2021 ESC/EACTS Guidelines for the management of valvular heart disease

Guideline-directed medical therapy in patients undergoing transcatheter edge-to-edge repair for secondary mitral regurgitation

AIMS

Guideline-directed medical therapy (GDMT), based on the combination of beta-blockers (BB), renin-angiotensin system inhibitors (RASI), and mineralocorticoid receptor antagonists (MRA), is known to have a major impact on the outcome of patients with heart failure with reduced ejection fraction (HFrEF). Although GDMT is recommended prior to mitral valve transcatheter edge-to-edge repair (M-TEER), not all patients tolerate it. We studied the association of GDMT prescription with survival in HFrEF patients undergoing M-TEER for secondary mitral regurgitation (SMR).

METHODS AND RESULTS

EuroSMR, a European multicentre registry, included SMR patients with left ventricular ejection fraction <50%. The outcome was 2-year all-cause mortality. Of 1344 patients, BB, RASI, and MRA were prescribed in 1169 (87%), 1012 (75%), and 765 (57%) patients at the time of M-TEER, respectively. Triple GDMT prescription was associated with a lower 2-year all-cause mortality compared to non-triple GDMT (hazard ratio [HR] 0.74; 95% confidence interval [CI] 0.60-0.91). The association persisted in patients with glomerular filtration rate <30 ml/min, ischaemic aetiology, or right ventricular dysfunction. Further, a positive impact of triple GDMT prescription on survival was observed in patients with residual mitral regurgitation of ≥2+ (HR 0.62; 95% CI 0.44-0.86), but not in patients with residual mitral regurgitation of ≤1+ (HR 0.83; 95% CI 0.64-1.08).

CONCLUSION

Triple GDMT prescription is associated with higher 2-year survival after M-TEER in HFrEF patients with SMR. This association was consistent also in patients with major comorbidities or non-optimal results after M-TEER.

Treatment in patients with severe asymptomatic aortic stenosis: is it best not to wait?

New insights into the natural history and pathophysiology of patients with aortic stenosis (AS), coupled with the dramatic evolution of transcatheter aortic valve implantation (TAVI), are fuelling intense interest in the management of asymptomatic patients with severe AS. This patient presenting for elective intervention poses a unique challenge. These patients are not traditionally offered surgical aortic valve replacement or TAVI given their lack of symptoms; however, they are at increased risk given the severity of their AS. Furthermore, clinical experience has shown that symptoms can be challenging to ascertain in many sedentary, deconditioned, and/or elderly patients. In addition, evolving data based on imaging and biomarker evidence of adverse ventricular remodelling, hypertrophy, inflammation, or fibrosis may radically transform existing clinical decision paradigms. However, management of asymptomatic severe AS is otherwise controversial and the decision to intervene requires careful assessment of the benefits and risks in an individual patient. Further randomized trials [EARLY TAVI (NCT03042104), AVATAR (NCT02436655), EVOLVED (NCT03094143)] will help determine future recommendations.

Transcatheter mitral valve repair is feasible and effective in oldest-old patients: results from real-world cohort

OBJECTIVE

To evaluate the safety and efficacy of transcatheter mitral valve repair (TMVR) using MitraClip^® devices in oldest-old patients compared to younger patients.

METHODS

The study retrospectively included 340 consecutive patients who underwent TMVR. Patients were classified according to age into the oldest-old (age ≥ 85 years) patient group or the younger (age < 85 years) patient group. Immediate results of the procedure, intrahospital outcomes and one-year outcomes were compared.

RESULTS

Oldest-old patients represented 15.9% (n = 54) of all patients. Procedure success was comparable for the oldest-old patient group and the younger patient group (92.6% vs. 95.8%, P = 0.30), and there was no difference in intrahospital mortality (9.2% vs. 4.2%, P = 0.12). At a one-year follow-up (interquartile range: 6-16 months), there was no significant difference in rehospitalization due to decompensated heart failure (25.5% vs. 34.3%, P = 0.24) or all-cause mortality (29.8% vs. 22.2%, P = 0.26) between the oldest-old patient group and the younger patient group. In patients with available echocardiographic follow-up, severity of residual mitral regurgitation was also comparable between the oldest-old patient group and the younger patient group.

CONCLUSIONS

TMVR seems to be feasible and effective in oldest-old patients and should be considered for oldest-old patients presenting with symptomatic severe mitral regurgitation and high surgical risk.

Cellular Senescence, Aging and Non-Aging Processes in Calcified Aortic Valve Stenosis: From Bench-Side to Bedside

Aortic valve stenosis (AS) is the most common valvular heart disease. The incidence of AS increases with age, however, a significant proportion of elderly people have no significant AS, indicating that both aging and nonaging pathways are involved in the pathomechanism of AS. Age-related and stress-induced cellular senescence accompanied by further active processes represent the key elements of AS pathomechanism. The early stage of aortic valve degeneration involves dysfunction and disruption of the valvular endothelium due to cellular senescence and mechanical stress on blood flow. These cells are replaced by circulating progenitor cells, but in an age-dependent decelerating manner. When endothelial denudation is no longer replaced by progenitor cells, the path opens for focal lipid deposition, initiating subsequent oxidation, inflammation and micromineralisation. Later stages of AS feature a complex active process with extracellular matrix remodeling, fibrosis and calcification. Echocardiography is the gold standard method for diagnosing aortic valve disease, although computed tomography and cardiac magnetic resonance are useful additional imaging methods. To date, no medical treatment has been proven to halt the progression of AS. Elucidation of differences and similarities between vascular and valvular calcification pathomechanisms may help to find effective medical therapy and reduce the increasing health burden of the disease.

The evolving role of multi-modality imaging in transcatheter tricuspid valve interventions

Tricuspid valve pathophysiology is not well-understood. Emergence of novel transcatheter tricuspid therapies has fueled the requirements for improved imaging visualization techniques and interventional imaging physician skillsets in guiding these complex transcatheter procedures. There is growing understanding on the clinical significance of tricuspid regurgitation which expanded the interest for percutaneous tricuspid valve interventions. The present review concentrates on three essential aspects of tricuspid valve pathophysiology: anatomical considerations for tricuspid interventions, optimal timing of tricuspid interventions by imaging guidance, and the role of interventional imaging physicians’ skillset and knowledge in this field.

