doi:10.1002/ejhf.2918
Acuteheartfailureandvalvularheartdisease: AscientificstatementoftheHeartFailure Association,theAssociationforAcute CardioVascularCareandtheEuropean AssociationofPercutaneousCardiovascular InterventionsoftheEuropeanSociety
ofCardiology
OvidiuChioncel1,2*,MariannaAdamo3*,MariaNikolaou4,JohnParissis5, AlexandreMebazaa6,MehmetBirhanYilmaz7,ChristianHassager8, BrendaMoura9,JohannBauersachs10,Veli-PekkaHarjola11,Elena-LauraAntohi1,2 , TuviaBen-Gal12,SeanP.Collins13,VladAntonIliescu1,2,MagdyAbdelhamid14 , Jelena ˇ Celutkien ˙ e15,StamatisAdamopoulos16,LarsH.Lund17 , MariantoniettaCicoira18,JosepMasip19,20,HadiSkouri21,FinnGustafsson22, AminaRakisheva23,IngoAhrens24,25,AndreaMortara26,EwaA.Janowska27,28, AbdallahAlmaghraby29,KevinDamman30,OscarMiro31,KurtHuber32,33, ArsenRistic34,35,LoreenaHill36,WilfriedMullens37,38,AlaideChieffo39,40, JozefBartunek41,PasqualePaolisso42,AntoniBayes-Genis43,44,StefanD.Anker45, SusannaPrice46,GerasimosFilippatos47,FrankRuschitzka48,49,PetarSeferovic35,50, RafaelVidal-Perez51,AlecVahanian52,MarcoMetra3,TheresaA.McDonagh53,54, EmanueleBarbato55,AndrewJ.S.Coats56,andGiuseppeM.C.Rosano57
1 EmergencyInstituteforCardiovascularDiseases‘Prof.C.C.Iliescu’,Bucharest,Romania; 2 UniversityofMedicineCarolDavila,Bucharest,Romania; 3 Cardiology,ASSTSpedali Civili,DepartmentofMedicalandSurgicalSpecialties,RadiologicalSciences,andPublicHealth,UniversityofBrescia,Brescia,Italy; 4 CardiologyDepartment,GeneralHospital ’Sismanogleio-AmaliaFleming’,Athens,Greece; 5 HeartFailureUnitandUniversityClinicofEmergencyMedicine,AttikonUniversityHospital,NationalandKapodistrian UniversityofAthensMedicalSchool,Athens,Greece; 6 UniversitéParisCité,MASCOTInserm,HôpitauxUniversitairesSaintLouisLariboisière,APHP,Paris,France; 7 Divisionof Cardiology,DepartmentofInternalMedicalSciences,SchoolofMedicine,DokuzEylulUniversity,Izmir,Turkey; 8 DepartmentofCardiology,RigshospitaletandDeptofClinical Medicine,UniversityofCopenhagen,Copenhagen,Denmark; 9 ArmedForcesHospital,FacultyofMedicineofPorto,Porto,Portugal;
10 DepartmentofCardiologyandAngiology, HannoverMedicalSchool,Hannover,Germany; 11 EmergencyMedicine,UniversityofHelsinkiandDepartmentofEmergencyMedicineandServices,HelsinkiUniversityHospital, Helsinki,Finland; 12 HeartFailureUnit,CardiologyDepartment,RabinMedicalCenter,SacklerFacultyofMedicine,TelAvivUniversity,TelAviv,Israel; 13 Departmentof EmergencyMedicine,VanderbiltUniversityMedicalCenterandVeteransAffairsTennesseeValleyHealthcareSystem,GeriatricResearch,EducationandClinicalCenter(GRECC), Nashville,TN,USA; 14 FacultyofMedicine,KasrAlAiny,CardiologyDepartment,CairoUniversity,Cairo,Egypt; 15 ClinicofCardiacandVascularDiseases,InstituteofClinical Medicine,FacultyofMedicine,VilniusUniversity,Vilnius;CentreofInnovativeMedicine,Vilnius,Lithuania; 16 OnassisCardiacSurgeryCenter,Athens,Greece; 17 Karolinska Institute,DepartmentofMedicine,andKarolinskaUniversityHospital,DepartmentofCardiology,Stockholm,Sweden; 18 MagaliniHospital,Verona,Italy; 19 ResearchDirection, ConsorciSanitariIntegral,Barcelona,Spain; 20 UniversityofBarcelona,Barcelona,Spain; 21 DivisionofCardiology,InternalMedicineDepartment,AmericanUniversityofBeirut MedicalCenter,Beirut,Lebanon; 22 DepartmentofCardiology,Rigshospitalet,UniversityofCopenhagen,Copenhagen,Denmark; 23 ScientificandResearchInstituteofCardiology andInternalDisease,Almaty,Kazakhstan; 24 DepartmentofCardiologyandMedicalIntensiveCare,AugustinerinnenHospital,Cologne,Germany; 25 FacultyofMedicine, UniversityofFreiburg,Freiburg,Germany; 26 DepartmentofCardiology,PoliclinicodiMonza,Monza,Italy; 27 InstituteofHeartDiseases,WroclawMedicalUniversity,Wroclaw, Poland; 28 InstituteofHeartDiseases,UniversityHospital,Wroclaw,Poland; 29 CardiologyDepartment,FacultyofMedicine,AlexandriaUniversity,Alexandria,Egypt;
*Correspondingauthors.OvidiuChioncel:EmergencyInstituteforCardiovascularDiseases‘Prof.C.C.Iliescu’,Bucharest;UniversityofMedicineCarolDavila,Bucharest,Fundeni 258,072435Romania.Email:ochioncel@yahoo.co.uk
MariannaAdamo:Cardiology,DepartmentofMedicalandSurgicalSpecialties,RadiologicalSciences,andPublicHealth,UniversityofBrescia,PiazzaMercato 15,25121 Brescia, Italy.Email:mariannaadamo@hotmail.com
©2023EuropeanSocietyofCardiology
30 UniversityofGroningen,DepartmentofCardiology,UniversityMedicalCenterGroningen,Groningen,TheNetherlands; 31 EmergencyDepartment,HospitalClínic,IDIBAPS, UniversityofBarcelona,Barcelona,Spain; 32 MedicalFaculty,SigmundFreudUniversity,Vienna,Austria; 33 3rdMedicalDepartment,WilhelminenHospital,Vienna,Austria; 34 DepartmentofCardiologyoftheUniversityClinicalCenterofSerbia,Belgrade,Serbia; 35 FacultyofMedicine,UniversityofBelgrade,Belgrade,Serbia; 36 SchoolofNursing& Midwifery,Queen’sUniversity,Belfast,UK; 37 DepartmentofCardiology,ZiekenhuisOost-Limburg,Genk,Belgium; 38 UHasselt,BiomedicalResearchInstitute,FacultyofMedicine andLifeSciences,LCRC,Diepenbeek,Belgium; 39 VitaSalute-SanRaffaeleUniversity,Milan,Italy; 40 IRCCSSanRaffaeleScientific,Institute,Milan,Italy; 41 CardiovascularCenter Aalst,OLVHospital,Aalst,Belgium; 42 DepartmentofAdvancedBiomedicalSciences,UniversityFedericoII,Naples,Italy; 43 InstitutdelCor,HospitalUniversitariGermansTriasi Pujol,Barcelona,Spain; 44 DepartmentofMedicine,UniversitatAutònomadeBarcelona,Barcelona,Spain; 45 DepartmentofCardiology(CVK)ofGermanHeartCenterCharité, InstituteofHealthCenterforRegenerativeTherapies(BCRT),GermanCentreforCardiovascularResearch(DZHK)PartnerSiteBerlin,CharitéUniversitätsmedizin,Berlin, Germany; 46 RoyalBromptonHospital&HarefieldNHSFoundationTrust,London,UK; 47 HeartFailureUnit,DepartmentofCardiology,AthensUniversityHospital,Attikon, NationalandKapodistrianUniversityofAthens,SchoolofMedicine,Athens,Greece; 48 DepartmentofCardiology,UniversityHeartCenter,UniversityHospitalZurichand UniversityofZurich,Zurich,Switzerland; 49 DepartmentofCardiology,CenterforTranslationalandExperimentalCardiology(CTEC),UniversityHospitalZurich,Zurich, Switzerland; 50 SerbianAcademyofSciencesandArts,Belgrade,Serbia; 51 DepartmentofCardiology,ComplejoHospitalarioUniversitariodeACoruña,ACoruña,Spain; 52 UniversityParisCite,INSERMLVTSU 1148Bichat,Paris,France; 53 DepartmentofCardiology,King’sCollegeHospitalLondon,London,UK; 54 SchoolofCardiovascular MedicineandSciences,King’sCollegeLondonBritishHeartFoundationCentreofExcellence,London,UK; 55 DepartmentofClinicalandMolecularMedicine,SapienzaUniversity ofRome,Rome,Italy; 56 HeartResearchInstitute,Sydney,Australia;and 57 DepartmentofMedicalSciences,IRCCSSanRaffaele-Roma,Roma,Italy
Received3April2023;revised9May2023;accepted 18May2023
Acuteheartfailure(AHF)representsabroadspectrumofdiseasestates,resultingfromtheinteractionbetweenanacuteprecipitantand apatient’sunderlyingcardiacsubstrateandcomorbidities.Valvularheartdisease(VHD)isfrequentlyassociatedwithAHF.AHFmayresult fromseveralprecipitantsthataddanacutehaemodynamicstresssuperimposedonachronicvalvularlesionormayoccurasaconsequence ofanewsignificantvalvularlesion.Regardlessofthemechanism,clinicalpresentationmayvaryfromacutedecompensatedheartfailure tocardiogenicshock.AssessingtheseverityofVHDaswellasthecorrelationbetweenVHDseverityandsymptomsmaybedifficultin patientswithAHFbecauseoftherapidvariationinloadingconditions,concomitantdestabilizationoftheassociatedcomorbiditiesandthe presenceofcombinedvalvularlesions.Evidence-basedinterventionstargetingVHDinsettingsofAHFhaveyettobeidentified,aspatients withsevereVHDareoftenexcludedfromrandomizedtrialsinAHF,soresultsfromthesetrialsdonotgeneralizetothosewithVHD. Furthermore,therearenotrigorouslyconductedrandomizedcontrolledtrialsinthesettingofVHDandAHF,mostofthedatacoming fromobservationalstudies.Thus,distincttochronicsettings,currentguidelinesareveryelusivewhenpatientswithsevereVHDpresent withAHF,andaclear-cutstrategycouldnotbeyetdefined.GiventhepaucityofevidenceinthissubsetofAHFpatients,theaimofthis scientificstatementistodescribetheepidemiology,pathophysiology,andoveralltreatmentapproachforpatientswithVHDwhopresent withAHF.
GraphicalAbstract
Assessingseverityofacuteheartfailure(AHF)inparallelwithevaluationoftheaetiology,mechanismandseverityofvalvularheartdisease(VHD). ManagementfollowsHeartTeamdiscussiontodecideemergency/urgent/electiveinterventionsorpalliation.Threepossiblescenariosshouldbe considered.First,ifthereisnoemergentindicationtointervention,patientsmustreceivemedicaltherapy(MT).MTmaybeappropriateasbridge toearlyin-hospitalorelectiveinterventionorasdestinationtherapyifinterventioniscontraindicatedbecauseofthecomorbidities.Second, patientspresentingwithcardiogenicshockorAHFrefractorytomedicaltreatmentrequireinterventionsonanurgent/emergencybasis,when VHDrepresentsthemaincontributortotheimmediatelife-threateninghaemodynamicdeterioration.Third,earlyuseofpercutaneousmechanical circulatorysupport(MCS)mayhelpbridgepatientstoadecisionofdelayedVHDrepair,leftventricularassistdevice(LVAD)and/orheart transplantation(HTX).ThesecondandthirdscenariosaremorelikelytobeconsideredaspatientswithAHFandVHDmayrequireemergent surgery,especiallyincaseofvalveendocarditisoracuteaorticregurgitationcausedbyaorticdissectionoracutemitralregurgitationcausedby papillarymusclerupture.ACS,acutecoronarysyndrome;AF,atrialfibrillation;AMI,acutemyocardialinfarction;CIED,cardiacimplantableelectronic device;PE,pulmonaryembolism;RV,rightventricular.*AHFphenotypes:cardiogenicshock,acutepulmonaryoedema,acutedecompensatedheart failure;rightheartfailure. ....
Keywords
Introduction
Definedaccordingtoguidelinesasthenewonsetorworsening ofsymptomsandsignsofheartfailure(HF)inthepresenceof anunderlyingstructuralorfunctionalcardiacdysfunction,oneor moreprecipitatingfactorscaninduceacuteHF(AHF).1 Valvular heartdisease(VHD)isoneofthemostcommonunderlying conditionsassociatedwithAHF.2– 10 AHFmayresultfromtheacute haemodynamicstresssuperimposedonachronicvalvularlesion ormayoccurbecauseofanewsignificantvalvularlesion.Patients withVHDpresentingwithAHFmayhavesignificantcomorbidities, anditisoftendifficulttoascribethecontributionofVHDto symptomseverity.Assessingaetiologymaynotbeimmediately availableincriticallyillpatientandaccuratevalvularassessmentcan bechallengingwithmultipleVHDorinthosewithextremeloading conditions.11 – 14
Therearenorigorouslyconductedrandomizedcontrolledtrials inthesettingofVHDwithAHF.Besides,patientswithsevereVHD areoftenexcludedfromAHFrandomizedcontrolledtrialsand thisleadstolackofaclear-cutstrategy.15,16 Hence,thecurrent EuropeanSocietyofCardiology(ESC)andUSguidelinesemphasize theneedofanearlyreferralofpatientswithHFandvalvular diseasetoamultidisciplinaryHeartTeam,includingHFspecialists, forassessmentandtreatmentplanning.1,15,16 Theguidelinesalso recommendtheHeartTeammustindividualizemultidisciplinary discussiontoofferthebestoptionforeachparticularcase.1,15,16
Itisthereforetheaimofthepresentscientificstatementto focusontheepidemiology,pathophysiology,diagnosticwork-up andmanagementofVHDwithAHF.
Epidemiology
InhospitalizedpatientsfromtheEURObservationalResearchProgramme(EORP)VHDIIsurvey,17 aorticstenosis(AS)wasthe mostcommonVHD(41.2%),followedbyprimarymitralregurgitation(MR)(13.8%)andsecondaryMR(7.8%).MultipleVHD wasreportedin26.5%patients.Isolatedright-sidedVHDwasrare (2.5%).
TheprevalenceofVHDinthesettingofAHFhasnotbeen clearlyembodied.AHFclinicaltrialsgenerallyexcludedpatients withmoderatetosevereVHDandinAHFregistries(Table 1), theVHDprevalencevariedaccordingtothemethodologyofthe registries.2– 10
AmongAHFpatients,VHDasprimarycauseofHFwasmore commoninHFwithpreservedejectionfraction(HFpEF)(20%),as comparedtoHFwithmildlyreducedejectionfraction(14%)and HFwithreducedejectionfraction(HFrEF)(6.2%).18
IntheinternationalREPORT-HFregistry,VHDwasconsidered asacauseofAHFin 13%ofpatients(rangingfrom7%inAsia andNorthAmericato 18%inWesternEurope),whilein20%of AHFpatientsVHDwaspresentasacomorbidity(rangingfrom
8%inAsiato30%inEasternEurope).19 Also,in-hospitalVHD interventionsvariedsubstantiallybygeographicregion(7.9%in WesternEuropevs. 1.2%inSouthEastAsia).20
IntheESCHFLong-TermRegistry,VHDwasreported astheprimarycauseofAHFin 11.8%ofpatients,though moderate/severeMRandtricuspidregurgitation(TR)werefound atechoin45.9%and35.4%ofpatientsrespectively,21 suggesting dynamicnatureoffunctionalregurgitations.
Intermsofprognosis,severeASwasanindependentpredictor of 1-yearall-causemortality.8 Mildtomoderateaorticregurgitation(AR)waslinkedtoall-causemortalityinpatientswithAHF andpreservedejectionfraction.22
Moderate/severeMRwasassociatedwithacompositeof all-causemortalityorHFreadmissionsinpatientswithbothworseningand denovo HFfromBIOSTAT-CHF.23 IntheARICstudy, moderate/severeMRwasassociatedwith 1-yearall-causemortalityonlyinAHFpatientswithejectionfraction <50%.24 Ofnote, residualfunctionalMRatdischargewasassociatedwithprognosis onlyinthegroupofAHFpatientswithhighB-typenatriureticpeptideatdischarge.25 Interestingly,inpatientshospitalizedforAHF, dynamicMR(severeonhospitalarrivalandimprovedatdischarge) waslinkedtoaworsecompositeoutcomeincludingdeathandHF readmissions.26
InhospitalizedAHFpatients,moderate/severeTRprevented successfuldecongestion,9 itwasastrongpredictorofHFreadmissions27 anditwasassociatedwithmortalityonlyinthesubset ofpatientswithHFpEF28 orthosewithpulmonaryhypertension (PH).29
Acuteheartfailure pathophysiology
PrimarysevereVHDmayrepresentanabnormalsubstrateoran underlyingcauseofAHF.Valvelesionsoftenprogressgradually overtimebutmanifestclinicallyorbecomeacutelyworsened duringthehaemodynamicstressfromasuperimposedprecipitant thatmayvaryinseverityandcaninteractadditively(Figure 1). Furthermore,alterationofthecardiovascularsubstrateduring HFprogressionmaycausefunctionalVHD,especiallyMRand TR,andcoexistenceofthesetwomaycomplicatetheclinical picture.Incontrasttoorganic(primary)valveregurgitation,where thevalveapparatusisstructurallynormal,secondaryMRand TRdevelopbystructuralalterationsoftheventricularoratrial geometry.Secondaryatrio-ventricularregurgitationsmayoccurin thefullspectrumofleftventricularejectionfraction(LVEF)andare dynamiclesions,changingseveritywithloadingconditions.30,31
AcuteVHDmayberesponsibleforAHFincasesofanewacute valvedysfunction(e.g.papillarymusclerupture,aorticdissection) oracutedeteriorationofapriormoderateVHDbyendocarditis,prostheticvalvethrombosis,andsoforth(Figure 1).Inaddition,haemodynamicsignificanceofevenmoderateVHDmightbe
aggravatedbythecoexistenceofdiverseprecipitantssuchasacute coronarysyndrome,hypertension,arrhythmia,fluidoverload,or worseningrenalfunction(Figure 1).
