Acute Valvular Heart Disease

The Association Between Mitral Regurgitation and Long-Term Outcomes in Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention: A Retrospective Large Sample Cohort Study

Background

The relationship between mitral regurgitation (MR) and long-term outcomes in Chinese patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) remains scarce. This study aimed to elucidate the connection between MR and long-term clinical outcomes following AMI treated with PCI.

Methods

In this retrospective study 6940 patients who were diagnosed with AMI were consecutively enrolled from General Hospital of Ningxia Medical University (2014-2019). The included AMI patients were divided into no MR, mild MR and moderate/serve MR according to MR occurred. All patients were clinically followed for 3-year to collect major adverse cardiac and cerebrovascular events (MACCEs), comprising all-cause death, nonfatal myocardial infarction (MI), rehospitalization for angina, rehospitalization for heart failure (RHF), and stroke. Cox regression models were employed to analyze the association between MR and 3-year clinical outcomes after adjusting for various confounding factors.

Results

Among the 6940 patients, 2871 (41.35%) exhibited no MR, 3681 (53.04%) had mild MR, and 388 (5.59%) had moderate/severe MR. The cumulative 3-year incidence of MACCEs was 19.21% overall, with rates of 15.26%, 20.37%, and 37.37% in the no MR, mild MR, and moderate/severe MR groups, respectively (log-rank p < 0.001). Kaplan-Meier survival curves of MR with all-cause death and RHF were also plotted (log-rank p < 0.001). After controlling confounding variables completely, we found that moderate/severe MR compared to none MR was found to be significantly associated with 3-year MACCEs [hazard ratio (HR) = 1.83; 95% confidence interval (CI) = 1.21-2.77; p = 0.0042], all-cause mortality (HR = 3.11; 95% CI = 1.75-5.50; p=0.001) and RHF (HR = 1.69; 95% CI = 1.09-2.62; p=0.019) through Cox proportional hazards regression models.

Conclusion

MR significantly predicted 3-year clinical outcomes in AMI patients undergoing PCI, highlighting the need for physicians to prioritize MR assessment in clinical practice.

Acute Decompensated Valvular Disease in the Intensive Care Unit

Acute decompensated valvular disease encompasses a group of complex and challenging conditions, which are often the primary reason for admission to the cardiac intensive care unit and can also complicate the management of other primary cardiac disorders. Critically ill patients with valvular disease also present unique diagnostic and management challenges. Historically, medical and percutaneous interventional therapies have been limited and surgery was the only definitive treatment; however, surgical risk can at times be prohibitive. High-quality evidence to direct management of acute valvular disorders in this population is lacking and societal guidelines largely do not address treatment options for critically ill patients with decompensated valvular disease. In this review, we discuss the clinical presentation and epidemiology of commonly encountered valvular diseases in the modern cardiac intensive care unit, highlight key pathophysiology, detail gaps in evidence, describe the pivotal role of multidisciplinary Heart Teams, and provide guidance for management.

Native Valve Infective Endocarditis with Severe Regurgitation: What Matters Is Heart Failure

Background/Objectives: Heart failure worsens the prognosis of patients with infective endocarditis (IE) and is mainly caused by severe valvular regurgitation. The aim of our investigation is to describe the clinical, epidemiological, microbiological, and echocardiographic characteristics of patients with native left-sided infective endocarditis (NLSIE) with severe valvular regurgitation; to describe the prognosis according to the therapeutic approach; and to determine the prognostic factors of in-hospital mortality. Methods: We prospectively recruited all episodes of possible or definite NLSIE diagnosed at three tertiary hospitals between 2005 and 2022. Patients were divided into two groups: patients with severe valvular regurgitation at the time of admission or during hospitalization and patients without severe valvular regurgitation. We analyzed up to 85 variables concerning epidemiological, clinical, analytical, microbiological, and echocardiographic data. Results: We recovered 874 patients with NLSIE, 564 (65%) of them with severe valvular regurgitation. There were no differences in mortality among patients with and without severe regurgitation (30.2% vs. 26.5%, p = 0.223). However, mortality increased when patients with severe regurgitation developed heart failure (33% vs. 11.4%, p < 0.001). Independent factors related to heart failure were age (OR 1.02 [1.01-1.034], p = 0.001), anemia (OR 1.2 [1.18-3.31], p = 0.01), atrial fibrillation (OR 2.3 [1.08-4.89], p = 0.03), S. viridans-related IE (OR 0.47 [0.3-0.73], p = 0.001), and mitroaortic severe regurgitation (OR 2.4 [1.15-5.02], p = 0.019). Conclusions: Severe valvular regurgitation is very frequent among patients with NLSIE, but it does not worsen the prognosis of patients unless complicated with heart failure.