Invasive electrophysiological testing to predict and guide permanent pacemaker implantation after transcatheter aortic valve implantation: A meta-analysis

Background

Atrioventricular conduction abnormalities after transcatheter aortic valve implantation (TAVI) are common. The value of electrophysiological study (EPS) for risk stratification of high-grade atrioventricular block (HG-AVB) and guidance of permanent pacemaker (PPM) implantation is poorly defined.

Objective

The purpose of this study was to identify EPS parameters associated with HG-AVB and determine the value of EPS-guided PPM implantation after TAVI.

Methods

We performed a systematic review and meta-analysis of studies investigating the value of EPS parameters for risk stratification of TAVI-related HG-AVB and for guidance of PPM implantation among patients with equivocal PPM indications after TAVI.

Results

Eighteen studies (1230 patients) were eligible. In 7 studies, EPS was performed only after TAVI, whereas in 11 studies EPS was performed both before and after TAVI. Overall PPM implantation rate for HG-AVB was 16%. AV conduction intervals prolonged after TAVI, with the AH and HV intervals showing the largest magnitude of changes. Pre-TAVI HV >70 ms and the absolute value of the post-TAVI HV interval were associated with subsequent HG-AVB and PPM implantation with odds ratios of 2.53 (95% confidence interval [CI] 1.11-5.81; P = .04) and 1.10 (95% CI 1.03-1.17; P = .02; per 1-ms increase), respectively. In 10 studies, PPM was also implanted due to abnormal EPS findings in patients with equivocal PPM indications post-TAVI (typically new left bundle branch block or transient HG-AVB). Among them, the rate of long-term PPM dependency was 57%.

Conclusion

Selective EPS testing may assist in the risk stratification of post-TAVI HG-AVB and in the guidance of PPM implantation, especially in patients with equivocal PPM indications post-TAVI.

Transcatheter mitral valve replacement in native mitral valve with severe mitral annular calcification: Skirting the Sapien 3 to reduce the risk of paravalvular leaks

BACKGROUND

Mitral annular calcification (MAC) may represent a significant challenge for heart surgeons with an extremely high perioperative risk during mitral valve (MV) surgery. The risk is further increased when patients fail to be eligible for any percutaneous treatment, particularly because circumferential calcifications involving the anterior leaflet suggest a critical obstruction of the left ventricular outflow tract (LVOT).

OBJECTIVES

The objective of this study was to evaluate residual mitral regurgitation (MR) after surgical mitral valve replacement using a Sapien 3 Ultra (Edwards Lifesciences, CA, USA) transcatheter aortic valve implantation (TAVI) prosthesis, reinforced with a pericardial skirt, in high-risk selected patients with severe MAC.

METHODS

Since 2020, five high-risk patients (mean age 70 years; 63-76; four women) with severe mitral disease in the context of severe MAC (computed tomography-based mean MAC Score 8.2 ± 1.1) were operated on after we adopted this novel technique. The operations were performed under general anesthesia, using a transapical TAVI delivery system to position the Sapien 3 in the mitral position under direct vision. To reinforce and avoid paravalvular leakages, a pericardial skirt was previously sewn around the prosthesis, securing it to the annulus and perivalvular atrial surface.

RESULTS

Sapien 3 Ultra implantation was successful without residual MR in all five patients (mild paravalvular leak in one case). Four patients had a 29-mm valve implanted, while one had a 26-mm valve implanted. Predilatation of the native annulus was never performed. Perfusion and clamping times were 134 ± 53 mins and 108 ± 43 mins, respectively. The presence of the pericardial skirt reduced the risk of leakage between the prosthesis and the rigid calcium surface, with final mean and maximal gradients of the TAVI prosthesis of 4.1 and 10.8 mmHg, respectively. There were no left ventricular outflow tract obstructions (mean LVOT gradient of 8 ± 1 mmHg). All patients were discharged, and neither mortality nor prosthetic dysfunction, nor residual mitral regurgitation was recorded. During follow-up, the last patient treated (MAC Score 10, severe calcification of the mitro-aortic junction) returned to our attention with a significant recurrent jet originating from the anterolateral commissure, currently medically treated, given the prohibitive redo risk.

CONCLUSION

Direct open surgical implantation of the Sapien 3 valve can be safely done in patients with severe MAC in dedicated centers. Reinforcing the TAVI prosthesis by sewing a pericardial skirt led to satisfactory perioperative and early postoperative results, reducing paravalvular leakages. Complex anatomies have a CERTAIN risk of recurrence.

IL6 gene polymorphism association with calcific aortic valve stenosis and influence on serum levels of interleukin-6

Aortic valve stenosis is the most frequent valve disease in developed countries and its prevalence will increase with population aging. There is still no pharmaceutical treatment nor biomarker to determine the susceptibility to develop aortic stenosis. Therefore, we analyzed the association of polymorphisms in risk loci with calcific aortic stenosis. Patients with aortic valve disease were genotyped for PALMD rs6702619, LPA rs10455872, and IL6 rs1800795 polymorphisms and circulating levels of interleukin-6 (IL-6) were measured. Calcium content of leaflets obtained in valve replacement surgeries was determined by micro-computed tomography. In the genotyping of 578 individuals, we found significant association between PALMD and IL6 polymorphisms and aortic stenosis in patients with tricuspid aortic valve, independently of other potentially confounding variables such as age and dyslipidemia. There was no association of these polymorphisms with valve calcium content, but this value correlated with the mean aortic pressure gradient (r = 0.44; P < 0.001). The CC genotype of IL6 polymorphism was associated with higher levels of serum IL-6 compared to other genotypes (23.5 vs. 10.5 pg/ml, respectively; P = 0.029). Therefore, patients carrying the CC genotype of IL6 rs1800795 polymorphism present higher levels of circulating IL-6 and this could contribute to the severity of the aortic valve stenosis. Our results agree with the identification of IL6 as a locus risk for stenosis and also with the intervention of this cytokine in aortic valve calcification. A more exhaustive follow-up of those patients carrying risk genotypes is therefore recommended.