Pulmonaryhypertension
Pulmonaryhypertensionisfrequentlyaconsequenceofleft-sided VHDandcontributesto,oraggravates,secondaryTR.32–35
Inleft-sidedVHD,leftventricularpressureand/orvolumeoverloadinducesleftatrialpressureoverloadandapassivebackward riseofpulmonaryvenouspressure.Thissuddenincreaseinpulmonaryvenouspressurecausesalveolar-capillarymembranedisruptionproducingreversibleacutealveolaroedema,whilechronic adaptation,includingleftatrialdilatationandalveolarcapillary remodellingwithcollagendeposition,isapartiallyirreversibleprocess.33,34 PHinducesrightventricularpressureoverloadcausing rightventricularhypertrophyanddilatationandconsequentlyannulusdilatationwithsecondaryTRthatfurtherdeterioratesright ventricularfunction.
Pulmonaryhypertensionduetoleftheartdisease,including VHD,representsgroup2PHdefinedbyanmeanpulmonary arterypressure >20mmHgandapulmonarycapillarywedge pressure >15mmHg.Withinthishaemodynamicconditionof post-capillaryPH,isolatedPHisdefinedbypulmonaryvascular resistance(PVR) ≤2Woodunits(WU)andcombinedPHbyPVR >2WU.35 SeverePHisdefinedas >5WU.35 Inpatientswith VHDundergoingintervention,increasedPVR,particularlyif >5 WU,isassociatedwithanincreaseddiseaseburdenandaworse outcome.35 Furthermore,regressionofPHaftercorrectionof VHDisfrequentlyincompleteandpersistentPHisassociatedwith adverseoutcomes.36
TheprevalenceofPHincreaseswithseverityofleft-sidedVHD37 andseverityofsymptoms.33,38 Inmitralstenosis(MS),PHis linkedtosymptomseverityandvalveareaandisassociatedwith long-termprognosis.39
TheprevalenceofPHinprimaryMRmayvaryaccordingto clinicalseverityandreaches64%forpatientswithNewYorkHeart Association(NYHA)classIII/IV.33,40,41 Earlysurgicaltreatmentis advisableinthesepatients,sincepre-existingPHisassociated withpost-operativeleftventricularsystolicdeclineandanalmost two-foldincreaseinpost-operativemortality.15,16,39,42
InAS,PHprevalencerangesfrom6%to30%.43 Themechanism ofPHinASiscontroversialandattributedmoretotheleft ventriculardiastolicdysfunctionandlesstoASseverityitself.The reversibilityofPHpost-operativelycorrelateswithimprovement ofdiastolicfunctionandwaslinkedtobetteroutcomes.44,45
InsevereAR,theprevalenceofPHisbetween30%and37%and representsapredictorofworseprognosispost-intervention.46
Investigationsandin-hospital monitoringforvalvularheart disease
AsmanyofthesepatientswithVHDandatrialfibrillationundergo urgentsurgicalorpercutaneouscorrection,itisimportantto
concomitantlyevaluate:(i)theclinicalstatusandrapidlyidentify earlysignsofhypoperfusionandrespiratorydistress;(ii)theseverityofthevalvulardiseaseanditsimpactonthecardiacchambers andpulmonarycirculationandoverallhaemodynamicstatus;(iii) markersofend-organdysfunction;and(iv)thepresence/absence ofsignificantcoronaryarterydisease,precipitants,comorbidities.
Clinicalexamination
Ingeneral,whileallleft-sidedVHDscontributetosymptomsand signsofpulmonarycongestion,right-sidedVHDscontributeto symptomsandsignsofsystemiccongestion(Table 2).27,47–56
Tonote,clinicalexaminationalone,inparticularauscultation, hasalimitedsensitivity,57 beinginsufficientforthediagnosisof VHD,particularlyincriticallyillpatientsorinthosewithacute VHD,whenthemurmurintensityanddurationmaybediminished duetosystemichypotensionandrapidpressureequilibration betweencardiacchambers.14 However,somesymptomsmaybe especiallyinformativeoftheunderlingaetiology(i.e.feverin infectiveendocarditis,chestpaininaorticdissection).
Biomarkers,arterialbloodgasanalysis, lactate,electrolytes
Thevalueofnatriureticpeptidesfordiagnosisandprognostic evaluationhasbeenreportedintheESCHFguidelines.1,58 In veryacutesettings,suchasMSwithflashpulmonaryoedema,
natriureticpeptidevaluesmaynotreachtherecommended‘likely’ cut-offs.59
Theidentificationofacidosisandespeciallyelevatedlactate remainreliablemarkersforhypoperfusionanditisadvisedtobe checkedroutinely.1,60
The electrocardiogram mayhelpthediagnosticbyidentification rightventricularhypertrophy(PH),arrhythmias,conductionabnormalities(extensionofannularaorticabscesses)andischaemia.
Cineradiography canaidthediagnosisofmechanicalvalve obstruction.
Transthoracicechocardiography (TTE)isessentialforthediagnosis andpreciseevaluationoftheseverityofvalvularlesions(onlinesupplementary TableAppendix S1),theimpactonleftventricularsize andfunction,rightventricularfunctionandpulmonarycirculation (pulmonarypressureaswellaspulmonaryresistance).
Carefulquantificationisrequired,astheseverityofthe mitral/aorticlesionmaybeunderestimatedwhentheleftventricularsystolicfunctionisdepressedasinAHForcardiogenicshock (CS).Adequateassessmentofleftventricularcontractile/flow reservemaybedifficultwhenthepatientisunderinotropic support.16
Transoesophagealechocardiography (TEE)isessentialbeforeor duringmitralandtricuspidvalveinterventions,inpatientswith prostheticvalvedysfunctionaswellaswhenevertheTTEexaminationisnotinformative.TEEremainsverysensitiveandspecific forthediagnosisofvalvevegetations(consistentlyabove95%)and otherimagingfindingsofinfectiveendocarditis.61,62
Clinicalpresentation
Pathophysiologyandclinicalpresentationofvalvularheartdiseaseinacutesettings
Table2
• Maypresentwithanyclinicalprofile
• ClinicalpresentationismoresevereinpatientswithLVEF < 50%,peak aorticjetvelocity ≥ 5m/s,TRpressuregradient ≥ 40mmHg,combined valvulardisease 1 7,37
• CSpresentationisstronglyrelatedtomortalityevenafter interventions
• RHFmayoccurinthelaterstagesofASevolutionasconsequenceof PHorassociatedright-sidedVHD
• ThereisapoorcorrelationbetweenARseverityandsymptomsand inacutesettingstheauscultationhaspooraccuracyfordiagnosisor estimatingseverity
• MaypresentwithanyclinicalprofilebutchronicMRpresentsmore frequentlyasADHFandacuteMRcommonlypresentsasCSorAPO 1
• Inacutesettings,symptomsatpresentationmayalsoreflectthe underlyingpathogenesisofacuteAR,suchasseverechestpainfrom aorticdissectionorfeverfromendocarditis
• Haemolyticanaemiaistheconsequenceofparavalvularleak 1 57
• Mixedshock(cardiogenicandseptic)mayoccurinpatientswith endocarditisandacuteMR 1 54, 1 55
• Septicembolusmayoccurin20–50%ofpatientswith endocarditis 80, 1 54
• RHFmayoccurasaconsequenceofPHorassociated right-sidedVHD
Pathophysiology
• ASrepresentsanincreasedafterloadstatefortheleftventricle.Thereductionofvalveareaproducesa pressuregradientacrosstheaorticvalveandconsequentlyanincreaseinLVsystolicwallstressthatleads toincreasedLVdiastolicpressure,LVconcentrichypertrophy,diastolicstiffnessandimpairedcompliance. LVdiastolicfillingisimpairedandtheleftventricleisdependentonincreasingfillingpressuretomaintain cardiacoutput. 11
6 LVhypertrophyisakeyadaptivemechanismtothepressureloadbutitincreasesLV massleadingtodiscrepancyinoxygendemandandsupplyandrelativemyocardialischaemia.
AfterloadmismatchisinitiallyresponsibleofdecreasinginEFandstrokevolume,butlateronlong-term exposuretopressureoverloadanddemandischaemiaproduceintrinsicmyocardialcontractility dysfunctionwithfurtherdecreaseofEF,LVdilatationandsecondarymitralregurgitation
• Variousprecipitantsmayinterveneindifferentstagesofseverityandventricularadaptationandmaylead todecompensation,whenSVisdecreasedatrest,anddevelopmentofAHF
• AcuteobstructionofaorticprostheticvalvemayleadtoAHF.Theacuteoutflowobstruction,ifleft untreated,leadstoarapidclinicaldeteriorationwithdecreaseofSVandLVdilatation
SevereAS
,
• MaypresentwithanyclinicalprofilebutchronicMRpresentsmore frequentlyasADHFandacuteMRcommonlypresentsasCSorAPO; unilateralAPOmayoccurinacuteMRwitheccentricjet
• Cardiacauscultationhaspooraccuracyfordiagnosisorestimating severity 11 –1 4
• BackflowofejectedbloodintotheLVcavityduringdiastoleandregurgitantvolumeisdependentonthe regurgitantarea,diastolicgradientanddiastolictime.
SevereAR
ARmayproducerelativeischaemiaas
1 54, 1 55
• Mixedshock(cardiogenicandseptic)mayoccurinpatientswith endocarditisandacuteMR
• Haemolyticanaemiaistheconsequenceofparavalvularleak
• RHFmayoccurasaconsequenceofPHorassociated right-sidedVHD
1 6
11 –
consequenceofthedecreasingdiastoliccoronaryflowandasresultofelevatedend-diastolicpressures andtachycardiathatincreasemyocardialoxygendemand.Thissupply–demandmismatchisfurther aggravatedwhensignificantcoronarylesionsarepresentorifaorticdissectionimpairscoronary flow.
ChronicAR :increasedLVpreload,LVdilatation,LVeccentrichypertrophy;lowaorticdiastolicpressure andLVeccentrichypertrophycontributetorelativemyocardialischaemia.Incompensatedstages,SVis maintainedviacompensatorymechanisms,butseveralprecipitantsmayleadtodecompensationandSV cannotincreaseinresponsetodemandingconditions(exercise,infection,arrhythmia,etc.)and progressivelyitdecreasesatrest. 11 –1 6
AcuteARmayoccurinsettingsofendocarditis,eithernativeor
AcuteAR
:acuteincreaseofLVEDPwithoutthechronicadaptivemechanismsofhypertrophyand dilatation.Thesuddenincreaseofend-diastolicpressureinanormalsizedleftventriclerapidlyleadstoa decreaseinforwardcardiacflow. 11 –1 6
prostheticvalve,whendetrimentaleffectsofbothinfectionandhaemodynamicinstabilitypotentiateeach other 1 50, 1 5 1
• Leakageofbloodintotheleftatriumduringsystole;regurgitantvolumedependsontheregurgitant orificearea,systolictime,systemicvascularresistance,LApressureandLVESP 11 –
1 6
ChronicMR
SevereMR (primary and secondary)
11 –
:increasedLVpreload,LVdilatation,LVeccentrichypertrophy.Incompensatedstages,SVis maintainedviacompensatorymechanisms,butseveralprecipitantsmayleadtodecompensationwhenSV isdecreasedatrest
1 6
11 –
AcuteMR :thereisasuddenvolumeincreaseintoanormalsizedandpoorlycompliantleftatrium,an excessiveincreaseinLApressureandcongestionofpulmonarycirculationandanacutereductioninthe forwardcardiacoutput.
AcuteMRmayoccurinsettingsofendocarditis,eithernativeorprosthetic valves,whendetrimentaleffectsofbothinfectionandhaemodynamicinstabilitypotentiateeach other.
1 50, 1 5 1 InacutesecondaryMR(insettingsofACS)poorLVcomplianceaggravatepulmonary congestion
©2023EuropeanSocietyofCardiology
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Clinicalpresentation
Table2 (Continued) Pathophysiology
SevereMS
< 1 .0cm 2 .However, symptomsoftenoccurinpatientswithlargervalveareasifthetimeofdiastolic fillingdecreasesand/ortransmitralflowincreases(pregnancy,infection, new-onsetorrapidAF,fever,anaemia,hyperthyroidismorhaemodynamicshifts intheperioperativeperiodofpatientsundergoingnon-cardiacsurgery).
• Restingsymptomsusuallydevelopwhenthevalveareais
11 –1 6
However,symptomstatusmaychangewithnochangeinMSseveritybecauseof anincreasedhaemodynamicload
• PatientsmayalsopresentwithAF,oranembolicevent
• RHFmayoccurasaconsequenceofPHorassociatedright-sidedVHD
11 –1 6,55,57–59 However,fatigue, decreasedexercisetolerance,peripheraloedema,hepaticcongestion,decreased appetite,ascites/anasarcaarenon-specificandoftenerroneouslyconsidered non-TR-related
• ClinicalmanifestationsofTRarecharacterizedbytheconsequencesofincrease inCVPwithsystemicvenouscongestionandinadvancedstages,decreaseof cardiacoutputandsignsofend-organdysfunction.
• Systemicvenouscongestionisamaindeterminantofthedeclineofglomerular filtrationrateandoftheexhaustionofrenalautoregulatorycapacity.
5 1 A pathologicalriseinrenalvenouspressureisanindependentriskfactorfor worseningrenalfunctioninpatientswithAHF,evenintheabsenceofimpaired cardiacoutput
• Hepaticfailure,resultingfrombothhepaticcongestionandreducedhepatic perfusion,iscruciallycombinedtoTRseverity. 55,57–59 TRisparticularly susceptibletoresultinseverepassivecongestion, 55 andthisleadstoatrophyof thehepatocytesandsinusoidaloedemathatcandirectlyaffectoxygendiffusion tothehepatocytewithsubsequenthepaticfailure(increasedmarkersof cholestasisandreducedalbuminsynthesis),leadingtoaviciouscyclethatsustains theincreaseofhydrostaticpressureandabdominaloedema 57–59
• Compromisedgastrointestinalfunction:visceraloedemaandintra-abdominal hypertensioncanleadtomalnutrition,protein-losingenteropathy,bacterial translocationfromtheintestinalgutanddiureticmalabsorptionand resistance 53,55,59
• Theclinicalpresentationcanalsoincludesymptomsmimickingleft-sidedheart diseasebecauseTR-inducedRVvolumeoverloadimpairsLVfillingbydirect ventricularinteractionthroughtheinterventricularseptum 55,57–59
• SevereMSmanifestsasobstructiontoLVfilling,increasedLApressure,LAvolume, decreasedLVpreloadanddependenceonLAkick 11 –
• In25%ofpatients,systolicdysfunctionisalsopresentduetochronicdecreaseof preloadbutalsoduetorheumaticcardiomyopathy 11 –
• AcuteobstructionofmitralprostheticvalvemayleadtoAHF.Theacuteobstruction leadstoarapidclinicaldeterioration 11
• VeryoftenTRistheconsequenceofleft-sideddiseasesorleft-sidedVHD.
SevereTR
1 6
11 –
59 Chronic volumeoverload,inducedbysevereTR,promotesanincreaseinRVend-diastolic volume,preloadandwalltension,resultinginRVischaemiaand,accordingly,RVsystolic dysfunctionandincreasedoverallmortality.
TheRVremodellingprocessassociated withsecondaryTRvariestremendouslybetweenpatients.ThedifferentpatternsofRV remodellingmayberelatedtotheunderlyingpathophysiologyandtothetimingin naturalhistoryofsecondaryTRwhenthesepatternsareassessed 57
• TRcreatesaviciouscycleofprogressiveRVdilatation,annulardilatationandleaflet tetheringthatresultsinincreasedTRseverityandRVdilatation,eventuallyleadingtoRV dysfunction.Also,significantTRreducesRVSVand,therefore,LVpreloadandcardiac output 27,52,54,56
• IncreaseofRVvolumeandRVpressureproducesleftwardinterventricularseptal displacementwithLVcompressionandrestrictedLVfilling,resultinginthesubsequent reductioninLVpreloadwithincreaseinLVEDPandPAPanddecreaseofcardiac output 55,57,58
• ElevatedRApressurecausedbyTRdeterminesincreaseinCVPandsystemicvenous congestion.Also,highRApressurecanleadtoatrialremodellingandtothe developmentofsupraventriculartachyarrhythmias,compromisingcardiacstabilityof patientswithsevereTR 54
• IncreaseinCVPwithsystemicvenouscongestionisthemaindeterminantofworsening renalfunction,hepaticfailure,compromisedgastrointestinalfunction
ACS,acutecoronarysyndrome;ADHF,acutedecompensatedheartfailure;AF,atrialfibrillation;AHF,acuteheartfailure;APO,acutepulmonaryoede ma;AR,aorticregurgitation;AS,aorticstenosis;CS,cardiogenicshock;CVP, centralvenouspressure;EF,ejectionfraction;LA,leftatrial;LV,leftventricular;LVEDP,leftventricularend-diastolicpressure;LVEF,left ventricularejectionfraction;LVESP,leftventricularend-systolicpressure;MR,mitralregurgitation; MS,mitralstenosis;PAP,pulmonaryarterypressure;PH,pulmonaryhypertension;RA,rightatrial;RHF,rightheartfailure;RV,rightventricular ;SV,strokevolume;TR,tricuspidregurgitation;VHD,valvularheartdisease.
Multidetectorcomputedtomography (MDCT)isextensivelyusedin perioperativecareofpercutaneousvalveprocedures.61,63 MDCT maydiagnoseleafletthrombosis.61 Ithasalsoaroletoassess theextentofaorticcalcificationand‘porcelainaorta’inthe elderly64 andforthoserequiringredosurgery.65 MDCTcan identifynativecusp/prostheticleafletvegetations,62,66,67 thoughit ismoreusefulasanadd-ontoTTEandTEE,withsensitivityupto 100%forthedetectionofperivalvularcomplications (abscesses/pseudoaneurysms).62
18-Fluoro-2-deoxyglucosepositronemissiontomography-computed tomography improvesthediagnosticabilityofTEEinprosthetic valveendocarditis(100%sensitivityand91%specificity),68 butit isnotassensitiveforthenativevalves.69
Magneticresonanceimaging canovercometheshortcomingsof echocardiography(i.e.difficultacousticwindow)forevaluatingthe severityofaorticinsufficiency,hasaverygoodaccuracyforcharacterizationofrightventricularsystolicfunctionandpreciselycharacterizesmyocardialtissue(includingdisplaced/anomalous/ischaemic papillarymuscles).70
Rightheartcatheterization–pulmonary arterycatheter
ThereisnoagreementontheoptimalmethodofhaemodynamicmonitoringinpatientswithAHF.Pulmonaryarterycatheter (PAC)measurementsguidevolume,drug(inotrope,vasopressor) mechanicalcirculatorysupport(MCS)andpatient’sresponseto theseinterventions.71 PACisguideline-recommendedinpatients withsevereTRpriortosurgicalorinterventionalvalverepair.35 In thecomplexpatientswithVHDandAHF,PACmaybeappropriate fordiagnosisandtherapeuticmanagement,especiallyinpatients withPHand/orrightventricularfailure,inpatientsdeterioratingtoCS,inpatientswithplannedMCS,orincasesofadditionalrespiratorydistresssyndromeorsepsis.Inaddition,the PACdoesprovideimportantdiagnosticinformationinselected patientswhofailtorespondtoinitialtherapeuticinterventions (persistenceofhypotensionandhypoperfusion),orincaseofdiagnostic/therapeuticuncertainty(casesofmixedshockorpatients withadvancedrightHF).72
Asfirmevidenceislacking,PACindicationmustbechecked carefully,itsplacementandmeasurementsbedonewithcaution, andearlyremovalisadvisedwhenpatientconditionimproves.
