et al. Transcatheter mitral valve repair in patients with heart failure. N. Engl. J. Med. https://doi.org/10.1056/NEJMoa1806640 (2018).

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  4. Witberg, G. et al. Transcatheter versus surgical aortic valve replacement in patients at low surgical risk: a meta-analysis of randomized trials and propensity score matched observational studies. Catheter. Cardiovasc. Interv. 92, 408–416 (2018).

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Acknowledgements

The author thanks Davide Schiavi (Alfieri Heart Foundation, Milan, Italy) for the help provided.

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Authors and Affiliations

  1. Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy

    Ottavio Alfieri

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  1. Ottavio Alfieri
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Correspondence to Ottavio Alfieri.

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The author declares no competing interests.

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Alfieri, O. Informed decision-making in patients with valvular disease. Nat Rev Cardiol 16, 81–82 (2019). https://doi.org/10.1038/s41569-018-0146-1

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  • DOI: https://doi.org/10.1038/s41569-018-0146-1

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