Core Lab Adjudication of the ACURATE neo2 Hemodynamic Performance Using Computed-Tomography-Corrected Left Ventricular Outflow Tract Area

(1) Background: Hemodynamic assessment of prosthetic heart valves using conventional 2D transthoracic Echocardiography-Doppler (2D-TTE) has limitations. Of those, left ventricular outflow tract (LVOT) area measurement is one of the major limitations of the continuity equation, which assumes a circular LVOT. (2) Methods: This study comprised 258 patients with severe aortic stenosis (AS), who were treated with the ACURATE neo2. The LVOT area and its dependent Doppler-derived parameters, including effective orifice area (EOA) and stroke volume (SV), in addition to their indexed values, were calculated from post-TAVI 2D-TTE. In addition, the 3D-LVOT area from pre-procedural MDCT scans was obtained and used to calculate corrected Doppler-derived parameters. The incidence rates of prosthesis patient mismatch (PPM) were compared between the 2D-TTE and MDCT-based methods (3) Results: The main results show that the 2D-TTE measured LVOT is significantly smaller than 3D-MDCT (350.4 ± 62.04 mm² vs. 405.22 ± 81.32 mm²) (95% Credible interval (CrI) of differences: −55.15, −36.09), which resulted in smaller EOA (2.25 ± 0.59 vs. 2.58 ± 0.63 cm²) (Beta = −0.642 (95%CrI of differences: −0.85, −0.43), and lower SV (73.88 ± 21.41 vs. 84.47 ± 22.66 mL), (Beta = −7.29 (95% CrI: −14.45, −0.14)), respectively. PPM incidence appears more frequent with 2D-TTE- than 3D-MDCT-corrected measurements (based on the EOAi) 8.52% vs. 2.32%, respectively. In addition, significant differences regarding the EOA among the three valve sizes (S, M and L) were seen only with the MDCT, but not on 2D-TTE. (4) Conclusions: The corrected continuity equation by combining the 3D-LVOT area from MDCT with the TTE Doppler parameters might provide a more accurate assessment of hemodynamic parameters and PPM diagnosis in patients treated with TAVI. The ACURATE neo2 THV has a large EOA and low incidence of PPM using the 3D-corrected LVOT area than on 2D-TTE. These findings need further confirmation on long-term follow-up and in other studies.

Do all patients with asymptomatic severe aortic stenosis need treatment?

INTRODUCTION

Although guidelines recommend a watchful waiting strategy for patients with asymptomatic severe aortic stenosis, there have been considerable advancements in surgical and anaesthetic techniques along with the success of transcatheter aortic valve replacement (AVR) as a viable alternative to surgical AVR. Inevitably, these developments have raised questions as to whether or not there is still merit in waiting for symptoms to ensue before treatment may offered to these patients.

AREA COVERED

The principal purpose of this paper is to review the data supporting earlier intervention in patients with asymptomatic severe aortic stenosis, and to project the implications these and other ongoing trials will have on indications for AVR in asymptomatic patients in the future.

EXPERT OPINION

The threshold for intervention in certain subgroups of asymptomatic patients with severe AS has already been lowered. The next frontier will inevitably be determining whether all patients with severe AS should undergo AVR irrespective of their symptomatic status.

Evaluation of the safety and efficacy of a novel Anatomical classification and dUal anchoRing theory to Optimize the tavR strategy for pure severe Aortic regurgitation (AURORA): a prospective cohort study

BACKGROUND

Success rate of transcatheter aortic valve replacement (TAVR) in aortic regurgitation (AR) patients is relatively low on account of the absence of calcified anchoring structures. Morphological classification and corresponding TAVR strategies for AR are lacking yet.

METHODS

The AURORA study is a prospective, multicenter, single-arm cohort study to evaluate the safety and efficacy of transfemoral TAVR for severe AR in patients with high or prohibitive risk for surgery. Patients who are ≥ 65 years and diagnosed with severe pure AR as defined by the Echocardiographic Core Laboratory will be consecutively enrolled for further multidetector computed tomography (MDCT) scanning and multiplanar analyses. Based on a new anatomical classification and dual anchoring theory, patients will be classified into 4 types according to the level of the anchoring area. Types 1, 2 and 3 (at least 2 anchoring areas) will undergo the TAVR procedure with a domestic Chinese self-expanding valve (VitaFlow Valve, MicroPort, Shanghai, China), whereas type 4 (0 or 1 anchoring area) patients will be considered unsuitable for TAVR and will receive medical treatment. Our goal is to recruit 100 patients to account for 10% missing data or loss of patients to follow-up. Procedural, 30-day, 6-month and 12-month outcomes will be assessed according to Valve Academic Research Consortium-3 criteria.

DISCUSSION

The AURORA study will establish a new AR anatomical classification based on dual anchoring theory through MDCT multiplanar measurement and assess the safety and efficacy of TAVR guided by this new classification and strategy in AR patients.

TRIAL REGISTRATION

This Study was registered at Chinses Clinical Trial Registry. The registration number: ChiCTR2200055415; The date of registration: 9, January 2022; The URL of the registration: http://www.chictr.org.cn/showproj.aspx?proj=141209 .

Hemodynamics of transcatheter tricuspid valve replacement with Lux-Valve

Objective

Transcatheter tricuspid valve intervention (TTVI) has emerged as an alternative treatment option for high-risk and inoperable patients with symptomatic tricuspid regurgitation (TR). However, scarce data in hemodynamic profiles were available on TTVI. In this paper, we attempt to report the hemodynamic profiles of LuX-Valve.

Methods

30 patients from July 2020 to July 2021 were enrolled in this study. The patient was diagnosed with severe symptomatic TR. The clinical, invasive hemodynamic, and echocardiographic data were collected.

Results

The surgical success rate was 100%. The cardiac index and stroke volume increased sharply from 2.42(2.27, 2.85) and 47.8(43.6, 62.0) to 3.04 ± 0.63 and 57.2 ± 14.7, respectively. With the elimination of TR and the increase of forward blood flow of the tricuspid valve, the extravascular lung water [798.0 (673.0, 1147.0) vs. 850.3 ± 376.1, P < 0.01] increased subsequently. The peak right atrium pressure decreased after Lux-Valve implantation (21.0 ± 6.4 vs. 19.4 ± 6.5, P < 0.05). On the contrary, the nadir right atrium pressure increased [10.0(8.0, 15.0) vs. 12.0(10.0, 17.0), P < 0.01]. Notably, the right atrium pressure difference dropped sharply from 9.0(5.0, 13.0) to 5.0(4.0, 8.0) after Lux-Valve implantation. There was no significant change in the pulmonary artery pressure. The right atrium volume decreased from 128(83, 188) to 91(67, 167) mL at 1 month and 107(66,157) mL at 6 months. With the remolding of the right heart chamber, the tricuspid annulus diameter shrank significantly from 42.5 ± 5.6 to 36.6 ± 6.3 mm at 1 month and 36.0 (33.0, 38.0) at 6 months.