Specificclinicalsettings
Prosthesisvalvedysfunction
Bothmechanicalandbiologicalprosthesesinanylocationarevulnerabletoacuteparavalvularregurgitantdiseasebecauseofsuture failureorvalvedehiscencerelatedtoendocarditis.Mechanical prosthesesarealsosubjecttoacutethrombosis(whichhasthe potentialtoresultinstenosis,regurgitation,orboth).11 Inbiologic prosthesis,infectiveendocarditismightalsoleadtoacuteregurgitationduetoleaflettear/perforationoracutestenosisdueto obstructivevegetations.11
ThesuddenoccurrenceofAHFsymptomsinapatientwitha valveprosthesisshouldraisethesuspicionofprosthesismalfunctioning,whichcanbeacute,duetothrombosisorendocarditis.
Theincidenceofthrombosisinmitralvalveprosthesisranges from0.1 to5.7per 100patient-years,73 whereasthrombotic obstructioninaorticvalveprosthesishasaprevalenceof 1% to3%.74
Obstructivevalvethrombosisgenerallyleadstoasuddenonset ofsevereHFsymptomsandhaemodynamicinstability.Prognosisis poorinabsenceofappropriatetreatment.
Clinicalexaminationrevealstheabsenceordampingofprostheticvalvesounds.TTEcanidentifyincreasedtransvalvulargradients,reducedvalvemotion,andvalvethrombosis.73
Infectiveendocarditisoccursin 1 –6%inpatientswithprosthetic valve.Inearlyprostheticvalveinfectiveendocarditis(PVIE),which occurswithin 1 yearofsurgery,endocarditisisconsideredas aperioperativecontaminationandusuallyleadstoperivalvular abscess,fistulaeorpseudo-aneurysms.EarlyPVIEmayalsoleadto paravalvularleakthatmaycausehaemolysis.LatePVIEoccursmore than 1 yearaftervalvereplacementandischaracterizedbyinfective involvementoftheleafletscausingvegetationsorperforation.Both conditionsmayleadtoAHFduetobioprosthesisdysfunction (stenosisand/orinsufficiency).
BioprosthesisdegenerationcanalsocauseAHF.75 Timeof degenerationdependsonpatientageandcomorbidities,valveposition(atrio-ventricularvs.aortic),typeandsizeofbioprosthesis.75 Differentmechanismsofdegenerationmayoccur(calcification, fibrosis,leaflettearordisruption,pannusorthrombus)leadingto valvestenosisorinsufficiency.
Nativevalveendocarditis
AcuteHFisamongthemostfrequentcomplicationsofnativevalve endocarditis(NVE)andrepresentsthemostcommonindication forsurgeryinthesepatients.AHFoccurssecondaryasaresultof ARorMR(duetoleafletorchordaeruptureorleafletperforation), intracardiacfistulaeorvalveobstructioncausedbyvegetations. Tricuspidvalveendocarditisiscommonlyassociatedwithcardiac implantableelectronicdevices(CIED).
IntheESC-EORPEURO-ENDO(Europeaninfectiveendocarditisregistry),76 congestiveHFwasobservedin 15.9%andCSin6.2% ofpatientswithNVE.Inthatregistry,bothculturepositiveandnegativewereassociatedwithvalvulardestruction,butHFwasmore commonandmoresevereinpatientswithculturenegativeNVE.77
Inaprospectiveobservationalcohortstudy,Roux etal.78 found thatHFwas2.5timesmorefrequentandmortalitytwotimes higherwhenNVEwascomplicatedwithanacutecoronarysyndrome,duetocoronaryembolism,coronarycompressionby anabscessandobstructionofleftcoronaryostiumbyalarge vegetation.
Secondarymitralandtricuspid regurgitation
SecondaryMRisaconsequenceofleftventricularand/orleft atrialremodelling.Manyconcernsariseregardingtheprognostic
benefitofinterveningsecondaryMRinAHF.TheonlyrandomizedtrialshowingabenefitofMRcorrectioninpatientswith chronicHFistheCOAPTtrial79 whichcomparedoptimalmedicaltherapyandtranscatheteredge-to-edgerepair(TEER)versus optimalmedicaltherapyalone.Asimultaneouslypublishedtrial, MITRA-FR,80 showedneutralresultsthoughitincludedadifferent populationwithmoreadvancedHF.Therefore,carefullyselected patientswithaCOAPT-likeprofileshouldbenefitfromTEER.81 However,non-ambulatoryNYHAclassIVwithsignsofhypoperfusionorneedforinotropesorMCSwereexclusioncriteriainthe COAPTtrial.Thus,wedonothavestrongevidencesupporting treatmentofsecondaryMRinAHFsetting,withlimiteddataonly fromobservationalstudies.
TheprognosticrelevanceofsecondaryTRinthecontextof AHFdependsontherelativecontributionofrightventricular dysfunctionandthestageofHF.Recentdatasuggestthatitcouldbe amarkerofdiseaseseverityratherthananindependentprognostic factor.82 Fortreatment,althoughretrospectivedatashowpromise, furtherstudiesaredefinitelyneededtoidentifythepointofno returnbeyondwhichTRinterventionisfutile.Todate,indications fromcurrentguidelinesarevaluablealsointheAHFsetting.
Combinedvalvularheartdisease
MultipleVHD,definedbythepresenceofaregurgitantand/or stenoticlesioninvolvingatleasttwocardiacvalves,hasaprevalence of20%,ifmoderateand/orseveredysfunctionisconsidered83–85 (Table 3).PatientswithmultipleVHDaremoresymptomaticwith highermortalitythanthosewithsingleVHD.85
PatientswithcombinedVHDrepresentaparticulardiagnostic challengenotonlyforassessingthetrueseverityofthedifferent valvularlesionsbutalsofortheoptimaltimingoftheintervention. ThehaemodynamicinteractionbetweendifferentVHDsgenerally exacerbate,butalsomitigatetheexpressionofasinglevalvular lesion.‘Flow-dependent’or‘loadingcondition-dependent’echocardiographicparametersofquantificationaresourcesoferrorinthe contextofmultipleVHD,particularlyinpatientswithAHF.TEE playsanimportantrole,bothtoassesstheseverityofindividualvalvularlesionsandtodeterminetheoptimalstrategy,based onmorphologicfeaturesofthevalveswhenispossible.86 InAHF patientswhocombinemoderatetosevereASwithsevereMR, transaorticpressuregradientmaybereduced,evenduringdobutaminestressechocardiography,leadingtounderestimationofAS severity.Inthisclinicalsetting,aswellasinparadoxicallow-flow, low-gradientAS,quantitationofaorticvalvecalciumscoreby MDCTmayprovidemoreaccurateassessmentofAS.16
Complexclinicaljudgmentisnecessary,sincethecorrectionof asinglevalvelesioncanexacerbate,oronthecontrary,reduce theseverityofanothervalvularlesionthroughchangesinloading conditionsandreverseremodelling.85,87 Currentguidelineslack evidence-basedrecommendationstoguideclinicaldecision-making inmultipleVHD,asmoststudieshavefocusedonsinglevalve disease.Itisadvisedasmedicaldecisiontocarefullyindividually evaluateandbalancetheriskofcombinedinterventionagainstthe evolutionof‘leftuntreated’valvediseasewiththeinherentriskof subsequentintervention.
InpatientsundergoingsurgicalinterventionforVHD,multivalve diseasecanbetreatedduringasingleprocedure,althoughoften withanincreaseinsurgicalrisk.Whilesurgicalinterventionto addressmixedVHDmightbebestforsomepatients,transcatheter interventionsoffertheoptionofastepwiseapproachwhensurgery ishighrisk,treatingthemostseverelesionfirstandthenreassessmentfollowedbysubsequentinterventionsifneeded.91
Accordingtocurrentguidelines,15,16 patientswithmultipleVHD shouldbereferredtoaspecializedHeartValveCentrewherea HeartTeam,includingHFspecialists,canofferthebesttherapeutic option15,16,86–91 (Table 3).
Treatment
ItisadvisedasmanagementprinciplesinAHFpatientswithVHD16 tofollowastagedapproach(Figure 2)includingthefollowingsteps: (i)diagnosisincludingassessmentofVHDseverity,identificationof theclinicalphenotypeofAHFandestimationofthepatient’sprognosis;(ii)stabilizationandreassessment;(iii)definitivetreatment; and(iv)post-interventioncare.
SinceAHFisamajorriskfactorforperioperativemortality, allattemptsshouldbeundertakentostabilizethepatientbefore treatmentviaHeartTeamevaluation.Threepossiblescenarios shouldbeconsidered.First,ifthereisnoemergentindicationto intervention,patientsmustreceivemedicaltherapyasoutlinedin currentguidelines.1 Medicaltherapymaybeappropriateasbridge todelayedorelectiveinterventionorasdestinationtherapyif interventioniscontraindicatedbecauseofthecomorbiditiesand thiscaseisassociatedwithpoorprognosis.12 Second,patients presentingwithCSorAHFrefractorytomedicaltreatment requireinterventionsonanurgent/emergencybasis,whenVHD representsthemaincontributortotheimmediatelife-threatening haemodynamicdeterioration.Third,earlyuseofpercutaneous MCSmayhelpbridgepatientstoadecisionofdelayedVHD repair,leftventricularassistdevice(LVAD)and/ortransplantation. Thesecondandthirdscenariosaremorelikelytobeconsidered aspatientswithAHFandVHDmayrequireemergentsurgery, especiallyincaseofvalveendocarditisoracuteAR,causedby aorticdissectionoracuteMR,causedbypapillarymusclerupture. Followingintervention,ifLVEFremains <40%,guideline-directed medicaltherapiesshouldbeinitiatedduringthepre-discharge phase.1
Earlyintravenousmedicaltreatment
ThegoalofmedicaltherapyistostabilizetheAHFpatientprior todefinitivecorrectionoftheVHD.Thesetherapiesaimto optimizeleftandrightventricularloadingconditionsandtoreduce congestionwhilemaintainingtissueperfusion.Incaseofpersistent haemodynamicinstability,urgentintervention(transcatheteror surgical)isguideline-recommended16 (Figure 2).
Aorticregurgitation
InAR,intravenousloopdiuretics,generallyintravenous furosemide,canbeusedifthereisvolumeoverload.Intravenous
Table3 Pathophysiology,diagnosisandmanagementofcombinedvalvularheartdisease
PathophysiologyDiagnosisManagement
• Concomitantsurgeryoftheaorticandmitralvalveshouldbe performedforpatientswithsevereASandsevereprimaryMR wheneverpossible
• TTE/TEE:increasedareaofMRjetusing colour-flowmappingisunreliable;PISAmethodis stillreliable
• MRmayleadtoanunderestimationof theseverityofAS 87,89
ASandMR
• SAVRandconcomitantrepair/replacementofthemitralvalvein caseofseveresecondaryMR
1 5, 1 6,87,89
• Mitraleffectiveregurgitantorificelessaffectedthan MRvolumeandcolour-flowmappingparameters
• Anincreasedmitralregurgitantvolume istobeexpected
1 6,87,89
• FormoderatesecondaryMR,TAVIfollowedbyre-evaluationof MRandtranscatheteredge-to-edgerepairifneeded
• TAVIwithstagedtranscatheteredge-to-edgerepairisreasonable forpatientswithsevereASandpersistentsecondaryMRafter TAVI 1 5, 1 6,87,89
• UnderestimationofASseveritywilloccurwith significantMR,asforwardLVOTflowisreduced
• SecondaryMRiscommon,buteven whensevere,mayregressfollowingAS correction
• AorticvalvecalciumscoringbyCCTforconfirming ASseverity
• SecondaryMRmayimproveinupto 50%ofcasesafteraorticvalve intervention 88
• AScorrectionbyTAVIorsurgeryandsecondaryMRshouldbe medicallytreated > percutaneousmitralvalverepairindication shouldbereassessedduringfollow-up
• Low-flow,low-gradientASis common 87,89
1 5, 1 6,87,89
• Thetreatmentstrategyislargelydependentonmitralvalve morphologyandthepresenceofconcomitantMR
• TTE/TEE
1 5, 1 6,87–89
• Concomitantsurgicalreplacementoftheaorticandmitralvalveis indicated.Ifpatientcanbestabilizedandthereisno high/prohibitivesurgicalrisk
• Underestimationoflesionsmayoccurasforward flowisseverelydepressed
• TEEmaybeessentialforevaluationofcalcification criteriathatmaymakethevalvesamenableto percutaneoustherapies
• Usuallyduetoreumathismaldisease whichcausesextremefusionof commissures,andcalcificationbeyond valvetissues;patientsareespecially exposedtolowcardiacoutput
ASandMS
• Incasesofhighorprohibitivesurgicalriskandunfavourablevalve morphologysuchasseveremitralannularcalcification,TAVI followedbytranscathetermitralvalvereplacementisanoptionin experiencedheartvalvecentres
• 3Dmitralvalveanatomicareacanbeusedto confirmMSseverity
• Itisverydifficulttoassesstheseverity ofASinpatientswithsevereMS 87,89
1 5, 1 6,87–90
• SurgeryismainstayasrheumaticASmaynotbeamenableby percutaneoustherapy;TAVIandpercutaneousmitralvalvulopasty couldbeaccomplishedwhenechocriteriaarepresent
• DSEand/oraorticvalvecalciumscoringbyCCT canbeusedtoconfirmASseverity
• Verycommon,patientswithsevereAS andMShaveanunfavourableanatomy withheavilycalcifiedannulusand leaflets 87,89,92
1 5, 1 6,87–90
• Agentsthatpromotetachycardiashouldbeavoided,asfillingmay bedependentoncyclelengthduration
• Surgeryismainstaytherapy
• Bradicardicagentsshouldbebestavoidedinacutesettings
• TTE/TEE
• LVdilatationassociatedwithARmaynotbeas significant
• MSmayblunttheincreaseofpulse pressurecommonlyassociatedwithAR
ARandMS
• Pulmonicflowcouldbeusedasreferenceforthe continuityequation
• SeverityofMSmaybeunderrecognizedbythe increaseinLVpressure
• 3Dmitralvalveanatomicareacanbeusefulfor confirmingMSseverity
ARandMR
• BradicardicagentsshouldbebestavoidedinAHFsetting
• Surgeryisussuallyneededforbothvalves
• Therearenoevidence-basedrecommendationsregardingthe managementofmoderateARduringmitralsurgery
• Percutaneousprocedurescouldbepreferredforatleast intermediateandhigh-riskpatients
• Earlyinterventionmaybewarrantedasdiseasemaybepoorly tolerated
• Surgeryismainstayoftreatment
• PercutaneousproceduresareunderdevelopmentandmitralTAVI couldbeinsertediftherheumaticmitralringprovideenough support 87,89
• Alowthresholdforidentificationofthecriteriarequiringsurgery ofTR
• Previousevidenceofrightheartfailuremaybeanindicationaswell
• TTEandTEEforARmechanismevaluation
• Dopplervolumetricmethodusingleft-sided assessmentofnetforwardflowmaybeinvalid; mitral-to-aorticvelocitytimeintegralratiois unreliable,butthePISAmethodremainsaccurate fortheassessmentofMR
• SecondaryMRmaybecommonlypresent duetolonglastingLVdilatationand dysfunction
• Lowoutputmaybemorefrequentthanin othermultiplevalvediseases
• InacutesettingwithonlymildLVdilation, anacuteetiologysuchasinfective endocarditisshouldbesearchedfor
• WhenARissevere,MRwillworsenLV remodellinganddysfunction
• TTE/TEE
• ForARseverity,PHTmethodmaybeunreliable, especiallyinacutesettings
• DecreasedLVcompliancewith disproportionateincreaseinLVdiastolic pressure
• PeakaorticjetvelocityandDopplermeangradient willbeincreaseddisproportionallyfromASseverity asmayreflectseverityofbothARandAS
• Theleftventriclewillnotdilateasexpected withisolatedAR
• TTEandTEE
• ContinuityequationunreliableforMSevaluation
• PHTmethodmaynotbereliable
• Dopplermitralgradientreflectsseverityofboth MSandMR
• Assessementofmitralringcalcificationisrequired
• TTEandTEE
• Aetiologyismainlyrheumatic 1 6
ASandAR
MSandMR
• LApressureandpulmonarypressuresmay bemarkedlyincreased 1 6,87,89
• TheresponseofTRtoaorticormitralvalveinterventionsis unpredictableandinviewofthehighperi-operativemortalityof reoperationforsevereTRafterleft-sidedvalvesurgery,current guidelinessupporttheadditionoftricuspidvalvesurgerywhen performingleft-sidedvalvularsurgeryamongpatientswithsevere TRoramongpatientswithmoderateTRinthepresenceofa dilatedannulus( ≥ 40mm)
• Evaluationofrightatrium,rightventricleand pulmonarypressureandresistanceareequally significant
• TRshouldbebestevaluatedwitheuvolaemia
1 5, 1 6
• SecondaryTRassociatedwithleft-sided VHDiscommonandseverityishighly variable
TRandleft-sided VHD
• Ifpatientsaredeemedathighsurgicalriskorinoperable,staged transcathetertricuspidvalveinterventionforpersistentor worseningTRafterTAVIormitralTEERcanbe considered
1 5, 1 6,87,89
estressechocardiography;LA,leftatrial;LV,leftventricular;LVOT,leftventricular outflowtract;MR,mitralregurgitation;MS,mitralstenosis;PHT,pressurehalf-time;PISA,proximalisovelocitysurfacearea;SAVR,surgicalaor
3D,three-dimensional;AHF,acuteheartfailure;AR,aorticregurgitation;AS,aorticstenosis;CCT,cardiaccomputedtomography;DSE,dobutamin
ticvalvereplacement;TAVI,transcatheteraorticvalveimplantation;TEE,transoesophageal echocardiography;TR,tricuspidregurgitation;TTE,transthoracicechocardiography;VHD,valvularheartdisease.