The various perioperative issues of structural heart diseases and cardiogenic shock

Up to 20 % of patients presenting with acute heart failure and cardiogenic shock have a structural etiology. Despite efforts in timely management, mortality rates remain alarmingly high, ranging from 50 % to 80 %. Surgical intervention is often the definitive treatment for structural heart disease; however, many patients are considered high risk or unsuitable candidates for such procedures. Consequently, there has been a paradigm shift towards the development of novel percutaneous management strategies and temporizing interventions. This article aims to provide a comprehensive review of the pathophysiology of valvular and structural heart conditions presenting in cardiogenic shock, focusing on the evolving landscape of mechanical circulatory support devices and other management modalities.

Contemporary Echocardiographic Evaluation of Mitral Regurgitation and Guidance for Percutaneous Mitral Valve Repair

Mitral valve regurgitation (MR) is a multifaceted valvular heart disease. Echocardiography plays a central role in etiology assessment, severity quantification, treatment candidacy, outcome evaluation, and patient follow-up. In this review, we describe the comprehensive echocardiographic assessment of MR, including transthoracic (TTE) and transesophageal (TEE) approaches, 2D and 3D modalities, strain imaging, stress echocardiography, and artificial intelligence (AI) applications. Transcatheter edge-to-edge mitral valve repair (TEER) has been established as a key therapy for patients with severe, symptomatic MR and high surgical risk. TEER is performed under TEE guidance. We outline a practical overview of echocardiographic guidance on TEER.

Transcatheter interventions for left-sided valvular heart disease complicated by cardiogenic shock: a consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the Association for Acute Cardiovascular Care (ACVC) and the ESC Working Group on Cardiovascular Surgery

Valvular heart disease (VHD) is one of the most frequent causes of heart failure (HF) and is associated with poor prognosis, particularly among patients with conservative management. The development and improvement of catheter-based VHD interventions have broadened the indications for transcatheter valve interventions from inoperable/high-risk patients to younger/lower-risk patients. Cardiogenic shock (CS) associated with severe VHD is a clinical condition with a very high risk of mortality for which surgical treatment is often deemed a prohibitive risk. Transcatheter valve interventions might be a promising alternative in this setting given that they are less invasive. However, supportive scientific evidence is scarce and often limited to small case series. Current guidelines on VHD do not contain specific recommendations on how to manage patients with both VHD and CS. The purpose of this clinical consensus statement, developed by a group of international experts invited by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) Scientific Documents and Initiatives Committee, is to perform a review of the available scientific evidence on the management of CS associated with left-sided VHD and to provide a rationale and practical approach for the application of transcatheter valve interventions in this specific clinical setting.

Acute heart failure and valvular heart disease: A scientific statement of the Heart Failure Association, the Association for Acute CardioVascular Care and the European Association of Percutaneous Cardiovascular Interventions of the European Society of Cardiology

Acute heart failure (AHF) represents a broad spectrum of disease states, resulting from the interaction between an acute precipitant and a patient's underlying cardiac substrate and comorbidities. Valvular heart disease (VHD) is frequently associated with AHF. AHF may result from several precipitants that add an acute haemodynamic stress superimposed on a chronic valvular lesion or may occur as a consequence of a new significant valvular lesion. Regardless of the mechanism, clinical presentation may vary from acute decompensated heart failure to cardiogenic shock. Assessing the severity of VHD as well as the correlation between VHD severity and symptoms may be difficult in patients with AHF because of the rapid variation in loading conditions, concomitant destabilization of the associated comorbidities and the presence of combined valvular lesions. Evidence-based interventions targeting VHD in settings of AHF have yet to be identified, as patients with severe VHD are often excluded from randomized trials in AHF, so results from these trials do not generalize to those with VHD. Furthermore, there are not rigorously conducted randomized controlled trials in the setting of VHD and AHF, most of the data coming from observational studies. Thus, distinct to chronic settings, current guidelines are very elusive when patients with severe VHD present with AHF, and a clear-cut strategy could not be yet defined. Given the paucity of evidence in this subset of AHF patients, the aim of this scientific statement is to describe the epidemiology, pathophysiology, and overall treatment approach for patients with VHD who present with AHF.

