Valvular heart disease

In this Perspective article, Garg and colleagues discuss the evidence linking abnormal aortic flow patterns with adverse cardiovascular outcomes and describe how changes in aortic flow can be targeted by novel aortic valve interventions.

In this Review, Marsan et al. discuss the different clinical scenarios in which valvular heart diseases and cardiomyopathies coexist, either as the cause of one another or because of a common aetiology, to highlight the need for an improved classification of these diseases with potential repercussions in clinical management and personalized treatment.

Calcific aortic valve disease (CAVD) is a common disorder characterized by thickening, fibrosis and mineralization of the aortic valve leaflets. In this Review, Mathieu and colleagues summarize the risk factors, genetics and molecular mechanisms involved in CAVD and the implications for treatment of the condition.

In this Roadmap article, international experts summarize the evidence and provide consensus recommendations on the application of transcatheter aortic valve implantation in patients with bicuspid aortic valve anatomy in advance of the anticipated growth in the use of this procedure in this challenging cohort of patients.

Valvular heart disease (VHD) is a major contributor to loss of physical function, quality of life and longevity. In this Review, Prendergast and colleagues discuss the global burden of VHD, geographical variation in the presentation and clinical management, and temporal trends in disease burden.

Next-generation tissue-engineered heart valves (TEHVs) are a promising therapeutic option for patients with valvular heart disease. In this Review, Emmert and colleagues discuss the current heart valve replacement options, describe the design of TEHVs and summarize the data from preclinical and clinical studies on the use of TEHVs.

In this Review, Alfieri and colleagues focus on new concepts on mitral valve pathophysiology and patient risk profile assessment to guide the indication and timing of the management of mitral valve regurgitation. The authors also describe new imaging modalities and contemporary surgical and transcatheter techniques, highlighting the need for a multidisciplinary approach.

In this Consensus Statement, Garg and colleagues describe the current evidence on the use of cardiovascular magnetic resonance imaging for the assessment of mitral regurgitation, highlight its current clinical utility, and recommend a standardized imaging protocol and report.

This Review discusses the evolving indications of transcatheter aortic valve implantation (TAVI), including the latest clinical trials in young and low-risk patients with symptomatic severe aortic stenosis and ongoing studies exploring TAVI for other indications, including severe bicuspid aortic valve stenosis and pure native aortic regurgitation, highlighting procedural implications and caveats of new and future indications.

Infective endocarditis (IE) is not a common disease, but it has a poor prognosis. In this Review, contemporary findings concerning the epidemiology, diagnosis, therapeutic management and prevention of IE are highlighted, with a particular emphasis on innovations and changes in guidelines.

Tricuspid valve disease, particularly tricuspid regurgitation, is a highly prevalent condition with complex pathophysiology and long-term adverse consequences. In this Review, Rodés-Cabau and colleagues discuss the latest insights on the natural history and clinical and imaging assessment of tricuspid valve disease, highlighting the surgical management and emerging transcatheter therapies that are transforming clinical practice for this challenging disease.

Paravalvular leak (PVL) is a common complication after surgical prosthetic valve implantation. This Review details the role of cardiac imaging in the assessment and management of PVL, summarizes the clinical evidence for percutaneous closure of PVL and compares this procedure with surgical closure.

This Review summarizes the mechanisms of ectopic calcification processes in the cardiovascular system, with an emphasis on emerging knowledge obtained from advances in imaging methods, experimental models and multiomics-generated big data. This Review highlights the potential and challenges of artificial intelligence, machine learning and deep learning to integrate imaging and mechanistic data to identify biomarkers and effective treatments for cardiovascular calcification

This Review highlights the pathophysiology underlying changes in coronary blood flow and the role of functional assessment in patients with high-gradient, high-flow aortic stenosis. Michail and colleagues also discuss factors that influence the immediate and long-term consequences of stenosis treatment.