Figure2 Themanagementofpatientswithvalvularheartdisease(VHD)andacuteheartfailure(AHF)andtheroleoftheHeartTeam.The stagedmanagementapproachinAHFpatientswithVHDincludesthefollowingsteps:(i)diagnosis,includingassessmentofVHDseverity, identificationoftheclinicalphenotypeofAHFandestimationofthepatient’sprognosis;(ii)stabilizationwithcontinuousreassessment; (iii)definitiveVHDtreatment;(iv)post-interventioncare.Medicaltherapycanbeusedasbridgetoelectiveinterventionorasdestination therapyifinterventioniscontraindicatedbecauseofveryhighproceduralrisk,severecomorbiditiesorfutility.Highlysymptomaticpatients, despiteintravenous(IV)therapies +/ mechanicalcirculatorysupport(MCS),butnoteligibleforVHDinterventionsshouldbeevaluatedfor hearttransplant(HTX)andleftventricularassistdevice(LVAD)implantation.TheHeartTeammustindividualizemultidisciplinarydiscussion toofferthebestoptionforeachparticularcase.ACS,acutecoronarysyndrome;ACEinh,angiotensin-convertingenzymeinhibitor;ADHF, acutedecompensatedheartfailure;APO,acutepulmonaryoedema;BB,beta-blocker;CS,cardiogenicshock;DAPT,dualantiplatelettherapy; GDMT,guideline-directedmedicaltherapy;HFrEF,heartfailurewithreducedejectionfraction;MRA,mineralocorticoidreceptorantagonist; PVT,prostheticvalvethrombosis;RHF,rightheartfailure;RRT,renalreplacementtherapy.*Continuousreassessmentafterinitialtherapiesis mandatoryinordertoevaluatecongestionandperfusionstatus,toconfirmVHDseverity,todecidetheneedforfurtherescalationandto establishindicationofVHDinterventiononanemergencyorelectivebasis.
vasodilatorscanbeusedinnormotensiveorhypertensive patientstoimproveforwardflow.12 Inparticular,nitroprusside,reducingbothleftventricularafterloadandpreload,can reduceaorticregurgitantvolume.92
Inotropicagents,suchas milrinoneordobutamine,canbeusedinpatientswithAHFand hypotensiontoincreasestrokevolume.12 However,whenCS ensues,norepinephrinerepresentsthefirstchoice.14 Ingeneral, beta-blockersarenotappropriateinacuteAR,astheycanprolong diastolicregurgitationtimeanddecreasestrokevolume.12 In caseofCSandseverebradycardia,temporarycardiacpacingis advised.14
Aorticstenosis
IntravenoustherapyforsevereASislimitedbythepresenceof afixedobstructionandleftventricularhypertrophythatmake theventriclepreloadsensitive.14 Innormotensiveorhypertensive
patientswithASandcongestion,thecautioususeofvasodilators anddiureticscansafelymitigatecongestion,12 butexcessivedoses mayresultindecreasedcardiacoutputwithhypotension.Mixed vasodilators,suchasnitroglycerine,shouldbeavoided.Nitroprussidewasfoundtobeeffectiveinreducingleftventricularfilling pressureandimprovingcardiacoutputinasmallsetofpatients withsevereASandsevereleftventriculardysfunctionandwas safeasabridgetoaorticvalvereplacement.93 Inotropes(dobutamine)14 andlevosimendan94 maybeusedinextremelyselected patientswithseverelyimpairedcardiacoutput,buttheiruseis limitedastheymayincreasetransvalvulargradientwithoutincreasingforwardstrokevolumeandmayworsenmyocardialischaemia inpatientswithconcomitantcoronaryarterydisease.However, theincreaseinthevalvegradientandstrokevolumedueto inotropescanhelptoconfirmseverityofASinpatientswith HFrEF.InpatientswithsevereASandhypotension,intravenous norepinephrineincreasesbloodpressureandcanrestorecoronary
perfusionpressure.Phenylephrineisusefulforcounteractingthe vasodilatoryeffectsofanaesthesia.14
Mitralregurgitation
TheleftventricularfunctioninsevereMRishighlyafterloadsensitiveandvasodilatorsarefirst-linetherapyinpatientswithAHF andMRunlesshypotensive.95,96 Theyareeffectiveinreducingleft ventricularafterload,increasingforwardstrokevolumeandreducingMR.Fortheremainingpatients,carefullytitratedintravenous diureticsareeffectivetoachieveadequatedecongestion.Inotropic (dobutamine)andinodilator(milrinone)drugsmaybeappropriate toimprovestrokevolumeinpatientswithhypotensionand/or signsofhypoperfusion.14 InAHFpatientswithsecondaryMR, levosimendanacutelyimprovessystolicanddiastolicfunctionand reducesMRdegreeandmightbeparticularlyusefulinpatients alreadyonbeta-blockersandinthosewithPHand/orrightventriculardysfunction.97 IntravenousvasopressorsmayworsenMR, andeveninhypotensivepatientsitisadvisedasthelowestpossible dosetobeused.
Mitralstenosis
InMS,intravenousdiureticsreducepulmonarycongestionand improvesymptoms.12 Intravenousvasodilatorsandinotropesare ineffectiveatreducingcongestionorincreasingcardiacoutputin MSwithimpairedleftventricularfilling,butwithrelativelypreservedleftventricularfunction.98 Inhypotensivepatients,cautiouslytitratedintravenousnorepinephrineorvasopressorswithouttachycardiceffects,suchasvasopressin,increaseforward flow.14,60,72 ThemostcommonreasonforHFdecompensation inpatientswithMSisatrialfibrillationwithrapidventricular rate.Parenteralbeta-blockers(i.e.esmolol,landiolol)decrease heartrate,prolongdiastolicfillingtime,reduceleftatrialpressureandtransmitralgradient.Intravenousdigoxinandamiodaronemaybeappropriateforratecontrolinhypotensivepatients withatrialfibrillation.Arhythmcontrolstrategyusingelectricalcardioversionisguideline-recommended,1,16 ifthereishaemodynamicinstability,thoughanticoagulationandTEEareneeded frequently.99
Tricuspidregurgitation
InsecondaryTR,theunderlyingaetiologyshouldbeaddressed. Diuretics,intravenousfurosemidealoneorincombinationwith thiazides,decreasevolumeoverloadandmayimprovesymptoms insevereTRwithsignsofrightHF.16 Addinganaldosterone antagonistrepresentsapossibletreatmentoption,inparticular forpatientswithhepaticcongestionandsecondaryhyperaldosteronism.1 However,thebenefitofaldosteroneantagonistsor angiotensin-convertingenzymeinhibitors/angiotensinIIreceptor blockersonrightventricularremodellingorfunctionalimprovementinpatientswithseveresecondaryTRhasnotbeenvalidated inclinicalstudies.
Inotropicandvasopressoragentsmaysupportrightventricular contractility.Dobutamineupto5 μg/kg/min,milrinoneandlevosimendanimprovecardiacoutputwithoutincreasingPVRinpatients
withPH.InpatientswithPH,pulmonaryvasodilatorsmayleadto areductioninTRseverity.35,100
Specificconditions
WhenAHFiscausedbyprostheticvalveendocarditis,appropriate antibiotictherapiesshouldbeinitiatedandcontinued4–6weeks afterintervention.15,16,101 However,forpatientswithCSandprostheticvalveendocarditis,urgentcardiacsurgeryremainstheonly optionunlesscontraindicatedinHeartTeam.15,16 Inpresenceof obstructivethrombosisofamechanicalprosthesis,intravenous unfractionatedheparinisindicatedincaseofinadequaterecent anticoagulationandwithabsenceofhaemodynamicinstability. Accordingtoguidelinerecommendations,fibrinolysisshouldbe consideredifthepatientpresentswithseverehaemodynamicinstabilityandsurgeryisnotimmediatelyavailableorisdeemedhigh risk.16
Mechanicalventilation
Theassessmentofrespiratorystatusandanticipatinganeedfor airwaymanagementwitheitherintubationornon-invasivepositive pressureventilation(NIPPV)iscriticallyimportantinpatientswith VHDpresentingwithAHF.1,12,16 Therearenoparticularindications foranymodalityortechniqueofmechanicalventilationinpatients withVHDandAHF.102– 104 However,themostcommoncondition requiringinvasivemechanicalventilationinpatientswithsignificant VHDandAHFremainscardiacsurgery.104 Generalanaesthesia withmechanicalventilationviaintubationisalsorecommended duringpercutaneousprocedures,suchascomplexmitraland tricuspidtranscatheterinterventions,whenTEEisessentialto guideproceduresandtodetectearlypotentialcomplications.
Accordingtoguidelinerecommendations,NIPPVshouldbeconsideredinpatientswithAHFwhenoxygentherapyisnotsufficienttocontrolhypoxaemiaandhypercapnia.1 Itshouldbestarted assoonaspossibletodecreaserespiratorydistressandreduce theneedforendotrachealintubation.58 NIPPVcanpotentially improveMRseveritybyreducingleftventricularpreloadandafterload.103 PatientswithsevereASandMSandAHFmaynottolerate intubationwithmechanicalventilationaspositiveintra-thoracic pressuremayresultinreducedpreloadwithhypotension.Therefore,non-invasiveventilationispreferred.Moreover,positive intra-thoracicpressuremayprecipitaterightventricularfailurein patientswithseverePH,andaggravatesfunctionalTRandrightventriculardysfunctionsecondarytoVHD,andlowpressuresshould beusedinthissetting.102,104
Tonote,significantVHD,mainlyMRandAS,mayprecludeweaningfrommechanicalventilation,requiringprolongedintubation coupledwithweaningstrategies.61,104
Short-termmechanicalcirculatory support
Short-termMCSmaybeappropriateinpatientsVHDandrefractoryHForCS1,58 tosupportcardiacoutputandperipheralperfusionpressure,decreasemyocardialoxygendemandand,possibly,
increasecoronaryperfusion.105 EarlyescalationofMCSispreferredtoreducetheneedforvasopressorsandinotropes,which mayhaveunfavourableeffectsoncardiacloadingconditions,72 but thisstrategyisnotyetsupportedbytheresultsofclinicaltrials inpatientswithCSanddiverseaetiologies.Giventhecomplex decision-makingrequiredformanagementofVHDemergencies, referraltoacomprehensiveHeartValveCentreisadvised.Data fromrandomizedcontrolledtrialsdonotallowdrawingdefinitive conclusionsinfavourofonedeviceversustheothersinthesetting ofVHD.105
Allshort-termMCSarecontraindicatedinpresenceofsignificantARsincetheycanworsenseverityofregurgitation anddecreasecardiacoutput.Intra-aorticballoonpump(IABP), TandemHeartandperipheralextra-corporealmembraneoxygenation(ECMO)willallresultinanincreaseofleftventricular end-diastolicpressureduetotheincompetentaorticvalve,and therewillberecirculationwiththeImpella.14,72
InAHFpatientswithsevereAS,IABPandECMOcanbeused asbridgetointerventionorassupportduringandafterhigh-risk procedures.12 Impellacanalsobeusedinpatientswithsevere AS,althoughplacementacrossthestenoticaorticvalvemightbe challenging.106,107
InMS,peripheralECMOcanbeused,whileIABPandImpella aretypicallyineffective.TandemHeartistheoreticallyidealdueto directleftatrialunloading.14,72
InAHFpatientswithMR,short-termMCScanbeusedasbridge tointervention(i.e.papillarymusclerupture),asbridgetorecovery (i.e.acutemyocarditiswithsevereMR)orasbridgetolong-term MCSorhearttransplantation(i.e.advancedHF).Notably,ECMO canworsenfunctionalMRduetoleftventriculardistensionifno ventingisprovided.
SmallstudiesreportedtheroleofIABPinimprovingtechnical successinpatientswithsecondaryMRandpoorleafletcoaptationundergoingTEER.108,109 ImpellaandECMOhavealsobeen describedinafewcasereportsshowingtheireffectivenessin high-riskpercutaneousmitralvalveprocedures.110 However,cases reportingdamagetothesubvalvularapparatusafterImpelladevice positioningarealsodescribed.111
Valvularsurgeryandpercutaneous interventions
Distincttovalvularsurgeryinchronicsettings,16 therearemany challengingaspectsinthecontextofAHFincludingvarying cause–effectrelationshipbetweenAHFandVHD,timingofintervention(beforeorafterstabilization),typeofintervention(repair orreplacement,surgicalorpercutaneous).
Althoughthecurrentscoresfortheassessmentoftheoperative riskinpatientsundergoingcardiacsurgeryincludevariablesassociatedwithincreasedriskofmortality,112 thesevariableswerenot specificallyvalidatedinthesettingofAHF.SinceAHFpatientswith VHD,especiallythosewithmultipleorgandysfunctionsorsevere comorbidities,mayhavehighorprohibitivesurgicalrisk,16 percutaneousstrategiesmustbeintegratedintothetherapeuticspectrum.
However,therearesomeacuteconditions,suchasprosthetic valvethrombosis,acuteendocarditis,inwhichsurgery,evenathigh
risk,remainstheonlytherapeuticoptionwhenmedicaltreatment isnotsufficient.
Aorticregurgitation
InAHFpatientswithisolatedsevereARwithoutdissection, surgeryafterinitialstabilizationremainsthegoldstandard (Figure 3).Emergencysurgeryistheonlysolutioninacutesevere ARduetoaorticdissection,unlesscontraindicated.
16
Transcatheteraorticvalveimplantation(TAVI)representsan appropriateoptioninAHFpatientswithARif(i)surgicalrisk isprohibitive,and(ii)therearenoclinicaloranatomicalcontraindicationstoTAVI(i.e.activeendocarditis,aorticdissection orexcessivedilatedaorticannulus).Currently,therearenodedicatedandapproveddevicestotreatisolatedAR(Figure 3).Devices usedfortreatingASareadaptedtoisolatedAR,buttheseproceduresshouldbeconsideredoff-label.Themaintechnicalchallenge isvalveanchoringduetotheabsenceofcalcifications.Datafrom twolargemulticentreregistriesreportedfeasibilityandefficacyof TAVIinAR,butmostofthepatientswereelectivelytreated.113,114
Althoughthesecond-generationJenaValvehasrecentlyreceiveda CEmarkforthetranscathetertreatmentofseveresymptomatic AR,theresultsoftheALIGN-AREFStrial,115 evaluatingthesafety andeffectivenessofthetransfemoralJenaValveinthetreatmentof patientswithsymptomaticsevereAR,willbetterinformtheclinical practice.
FewcasereportsdescribedtreatingacuteARwithTAVIinthe emergencysetting.116,117
Aorticstenosis
InAHFpatientswithsevereAS,accordingtoguidelines,thechoice betweenTAVIandsurgicalaorticvalvereplacement(SAVR)should bebasedonHeartTeamdecisions(Figures 1 and 3).16,20 Although therearenospecificrandomizedcontrolledtrialstoevaluatethe roleofTAVIinthesettingofAHF,mostofthepatientsundergoing TAVIinrandomizedtrialsandobservationalstudieswereinNYHA classIIIorIV.NYHAclassIVwasfoundtobeassociatedwith pooroutcomewithin3monthsafterTAVI,butTAVIrecipientswith baselineNYHAclassIVwhosurvivedat3monthshadalong-term outcomecomparabletothatofpatientswithbaselineNYHAclass I–III.118 Similarly,emergentorurgentTAVIinpatientswithsevere ASandCShasworseprognosiscomparedtoelectiveTAVI.
119– 121 Nevertheless,thisdifferenceseemslimitedtothefirstmonthsafter theprocedureandisprobablylinkedtotheveryhigh-riskprofile.
120
InpatientswithsevereASandsignificantproximalcoronary arterydiseasewhoarecandidatesforcardiacsurgery,theguideline recommendationforconcomitantSAVRandcompleterevascularizationhasnotrecentlychanged.
16 ForTAVIcandidates,current guidelinesmentionedthatpercutaneouscoronaryintervention (PCI)shouldbeconsideredinpatientswithaprimaryindicationfor TAVIandcoronaryarterydiameterstenosis >70%inproximalsegments,16 butdidnotmakeanyrecommendationsforthetimingof PCI,pre-,concomitantorpost-TAVI.Routinerevascularizationof allsignificantcoronaryarterydiseasebeforeTAVIinpatientswith noorminimalanginaisnotsupportedbythelatestevidence.
122 In addition,otherfactorssuchassymptomseverity,haemodynamic
instability(eitherischaemia-inducedorassociatedwithAS),bleedingriskassociatedwithantiplatelettherapy,amountofcontrast use,durationofprocedureandcoronaryaccess(verychallenging post-TAVIwhenaprosthesiswithasupra-annularleafletposition ischosen),aredecisionalfortheappropriatetiming.123 However, thereiscurrentlyinsufficientevidenceregardingtheroleandtiming ofPCIinAHFpatientsundergoingTAVItoinformclinicalpractice andtheroleoftheHeartTeamremainsessentialinthiscomplex patientgroup.
InpatientswithCS,balloonaorticvalvuloplasty(BAV)remainsa reasonableoptionasabridgetoadefinitiveinterventionincentreswithoutavailabilityforTAVIorSAVR.15,16 Althoughacute proceduralsuccess,measuredasareduction ≥50%oftransaorticpressuregradient,wasconsistentlyreported,earlyrestenosis isfrequent.124,125
However,BAVcarriesriskofsignificantcomplicationsandshort-andmid-termoutcomesremainedpoor,with morethanhalfofpatientsdyingat 1 year,withasteadytrendover time.Inparticular,excessriskofmortalitywasobservedwhen BAVwasnotfollowedbydefinitivetherapy(SAVRorTAVI),ifthe delaytoSAVRorTAVIwaslongorthepatientrequiredrepeat procedure.126,127
notavailableforurgentTAVI,Dopplerechocardiographyofthe ileo-femoralarterialaxisandthree-dimensionalechocardiography canbeusedforaccesschoiceandvalvesizing.BAVcanbeperformedaspalliativemeasurewhengeneralconditionsprohibitany furtherintervention,anditmaybealsoappropriateinpatientswith multifactorialcausesofacutedecompensationandforwhomthe expectedbenefitofvalvereplacementislimited.