Incidental Finding of Traumatic Papillary Muscle Rupture on Intraoperative Transesophageal Echocardiogram following a Motor Vehicle Accident

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Traumatic papillary muscle rupture is a rare cause of acute MR.

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Acute MR is typically a low-velocity jet with a triangle-shaped Doppler spectrum.

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Methods of quantification using the continuity equation may not be accurate in acute MR.

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A high index of suspicion is required to detect acute papillary muscle rupture.

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Consider MR with a hyperdynamic LV, near-systolic LV obliteration, and pulmonary edema.

Structural Heart Disease Emergencies

Structural heart disease (SHD) emergencies include acute deterioration of a stable lesion or development of a new critical lesion. Structural heart disease emergencies can produce heart failure and cardiogenic shock despite preserved systolic function that may not respond to standard medical therapy and typically necessitate surgical or percutaneous intervention. Comprehensive Doppler echocardiography is the initial diagnostic modality of choice to determine the cause and severity of the underlying SHD lesion. Patients with chronic SHD lesions which deteriorate due to intercurrent illness (eg, infection or arrhythmia) may not require urgent intervention, whereas patients with an acute SHD lesion often require definitive therapy. Medical stabilization prior to definitive intervention differs substantially between stenotic lesions (aortic stenosis, mitral stenosis, left ventricular outflow tract obstruction) and regurgitant lesions (aortic regurgitation, mitral regurgitation, ventricular septal defect). Patients with regurgitant lesions typically require aggressive afterload reduction and inotropic support, whereas patients with stenotic lesions may paradoxically require β-blockade and vasoconstrictors. Emergent cardiac surgery for patients with decompensated heart failure or cardiogenic shock carries a substantial mortality risk but may be necessary for patients who are not eligible for catheter-based percutaneous SHD intervention. This review explores initial medical stabilization and subsequent definitive therapy for patients with SHD emergencies.

Mixed aortic valve disease treated with transcatheter aortic valve replacement in a high risk patient presenting with acute decompensated heart failure

Mixed aortic valve disease refers to the combination of aortic regurgitation (AR) and aortic stenosis (AS). Commonly etiologies include a bicuspid aortic valve, rheumatic heart disease, and endocarditis superimposed upon a stenotic aortic valve. Treatment depends upon the severity of disease, the presence of symptoms and the size and function of the left ventricle. We present a case of a young patient that presented with new onset acute decompensated heart failure with mixed aortic valve disease that was successful treated with transcatheter aortic valve replacement (TAVR). Invasive hemodynamics at baseline and following TAVR provide an insight into the characteristic features of mixed aortic valve disease. TAVR represents a new treatment option for critically ill patients deemed high risk or nonoperable for surgical aortic valve replacement.

Acute mitral regurgitation

The diagnosis of acute mitral regurgitation (MR) is often missed or delayed because the clinical presentation is substantially different from that in patients with chronic MR. Management of acute MR depends on the specific aetiology of valve dysfunction and there is a lack of consensus on the optimal therapeutic approach in many patients. In particular, management of secondary MR due to acute ischaemia is challenging because of unique mechanisms of valve incompetence compared with chronic ischaemic MR. Another clinical challenge is management of acute MR due to transient systolic anterior motion of the mitral valve in the acute phase of Takotsubo cardiomyopathy, which commonly resolves within a few weeks. Additionally, iatrogenic MR induced by intraventricular devices is a recently recognised aetiology of acute MR. Acute primary MR typically requires early surgical intervention, for example, with a flail leaflet or endocarditis, because of acute cardiovascular decompensation with an abrupt increase in left atrial pressure. In an emergency situation and high surgical risk, a percutaneous mitral valve edge-to-edge repair is an alternative therapeutic option. Firm diagnosis of the severity and aetiology of acute MR is necessary for proper decision making, including timing and types of surgical intervention.