In this Perspectives article, Rodés-Cabau and colleagues discuss the evolving indications and future applications of transcatheter aortic valve implantation (TAVI). The steady improvement in prosthetic heart valves and the development of novel devices have enabled the continued expansion of TAVI indications, including the use of this procedure in low-risk patients or in aortic pathologies such as pure aortic regurgitation and bicuspid valve disease.

Multivalvular disease is common among patients with valvular disease, and has a complex pathophysiology. In this Review, Unger et al. discuss the mechanisms, diagnosis, and percutaneous and surgical treatment of multivalvular disease, focusing on the combinations of valve pathologies that are most often encountered in clinical practice.

Transcatheter aortic valve implantation (TAVI) is increasingly being used in patients with intermediate-risk and lower-risk profiles, but little is known about the durability of TAVI devices beyond 5 years. In this Review, Arsalan and Walther summarize the existing data on TAVI durability, highlight differences between surgical and transcatheter treatment of aortic stenosis that might influence durability, and discuss clinical solutions for failed prostheses.

Coronary artery disease (CAD) is common in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI), but its clinical relevance is controversial. In this Review, Danson et al. summarize the methods of assessing CAD in TAVI populations, and the data on the safety and efficacy of percutaneous coronary intervention in patients undergoing TAVI.

Transcatheter aortic valve implantation (TAVI) has become an important treatment option for aortic stenosis, even among younger patients, with similar rates of efficacy as compared with surgical valve replacement. However, complications including device failure persist; these can be addressed by surgical explantation and repeat TAVI. Ongoing research emphasizes the long-term potential of TAVI as an alternative to surgical intervention for aortic stenosis.

Calcific aortic valve disease and stenosis have a complex pathogenesis, and no therapies are available that can halt or slow their progression. In this Perspective, Narula and colleagues explore a possible relationship between amyloid deposition, calcification and the development of aortic valve stenosis.

Surgical mitral valve repair produces exceptional long-term survival, durable relief from mitral regurgitation, and physiological valve performance. Percutaneous mitral valve repair might prohibit subsequent surgical reconstruction. This finding has important implications, including for patient consent and clinical trial design. The objectives of mitral valve intervention must focus on life expectancy and long-term valve function.

Valve replacement is currently the only treatment for calcific aortic valve disease. Studies of an uncommon, genetic form of aortic valve disease have yielded in vitro and mouse models of the disease and a transcriptomic disease signature. Machine learning-driven screens for compounds that normalize this signature promise to enable medical management of aortic valve disease.

Strategies that replicate the living aortic valve’s biological sophistication are likely to translate into optimal long-term outcomes.

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.

In 2017, several high-impact studies in thrombosis were published. Refinements were made in the optimal therapy for patients with stable atherosclerosis or with atrial fibrillation undergoing percutaneous coronary intervention. Risk scores to determine duration of antiplatelet therapy were developed. The potential risk of subclinical valve leaflet thrombosis was identified.

The combination of oral anticoagulation and the antiplatelet drug clopidogrel increases the risk of bleeding after transcatheter aortic valve implantation (TAVI) compared with oral anticoagulation alone, according to the results of the POPular TAVI trial cohort B.

In the RECOVERY trial, asymptomatic patients with very severe aortic stenosis who underwent early surgery had lower risk of cardiovascular death than those treated using a conservative-care strategy.

The 2-year results of the MITRA-FR trial confirm the 1-year findings showing that addition of percutaneous mitral valve repair to medical treatment does not reduce the risk of death or hospitalization for heart failure compared with medical treatment alone in patients with heart failure and severe secondary mitral regurgitation

A new study shows that clonal haematopoiesis of indeterminate potential (CHIP)-driver mutations in DNMT3A or TET2 are associated with increased medium-term mortality in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation.

A new study reveals a developmental basis for mitral valve prolapse, caused by altered primary cilia-mediated regulation of extracellular matrix deposition during development, and suggests that mutations in primary cilia genes can be the cause of mitral valve prolapse in some patients.

The Evolut Low Risk trial and the PARTNER 3 trial both show that transcatheter aortic valve replacement is at least equivalent to surgery in terms of efficacy and safety for patients with severe aortic stenosis at low operative risk.