Mitralregurgitation
InacuteischaemicMR,papillarymuscleruptureneedsimmediaterepair(Figure 4).Papillarymuscleruptureoccursin0.25%of patientsfollowingacutemyocardialinfarction(AMI)andrepresents upto7%ofpatientsinCSfollowingAMI.130 Unpredictabilityand rapiddeteriorationwithdeathmakessurgeryforpapillarymuscle rupturenecessary.Short-termMCScanbeusedtosupportthe intervention.Inthiscontext,mitralvalvereplacementrepresents thefirstchoiceandsurgicalrepairmaybeappropriateonlyincarefullyselectedcases.IncaseofsevereMRduetopapillarymuscle rupture,percutaneousTEERmaybeappropriateinexpertcentres, iftheHeartTeamdeemsthesurgicaloptionprohibitive.
InprimarysevereMRwithAHF,accordingtoguidelines,surgery remainsthegoldstandardandonlypatientsdeemedathighor prohibitiveriskshouldbeconsideredforalternativetherapies.
Ifpre-proceduralcomputedtomographyscanis
Thus,itiscrucialtoonlyperformBAVatexperiencedcentres,ideallywhereaccesstoTAVIisavailable.IfTAVIis notavailable,thentransferringthepatienttoacentrewithSAVR orTAVIcapabilitiesisanimportantconsiderationwhenperformingBAV.Inaddition,urgentBAVshowedahigherrateof30-and 90-dayHFreadmissioncomparedtoTAVIperformedinurgency settings.125,128,129
AseriesofsuchpatientswithacutesevereMRundergoingemergencysurgeryshowedthatpatientswithacuteendocarditis,coronaryarterydisease,pre-operativeatrialfibrillationandchronic
renalfailuremakeupthemostvulnerablegroup,withhighestrisk forearlyandlateadversecardiacevents.135– 138 Thus,accordingto guidelines,AHFpatientswithacuteprimaryMR,athighorprohibitivesurgicalriskmaybeconsideredbytheHeartTeamforpercutaneoustreatment.16 TEERisthemostusedtechnique,though otherdevicesmaybeappropriateaccordingtotheexpertiseofthe centre.
AcutesecondaryMR(i.e.afterAMI)requiresmitralvalveintervention,possiblyafterinitialstabilization.Theprognosticimpact ofsurgeryinthissettingisunproven,and 1-yearmortalityremains high(19–31%).134– 140 Timingofinterventiondependsonresponse tomedicaltherapyandclinicalandhaemodynamiccharacteristics ofthepatient.ShortreportsshowedfeasibilityandefficacyofTEER inpatientswithAMItreatedbyprimaryPCI,complicatedbyacute MR,133,136,141,142 butcarefulevaluationbyamultidisciplinaryHeart Teamisadvised.
havingfavourableclinicalandanatomiccharacteristicforPMC
(Figure 4).Althoughevidenceislimited,PMCseemsfeasiblealso intheAHFsetting.PMCisveryeffectiveduringpregnancysince manyofthesepatientshaveAHFandsurgeryiscontraindicated.
EmergentPMChashighmortality(about30%),thoughsurvivors seemtohaveasignificanthaemodynamicandclinicalbenefitfrom theprocedure.144,145 Accordingtoguidelines,inpatientsinwhom PMCiscontraindicatedorhaveunfavourableclinicalandanatomicalcharacteristics,surgeryshouldbeconsidered.
Tricuspidregurgitation
PatientswithchronicsecondaryMRwhodevelopAHFduring HFprogressionrepresentamorechallenginggroup.Efficacyof percutaneoustechniqueswasnotdemonstratedbyrandomized trialsinthissettingbutrecentmulticentreregistriessuggesteda possiblebeneficialeffectofTEERonprognosisofunstablepatients presentingwithCS.
Mitralstenosis
139,140,143
Ingeneral,percutaneousmitralcommissurotomy(PMC)isindicatedinpatientswithclinicallysignificantandsymptomaticMS
Mostpatientsremainasymptomaticforaprotractedspanoftime withmoderate-to-severeTR.Moreover,whensymptomsoccur theycaninitiallybeinsidiousanddifficulttoascribetotheTR. Fatigue,decreasedexercisetolerance,peripheraloedema,hepatic congestion,decreasedappetite,ascites/anasarcaarenon-specific andlatefindings.Surgeryisthetreatmentofchoiceinpatients withisolatedTRpresentingwithrightAHF(Figure 5).Ithasthe potentialtoreducecentralvenouspressure,haltrightventricular remodelling,increasestrokevolume,improveperipheralperfusion and,theoretically,permittherecoveryofrenalandhepaticfunction.52,56,89 However,in-hospitalmortalityremainshigh(9%)dueto theadvanceddisease.146 Tonote,correctingTRinpatientswithPH in(non-valvular)leftheartdiseasewithsignificantlyelevatedPVR and/orrightventriculardysfunctionishazardous,andassociated withseverepost-proceduraloutcomes.147,
Forpercutaneoustricuspidvalveinterventions,a propensity-matchedanalysisfromthelargestinternationalmulticentreregistryshowedabetteroutcomeinpatientsreceiving transcathetertricuspidvalveinterventionscomparedtothose managedmedically.Morethan90%ofthesepatientswerein NYHAclassIIIorIVandaboutone-thirdhadrightventricular failureand/orPH.89 AlthoughnotincludingpatientswithAHF, intherecentopen-labelTRILUMINATEtrial,tricuspidTEER comparedtomedicaltherapywasassociatedwithanimprovementinqualityoflife,butnotsignificantbenefitintermsof mortality,HFreadmissionsand6-minwalkdistance.149 This suggeststhatinpatientswithsevereHF,TRcanbecausedby anumberofdifferentunderlyingconditionsanditsreduction withTEERmaynotaddresstherootcausesofthevalvular disease.
AlthoughpercutaneousdevicesfortreatingTRarespreading,appropriatepatientselection,typeofdeviceandtimingare stillunclear.Onceatricuspidvalveinterventionisconsidered,it shouldbeperformedinaVHDcentrewithexperiencedoperatorsandwiththepotentialtoofferalltreatmentmodalities withproofofexcellentoutcomes.149 IntheseVHDcentres,the multidisciplinaryVHDHeartTeamswillevaluatetheneed,timing,andtypeofintervention.16,150 Although,transcatheterTV replacementorrepairrepresentnovelandlessinvasivealternativestosurgeryandhaveshownearlypromisingresults,larger randomizedstudiesareneededtodefinetheclinicalandproceduralendpointsandoutcomes,inordertodrawmoresolid conclusions,particularlyforthesubsetofpatientspresenting withAHF.
Infectiveendocarditis
Emergent/urgentsurgeryisindicatedininfectiveaortic,mitralor tricuspidvalveendocarditiswithsevereregurgitation,obstruction orfistulacausingAHF.15,16,101 153,154 Surgerymustbeperformed onanemergencybasis,irrespectiveofthestatusofinfection, whenpatientsareinpersistentpulmonaryoedemaorCS despitemedicaltherapy.15,16 SurgeryforCSandinfectiveendocarditishasbeenassociatedwithhigher30-daymortalitythan patientswithoutshock(19.5%vs. 14.6%),butthismortalityis significantlylowerthanmitralvalveinfectiveendocarditiscomplicatedbysepticshockwhounderwentsurgery(65.8%).153 Identifyingtheprimaryaetiologyofshockinthesehaemodynamicallyunstablepatientshasimportanttreatmentandprognostic implications.154
WhentricuspidvalveendocarditisiscausedbyaninfectedCIED, extractionoftheCIEDisguideline-recommended16 andsurgeryis typicallynotneededforremovaloftheinfecteddevice.101,153
Prostheticvalvedysfunction
Emergencyreintervention(<24h)isguideline-recommendedin criticallyillpatientswithobstructivethrombosisofamechanical prosthesisinabsenceofcontraindications.15,16,155
Fibrinolysismaybeconsideredifthepatientpresentswithsevere haemodynamicinstabilityandsurgeryisnotimmediatelyavailableorifthereisveryhighriskforthetreatmentofthrombosisofright-sidedprostheses.15,16 Arecentobservationalstudy suggestedabenefitofslow/ultraslowadministrationoflow-dose fibrinolysis.15,155
ForpatientswithAHFinsettingsofprostheticvalveendocarditis,urgentsurgery(withindays)isguideline-recommended, whileemergencysurgeryisindicatedonlyincaseswithrefractorypulmonaryoedemaorCS,asinNVE.156 Reoperationisalso guideline-recommendedasfirst-linetherapyinpatientswithprosthesisdysfunctionandsevereparavalvularleakcausingAHF.15,16 In acutesettings,thereisverylimitedexperiencewithtranscatheter closureofparavalvularleaksandthistherapymaybeappropriate foranatomicallysuitableparavalvularleaksincandidatesselected bytheHeartTeam.156
Transcathetervalve-in-valveproceduresarefeasibleinaortic, mitralandtricuspidpositionforbioprosthesisfailure.157 These interventionsmaybeappropriateonlyinselectedcaseswhere reoperationiscontraindicatedordeemedathighriskbythe HeartTeamorintheacutesettingsofHFsuchasbioprosthesis degenerationleadingtoacutedecompensationorCS.157– 159 Valve thrombosisoractiveendocarditisrepresentcontraindicationsto percutaneousprocedures.
Leftventricularassistdevicesandheart transplantation
LeftventricularassistdevicesandhearttransplantationareindicatedinpatientswithacuteadvancedHFwhenmedicaltherapyandshort-termMCSareinsufficienttoavoidHFprogressionandmulti-organimpairment.1 160 TypeandseverityofVHD shouldbecarefullyassessedbeforeLVADimplant.Inthesetting ofLVAD,ARcreatesacirculatoryshuntora‘closedcirculatory loop’betweenthepump,valve,theleftventricle,andbacktothe pumpagain.161 Thisphenomenonultimatelyreducespumpefficiencyanddecreasesleftventricularunloading,cardiacoutput,and organperfusion.ThepresenceofARislikelydetrimentaltoright ventricularfunction,especiallyinpatientswithmoderatetosevere pre-operativerightventricularfailure.Theincompleteleftventricularunloadingincreasesrightventricularafterloadandworsens rightventricularfailure.Concomitantaorticvalveproceduresat thetimeofLVADimplantation,inpatientswithmoderateorsevere ARisjustifiedandveryoftenperformedparticularlywhenthe anticipateddurationofsupportismorethan 1 year.162
Persistentmoderate/severeTRseemstobedetrimentalto LVADpatients,thoughthebenefitofaconcomitanttricuspidvalve procedureremainsunclearandthedecisionshouldbebasedona multidisciplinaryHeartTeamdiscussion.
TheInternationalSocietyforHeartandLungTransplantation guidelinessuggestthatmoderate/severeTRshouldbeconsideredforsurgicalrepairatthetimeofMCSimplantationbut morerecentstudiesdemonstratednosurvivalbenefitandan increaseinpost-operativemorbiditywhenaddressingsignificant TR.163,167,168 Inarecentclinicaltrial,tricuspidvalvesurgerywas successfulinreducingpost-implantTRcomparedwithnotricuspidvalvesurgery,butwasnotassociatedwithalowerincidenceof rightHF.169
Cardiacpacing
Accordingtotheguidelines,cardiacresynchronizationtherapy (CRT)isrecommendedforsymptomaticpatientswithHFand LVEF ≤35%insinusrhythmwithaQRSduration >150msandleft bundlebranchblockmorphologydespiteoptimalmedicaltherapy andinthosewithHFrEFandindicationforventricularpacingfor high-degreeatrio-ventricularblock.InpresenceofAHFwithsevere ARand/orAS,primaryMR,CRTmaybeappropriateonlyifthese criteriapersistaftervalvetreatment.1,58 Ontheotherhand,in presenceofsecondaryMR,CRTisadvisedtobeperformedfirstif indicated.
Implantationorextractionofpacemakerordefibrillatorleads, includingCRT,cancauseorworsenTRinupto 18%ofrecipients170 andpossiblyleadtoAHF.Whenmedicaltherapyisnotsufficientto controlsymptomsandsurgicalriskishigh,repositioning(viacoronarysinus)orextractionofCIEDleadscanbeenvisagedinselected patientswithdisturbedtricuspidleafletmotion.171 However,the efficacyofleadextractioninreducingTRisuncertainandadditionaldamagetothetricuspidvalvecanoccur.151,171 Ifsevereand symptomaticTRpersistsafterleadextraction,transcatheterinterventionsarefeasiblewithdifferenttechnologiesinwell-selected patientsinexperiencedcentres.151,171 TricuspidTEERisadvised whenthereisonlycommissuraljet,whileinpatientswithtricuspid annulardilatationandlargeleafletgap(>8.5mm),transcatheter annuloplastyplusTEERortranscathetertricuspidvalvereplacementisadvised.151
Palliativecare
163
PatientswithASassociatedwithmoderate/severeARare treatedsimilarlyaspatientswithAR.Aorticvalvereplacementin patientswithsevereisolatedASmaypotentiallyoptimizechances ofleftventricularrecoverybutdoesnotprovideclinicalorphysiologicalbenefits.
Managementofpre-existentsevereMRinpatientsundergoingLVADremainscontroversial.IntheINTERMACSdatabase, concomitantmitralvalveproceduresforsevereMRwerenot associatedwithincreasedsurvivalcomparedtonointervention cohorts.164 Inarecentstudy,therewasnosignificantdifference inmortalityfollowingMCSinthosewithorwithoutpre-existing severeMR.Intheabsenceofmitralintervention,93%ofpatients showedresolutionofMRat30days.165 Inaddition,asub-analysis ofMOMENTUM3includingpatientswhohadpreoperativesevere MRdemonstratedresidualMRinonly6.2%ofpatientswithHeartMate3.166 Inconclusion,overalldatasupportnointerventionfor pre-existingsevereMR.
ApalliativecareapproachwithintheVHDsettingiscurrentlyclinicallyrelevant.Increasingage,frailtyandassociatedcomorbidities, suchascancer,end-stagerenaldisease,frailty,putanincreasing numberofpatientswithVHDatveryhighorprohibitivesurgicalrisk.16,172 Also,forVHDpatientswithcomplexcomorbidities, cardiacdiseasemightnotbetheprimarydriverofsymptomsand reducedqualityoflifeandinthesecases,valveinterventionshave onlymarginaleffectsonapatient’soverallclinicalcourse,despite proceduralsuccess.172,173
Thedecisionnottooffersurgery/intervention,whentreatment isdeemedfutile,shouldnotmeanabandoningcareasthese patientsrequiretransitiontopalliativecareandcontinuityofhealth
services.Ideally,palliativecareshouldcontinuethroughoutthe diseasecourseandshouldbeinstitutedalongsidedisease-modifying interventions.173,174
Acollaborativeapproachisadvisedwherebymultidisciplinary teammembersfromcardiology(StructuralHeartTeam)and palliativecare,worktogethertoplanmanagement.172 Anumberofservicemodels,utilizingthissharedcareapproach,have beentestedwithinHFandfoundtoyieldpositiveoutcomes intermsofimprovedsymptomburden,depressionandspiritual well-being.173,174 Thecareprioritiesincludetreatingpain,other symptoms,andpsychologicaldistress,usingadvancedcommunicationskillstoestablishgoalsofcareandtomatchtreatmentoptions toindividualizedgoals.
Conclusions
AcuteHFinthesettingofVHDgeneratesseveraldiagnosticchallenges,includingdifficultiesinassessingVHDseveritybecauseof therapidchangeinloadingconditions,andtheinterferencewith acuteprecipitantsandassociatedcomorbiditiesthatmakesproblematictoascertainwhethertheVHDistheonlycontributor tothepatient’sclinicaldeterioration.Furthermore,therapeutic interventionsinpatientswithVHDandAHFarenotrigorously evidence-basedbecausetherearenorandomizedcontrolledtrials inthissettingandevenmore,patientswithsevereVHDareoften excludedfromAHFrandomizedtrials.Thus,aclear-cutstrategy regardingtimingofintervention(beforeorafterstabilization)or typeofintervention(repairorreplacement,surgicalorpercutaneous)cannotyetbedefined.However,sinceAHFpatientswith VHD,especiallythosewithmultipleorgandysfunctionorsevere comorbidities,mayhaveveryhighorprohibitivesurgicalrisk,percutaneousstrategiesmustbeintegratedintothetherapeuticspectrum,followingtheHeartTeamdecisionaimingtoofferthebest optionforeachparticularcase.
SupplementaryInformation
Additionalsupportinginformationmaybefoundonlineinthe SupportingInformationsectionattheendofthearticle.
Conflictofinterest: nonedeclared.