Conclusion

Invasive right atrium pressure may act as a potential candidate for TR evaluation and procedural guidance. Elimination of TR by LuX-Valve implantation improves the cardiac output and right atrium pressure and has no significant effect on the pulmonary artery pressure even with the increment of forward blood flow, suggesting the hemodynamic superiority of transcatheter tricuspid valve replacement but needs further study.

Outcomes of Transcatheter Edge-to-Edge Repair in Degenerative vs. Functional Mitral Regurgitation

Current guidelines support the use of transcatheter edge-to-edge repair (TEER) for patients with both primary and secondary mitral regurgitation. We aimed to compare the prognoses of TEER in degenerative mitral regurgitation (DMR) vs. functional mitral regurgitation (FMR). A total of 208 consecutive patients who underwent TEER over a ten-year period were analyzed. Primary endpoints included rates of all-cause death and major adverse cardiac events (MACE: composite of all-cause death, hospitalizations for heart failure, mitral valve surgery, or TEER re-intervention). A total of 148 (71%) patients were identified with FMR, while 60 (29%) were identified with DMR. Patients in the FMR group were younger (77.2 ± 8.4 vs. 80.2 ± 7.2, p = 0.02), suffered more frequently from coronary artery disease (54.1% vs. 10.0%, p = 0.02), and atrial fibrillation/flutter (70.9% vs. 38.3%, p = 0.02). Rates of 1-year death (21.6% vs. 10.0%, p = 0.03) and MACE (41.2% vs. 21.7%, p = 0.02) were higher for the FMR group, as compared to the DMR group. After correcting for variables, FMR independently predicted rates of MACE (HR-1.78, 95% CI 1.23-2.48, p = 0.04) and had a non-significant effect on one-year mortality (HR-1.67, 95%CI 0.98-3.74, p = 0.07). In our experience, worse overall 1-year composite MACE outcomes were observed after TEER in patients with FMR as compared to patients with DMR.

Mitral valve stenosis in the current era: a changing landscape

Mitral stenosis results from haemodynamic obstruction at the mitral valve level because of structural abnormalities of the valve apparatus, leading to increased resistance to the transmitral flow. Although rheumatic fever remains the predominant cause of mitral stenosis worldwide, other causes are increasingly relevant in the developed countries with degenerative mitral stenosis (DMS) because of mitral annulus calcification (MAC) becoming growingly prevalent in industrialized countries with higher life expectancy. Rheumatic mitral stenosis (RMS) and DMS display dramatic differences in pathophysiology, prognosis, and disease progression. Furthermore, to date, robust evidence regarding the management of DMS because of MAC is lacking. Nevertheless, new diagnostic techniques and catheter-based interventions are changing this landscape and paving the way to a significant reduction in DMS-related morbidity and mortality. Here we briefly review the current knowledge on the pathophysiology, diagnosis and treatment of DMS and RMS, underscoring the current diagnostic and therapeutic pathways, as well as persisting uncertainties and perspectives.

Transcatheter aortic valve replacement with or without anesthesiologist: results from a high-volume single center

AIMS

Local instead of general anesthesia has become the standard approach in many centers for transfemoral transcatheter aortic valve replacement (TAVR). New generation devices and an increase in operator skills had led to a drastic reduction in periprocedural complications, bringing in the adoption of a minimalist approach. In our study, we aimed to compare patients treated with TAVR under local anesthesia with or without the presence of an anesthesiologist on site (AOS).

METHODS

We compare procedural aspects and results of patients treated with TAVR with an AOS against patients treated with TAVR with an anesthesiologist on call (AOC). From January 2019 to December 2020, all consecutive patients undergoing transfemoral TAVR with either the self-expandable Evolut (Medtronic, MN, USA) or balloon-expandable SAPIEN 3 (Edwards Lifesciences, CA, USA) were collected.

RESULTS

Of 332 patients collected, 96 (29%) were treated with TAVR with AOS, while 236 (71%) were treated with TAVR with AOC. No differences in procedural time, fluoroscopy time and amount of contrast medium were observed. No procedural death and conversion to open-chest surgery was reported. The rate of stroke/transient ischemic attacks and major vascular complications was similar in the two groups. No patients in both groups required conversion to general anesthesia. Two patients (0.8%) in the AOC group required urgent intervention of the anesthesiologist. In the AOC group, there was a greater use of morphine (55.9% vs. 33.3%, P = 0.008), but with a lower dose for each patient (2.0 vs. 2.8 mg, P = 0.006). On the other hand, there was a lower use of other painkiller drugs (3.4% vs. 20.8%, P = 0.001). No difference in inotropic drugs use was observed.

CONCLUSION

In patients at low or intermediate risk undergoing transfemoral TAVR, a safe procedure can be performed under local anesthesia without the presence of an anesthesiologist in the catheterization laboratory.

Early and mid-term outcome of patients with low-flow-low-gradient aortic stenosis treated with newer-generation transcatheter aortic valves

Patients with non-paradoxical low-flow-low-gradient (LFLG) aortic stenosis (AS) are at increased surgical risk, and thus, they may particularly benefit from transcatheter aortic valve replacement (TAVR). However, data on this issue are still limited and based on the results with older-generation transcatheter heart valves (THVs). The aim of this study was to investigate early and mid-term outcome of TAVR with newer-generation THVs in the setting of LFLG AS. Data for the present analysis were gathered from the OBSERVANT II dataset, a national Italian observational, prospective, multicenter cohort study that enrolled 2,989 consecutive AS patients who underwent TAVR at 30 Italian centers between December 2016 and September 2018, using newer-generation THVs. Overall, 420 patients with LVEF ≤50% and mean aortic gradient <40 mmHg were included in this analysis. The primary outcomes were 1-year all-cause mortality and a combined endpoint including all-cause mortality and hospital readmission due to congestive heart failure (CHF) at 1 year. A risk-adjusted analysis was performed to compare the outcome of LFLG AS patients treated with TAVR (n = 389) with those who underwent surgical aortic valve replacement (SAVR, n = 401) from the OBSERVANT I study. Patients with LFLG AS undergoing TAVR were old (mean age, 80.8 ± 6.7 years) and with increased operative risk (mean EuroSCORE II, 11.5 ± 10.2%). VARC-3 device success was 83.3% with 7.6% of moderate/severe paravalvular leak. Thirty-day mortality was 3.1%. One-year all-cause mortality was 17.4%, and the composite endpoint was 34.8%. Chronic obstructive pulmonary disease (HR 1.78) and EuroSCORE II (HR 1.02) were independent predictors of 1-year mortality, while diabetes (HR 1.53) and class NYHA IV (HR 2.38) were independent predictors of 1-year mortality or CHF. Compared with LFLG AS treated with SAVR, TAVR patients had a higher rate of major vascular complications and permanent pacemaker, while SAVR patients underwent more frequently to blood transfusion, cardiogenic shock, AKI, and MI. However, 30-day and 1-year outcomes were similar between groups. Patients with non-paradoxical LFLG AS treated by TAVR were older and with higher surgical risk compared with SAVR patients. Notwithstanding, TAVR was safe and effective with a similar outcome to SAVR at both early and mid-term.

