Valvular Heart Disease: Pathophysiology, Diagnosis, and Modern Treatment Approaches

Valvular heart disease represents a significant global health burden affecting millions of individuals across the age spectrum. From rheumatic heart disease still prevalent in developing regions to degenerative valve disorders increasingly common in aging populations, these conditions significantly impact quality of life and survival when left untreated. This comprehensive review explores the pathophysiology, diagnostic approaches, and contemporary management strategies for valvular heart disease, providing healthcare professionals with essential knowledge about this evolving field.

Pathophysiology of Valvular Heart Disease

Valve Anatomy and Function

The foundation of normal circulation:

Understanding valvular heart disease begins with appreciation of normal valve anatomy and function, which provides the foundation for comprehending pathological processes:

The four cardiac valves share common structural elements while maintaining unique anatomical features:
– Fibrous annulus providing structural support and attachment
– Leaflets or cusps forming the mobile components
– Commissures where adjacent leaflets meet
– Supporting structures including chordae tendineae and papillary muscles for atrioventricular valves
– Surrounding tissue including atrial and ventricular myocardium

The aortic valve, positioned at the junction between the left ventricle and aorta:
– Typically tricuspid configuration with three symmetric cusps
– Semilunar cusp shape with central coaptation
– Sinuses of Valsalva behind each cusp housing coronary ostia
– No direct supporting structures
– Functions primarily as a passive flow-dependent structure

The mitral valve, controlling flow between the left atrium and ventricle:
– Bicuspid configuration with anterior and posterior leaflets
– Asymmetric leaflets with posterior leaflet divided into scallops (P1, P2, P3)
– Complex three-dimensional saddle-shaped annulus
– Extensive subvalvular apparatus including chordae and papillary muscles
– Dynamic function integrated with left ventricular contraction

The tricuspid valve, regulating right atrial to ventricular flow:
– Three leaflets (anterior, posterior, and septal)
– Larger orifice than mitral valve
– More apical position of septal leaflet compared to others
– Variable chordal attachments including to ventricular septum
– More susceptible to annular dilation due to less fibrous support

The pulmonary valve, positioned between right ventricle and pulmonary artery:
– Tricuspid semilunar configuration similar to aortic valve
– Thinner cusps reflecting lower pressure environment
– No associated coronary arteries
– Rarely affected by acquired disease in adults

Normal valve function depends on the coordinated interaction of these components:
– Proper leaflet tissue integrity and pliability
– Synchronized annular dynamics during cardiac cycle
– Intact supporting structures for atrioventricular valves
– Appropriate relationship with surrounding chambers
– Normal pressure and flow conditions

Disruption of any of these elements can lead to valve dysfunction, manifesting as either stenosis (restricted opening) or regurgitation (incomplete closure), with specific pathophysiological consequences depending on the affected valve and the nature of the dysfunction.

Mechanisms of Valve Dysfunction

Pathways to disease:

Valvular heart disease develops through several distinct pathophysiological mechanisms, each leading to characteristic patterns of dysfunction:

Degenerative processes represent the most common mechanism in developed countries:
– Fibrocalcific degeneration affecting primarily the aortic valve
Progressive leaflet calcification beginning at the base
Reduced leaflet mobility leading to stenosis
Associated with traditional atherosclerotic risk factors
Accelerated in congenital bicuspid valves

• Myxomatous degeneration primarily affecting the mitral valve
• Proteoglycan accumulation in valve matrix
• Disruption of normal collagen and elastin architecture
• Leaflet thickening, redundancy, and prolapse
• Potential for chordal elongation or rupture causing regurgitation

Inflammatory processes can affect any valve but show predilections:
– Rheumatic heart disease following streptococcal infection
Initial valvulitis with leaflet inflammation
Subsequent scarring and commissural fusion
Progressive leaflet thickening and calcification
Predominantly affects mitral valve, then aortic
Combined stenosis and regurgitation often present