References
1.McDonaghTA,MetraM,AdamoM,GardnerRS,BaumbachA,BohmM,etal. 2021 ESCGuidelinesforthediagnosisandtreatmentofacuteandchronicheart failure:DevelopedbytheTaskForceforthediagnosisandtreatmentofacute andchronicheartfailureoftheEuropeanSocietyofCardiology(ESC).With thespecialcontributionoftheHeartFailureAssociation(HFA)oftheESC. Eur JHeartFail 2022;24:4– 131 https://doi.org/10.1002/ejhf.2333
2.NieminenMS,BrutsaertD,DicksteinK,DrexlerH,FollathF,HarjolaVP, etal.;EuroHeartSurveyInvestigators;HeartFailureAssociation,European SocietyofCardiology.EuroHeartFailureSurveyII(EHFSII):Asurveyon hospitalizedacuteheartfailurepatients:Descriptionofpopulation. EurHeartJ 2006;27:2725–2736. https://doi.org/10.1093/eurheartj/ehl193
3.ChioncelO,VinereanuD,DatcuM,IonescuDD,CapalneanuR,BruknerI,etal. TheRomanianAcuteHeartFailureSyndromes(RO-AHFS)registry. AmHeartJ 2011;162:142–53.e1 https://doi.org/10.1016/j.ahj.2011.03.033
4.SpinarJ,ParenicaJ,VitovecJ,WidimskyP,LinhartA,FedorcoM,etal. BaselinecharacteristicsandhospitalmortalityintheAcuteHeartFailure
Database(AHEAD)Mainregistry. CritCare 2011;15:R291 https://doi.org/10 1186/cc10584
5.OlivaF,MortaraA,CacciatoreG,ChinagliaA,DiLenardaA,GoriniM,etal.; IN-HFOutcomeInvestigators.Acuteheartfailurepatientprofiles,management andin-hospitaloutcome:ResultsoftheItalianRegistryonHeartFailure Outcome. EurJHeartFail 2012;14:1208– 1217. https://doi.org/10.1093/eurjhf/ hfs117
6.LogeartD,IsnardR,Resche-RigonM,SerondeMF,deGrooteP,JondeauG, etal.Currentaspectsofthespectrumofacuteheartfailuresyndromesina real-lifesetting:TheOFICAstudy. EurJHeartFail 2013;15:465–476. https://doi .org/10.1093/eurjhf/hfs189
7.AmbrosyAP,FonarowGC,ButlerJ,ChioncelO,GreeneSJ,VaduganathanM, etal.Theglobalhealthandeconomicburdenofhospitalizationsforheart failure:Lessonslearnedfromhospitalizedheartfailureregistries. JAmCollCardiol 2014;63:1123– 1133. https://doi.org/10.1016/j.jacc.2013.11.053
8.Crespo-LeiroMG,AnkerSD,MaggioniAP,CoatsAJ,FilippatosG,RuschitzkaF,etal.EuropeanSocietyofCardiologyHeartFailureLong-TermRegistry(ESC-HF-LT): 1-yearfollow-upoutcomesanddifferencesacrossregions. EurJHeartFail 2016;18:613–625. https://doi.org/10.1002/ejhf.566
9.ChioncelO,MebazaaA,MaggioniAP,HarjolaVP,RosanoG,LarocheC,etal.; ESC-EORP-HFAHeartFailureLong-TermRegistryInvestigators.Acuteheart failurecongestionandperfusionstatus–impactoftheclinicalclassificationon in-hospitalandlong-termoutcomes;insightsfromtheESC-EORP-HFAHeart FailureLong-TermRegistry. EurJHeartFail 2019;21:1338– 1352. https://doi.org/ 10.1002/ejhf.1492
10.JavaloyesP,MiroO,GilV,Martin-SanchezFJ,JacobJ,HerreroP,etal.; ICA-SEMESResearchGroup.Clinicalphenotypesofacuteheartfailurebased onsignsandsymptomsofperfusionandcongestionatemergencydepartment presentationandtheirrelationshipwithpatientmanagementandoutcomes. Eur JHeartFail 2019;21:1353– 1365. https://doi.org/10.1002/ejhf.1502
11.McClungJA.Nativeandprostheticvalveemergencies. CardiolRev 2016;24:14– 18. https://doi.org/10.1097/CRD.0000000000000079
12.MaheshwariV,BarrB,SrivastavaM.Acutevalvularheartdisease. CardiolClin 2018;36:115– 127. https://doi.org/10.1016/j.ccl.2017.08.006
13.AkodadM,SchurtzG,AddaJ,LeclercqF,RoubilleF.Managementofvalvulopathieswithacutesevereheartfailureandcardiogenicshock. ArchCardiovasc Dis 2019;112:773–780. https://doi.org/10.1016/j.acvd.2019.06.009
14.JentzerJC,TernusB,EleidM,RihalC.Structuralheartdiseaseemergencies. JIntensiveCareMed 2021;36:975–988. https://doi.org/10.1177/ 0885066620918776
15.OttoCM,NishimuraRA,BonowRO,CarabelloBA,ErwinJP3rd,GentileF, etal.2020ACC/AHAGuidelineforthemanagementofpatientswithvalvular heartdisease:AreportoftheAmericanCollegeofCardiology/American HeartAssociationJointCommitteeonClinicalPracticeGuidelines. Circulation 2021;143:e72–e227. https://doi.org/10.1161/CIR.0000000000000923
16.VahanianA,BeyersdorfF,PrazF,MilojevicM,BaldusS,BauersachsJ,etal.2021 ESC/EACTSGuidelinesforthemanagementofvalvularheartdisease. EurHeartJ 2022;43:561 –632. https://doi.org/10.1093/eurheartj/ehab395
17.IungB,DelgadoV,RosenhekR,PriceS,PrendergastB,WendlerO,etal.; EORPVHDIIInvestigators.Contemporarypresentationandmanagementof valvularheartdisease:TheEURObservationalResearchProgrammeValvular HeartDiseaseIIsurvey. Circulation 2019;140:1156– 1169. https://doi.org/10 1161/CIRCULATIONAHA.119.041080
18.Kaplon-CieslickaA,BensonL,ChioncelO,Crespo-LeiroMG,CoatsAJS, AnkerSD,etal.;HeartFailureAssociation(HFA)oftheEuropeanSocietyof Cardiology(ESC)andtheESCHeartFailureLong-TermRegistryInvestigators. Acomprehensivecharacterizationofacuteheartfailurewithpreservedversus mildlyreducedversusreducedejectionfraction–insightsfromtheESC-HFA EORPHeartFailureLong-TermRegistry. EurJHeartFail 2022;24:335–350. https://doi.org/10.1002/ejhf.2408
19.TrompJ,BamadhajS,ClelandJGF,AngermannCE,DahlstromU,OuwerkerkW, etal.Post-dischargeprognosisofpatientsadmittedtohospitalforheart failurebyworldregion,andnationallevelofincomeandincomedisparity (REPORT-HF):Acohortstudy. LancetGlobHealth 2020;8:e411 –e422. https:// doi.org/10.1016/S2214- 109X(20)30004-8
20.FilippatosG,AngermannCE,ClelandJGF,LamCSP,DahlstromU,DicksteinK, etal.Globaldifferencesincharacteristics,precipitants,andinitialmanagement ofpatientspresentingwithacuteheartfailure. JAMACardiol 2020;5:401 –410. https://doi.org/10.1001/jamacardio.2019.5108
21.ChioncelO,MebazaaA,HarjolaVP,CoatsAJ,PiepoliMF,Crespo-LeiroMG, etal.;ESCHeartFailureLong-TermRegistryInvestigators.Clinicalphenotypes andoutcomeofpatientshospitalizedforacuteheartfailure:TheESCHeart FailureLong-TermRegistry. EurJHeartFail 2017;19:1242– 1254. https://doi.org/ 10.1002/ejhf.890
22.AbdurashidovaT,MonneyP,TzimasG,SoborunN,RegameyJ,DauxA,etal. Non-severeaorticregurgitationincreasesshort-termmortalityinacuteheart failurewithpreservedejectionfraction. ESCHeartFail 2020;7:3901 –3909. https://doi.org/10.1002/ehf2.12983
23.PagnesiM,AdamoM,SamaIE,AnkerSD,ClelandJG,DicksteinK,etal.Impact ofmitralregurgitationinpatientswithworseningheartfailure:Insightsfrom BIOSTAT-CHF. EurJHeartFail 2021;23:1750– 1758. https://doi.org/10.1002/ ejhf.2276
24.AroraS,SivarajK,HendricksonM,ChangPP,WeickertT,QamarA,etal.Prevalenceandprognosticsignificanceofmitralregurgitationinacutedecompensated heartfailure:TheARICstudy. JACCHeartFail 2021;9:179– 189. https://doi.org/ 10.1016/j.jchf.2020.09.015
25.WadaY,OharaT,FunadaA,HasegawaT,SuganoY,KanzakiH,etal. Prognosticimpactoffunctionalmitralregurgitationinpatientsadmittedwith acutedecompensatedheartfailure. CircJ 2016;80:139– 147. https://doi.org/10 1253/circj.CJ- 15-0663
26.KuboS,KawaseY,HataR,MaruoT,TadaT,KadotaK.Dynamicseveremitral regurgitationonhospitalarrivalasprognosticpredictorinpatientshospitalized foracutedecompensatedheartfailure. IntJCardiol 2018;273:177– 182. https:// doi.org/10.1016/j.ijcard.2018.09.093
27.DelaEspriellaR,SantasE,ChorroFJ,MinanaG,SolerM,BodiV,etal.Functional tricuspidregurgitationandrecurrentadmissionsinpatientswithacuteheart failure. IntJCardiol 2019;291:83–88. https://doi.org/10.1016/j.ijcard.2019.03 .051
28.SantasE,ChorroFJ,MinanaG,MendezJ,MunozJ,EscribanoD,etal.Tricuspid regurgitationandmortalityriskacrossleftventricularsystolicfunctioninacute heartfailure. CircJ 2015;79:1526– 1533. https://doi.org/10.1253/circj.CJ- 150129
29.MutlakD,LessickJ,KhalilS,YalonetskyS,AgmonY,AronsonD.Tricuspid regurgitationinacuteheartfailure:Isthereanyincrementalrisk? EurHeart JCardiovascImaging 2018;19:993– 1001 https://doi.org/10.1093/ehjci/jex343
30.LancellottiP,GerardPL,PierardLA.Long-termoutcomeofpatients withheartfailureanddynamicfunctionalmitralregurgitation. EurHeartJ 2005;26:1528– 1532. https://doi.org/10.1093/eurheartj/ehi189
31.BartkoPE,HulsmannM,HungJ,PavoN,LevineRA,PibarotP,etal.Secondary valveregurgitationinpatientswithheartfailurewithpreservedejectionfraction, heartfailurewithmid-rangeejectionfraction,andheartfailurewithreduced ejectionfraction. EurHeartJ 2020;41:2799–2810. https://doi.org/10.1093/ eurheartj/ehaa129
32.GalieN,HumbertM,VachieryJL,GibbsS,LangI,TorbickiA,etal.2015ESC/ERS Guidelinesforthediagnosisandtreatmentofpulmonaryhypertension:The JointTaskForcefortheDiagnosisandTreatmentofPulmonaryHypertension oftheEuropeanSocietyofCardiology(ESC)andtheEuropeanRespiratory Society(ERS):Endorsedby:AssociationforEuropeanPaediatricandCongenital Cardiology(AEPC),InternationalSocietyforHeartandLungTransplantation (ISHLT). EurHeartJ 2016;37:67– 119. https://doi.org/10.1093/eurheartj/ehv317
33.MagneJ,PibarotP,SenguptaPP,DonalE,RosenhekR,LancellottiP.Pulmonary hypertensioninvalvulardisease:Acomprehensivereviewonpathophysiologyto therapyfromtheHAVECGroup. JACCCardiovascImaging 2015;8:83–99. https:// doi.org/10.1016/j.jcmg.2014.12.003
34.YamamotoK,IkedaU,MitoH,FujikawaH,SekiguchiH,ShimadaK.Endothelin productioninpulmonarycirculationofpatientswithmitralstenosis. Circulation 1994;89:2093–2098. https://doi.org/10.1161/01.cir.89.5.2093
35.HumbertM,KovacsG,HoeperMM,BadagliaccaR,BergerRMF,BridaM,etal. 2022ESC/ERSGuidelinesforthediagnosisandtreatmentofpulmonaryhypertension. EurHeartJ 2022;43:3618–3731 https://doi.org/10.1093/eurheartj/ ehac237
36.BermejoJ,YottiR,Garcia-OrtaR,Sanchez-FernandezPL,CastanoM, Segovia-CuberoJ,etal.;SildenafilforImprovingOutcomesafterVAlvular Correction(SIOVAC)investigators.Sildenafilforimprovingoutcomesin patientswithcorrectedvalvularheartdiseaseandpersistentpulmonary hypertension:Amulticenter,double-blind,randomizedclinicaltrial. EurHeartJ
2018;39:1255– 1264. https://doi.org/10.1093/eurheartj/ehx700
37.TichelbackerT,DumitrescuD,GerhardtF,SternD,WissmullerM, AdamM,etal.Pulmonaryhypertensionandvalvularheartdisease. Herz
2019;44:491 –501
https://doi.org/10.1007/s00059-019-4823-6
38.Al-OmaryMS,SugitoS,BoyleAJ,SverdlovAL,CollinsNJ.Pulmonaryhypertensionduetoleftheartdisease:Diagnosis,pathophysiology,andtherapy. Hypertension 2020;75:1397– 1408. https://doi.org/10.1161/HYPERTENSIONAHA.119
14330
39.FawzyME,HassanW,StefadourosM,MoursiM,ElShaerF,ChaudharyMA. Prevalenceandfateofseverepulmonaryhypertensionin559consecutive patientswithsevererheumaticmitralstenosisundergoingmitralballoonvalvotomy. JHeartValveDis 2004;13(6):942–947.PMID: 15597587
40.LeTourneauT,RichardsonM,JuthierF,ModineT,FayadG,PolgeAS,etal. Echocardiographypredictorsandprognosticvalueofpulmonaryarterysystolic pressureinchronicorganicmitralregurgitation. Heart 2010;96:1311 – 1317. https://doi.org/10.1136/hrt.2009.186486
41.BarbieriA,BursiF,GrigioniF,TribouilloyC,AvierinosJF,MichelenaHI,etal.; MitralRegurgitationInternationalDAtabase(MIDA)Investigators.Prognostic andtherapeuticimplicationsofpulmonaryhypertensioncomplicatingdegenerativemitralregurgitationduetoflailleaflet:Amulticenterlong-terminternational study. EurHeartJ 2011;32:751 –759. https://doi.org/10.1093/eurheartj/ehq294
42.KusunoseK,PopovicZB,MotokiH,MarwickTH.Prognosticsignificanceof exercise-inducedrightventriculardysfunctioninasymptomaticdegenerative mitralregurgitation. CircCardiovascImaging 2013;6:167– 176. https://doi.org/10 1161/CIRCIMAGING.112.000162
43.FaggianoP,Antonini-CanterinF,RibichiniF,D’AloiaA,FerreroV,CervesatoE, etal.Pulmonaryarteryhypertensioninadultpatientswithsymptomaticvalvular aorticstenosis. AmJCardiol 2000;85:204–208. https://doi.org/10.1016/s00029149(99)00643-8
44.CamA,GoelSS,AgarwalS,MenonV,SvenssonLG,TuzcuEM,etal.Prognostic implicationsofpulmonaryhypertensioninpatientswithsevereaorticstenosis. JThoracCardiovascSurg 2011;142:800–808. https://doi.org/10.1016/j.jtcvs.2010 12.024
45.LancellottiP,MagneJ,DonalE,O’ConnorK,DulgheruR,RoscaM,etal. Determinantsandprognosticsignificanceofexercisepulmonaryhypertension inasymptomaticsevereaorticstenosis. Circulation 2012;126:851 –859. https:// doi.org/10.1161/CIRCULATIONAHA.111.088427
46.KhandharS,VaradarajanP,TurkR,SampatU,PatelR,KamathA,etal.Survival benefitofaorticvalvereplacementinpatientswithsevereaorticregurgitation andpulmonaryhypertension. AnnThoracSurg 2009;88:752–756. https://doi.org/ 10.1016/j.athoracsur.2009.05.025
47.LauGT,TanHC,KritharidesL.Typeofliverdysfunctioninheartfailureanditsrelationtotheseverityoftricuspidregurgitation. AmJCardiol 2002;90:1405– 1409. https://doi.org/10.1016/s0002-9149(02)02886-2
48.MullensW,AbrahamsZ,FrancisGS,SokosG,TaylorDO,StarlingRC,etal. Importanceofvenouscongestionforworseningofrenalfunctioninadvanced decompensatedheartfailure. JAmCollCardiol 2009;53:589–596. https://doi.org/ 10.1016/j.jacc.2008.05.068
49.TopilskyY,KhannaA,LeTourneauT,ParkS,MichelenaH,SuriR,etal.Clinical contextandmechanismoffunctionaltricuspidregurgitationinpatientswith andwithoutpulmonaryhypertension. CircCardiovascImaging 2012;5:314–323. https://doi.org/10.1161/CIRCIMAGING.111.967919
50.VerbruggeFH,DupontM,SteelsP,GrietenL,MalbrainM,TangWH,etal. Abdominalcontributionstocardiorenaldysfunctionincongestiveheartfailure. JAmCollCardiol 2013;62:485–495. https://doi.org/10.1016/j.jacc.2013.04.070
51.ShiranA,NajjarR,AdawiS,AronsonD.Riskfactorsforprogressionof functionaltricuspidregurgitation. AmJCardiol 2014;113:995– 1000. https://doi .org/10.1016/j.amjcard.2013.11.055
52.MangieriA,MontaltoC,PagnesiM,JabbourRJ,Rodes-CabauJ,MoatN, etal.Mechanismandimplicationsofthetricuspidregurgitation:Fromthe pathophysiologytothecurrentandfuturetherapeuticoptions. CircCardiovasc Interv 2017;10:e005043. https://doi.org/10.1161/CIRCINTERVENTIONS.117 .005043
53.BartkoPE,ArfstenH,FreyMK,HeitzingerG,PavoN,ChoA,etal.Natural historyoffunctionaltricuspidregurgitation:ImplicationsofquantitativeDoppler assessment. JACCCardiovascImaging 2019;12:389–397. https://doi.org/10.1016/ j.jcmg.2018.11.021
54.DietzMF,PrihadiEA,vanderBijlP,GoedemansL,MertensBJA,GursoyE,etal.Prognosticimplicationsofrightventricularremodelingandfunctioninpatientswithsignificantsecondarytricuspidregurgitation. Circulation 2019;140:836–845. https://doi.org/10.1161/CIRCULATIONAHA.119.039630
55.SanzJ,Sanchez-QuintanaD,BossoneE,BogaardHJ,NaeijeR.Anatomy, function,anddysfunctionoftherightventricle:JACCstate-of-the-artreview. JAmCollCardiol 2019;73:1463– 1482. https://doi.org/10.1016/j.jacc.2018.12 .076
56.MargonatoD,AnconaF,IngallinaG,MelilloF,StellaS,BiondiF,etal.Tricuspid regurgitationinleftventricularsystolicdysfunction:Markerortarget? Front CardiovascMed 2021;8:702589. https://doi.org/10.3389/fcvm.2021.702589
57.ArdenC,ChambersJB,SandoeJ,RayS,PrendergastB,TaggartD,etal.Canwe improvethedetectionofheartvalvedisease? Heart 2014;100:271 –273. https:// doi.org/10.1136/heartjnl-2013-304223
58.PonikowskiP,VoorsAA,AnkerSD,BuenoH,ClelandJGF,CoatsAJS,etal. 2016ESCGuidelinesforthediagnosisandtreatmentofacuteandchronicheart failure:TheTaskForceforthediagnosisandtreatmentofacuteandchronic heartfailureoftheEuropeanSocietyofCardiology(ESC).Developedwiththe specialcontributionoftheHeartFailureAssociation(HFA)oftheESC. Eur HeartJ 2016;37:2129–2200. https://doi.org/10.1093/eurheartj/ehw128
©2023EuropeanSocietyofCardiology
59.MuellerC,McDonaldK,deBoerRA,MaiselA,ClelandJGF,KozhuharovN, etal.HeartFailureAssociationoftheEuropeanSocietyofCardiologypractical guidanceontheuseofnatriureticpeptideconcentrations. EurJHeartFail 2019;21:715–731 https://doi.org/10.1002/ejhf.1494
60.FuernauG,DeschS,deWaha-ThieleS,EitelI,NeumannFJ,HennersdorfM, etal.Arteriallactateincardiogenicshock:Prognosticvalueofclearance versussinglevalues. JACCCardiovascInterv 2020;13:2208–2216. https://doi.org/ 10.1016/j.jcin.2020.06.037
61.JilaihawiH,AschFM,ManasseE,RuizCE,JelninV,KashifM,etal.SystematicCT methodologyfortheevaluationofsubclinicalleafletthrombosis. JACCCardiovasc Imaging 2017;10:461 –470. https://doi.org/10.1016/j.jcmg.2017.02.005
62.HryniewieckiT,ZatorskaK,AbramczukE,ZakrzewskiD,SzymanskiP, KusmierczykM,etal.TheusefulnessofcardiacCTinthediagnosisof perivalvularcomplicationsinpatientswithinfectiveendocarditis. EurRadiol 2019;29:4368–4376. https://doi.org/10.1007/s00330-018-5965-2
63.BlankeP,Weir-McCallJR,AchenbachS,DelgadoV,HausleiterJ,JilaihawiH, etal.Computedtomographyimaginginthecontextoftranscatheteraorticvalve implantation(TAVI)/transcatheteraorticvalvereplacement(TAVR):Anexpert consensusdocumentoftheSocietyofCardiovascularComputedTomography.