Transcatheter Aortic Valve Replacement as a Rescue Treatment for Prosthetic Valve Endocarditis

A 74-year-old man with a history of bioprosthetic aortic valve replacement presented with acute severe aortic insufficiency and cardiogenic shock secondary to Diphtheroides and Enterococcus endocarditis. The patient was deemed to be not a surgical candidate by the multidisciplinary team and underwent rescue transcatheter aortic valve-in-valve replacement, resulting in complete recovery. (Level of Difficulty: Advanced.).

Predictors and neurological consequences of periprocedural cerebrovascular events following transcatheter aortic valve implantation with self-expanding valves

Aims

To evaluate the patient- and procedure-related predictors of transcatheter aortic-valve implantation (TAVI)-associated ischemic brain lesions and to assess the effect of silent cerebral ischemic lesions (SCIL) on neurocognitive function.

Methods and results

We investigated 113 consecutive patients with severe aortic stenosis who underwent brain magnetic resonance imaging (MRI) within a week following TAVI. To assess periprocedural cerebral ischemic lesions, diffusion-weighted MRI was utilized. We used multivariate linear regression to identify the independent predictors of TAVI-related ischemic lesion volume (ILV) and periprocedural stroke. Neurocognitive evaluation was performed before and following TAVI at 6-month and one-year follow-up. Following TAVI, a total of 944 new cerebral ischemic lesions were detected in 104 patients (92%). The median ILV was 257 μl (interquartile range [IQR]:97.1–718.8μl) with a median lesion number of 6/patient [IQR:2–10]. The majority of ischemic lesions were clinically silent (95%), while 5% of the lesions induced a stroke, which was confirmed by MRI. Predilatation (β = 1.13[95%CI:0.32–1.93], p = 0.01) and the number of valve positioning attempts during implantation (β = 0.28[95%CI:0.06–0.50], p = 0.02) increased the log-transformed total ILV. Predilatation (OR = 12.04[95%CI:1.46–99.07], p = 0.02) and alternative access routes (OR = 7.84[95%CI:1.01–61.07], p = 0.02) were associated with stroke after adjustments for comorbidities and periprocedural factors. The presence of SCILs were not associated with a change in neurocognitive function that remained stable during the one-year follow-up.

Conclusion

While periprocedural ischemic lesions are frequent, most of them are clinically silent and might not impact the patients' neurocognitive function. The number of valve positioning attempts, predilatation, and alternative access routes should be taken into consideration during TAVI to reduce the ILV and risk for stroke.

COVID-19 in a patient implanted with a total artificial heart: a case report

Background

The coronavirus disease 2019 (COVID-19) was first identified in December 2019 and is currently still a public health issue affecting millions of people worldwide. Heart failure patients are known to be at higher risk of morbidity and mortality in this case. Yet, few data exist concerning COVID-19 among patients with a left ventricular assistance device, and even less among those with a total artificial heart (TAH).

Case summary

A 27-year-old man with Marfan syndrome underwent prophylactic ascending aorta replacement. Shortly after surgery completion, he developed refractory cardiogenic shock with biventricular dysfunction leading to veno-arterial extracorporeal membrane oxygenation (VA-ECMO) implantation. In the context of no appropriate eligible donor during the following 10 days while waiting on the heart transplantation list, the patient was scheduled for a TAH as a bridge to transplantation. Meanwhile, he developed an acute respiratory distress syndrome secondary to SARS-CoV-2. The patient was successfully treated with corticosteroids, prone positioning and mechanical ventilation, and heart transplantation occurred 5 weeks after COVID-19 onset.

Discussion

Here, we report the first case of a patient presenting with COVID-19 infection following TAH implantation in a bridge to transplantation. We highlight that (i) cardiogenic shock patients simultaneously infected by COVID-19 should be treated instantly with all-time available technology to ensure best outcomes, including TAH and prone positioning, (ii) heart transplantation safety 5 weeks after COVID-19 onset.

Additive value of the right parasternal view for the assessment of aortic stenosis

BACKGROUND

Although Doppler evaluation using a multiplanar method is recommended to assess the severity of aortic stenosis (AS) with transthoracic echocardiography, evidence on the diagnostic significance of a non-apical method is limited. This study aimed to compare the use of the apical with the use of the right parasternal view (RPV) method to evaluate AS severity and to examine the diagnostic significance of performing the RPV method in addition to the apical method during the evaluation.

METHODS

This retrospective observational study included 276 consecutive patients (mean age: 79 ± 10 years; women, 56%) with severe AS (aortic valve area [AVA] ≤1.0cm² ). The severity of AS according to the apical method and that according to the RPV for all subjects were compared, and the significance of performing the RPV method in addition to the apical method was examined. Furthermore, we compared the concordance group, in which the apical and RPV methods indicated matching in severity, and the discordant group, in which the apical and RPV methods did not indicate matching severity.

RESULTS

Peak velocity (V_max ), mean pressure gradient (MG) were significantly higher and the AVA, AVAi, and Doppler velocity index (DVI) were significantly smaller when the RPV was added to the apical view. Performing the RPV method in addition to the apical method significantly decreased the number of low PG AS cases (MG < 40 mmHg) from 69.9% to 65.0% and it increased the number of very severe AS cases (V_max ≥ 5 m/s) from 8.7% to 14.5%. Deviation of Doppler angle was significantly greater in the discordant group compared to the concordant group (22.5 ± .6 vs. 31.8 ± 1.7, p < .001).

CONCLUSIONS

By performing the RPV method in addition to the apical method to determine AS severity, the diagnosis of AS to be resolved in approximately 10% of cases. These results suggest that AS severity may be underestimated by using the apical method alone.