• Infective endocarditis
• Microbial colonization of valve surfaces
• Vegetation formation with potential embolization
• Leaflet destruction or perforation causing regurgitation
• Potential for abscess formation and annular involvement
• Predilection for previously damaged or prosthetic valves

Structural heart disease can lead to secondary valve dysfunction:
– Functional mitral regurgitation in left ventricular dysfunction
Ventricular dilation altering papillary muscle position
Annular dilation reducing coaptation
Altered ventricular geometry affecting leaflet tethering
Normal leaflet structure despite abnormal function

• Functional tricuspid regurgitation in right ventricular pressure/volume overload
• Annular dilation from right ventricular enlargement
• Altered papillary muscle position affecting leaflet coaptation
• Often secondary to left-sided heart disease or pulmonary hypertension

Congenital abnormalities present from birth:
– Bicuspid aortic valve (1-2% of population)
Two functional cusps instead of three
Accelerated degeneration and calcification
Associated with aortopathy and risk of aneurysm
May present with stenosis, regurgitation, or both

• Other congenital valve anomalies
• Unicuspid or quadricuspid aortic valves
• Cleft mitral valve leaflet
• Ebstein’s anomaly of the tricuspid valve
• Pulmonary valve stenosis

These diverse mechanisms produce distinct pathological and clinical patterns, influencing both the natural history of disease and the approach to management, highlighting the importance of understanding the specific mechanism involved in each patient’s valve dysfunction.

Hemodynamic Consequences

From valve dysfunction to clinical impact:

The hemodynamic consequences of valvular heart disease depend on both the affected valve and the nature of the dysfunction, with distinct patterns for stenosis and regurgitation:

Valve stenosis creates pressure overload through outflow obstruction:
– Aortic stenosis increases left ventricular afterload
Progressive left ventricular hypertrophy as compensatory mechanism
Increased myocardial oxygen demand with reduced supply
Potential for diastolic dysfunction and elevated filling pressures
Eventually, systolic dysfunction and heart failure if untreated

• Mitral stenosis restricts left atrial emptying
• Left atrial enlargement and pressure elevation
• Pulmonary venous hypertension leading to pulmonary congestion
• Right ventricular pressure overload from pulmonary hypertension

• Potential for atrial fibrillation due to atrial enlargement

• Tricuspid stenosis impedes right atrial emptying

• Right atrial enlargement and pressure elevation
• Systemic venous congestion with hepatomegaly and edema
• Reduced cardiac output due to limited right ventricular filling

Valve regurgitation creates volume overload through backward flow:
– Aortic regurgitation increases left ventricular preload and afterload
Left ventricular dilation accommodating regurgitant volume
Eccentric hypertrophy with increased wall stress
Wide pulse pressure with low diastolic pressure
Eventually, systolic dysfunction if compensation fails

• Mitral regurgitation increases left atrial volume load
• Left atrial enlargement with potential for atrial fibrillation
• Pulmonary venous hypertension and congestion
• Left ventricular volume overload with potential masking of dysfunction

• Different patterns in primary versus secondary regurgitation

• Tricuspid regurgitation increases right atrial pressure

• Right atrial enlargement and elevated systemic venous pressure
• Hepatic congestion, ascites, and peripheral edema
• Reduced forward cardiac output with exercise intolerance

The time course of these hemodynamic changes varies significantly:
– Chronic progressive conditions allowing compensatory mechanisms
– Acute severe regurgitation overwhelming compensatory capacity
– Mixed patterns with elements of both stenosis and regurgitation
– Combined valve disease with complex hemodynamic interactions

Compensatory mechanisms initially maintain cardiac output:
– Chamber dilation increasing preload (Frank-Starling mechanism)
– Myocardial hypertrophy normalizing wall stress
– Neurohormonal activation enhancing contractility
– Increased heart rate augmenting cardiac output

Eventually, these compensatory mechanisms fail, leading to:
– Myocardial dysfunction from chronic overload
– Pulmonary hypertension from chronic left-sided congestion
– Right ventricular failure secondary to pulmonary hypertension
– Systemic congestion and reduced cardiac output

Understanding these hemodynamic patterns is essential for clinical assessment, timing of intervention, and management of complications, as the goal of treatment is ultimately to restore normal hemodynamics before irreversible myocardial or end-organ damage occurs.