64.OsakaS,TanakaM.Strategyforporcelainascendingaortaincardiacsurgery.
00181
65.AviramG,SharonyR,KramerA,NesherN,LobermanD,Ben-GalY,etal. Modificationofsurgicalplanningbasedoncardiacmultidetectorcomputed tomographyinreoperativeheartsurgery. AnnThoracSurg 2005;79:589–595. https://doi.org/10.1016/j.athoracsur.2004.07.012
66.KooHJ,YangDH,KangJW,LeeJY,KimDH,SongJM,etal.Demonstration ofinfectiveendocarditisbycardiacCTandtransoesophagealechocardiography:Comparisonwithintra-operativefindings. EurHeartJCardiovascImaging 2018;19:199–207. https://doi.org/10.1093/ehjci/jex010
67.OuchiK,SakumaT,OjiriH.Cardiaccomputedtomographyasaviablealternativetoechocardiographytodetectvegetationsandperivalvularcomplications inpatientswithinfectiveendocarditis. JpnJRadiol 2018;36:421 –428. https://doi .org/10.1007/s11604-018-0740-5
68.SwartLE,GomesA,ScholtensAM,SinhaB,TanisW,LamM,etal.Improvingthediagnosticperformanceof 18 F-fluorodeoxyglucosepositron-emission tomography/computedtomographyinprostheticheartvalveendocarditis. Circulation 2018;138:1412– 1427. https://doi.org/10.1161/CIRCULATIONAHA.118 .035032
69.RicciardiA,SordilloP,CeccarelliL,MaffongelliG,CalistiG,DiPietroB,etal. 18-Fluoro-2-deoxyglucosepositronemissiontomography-computedtomography:Anadditionaltoolinthediagnosisofprostheticvalveendocarditis. IntJInfect Dis 2014;28:219–224. https://doi.org/10.1016/j.ijid.2014.04.028
70.RajiahP,FultonNL,BolenM.Magneticresonanceimagingofthepapillary musclesoftheleftventricle:Normalanatomy,variants,andabnormalities. InsightsImaging 2019;10:83. https://doi.org/10.1186/s13244-019-0761-3 71.GidwaniUK,MohantyB,ChatterjeeK.Thepulmonaryarterycatheter:A criticalreappraisal. CardiolClin 2013;31:545–565. https://doi.org/10.1016/j.ccl .2013.07.008
72.ChioncelO,ParissisJ,MebazaaA,ThieleH,DeschS,BauersachsJ,etal. Epidemiology,pathophysiologyandcontemporarymanagementofcardiogenic shock–apositionstatementfromtheHeartFailureAssociationofthe EuropeanSocietyofCardiology. EurJHeartFail 2020;22:1315– 1341 https:// doi.org/10.1002/ejhf.1922
73.LinSS,TiongIY,AsherCR,MurphyMT,ThomasJD,GriffinBP.Predictionof thrombus-relatedmechanicalprostheticvalvedysfunctionusingtransesophageal echocardiography. AmJCardiol 2000;86:1097– 1101 https://doi.org/10.1016/ s0002-9149(00)01166-8
74.RoudautR,SerriK,LafitteS.Thrombosisofprostheticheartvalves:Diagnosis andtherapeuticconsiderations. Heart 2007;93:137– 142. https://doi.org/10 1136/hrt.2005.071183
75.KostyuninAE,YuzhalinAE,RezvovaMA,OvcharenkoEA,GlushkovaTV, KutikhinAG.Degenerationofbioprostheticheartvalves:Update2020. JAm HeartAssoc 2020;9:e018506. https://doi.org/10.1161/JAHA.120.018506
76.HabibG,ErbaPA,IungB,DonalE,CosynsB,LarocheC,etal.;EURO-ENDO Investigators.Clinicalpresentation,aetiologyandoutcomeofinfectiveendocarditis.ResultsoftheESC-EORPEURO-ENDO(Europeaninfectiveendocarditis)registry:Aprospectivecohortstudy. EurHeartJ 2019;40:3222–3232. https://doi.org/10.1093/eurheartj/ehz620
77.KongWKF,SalsanoA,GiacobbeDR,PopescuBA,LarocheC,DuvalX,etal. Outcomesofculture-negativevs.culture-positiveinfectiveendocarditis:The ESC-EORPEURO-ENDOregistry. EurHeartJ 2022;43:2770–2780. https://doi .org/10.1093/eurheartj/ehac307
78.RouxV,SalaunE,TribouilloyC,HubertS,BohbotY,CasaltaJP,etal.Coronary eventscomplicatinginfectiveendocarditis. Heart 2017;103:1906– 1910. https:// doi.org/10.1136/heartjnl-2017-311624
79.StoneGW,LindenfeldJ,AbrahamWT,KarS,LimDS,MishellJM,etal.;COAPT Investigators.Transcathetermitral-valverepairinpatientswithheartfailure. NEnglJMed 2018;379:2307–2318. https://doi.org/10.1056/NEJMoa1806640
80.ObadiaJF,Messika-ZeitounD,LeurentG,IungB,BonnetG,PiriouN,etal.; MITRA-FRInvestigators.Percutaneousrepairormedicaltreatmentforsecondarymitralregurgitation. NEnglJMed 2018;379:2297–2306. https://doi.org/ 10.1056/NEJMoa1805374
81.AdamoM,FiorelliF,MelicaB,D’OrtonaR,LupiL,GianniniC,etal.COAPT-like profilepredictslong-termoutcomesinpatientswithsecondarymitralregurgitationundergoingMitraClipimplantation. JACCCardiovascInterv 2021;14:15–25. https://doi.org/10.1016/j.jcin.2020.09.050
82.NeuholdS,HuelsmannM,PernickaE,GrafA,BondermanD,AdlbrechtC, etal.Impactoftricuspidregurgitationonsurvivalinpatientswithchronicheart failure:Unexpectedfindingsofalong-termobservationalstudy. EurHeartJ 2013;34:844–852. https://doi.org/10.1093/eurheartj/ehs465
83.IungB,BaronG,ButchartEG,DelahayeF,Gohlke-BarwolfC,LevangOW,etal. AprospectivesurveyofpatientswithvalvularheartdiseaseinEurope:The EuroHeartSurveyonValvularHeartDisease. EurHeartJ 2003;24:1231 – 1243. https://doi.org/10.1016/s0195-668x(03)00201-x
84.AndellP,LiX,MartinssonA,AnderssonC,StagmoM,ZollerB,etal. EpidemiologyofvalvularheartdiseaseinaSwedishnationwidehospital-based registerstudy. Heart 2017;103:1696– 1703. https://doi.org/10.1136/heartjnl2016-310894
85.TribouilloyC,BohbotY,KubalaM,RuschitzkaF,PopescuB,WendlerO, etal.Characteristics,management,andoutcomesofpatientswithmultiple nativevalvularheartdisease:AsubstudyoftheEURObservationalResearch ProgrammeValvularHeartDiseaseIISurvey. EurHeartJ 2022;43:2756–2766. https://doi.org/10.1093/eurheartj/ehac209
86.WindeckerS,OkunoT,UnbehaunA,MackM,KapadiaS,FalkV.Whichpatients withaorticstenosisshouldbereferredtosurgeryratherthantranscatheter aorticvalveimplantation? EurHeartJ 2022;43:2729–2750. https://doi.org/10 1093/eurheartj/ehac105
87.VahanianA,HimbertD,BrochetE.Multiplevalvedisease–assessment,strategy andintervention. EuroIntervention 2015;11:W14–W16. https://doi.org/10.4244/ EIJV11SWA3
88.SinningJM,MellertF,SchillerW,WelzA,NickenigG,HammerstinglC. Transcathetermitralvalvereplacementusingaballoon-expandableprosthesis inapatientwithcalcifiednativemitralvalvestenosis. EurHeartJ 2013;34:2609. https://doi.org/10.1093/eurheartj/eht254
89.TaramassoM,BenfariG,vanderBijlP,AlessandriniH,Attinger-TollerA, BiascoL,etal.Transcatheterversusmedicaltreatmentofpatientswithsymptomaticseveretricuspidregurgitation. JAmCollCardiol 2019;74:2998–3008. https://doi.org/10.1016/j.jacc.2019.09.028
90.OkunoT,AsamiM,KhanF,PrazF,HegD,LanzJ,etal.Doesisolated mitralannularcalcificationintheabsenceofmitralvalvediseaseaffectclinical outcomesaftertranscatheteraorticvalvereplacement? EurHeartJCardiovasc Imaging 2020;21:522–532. https://doi.org/10.1093/ehjci/jez208
91.HahnRT,PibarotP,OttoCM.Transcatheterinterventionssparkaparadigm changeformanagementofpatientswithmixedvalvedisease. EurHeartJ 2022;43:2767–2769. https://doi.org/10.1093/eurheartj/ehac229
92.MillerRR,VismaraLA,DeMariaAN,SalelAF,MasonDT.Afterloadreduction therapywithnitroprussideinsevereaorticregurgitation:Improvedcardiac performanceandreducedregurgitantvolume. AmJCardiol 1976;38:564–567. https://doi.org/10.1016/s0002-9149(76)80003-3
93.KhotUN,NovaroGM,PopovicZB,MillsRM,ThomasJD,TuzcuEM,etal. Nitroprussideincriticallyillpatientswithleftventriculardysfunctionand aorticstenosis. NEnglJMed 2003;348:1756– 1763. https://doi.org/10.1056/ NEJMoa022021
94.Garcia-GonzalezMJ,Jorge-PerezP,Jimenez-SosaA,AceaAB,LacalzadaAlmeida JB,FerrerHitaJJ.Levosimendanimproveshemodynamicstatusincriticallyill patientswithsevereaorticstenosisandleftventriculardysfunction:Aninterventionalstudy. CardiovascTher 2015;33:193– 199. https://doi.org/10.1111/17555922.12132
95.StevensonLW,BellilD,Grover-McKayM,BrunkenRC,SchwaigerM,TillischJH, etal.Effectsofafterloadreduction(diureticsandvasodilators)onleftventricular volumeandmitralregurgitationinseverecongestiveheartfailuresecondaryto ischemicoridiopathicdilatedcardiomyopathy. AmJCardiol 1987;60:654–658. https://doi.org/10.1016/0002-9149(87)90376-6
96.HamiltonMA,StevensonLW,ChildJS,MoriguchiJD,WaldenJ,WooM. Sustainedreductioninvalvularregurgitationandatrialvolumeswithtailored vasodilatortherapyinadvancedcongestiveheartfailuresecondarytodilated
(ischemicoridiopathic)cardiomyopathy. AmJCardiol 1991;67:259–263. https:// doi.org/10.1016/0002-9149(91)90556-z
97.BranziG,MalfattoG,VillaniA,CiambellottiF,ReveraM,GiglioA,etal. Acuteeffectsoflevosimendanonmitralregurgitationanddiastolicfunction inpatientswithadvancedchronicheartfailure. JCardiovascMed(Hagerstown) 2010;11:662–668. https://doi.org/10.2459/JCM.0b013e32833832f6
98.WunderlichNC,DalviB,HoSY,KuxH,SiegelRJ.Rheumaticmitralvalve stenosis:Diagnosisandtreatmentoptions. CurrCardiolRep 2019;21:14. https:// doi.org/10.1007/s11886-019- 1099-7
99.IungB,LeenhardtA,ExtramianaF.Managementofatrialfibrillationinpatients withrheumaticmitralstenosis. Heart 2018;104:1062– 1068. https://doi.org/10 1136/heartjnl-2017-311425
100.KholdaniCA,FaresWH.Managementofrightheartfailureintheintensive careunit. ClinChestMed 2015;36:511 –520. https://doi.org/10.
.05.015
101.HabibG,LancellottiP,AntunesMJ,BongiorniMG,CasaltaJP,DelZottiF,etal. 2015ESCGuidelinesforthemanagementofinfectiveendocarditis:TheTask ForcefortheManagementofInfectiveEndocarditisoftheEuropeanSociety ofCardiology(ESC).Endorsedby:EuropeanAssociationforCardio-Thoracic Surgery(EACTS),theEuropeanAssociationofNuclearMedicine(EANM). Eur HeartJ 2015;36:3075–3128. https://doi.org/10.1093/eurheartj/ehv319
102.HarjolaVP,MebazaaA,CelutkieneJ,BettexD,BuenoH,ChioncelO,etal. Contemporarymanagementofacuterightventricularfailure:Astatementfrom theHeartFailureAssociationandtheWorkingGrouponPulmonaryCirculation andRightVentricularFunctionoftheEuropeanSocietyofCardiology. EurJHeart Fail 2016;18:226–241 https://doi.org/10.1002/ejhf.478
103.AlviarCL,MillerPE,McAreaveyD,KatzJN,LeeB,MoriyamaB,etal. Positivepressureventilationinthecardiacintensivecareunit. JAmCollCardiol 2018;72:1532– 1553. https://doi.org/10.1016/j.jacc.2018.06.074
104.MasipJ,PeacockWF,PriceS,CullenL,Martin-SanchezFJ,SeferovicP,etal. Indicationsandpracticalapproachtonon-invasiveventilationinacuteheart failure. EurHeartJ 2018;39:17–25. https://doi.org/10.1093/eurheartj/ehx580
105.BalthazarT,VandenbrieleC,VerbruggeFH,DenUilC,EngströmA,JanssensS, etal.Managingpatientswithshort-termmechanicalcirculatorysupport:JACC reviewtopicoftheweek. JAmCollCardiol 2021;77:1243– 1256. https://doi.org/ 10.1016/j.jacc.2020.12.054
106.SinghV,MendirichagaR,Inglessis-AzuajeI,PalaciosIF,O’NeillWW.Therole ofImpellaforhemodynamicsupportinpatientswithaorticstenosis. CurrTreat OptionsCardiovascMed 2018;20:44. https://doi.org/10.1007/s11936-018-06449
107.AlkhalilA,HajjarR,IbrahimH,RuizCE.Mechanicalcirculatorysupportin transcatheteraorticvalveimplantationintheUnitedStates(fromtheNational InpatientSample). AmJCardiol 2019;124:1615– 1620. https://doi.org/10.101
108.AdamoM,ChiariE,CurelloS,MaiandiC,ChizzolaG,FiorinaC,etal.Mitraclip therapyinpatientswithfunctionalmitralregurgitationandmissingleaflet coaptation:Isitstillanexclusioncriterion? EurJHeartFail 2016;18:1278– 1286. https://doi.org/10.1002/ejhf.520
109.EliazR,TuryanA,BeeriR,ShuvyM.Utilizationofintra-aorticballoonpumpto allowMitraClipprocedureinpatientswithnon-coaptingmitralvalveleaflets:A caseseries. EurHeartJCaseRep 2019;3:ytz045. https://doi.org/10.1093/ehjcr/ ytz045
110.VandenbrieleC,BalthazarT,WilsonJ,AdriaenssensT,DaviesS,DroogneW, etal.LeftImpella®-deviceasbridgefromcardiogenicshockwithacute,severe mitralregurgitationtoMitraClip®-procedure:Anewoptionforcriticallyill patients. EurHeartJAcuteCardiovascCare 2021;10:415–421 https://doi.org/ 10.1093/ehjacc/zuaa031
111.ElhusseinTA,HutchisonSJ.Acutemitralregurgitation:UnforeseennewcomplicationoftheImpellaLP5.0ventricularassistdeviceandreviewofliterature. HeartLungCirc 2014;23:e100–e104. https://doi.org/10.1016/j.hlc.2013.10.098
112.NashefSA,RoquesF,SharplesLD,NilssonJ,SmithC,GoldstoneAR,etal. EuroSCOREII. EurJCardiothoracSurg 2012;41:734–745. https://doi.org/10 1093/ejcts/ezs043
113.YoonSH,SchmidtT,BleizifferS,SchoferN,FiorinaC,Munoz-GarciaAJ,etal. Transcatheteraorticvalvereplacementinpurenativeaorticvalveregurgitation.
JAmCollCardiol 2017;70:2752–2763. https://doi.org/10.1016/j.jacc.2017.10 .006
114.DeBackerO,PilgrimT,SimonatoM,MackensenGB,FiorinaC,VeulemannsV, etal.Usefulnessoftranscatheteraorticvalveimplantationfortreatmentofpure nativeaorticvalveregurgitation. AmJCardiol 2018;122:1028– 1035. https://doi .org/10.1016/j.amjcard.2018.05.044
115.ClinicalTrials.gov.THEALIGN-AREFSTRIAL:JenaValvePericardialTAVR AorticRegurgitationStudy,[NCT02732704].
