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Informed decision-making in patients with valvular disease

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.

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


  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. (2018).

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  3. Stone, G. W. et al. Transcatheter mitral valve repair in patients with heart failure. N. Engl. J. Med. (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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The author thanks Davide Schiavi (Alfieri Heart Foundation, Milan, Italy) for the help provided.

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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).

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