Funktionelle Trikuspidalklappeninsuffizienz – Klinische und echokardiografische Parameter für die Auswahl von Patient und Verfahren

Die sekundäre Trikuspidalklappeninsuffizienz (TI) ist ein häufiger Klappenfehler und führt oft erst in fortgeschrittenen Stadien zu Symptomen. Die Prognose von betroffenen Patienten ist eingeschränkt und die perioperative Letalität bei konventioneller Chirurgie der isolierten TI hoch, sodass kathetergestützte Verfahren einen enormen technischen Fortschritt in den letzten Jahren gemacht haben. Zudem hat die anatomische und auch klinische Patientenauswahl an Bedeutung gewonnen, da sowohl in der klinischen Präsentation als auch in der individuellen Anatomie der Trikuspidalklappe eine große Variabilität herrscht. Klinisch ist bzw. sind insbesondere das Vorhandensein einer (präkapillären) pulmonalen Hypertonie oder fortgeschrittene Stadien des Rechtsherz-Remodelings mit einer reduzierten Prognose nach kathetergestützten Eingriffen assoziiert. Zudem sind relevante Komorbiditäten und funktionelle Fitness/Gebrechlichkeit zu evaluieren. Echokardiografisch ist die funktionelle TI durch eine Anulus- und/oder rechtsventrikuläre bzw. rechtsatriale Dilatation gekennzeichnet, welche zu Koaptationsdefekten der Trikuspidalklappensegel und einer Zügelung der Segel („Tethering“) führen können. Die Ausprägung dieser Parameter sowie die Anulusgröße, der Schweregrad der TI und das Vorhandensein von transvalvulären Sonden im Bezug zur Trikuspidalklappe sind die wichtigsten echokardiografischen Parameter, die in die Patientenauswahl einfließen müssen.

Die Aortenklappeninsuffizienz – können wir mit interventionellen Therapieoptionen mehr Patienten helfen?

Die hochgradige, symptomatische Aortenklappeninsuffizienz ist häufig nicht einfach zu diagnostizieren und bei einem relevanten Anteil der Patienten noch nicht ausreichend gut behandelt. Dabei können auch Patienten mit höherem operativen Risiko von einem Aortenklappenersatz profitieren. Durch das Fortschreiten der interventionellen Therapieoptionen stellt die Transkatheter-Aortenklappenimplantation (TAVI) mittlerweile eine ebenfalls zu berücksichtigende Therapieoption dar. Dadurch kann es möglich werden, auch ältere und kränkere Patienten einer adäquaten und notwendigen Therapie der Aortenklappeninsuffizienz zuzuführen.

Frühe Herzklappentherapie bei asymptomatischen Patienten – was gilt schon jetzt?

Bei einer asymptomatischen hochgradigen Aortenklappenstenose (AS) mit normaler linksventrikulärer Funktion sollte eine „Watchful-Waiting“-Strategie verfolgt werden. Asymptomatische Patienten mit Risikofaktoren, wie sehr schwere AS, schwere kalzifizierter AS oder 3-fach erhöhtem proBNP-Level, können bei niedrigem operativem Risiko eine Intervention erhalten. Erste randomisierte Studien weisen auf einen Vorteil des frühzeitigen Aortenklappenersatzes bei niedrigem OP-Risiko hin.

Für Patienten mit einer asymptomatischen hochgradigen Aortenklappeninsuffizienz sollte bei niedrigem operativem Risiko bereits frühzeitig eine OP erwogen werden, wenn sich Zeichen der linksventrikulären Schädigung zeigen.

Bei asymptomatischer primärer Mitralklappeninsuffizienz (MI) kann die chirurgische Mitralklappenrekonstruktion bereits vor dem Auftreten einer linksventrikulären Dilatation oder anderweitigen Folgeschäden erwogen werden, falls mit einer hohen Rekonstruktionswahrscheinlichkeit zu rechnen ist.

Multimodality imaging for the management of patients with primary mitral regurgitation

Advanced cardiac imaging (ACI), including myocardial deformation imaging, 3D echocardiography and cardiac magnetic resonance, overcomes the limitations of conventional echocardiography in the assessment of patients with primary mitral regurgitation (MR). They enable a more precise MR quantification and reveal early changes before advanced and irreversible remodeling with depressed heart function occurs. ACI permits a thorough analysis of mitral valvular anatomy and MR mechanisms (important for planning and guiding percutaneous and surgical procedures) and helps to identify structural and functional changes coupled with a high arrhythmogenic potential, especially the occurrence of atrial fibrillation and heart failure development. The key question is how the data provided by ACI can improve the current management of primary MR.

Biomarkers in heart failure clinical trials. A review from the Biomarkers Working Group of the Heart Failure Association of the European Society of Cardiology

The approval of new heart failure (HF) therapies has slowed over the past two decades in part due to the high costs of conducting large randomized clinical trials that are needed to adequately power major clinical endpoint studies. Several biomarkers have been identified reflecting different elements of HF pathophysiology, with possible applications in diagnosis, risk stratification, treatment monitoring, and even in the design of clinical trials. Biomarkers could potentially be used to refine study inclusion criteria to enable enrolment of patients who are more likely to respond to a therapeutic intervention, despite being at sufficient risk to meet pre-determined study endpoint rates. When there is a close relationship between biomarker levels and clinical endpoints, changes in biomarker levels after a given treatment can act as a surrogate endpoint, potentially reducing the duration and cost of a clinical trial. Natriuretic peptides have been widely used in clinical trials with a variable amount of added value, which such variation being probably due to the absence of a close pathophysiological connection to the study drug. Notable exceptions to this include sacubitril/valsartan and vericiguat. Future studies should seek to adopt unbiased approaches for discovery of true companion diagnostics; with -omics-based tools, biomarkers might be more precisely selected for use in clinical trials to identify responses that closely reflect the biological effects of the drug under investigation. Finally, biomarkers associated with cardiac damage and remodelling, such as cardiac troponin, could be employed as safety endpoints provided that standardization between different assays is achieved.

Re-intervention percutaneous balloon mitral valvuloplasty in a patient with left atrial appendage thrombus: a case report

Background

Percutaneous balloon mitral valvuloplasty (PBMV) using an Accura balloon is an effective method for management of rheumatic mitral stenosis.