116.AchkoutyG,AmabileN,ZannisK,VeugeoisA,CaussinC.Transcatheter aorticvalvereplacementforsevereaorticregurgitationwithacuterefractory
cardiogenicshock. CanJCardiol 2018;34:342.e5–342.e7. https://doi.org/10 1016/j.cjca.2017.11.024
117.BrancaL,AdamoM,FiorinaC,EttoriF,ChizzolaG,ScodroM,etal. Life-savingtranscatheteraorticvalveimplantationforacutesevereaorticregurgitationduetorheumatoidarthritisandcomplicatedbycardiogenicshock. JCardiovascMed(Hagerstown) 2020;21:268–271 https://doi.org/10.2459/JCM .0000000000000873
118.AdamoM,FiorinaC,PetronioAS,GianniniC,TamburinoC,BarbantiM,etal. Comparisonofearlyandlong-termoutcomesaftertranscatheteraorticvalve implantationinpatientswithNewYorkHeartAssociationfunctionalclassIVto thoseinclassIIIandless. AmJCardiol 20
1016/j.amjcard.2018.08.006
119.FrerkerC,SchewelJ,SchluterM,SchewelD,RamadanH,SchmidtT,etal. Emergencytranscatheteraorticvalvereplacementinpatientswithcardiogenicshockduetoacutelydecompensatedaorticstenosis. EuroIntervention 2016;11:1530– 1536. https://doi.org/10.4244/EIJY15M03_03
120.KolteD,KheraS,VemulapalliS,DaiD,HeoS,GoldsweigAM,etal.Outcomes followingurgent/emergenttranscatheteraorticvalvereplacement:Insightsfrom theSTS/ACCTVTRegistry. JACCCardiovascInterv 2018;11(12):1175– 1185. https://doi.org/10.1016/j.jcin.2018.03.002
121.MashaL,VemulapalliS,ManandharP,BalanP,ShahP,KosinskiAS,etal. Demographics,proceduralcharacteristics,andclinicaloutcomeswhencardiogenicshockprecedesTAVRintheUnitedStates. JACCCardiovascInterv 2020;
122.PattersonT,ClaytonT,DoddM,KhawajaZ,MoriceMC,WilsonK,etal. ACTIVATION(PercutAneouscoronaryinTerventionprIortotranscatheter aorticVAlveimplantaTION):Arandomizedclinicaltrial. JACCCardiovascInterv 202
10.1016/j.jcin.2021.06.041
123.TarantiniG,TangG,NaiFovinoL,BlackmanD,VanMieghemNM,KimWK, etal.Managementofcoronaryarterydiseaseinpatientsundergoingtranscatheteraorticvalveimplantation.Aclinicalconsensusstatementfromthe EuropeanAssociationofPercutaneousCardiovascularInterventionsincollaborationwiththeESCWorkingGrouponCardiovascularSurgery. EuroIntervention 2023;19:37–52. https://doi.org/10.4244/EIJ-D-22-00958
124.WilliamsT,Hildick-SmithDJR.Balloonaorticvalvuloplasty:Indications,patient eligibility,techniqueandcontemporaryoutcomes. Heart 2020;106:1102– 1110. https://doi.org/10.1136/heartjnl-2019-315904
125.DebryN,KoneP,VincentF,LemesleG,DelhayeC,SchurtzG,etal.Urgent balloonaorticvalvuloplastyinpatientswithcardiogenicshockrelatedtosevere aorticstenosis:Timematters. EuroIntervention 2018;14:e519–e525. https://doi .org/10.4244/EIJ-D- 18-00029
126.EugeneM,UrenaM,AbtanJ,CarrascoJL,GhodbaneW,NatafP,etal.Effectivenessofrescuepercutaneousballoonaorticvalvuloplastyinpatientswithsevere aorticstenosisandacuteheartfailure. AmJCardiol 2018;121:746–750. https:// doi.org/10.1016/j.amjcard.2017.11.048
127.BulargaA,BingR,ShahAS,AdamsonPD,BehanM,NewbyDE,etal.Clinical outcomesfollowingballoonaorticvalvuloplasty. OpenHeart 2020;7:e001330. https://doi.org/10.1136/openhrt-2020-001330
128.BongiovanniD,KuhlC,BleizifferS,StecherL,PochF,GreifM,etal.Emergency treatmentofdecompensatedaorticstenosis. Heart 2018;104:23–29. https:// doi.org/10.1136/heartjnl-2016-311037
129.ChakrabortyS,PatelN,BandyopadhyayD,HajraA,AmgaiB,ZaidS,etal. Readmissionfollowingurgenttranscatheteraorticvalveimplantationversus urgentballoonaorticvalvuloplastyinpatientswithdecompensatedheartfailure orcardiogenicshock. CatheterCardiovascInterv 2021;98:607–612. https://doi .org/10.1002/ccd.29690
130.ThompsonCR,BullerCE,SleeperLA,AntonelliTA,WebbJG,JaberWA,etal. Cardiogenicshockduetoacuteseveremitralregurgitationcomplicatingacute myocardialinfarction:AreportfromtheSHOCKTrialRegistry.SHouldweuse emergentlyrevascularizeOccludedCoronariesincardiogenicshocK? JAmColl Cardiol 2000;36:1104– 1109. https://doi.org/10.1016/s0735- 1097(00)00846-9
131.WolffR,CohenG,PetersonC,WongS,HockmanE,LoJ,etal.MitraClip forpapillarymuscleruptureinpatientwithcardiogenicshock. CanJCardiol 2014;30:1461.e13– 1461.e14. https://doi.org/10.1016/j.cjca.2014.07.015
132.BahlmannE,FrerkerC,KreidelF,ThielsenT,GhanemA,vanderSchalkH, etal.MitraClipimplantationafteracuteischemicpapillarymuscleruptureina patientwithprolongedcardiogenicshock. AnnThoracSurg 2015;99:e41 –e42. https://doi.org/10.1016/j.athoracsur.2014.09.075
133.KomatsuI,CohenEA,CohenGN,CzarneckiA.Transcathetermitral valveedge-to-edgerepairwiththenewMitraClipXTRsystemforacute mitralregurgitationcausedbypapillarymusclerupture. CanJCardiol 2019;35:1604.e5– 1604.e7. https://doi.org/10.1016/j.cjca.2019.06.024
134.McGeeECJr.Shouldmoderateorgreatermitralregurgitationberepairedinall patientswithLVEF <30%?Surgery,mitralregurgitation,andheartfailure:The
valvesareallrepairablebutthepatientsarenot. CircHeartFail 2008;1:285–289. https://doi.org/10.1161/CIRCHEARTFAILURE.108.800185
135.LavallD,HagendorffA,SchirmerSH,BohmM,BorgerMA,LaufsU.Mitralvalve interventionsinheartfailure. ESCHeartFail 2018;5:552–561 https://doi.org/10 1002/ehf2.12287
136.HabermanD,TaramassoM,CzarneckiA,KernerA,ChrissoherisM,SpargiasK, etal.SalvageMitraClipinseveresecondarymitralregurgitationcomplicating acutemyocardialinfarction:Datafromamulticentreinternationalstudy. Eur JHeartFail 2019;21:1161 – 1164. https://doi.org/10.1002/ejhf.1565
137.HabermanD,Estevez-LoureiroR,Benito-GonzalezT,DentiP,ArzamendiD, AdamoM,etal.Conservative,surgical,andpercutaneoustreatmentfor mitralregurgitationshortlyafteracutemyocardialinfarction. EurHeartJ 2022;43:641 –650. https://doi.org/10.1093/eurheartj/ehab496
138.Estevez-LoureiroR,ShuvyM,TaramassoM,Benito-GonzalezT,DentiP, ArzamendiD,etal.UseofMitraClipformitralvalverepairinpatients withacutemitralregurgitationfollowingacutemyocardialinfarction:Effectof cardiogenicshockonoutcomes(IREMMIRegistry). CatheterCardiovascInterv 2021;97:1259– 1267. https://doi.org/10.1002/ccd.29552
139.FalasconiG,MelilloF,PannoneL,AdamoM,RoncoF,LatibA,etal.Useof edge-to-edgepercutaneousmitralvalverepairforseveremitralregurgitation incardiogenicshock:Amulticenterobservationalexperience(MITRA-SHOCK study). CatheterCardiovascInterv 2021;98:E163–E170. https://doi.org/10.1002/ ccd.29683
140.JungRG,SimardT,KovachC,FlintK,DonC,DiSantoP,etal.Transcatheter mitralvalverepairincardiogenicshockandmitralregurgitation:Apatient-level multicenteranalysis. JACCCardiovascInterv 2021;14:1 – 11 https://doi.org/10 1016/j.jcin.2020.08.037
141.AdamoM,CurelloS,ChiariE,FiorinaC,ChizzolaG,MagatelliM,etal. Percutaneousedge-to-edgemitralvalverepairforthetreatmentofacutemitral regurgitationcomplicatingmyocardialinfarction:Asinglecentreexperience. Int JCardiol 2017;234:53–57. https://doi.org/10.1016/j.ijcard.2017.02.072
142.Estevez-LoureiroR,AdamoM,ArzamendiD,DentiP,FreixaX, Nombela-FrancoL,etal.Transcathetermitralvalverepairinpatients withacutemyocardialinfarction:InsightsfromtheEuropeanRegistryof MitraClipinAcuteMitralRegurgitationfollowinganacutemyocardialinfarction (EREMMI). EuroIntervention 2020;15:1248– 1250. https://doi.org/10.4244/EIJD- 19-00653
143.TangGHL,Estevez-LoureiroR,YuY,PrillingerJB,ZaidS,PsotkaMA.Survival followingedge-to-edgetranscathetermitralvalverepairinpatientswithcardiogenicshock:Anationwideanalysis. JAmHeartAssoc 2021;10:e019882. https:// doi.org/10.1161/JAHA.120.019882
144.AnanthakrishnaPillaiA,RamasamyC,KottyathH.Outcomesfollowingballoon mitralvalvuloplastyinpregnantfemaleswithmitralstenosisandsignificant subvalvediseasewithseveredecompensatedheartfailure. JIntervCardiol 2018;31:525–531 https://doi.org/10.1111/joic.12507
145.GaluskoV,IonescuA,EdwardsA,SekarB,WongK,PatelK,etal.Management ofmitralstenosis:Asystematicreviewofclinicalpracticeguidelinesand recommendations. EurHeartJQualCareClinOutcomes 2022;8:602–618. https:// doi.org/10.1093/ehjqcco/qcab083
146.DreyfusJ,AudureauE,BohbotY,CoisneA,Lavie-BadieY,BoucheryM,etal. TRI-SCORE:Anewriskscoreforin-hospitalmortalitypredictionafterisolated tricuspidvalvesurgery. EurHeartJ 2022;43:654–662. https://doi.org/10.1093/ eurheartj/ehab679
147.LurzP,OrbanM,BeslerC,BraunD,SchlotterF,NoackT,etal.Clinical characteristics,diagnosis,andriskstratificationofpulmonaryhypertension inseveretricuspidregurgitationandimplicationsfortranscathetertricuspid valverepair. EurHeartJ 2020;41:2785–2795. https://doi.org/10.1093/eurheartj/ ehaa138
148.BrenerMI,LurzP,HausleiterJ,Rodes-CabauJ,FamN,KodaliSK,etal.Right ventricular-pulmonaryarterialcouplingandafterloadreserveinpatientsundergoingtranscathetertricuspidvalverepair. JAmCollCardiol 2022;79:448–461 https://doi.org/10.1016/j.jacc.2021 11.031
149.SorajjaP,WhisenantB,HamidN,NaikH,MakkarR,TadrosP,etal.;TRILUMINATEPivotalInvestigators.Transcatheterrepairforpatientswithtricuspidregurgitation. NEnglJMed 2023;388:1833– 1842. https://doi.org/10.1056/
NEJMoa2300525
150.Messika-ZeitounD,BaumgartnerH,BurwashIG,VahanianA,BaxJ,PibarotP, etal.Unmetneedsinvalvularheartdisease. EurHeartJ https://doi.org/10.1093/ eurheartj/ehad121 Publishedonlineaheadofprint 16/03/23.
151.PrazF,MuraruD,KreidelF,LurzP,HahnRT,DelgadoV,etal.Transcatheter treatmentfortricuspidvalvedisease. EuroIntervention 2021;17:791 –808. https:// doi.org/10.4244/EIJ-D-21-00695
152.RussoG,TaramassoM,PedicinoD,GennariM,GavazzoniM,PozzoliA, etal.Challengesandfutureperspectivesoftranscathetertricuspidvalve
interventions:Adoptoldstrategiesoradapttonewopportunities? EurJHeart Fail 2022;24:442–454. https://doi.org/10.1002/ejhf.2398
153.GelsominoS,MaessenJG,vanderVeenF,LiviU,RenzulliA,LucaF,etal. Emergencysurgeryfornativemitralvalveendocarditis:Theimpactofseptic andcardiogenicshock. AnnThoracSurg 2012;93:1469– 1476. https://doi.org/10 1016/j.athoracsur.2011 11.025
154.ThunyF,GrisoliD,CollartF,HabibG,RaoultD.Managementofinfective endocarditis:Challengesandperspectives. Lancet 2012;379:965–975. https:// doi.org/10.1016/S0140-6736(11)60755- 1
155.ÖzkanM,GündüzS,GünerA,Kalç��kM,GürsoyMO,UygurB,etal.Thrombolysisorsurgeryinpatientswithobstructivemechanicalvalvethrombosis:The multicenterHATTUSHAstudy. JAmCollCardiol 2022;79:977–989. https://doi .org/10.1016/j.jacc.2021 12.027
156.RuizCE,HahnRT,BerrebiA,BorerJS,CutlipDE,FontanaG,etal.;Paravalvular LeakAcademicResearchConsortium.Clinicaltrialprinciplesandendpoint definitionsforparavalvularleaksinsurgicalprosthesis:Anexpertstatement. JAmCollCardiol 2017;69:2067–2087. https://doi.org/10.1016/j.jacc.2017.02.038
157.RavalJ,NagarajaV,EslickGD,DennissAR.Transcathetervalve-in-valveimplantation:Asystematicreviewofliterature. HeartLungCirc 2014;23:1020– 1028. https://doi.org/10.1016/j.hlc.2014.06.001
158.HansonID,DalalPK,RenardBM,HanzelGS,VivacquaA.Emergency valve-in-valvetranscatheteraorticvalveimplantationforthetreatmentofacute stentlessbioprostheticaorticinsufficiencyandcardiogenicshock. CaseRepCardiol 2018;2018:6872748. https://doi.org/10.1155/2018/6872748
159.Rufian-AndujarS,IftikharO,SalingerM,SaucedoJ,FeldmanT,GuerreroM. Transseptaltranscathetermitralvalve-in-valvefortreatmentofseveremitral regurgitationinfailedbioprosthesiscomplicatedwithcardiogenicshock:Case reportandreviewoftheliterature. CardiovascRevascMed 2018;19:874–878. https://doi.org/10.1016/j.carrev.2018.02.011
160.NolyPE,PaganiFD,NoiseuxN,StulakJM,KhalpeyZ,CarrierM,etal. Continuous-flowleftventricularassistdevicesandvalvularheartdisease:A comprehensivereview. CanJCardiol 2020;36:244–260. https://doi.org/10.1016/ j.cjca.2019.11.022
161.BouabdallaouiN,El-HamamsyI,PhamM,GiraldeauG,ParentMC,CarrierM, etal.Aorticregurgitationinpatientswithaleftventricularassistdevice:A contemporaryreview. JHeartLungTransplant 2018;37:1289– 1297. https://doi .org/10.1016/j.healun.2018.07.002
162.CowgerJ,RaoV,MasseyT,SunB,May-NewmanK,JordeU,etal.Comprehensivereviewandsuggestedstrategiesforthedetectionandmanagementofaortic insufficiencyinpatientswithacontinuous-flowleftventricularassistdevice. JHeartLungTransplant
163.FeldmanD,PamboukianSV,TeutebergJJ,BirksE,LietzK,MooreSA,etal. The2013InternationalSocietyforHeartandLungTransplantationGuidelines formechanicalcirculatorysupport:Executivesummary. JHeartLungTransplant 2013;32:157– 187. https://doi.org/10.1016/j.healun.2012.09.013
164.RobertsonJO,NaftelDC,MyersSL,TedfordRJ,JosephSM,KirklinJK, etal.Concomitantmitralvalveproceduresinpatientsundergoingimplantation ofcontinuous-flowleftventricularassistdevices:AnINTERMACSdatabase analysis. JHeartLungTransplant 2018;37:79–88. https://doi.org/10.1016/j.healun .2017.09.016
165.CoyanGN,PierceBR,RhinehartZJ,RuppertKM,KatzW,KilicA,etal. Impactofpre-existingmitralregurgitationfollowingleftventricularassist deviceimplant. SeminThoracCardiovascSurg 2021;33:988–995. https://doi.org/ 10.1053/j.semtcvs.2020.12.007
166.KanwarMK,RajagopalK,ItohA,SilvestrySC,UrielN,ClevelandJCJr,etal. Impactofleftventricularassistdeviceimplantationonmitralregurgitation:An analysisfromtheMOMENTUM3trial. JHeartLungTransplant 2020;39:529–537. https://doi.org/10.1016/j.healun.2020.03.003
167.MaltaisS,TopilskyY,TchantchaleishviliV,McKellarSH,DurhamLA,Joyce LD,etal.Surgicaltreatmentoftricuspidvalveinsufficiencypromotesearly reverseremodelinginpatientswithaxial-flowleftventricularassistdevices. JThoracCardiovascSurg 2012;143:1370– 1376. https://doi.org/10.1016/j.jtcvs .2011.07.014
168.DunlaySM,DeoSV,ParkSJ.Impactoftricuspidvalvesurgeryatthetime ofleftventricularassistdeviceinsertiononpostoperativeoutcomes. ASAIOJ 2015;61:15–20. https://doi.org/10.1097/MAT.0000000000000145
169.MendiolaPlaM,ChiangY,NicoaraA,PoehleinE,GreenCL,GrossR,etal. Surgicaltreatmentoftricuspidvalveregurgitationinpatientsundergoingleft ventricularassistdeviceimplantation:InterimanalysisoftheTVVADtrial. JThoracCardiovascSurg https://doi.org/10.1016/j.jtcvs.2022.10.054 Published onlineaheadofprint 16/11/22.
170.TrankleCR,GertzZM,KoneruJN,KasirajanV,NicolatoP,Bhardwaj HL,etal.Severetricuspidregurgitationduetointeractionswithright
ventricularpermanentpacemakerordefibrillatorleads. PacingClinElectrophysiol 2018;41:845–853. https://doi.org/10.1111/pace.13369
171.TaramassoM,GavazzoniM,PozzoliA,AlessandriniH,LatibA,Attinger-TollerA, etal.OutcomesofTTVIinpatientswithpacemakerordefibrillatorleads:Data fromtheTriValveregistry. JACCCardiovascInterv 2020;13:554–564. https://doi .org/10.1016/j.jcin.2019.10.058
172.HillL,PragerGellerT,BaruahR,BeattieJM,BoyneJ,deStoutzN,etal.Integrationofapalliativeapproachintoheartfailurecare:AEuropeanSociety .................
ofCardiologyHeartFailureAssociationpositionpaper. EurJHeartFail 2020;22:2327–2339. https://doi.org/10.1002/ejhf.1994
173.BrannstromM,BomanK.Effectsofperson-centredandintegratedchronicheart failureandpalliativehomecare.PREFER:Arandomizedcontrolledstudy. Eur JHeartFail 2014;16:1142– 1151. https://doi.org/10.1002/ejhf.151
174.SidebottomAC,JorgensonA,RichardsH,KirvenJ,SillahA.Inpatientpalliative careforpatientswithacuteheartfailure:Outcomesfromarandomizedtrial. JPalliatMed 2015;18:134– 142. https://doi.org/10.1089/jpm.2014.0192