Contemporary Presentation and Management of Valvular Heart Disease

Abstract

Background: Valvular heart disease (VHD) is an important cause of mortality and morbidity and has been subject to important changes in management. The VHD II survey was designed by the EURObservational Research Programme of the European Society of Cardiology to analyze actual management of VHD and to compare practice with guidelines. Methods: Patients with severe native VHD or previous valvular intervention were enrolled prospectively across 28 countries over a 3-month period in 2017. Indications for intervention were considered concordant if the intervention was performed or scheduled in symptomatic patients, corresponding to Class I recommendations specified in the 2012 European Society of Cardiology and in the 2014 American Heart Association/American College of Cardiology VHD guidelines. Results: A total of 7247 patients (4483 hospitalized, 2764 outpatients) were included in 222 centers. Median age was 71 years (interquartile range, 62–80 years); 1917 patients (26.5%) were ≥80 years; and 3416 were female (47.1%). Severe native VHD was present in 5219 patients (72.0%): aortic stenosis in 2152 (41.2% of native VHD), aortic regurgitation in 279 (5.3%), mitral stenosis in 234 (4.5%), mitral regurgitation in 1114 (21.3%; primary in 746 and secondary in 368), multiple left-sided VHD in 1297 (24.9%), and right-sided VHD in 143 (2.7%). Two thousand twenty-eight patients (28.0%) had undergone previous valvular intervention. Intervention was performed in 37.0% and scheduled in 26.8% of patients with native VHD. The decision for intervention was concordant with Class I recommendations in symptomatic patients with severe single left-sided native VHD in 79.4% (95% CI, 77.1–81.6) for aortic stenosis, 77.6% (95% CI, 69.9–84.0) for aortic regurgitation, 68.5% (95% CI, 60.8–75.4) for mitral stenosis, and 71.0% (95% CI, 66.4–75.3) for primary mitral regurgitation. Valvular interventions were performed in 2150 patients during the survey; of them, 47.8% of patients with single left-sided native VHD were in New York Heart Association class III or IV. Transcatheter procedures were performed in 38.7% of patients with aortic stenosis and 16.7% of those with mitral regurgitation. Conclusions: Despite good concordance between Class I recommendations and practice in patients with aortic VHD, the suboptimal number in mitral VHD and late referral for valvular interventions suggest the need to improve further guideline implementation.

Therapeutic Decision-Making and Outcomes in Elderly Patients With Severe Symptomatic Aortic Stenosis: Prognostic Implications of Elderly Patients' Initial Decisions

“…In this prospective cohort study detailing contemporary therapeutic decision-making and outcomes of elderly patients with severe symptomatic AS in a wide range of centers throughout mainland China, our key findings are as follows: (1) In current clinical practice, the decision against intervention was taken in about one-fifth of elderly patients with symptomatic severe AS, half of which were due to patients' subjective preferences. (2) Reduced LVEF and increased EuroSCORE-II were strongly associated with physicians' decisions to deny intervention, suggesting that surgical risk remained the primary concern for physicians when making therapeutic decisions.…”

“…Therapeutic Decision-Making and Outcomes in Elderly Patients With Severe Symptomatic Aortic Stenosis: Prognostic Implications of Elderly Patients' Initial Decisions INTRODUCTION Aortic stenosis (AS) is a common disease in the elderly, and its prevalence continues to rise as the population ages (1,2). There is a general consensus that aortic valve replacement (AVR) should be advised in patients with severe symptomatic AS (3,4).…”

Community-based aortic stenosis detection: clinical and echocardiographic screening during influenza vaccination

“…3 However, the diagnosis of AS remains challenging, despite it being the most common valvular heart disease (VHD) in the Western world. 7 Diagnosis of AS needs to be established early when the asymptomatic patient is well, decompensation has not taken place and intervention can be planned. Recent data, however, confirm that diagnosis of AS-affected patients is often missed, 8 and by the time of referral for intervention ~80% have severe symptoms and frequently impaired left ventricular (LV) function.…”

“… 3 However, the diagnosis of AS remains challenging, despite it being the most common valvular heart disease (VHD) in the Western world. 7 …”

A systematic review of patient baseline characteristics, procedural details and outcomes of combined transcatheter valvular interventions.

“…The European Society of Cardiology's (ESC) EORP-VHD II registry demonstrated that 24.9% of patients with valvular disease had multiple left-sided lesions. 2 Multi-valve procedures exhibit higher operative mortality than do single valve procedures, with a mortality rate that is double its counterpart. 3 The evaluation of multivalvular disease is di cult due to the misleading hemodynamic interactions of sequential valves on each other.…”