Case summary

Herein, we present a case of a 43-year-old female, who had undergone a previous PBMV, who presented with very severe mitral re-stenosis with Type Ia left atrial (LA) clot, in atrial fibrillation and New York Heart Association functional Class III. We used the modified septal puncture and over-the-wire technique, avoiding inadvertent manipulation of the LA clot for PBMV. The mitral valve was successfully dilated from 0.9 to 1.5 cm2, and the patient had an uneventful post-procedure recovery.

Discussion

The presence of LA clot and mitral re-stenosis in a previously intervened valve are considered unfavourable characteristics for a PBMV procedure, and patients are usually advised surgical intervention. These patients are also high-risk candidates for surgery due to late presentation with advanced disease and poor functional capacity. Our patient underwent successful re-intervention with PBMV despite having suboptimal characteristics.

Self-expanding Transcatheter vs Surgical Aortic Valve Replacement in Intermediate-Risk Patients: 5-Year Outcomes of the SURTAVI Randomized Clinical Trial

Importance

In patients with severe aortic valve stenosis at intermediate surgical risk, transcatheter aortic valve replacement (TAVR) with a self-expanding supra-annular valve was noninferior to surgery for all-cause mortality or disabling stroke at 2 years. Comparisons of longer-term clinical and hemodynamic outcomes in these patients are limited.

Objective

To report prespecified secondary 5-year outcomes from the Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement (SURTAVI) randomized clinical trial.

Design, Setting, and Participants

SURTAVI is a prospective randomized, unblinded clinical trial. Randomization was stratified by investigational site and need for revascularization determined by the local heart teams. Patients with severe aortic valve stenosis deemed to be at intermediate risk of 30-day surgical mortality were enrolled at 87 centers from June 19, 2012, to June 30, 2016, in Europe and North America. Analysis took place between August and October 2021.

Intervention

Patients were randomized to TAVR with a self-expanding, supra-annular transcatheter or a surgical bioprosthesis.

Main Outcomes and Measures

The prespecified secondary end points of death or disabling stroke and other adverse events and hemodynamic findings at 5 years. An independent clinical event committee adjudicated all serious adverse events and an independent echocardiographic core laboratory evaluated all echocardiograms at 5 years.

Results

A total of 1660 individuals underwent an attempted TAVR (n = 864) or surgical (n = 796) procedure. The mean (SD) age was 79.8 (6.2) years, 724 (43.6%) were female, and the mean (SD) Society of Thoracic Surgery Predicted Risk of Mortality score was 4.5% (1.6%). At 5 years, the rates of death or disabling stroke were similar (TAVR, 31.3% vs surgery, 30.8%; hazard ratio, 1.02 [95% CI, 0.85-1.22]; P = .85). Transprosthetic gradients remained lower (mean [SD], 8.6 [5.5] mm Hg vs 11.2 [6.0] mm Hg; P < .001) and aortic valve areas were higher (mean [SD], 2.2 [0.7] cm2 vs 1.8 [0.6] cm2; P < .001) with TAVR vs surgery. More patients had moderate/severe paravalvular leak with TAVR than surgery (11 [3.0%] vs 2 [0.7%]; risk difference, 2.37% [95% CI, 0.17%- 4.85%]; P = .05). New pacemaker implantation rates were higher for TAVR than surgery at 5 years (289 [39.1%] vs 94 [15.1%]; hazard ratio, 3.30 [95% CI, 2.61-4.17]; log-rank P < .001), as were valve reintervention rates (27 [3.5%] vs 11 [1.9%]; hazard ratio, 2.21 [95% CI, 1.10-4.45]; log-rank P = .02), although between 2 and 5 years only 6 patients who underwent TAVR and 7 who underwent surgery required a reintervention.

Conclusions and Relevance

Among intermediate-risk patients with symptomatic severe aortic stenosis, major clinical outcomes at 5 years were similar for TAVR and surgery. TAVR was associated with superior hemodynamic valve performance but also with more paravalvular leak and valve reinterventions.

Characterizing the Accuracy of International Classification of Diseases, Tenth Revision Administrative Claims for Aortic Valve Disease

BACKGROUND

Administrative claims for aortic stenosis (AS) regurgitation may be useful, but their accuracy and ability to identify individuals at risk for valve-related outcomes have not been well characterized.

METHODS

Using echocardiographic (transthoracic echocardiogram [TTE]) reports linked to US Medicare claims, 2017 to 2018, the performance of candidate International Classification of Diseases, Tenth Revision claims to ascertain AS/aortic regurgitation was evaluated. The optimal performing algorithm was tested against outcomes at 1-year after TTE in a separate 100% sample of US Medicare claims, 2017 to 2019.

RESULTS

Of those included in the derivation (N=5497, mean age 74.4±11.0 years, 49.7% female), any AS or aortic regurgitation was present in 24% and 38.8%, respectively. The sensitivity and specificity of International Classification of Diseases, Tenth Revision code I35.0 for identification of any AS was 53.1% and 94.8%, respectively. Among those with an I35.0 code, 40.3% had severe AS. Claims were unable to distinguish disease severity (ie, severe versus nonsevere) or subtype (eg, bicuspid or rheumatic AS), and were insensitive and nonspecific for aortic regurgitation of any severity. Among all beneficiaries who received a TTE (N=4 033 844), adjusting for age, sex, and 27 comorbidities, those with an I35.0 code had a higher adjusted risk of all-cause mortality (adjusted hazard ratio, 1.33 [95% CI, 1.31-1.34]), heart failure hospitalization (adjusted hazard ratio, 1.37 [95% CI, 1.34-1.41]), and aortic valve replacement (adjusted hazard ratio, 34.96 [95% CI, 33.74-36.22]).

CONCLUSIONS

Among US Medicare beneficiaries receiving a TTE, International Classification of Diseases, Tenth Revision claims, though identifying a population at significant greater risk of valve-related outcomes, failed to identify nearly half of individuals with AS and were unable to distinguish disease severity or subtype. These results argue against the widespread use of International Classification of Diseases, Tenth Revision claims to screen for patients with AS and suggests the need for improved coding algorithms and alternative systems to extract TTE data for quality improvement and hospital benchmarking.

Comparison of efficacy and safety between VKAs and DOACs in patients with atrial fibrillation after transcatheter aortic valve replacement: A systematic review and meta-analysis

In the past decade, direct oral anticoagulants (DOACs) have proven to be the best option for patients with nonvalvular atrial fibrillation. Nevertheless, evidence for the use of DOACs for anticoagulation in valvular atrial fibrillation, particularly after aortic valve replacement, remains inadequate. Thus, we conducted a meta-analysis to compare the efficacy and safety of vitamin K antagonists (VKAs) and DOACs in patients with atrial fibrillation after transcatheter aortic valve replacement (TAVR). We conducted a comprehensive search of online databases, and 11 studies were included in the final analysis. The primary endpoint was all-cause mortality. Secondary endpoints included stroke and cardiovascular death. The safe endpoint is major and/or life-threatening bleeding. Subgroup analysis was conducted according to the different follow-up time of each study. Random-effects models were used for all outcomes. Statistical heterogeneity was assessed using χ2 tests and quantified using I2  statistics. Patients in the DOACs group had a significantly lower risk of all-cause mortality compared with patients in the VKAs group (relative risk [RR]: 1.20, 95% confidence interval [CI]: 1.01-1.43, p = .04). This benefit may be greater with longer follow-up. In a subgroup analysis based on the length of follow-up, a significantly lower risk of all-cause mortality was found in the DOACs group in the subgroup with a follow-up time of >12 months (RR: 1.50, 95% CI: 1.07-2.09, p = .001). There were no significant differences between the two groups in cardiovascular death, stroke, and major and/or life-threatening bleeding. For patients with atrial fibrillation after TAVR, the use of DOACs may be superior to VKAs, and the benefit may be greater with longer follow-up. The anticoagulant strategy for atrial fibrillation after TAVR is a valuable direction for future research.

Predictors of Clinical Success After Transcatheter Paravalvular Leak Closure: An International Prospective Multicenter Registry

BACKGROUND

Transcatheter closure of a symptomatic prosthetic paravalvular leak (PVL) is feasible, but there is presently no conclusive evidence to show consistent efficacy. We aimed to identify predictors of clinical success after transcatheter PVL closure.

METHODS

Consecutive patients referred to 24 European centers for transcatheter PVL closure in 2017 to 2019 were included in a prospective registry (Fermeture de Fuite ParaProthétique, FFPP). Clinical success was absence of any of the following within 1 month: re-admission for heart failure, blood transfusion, open-heart valvular surgery, and death.

RESULTS

We included 216 symptomatic patients, who underwent 238 percutaneous PVL closure procedures on the mitral (64.3%), aortic (34.0%), or tricuspid (1.7%) valve. Symptoms were heart failure, hemolytic anemia, or both in 48.9%, 7.8%, and 43.3% of patients, respectively. One, 2, and 3 leaks were treated during the same procedure in 69.6%, 26.6%, and 3.8% of patients, respectively. The PVL was pinpoint or involved 1/8 or 1/4 of the valve circumference in 18.6%, 52.4%, and 28.1% of cases, respectively. The most frequently used devices were the Vascular Plug 3, Ventricular Septal Defect Occluder, Vascular Plug 2, and Paravalvular Leak Device (45.0%, 16.6%, 14.2%, and 13.6% of cases, respectively). Successful device(s) implantation with leak reduction to ≤grade 2 was obtained in 85.0% of mitral and 91.4% of aortic procedures, respectively (P=0.164); with major periprocedural adverse event rates of 3.3% and 1.2%, respectively (P=0.371); and clinical success rates of 70.3% and 88.0%, respectively (P=0.004). By multivariate analysis, technical failure, mechanical valve, and hemolytic anemia were independently associated with absence of clinical success (odds ratios [95% CIs], 7.7 [2.0-25.0]; P=0.002; 3.6 [1.1-11.1]; P=0.036; and 3.7 [1.2-11.9]; P=0.025; respectively).

CONCLUSIONS

Transcatheter PVL closure is efficient and safe in symptomatic patients but is associated with a lower clinical success rate in patients with hemolysis and/or a mechanical valve.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifiers: NCT05089136.

Edge-to-edge percutaneous mitral repair for functional ischaemic and non-ischaemic mitral regurgitation: a systematic review and meta-analysis

AIM

Randomized controlled trials comparing the use of the MitraClip device in addition to guideline directed medical therapy (GDMT) to GDMT alone in patients with secondary mitral regurgitation (MR) have shown conflicting results. However, if these differences could be due to the underlying MR aetiology is still unknown. Therefore, we aimed to evaluate if the effects of percutaneous edge-to-edge repair with MitraClip implantation could differ in patients with ischaemic (I-MR) and non-ischaemic mitral regurgitation (NI-MR).

METHODS AND RESULTS

PubMed, Embase, BioMed Central, and the Cochrane Central Register of Controlled Trials were searched for all studies including patients with secondary MR treated with the MitraClip device. Data were pooled using a random-effects model. Primary endpoint was the composite of all-cause death and heart failure-related hospitalization. Secondary endpoints were the single components of the primary endpoint, New York Heart Association functional Classes III and IV, and mitral valve re-intervention. Seven studies enrolling 2501 patients were included. Patients with I-MR compared with patients with NI-MR had a similar risk of the primary endpoint (odds ratio: 1.17; 95% confidence interval: 0.93 to 1.46; I2 : 0%). The risk of all-cause death was increased in patients with I-MR (odds ratio: 1.31; 95% confidence interval: 1.07 to 1.62; I2 : 0%), while no differences were observed between the two groups in terms of the other secondary endpoints.

CONCLUSIONS

The risk of mortality after MitraClip implantation is lower in patients with NI-MR than in those with I-MR. No absolute differences in the risk of heart failure related hospitalization were observed between groups.

The Role of Stress Echocardiography in Valvular Heart Disease

PURPOSE OF REVIEW

Stress echocardiography is recommended in valvular heart disease when there is a mismatch between resting transthoracic echocardiography findings and symptoms during activities of daily living. We describe the current methodology and the evidence supporting these applications.

RECENT FINDINGS

The comprehensive stress echo assessment includes valve function (gradients and regurgitation), left ventricular global systolic and diastolic function, left atrial volume, pulmonary congestion, pulmonary arterial pressure, and right ventricular function, integrated with blood pressure response with cuff sphygmomanometer, chronotropic reserve with heart rate, and symptoms. Recent guidelines recommend the evaluation of asymptomatic severe or symptomatic non-severe mitral regurgitation or stenosis with exercise stress and suspected low-flow, low-gradient severe aortic stenosis with reduced ejection fraction with low dose (up to 20 mcg, without atropine) dobutamine stress. Prospective, large-scale studies based on a comprehensive protocol (ABCDE +) capturing the multiplicity of clinical phenotypes are needed to support stress echo-driven treatment strategies.