Diagnosis and Assessment

การประเมินทางคลินิก

From symptoms to suspicion:

The clinical evaluation of valvular heart disease begins with careful history and physical examination, which often provide crucial clues to the presence, severity, and chronicity of valve dysfunction:

Cardinal symptoms vary by valve lesion but commonly include:
– Dyspnea on exertion, the most common symptom across valve disorders
Progressive limitation of exercise capacity
Orthopnea and paroxysmal nocturnal dyspnea in advanced disease
Acute pulmonary edema in severe mitral regurgitation or stenosis

• Angina pectoris, particularly in aortic stenosis
• Reflects myocardial oxygen supply-demand mismatch
• May occur despite normal coronary arteries

• Often exertional and relieved by rest

• Syncope or presyncope

• Exertional syncope in severe aortic stenosis as ominous sign
• Arrhythmia-related syncope in mitral valve disease

• Postural symptoms in severe aortic regurgitation

• Palpitations from associated arrhythmias

• Atrial fibrillation commonly with mitral valve disease
• Ventricular arrhythmias in advanced disease

• Awareness of forceful heartbeat in volume overload states

• Systemic embolic events

• Stroke or peripheral embolism in mitral stenosis with atrial fibrillation
• Embolic phenomena in infective endocarditis
• Potential for paradoxical embolism with right-to-left shunting

Physical examination findings provide valuable diagnostic clues:
– Cardiac auscultation remains fundamental
Systolic murmurs of aortic stenosis or mitral regurgitation
Diastolic murmurs of aortic regurgitation or mitral stenosis
Opening snaps in mitral stenosis
Varying intensity with respiration in right-sided lesions
Dynamic maneuvers altering murmur characteristics

• Precordial palpation detecting:
• Hyperdynamic apical impulse in volume overload
• Sustained apical impulse in pressure overload
• Thrills representing palpable murmurs in severe stenosis

• Right ventricular heave in pulmonary hypertension

• Jugular venous pressure assessment

• Elevation in right-sided valve disease or secondary right heart failure
• Prominent v waves in tricuspid regurgitation

• Slow y descent in tricuspid stenosis

• Peripheral signs particularly in left-sided lesions

• Water-hammer pulse in aortic regurgitation
• Pulsus parvus et tardus in aortic stenosis
• Peripheral edema and hepatomegaly in right heart failure

The integration of history and physical findings often suggests specific valve lesions:
– Aortic stenosis: exertional symptoms with harsh systolic murmur radiating to carotids
– Mitral regurgitation: dyspnea with holosystolic murmur at apex radiating to axilla
– Aortic regurgitation: wide pulse pressure with early diastolic murmur along left sternal border
– Mitral stenosis: exercise intolerance with diastolic rumble and opening snap

While advanced imaging has revolutionized valve assessment, the clinical evaluation remains essential for:
– Initial diagnosis and suspicion of valve disease
– Assessment of symptom severity guiding intervention timing
– Detection of clinical deterioration during surveillance
– Evaluation of successful treatment and potential complications

This foundational clinical assessment should guide subsequent diagnostic testing and specialist referral, ensuring appropriate evaluation of suspected valvular heart disease.

Echocardiography

Visualizing valve function:

Echocardiography has revolutionized the assessment of valvular heart disease, providing detailed anatomical and functional information that forms the cornerstone of diagnosis, severity assessment, and management planning:

Transthoracic echocardiography (TTE) serves as the initial and most common imaging modality:
– Two-dimensional imaging providing:
Valve morphology and mobility assessment
Chamber size and function evaluation
Detection of associated abnormalities
Real-time visualization of valve dynamics

• Doppler techniques offering hemodynamic assessment:
• Color Doppler identifying regurgitant or stenotic flow
• Continuous-wave Doppler measuring peak and mean gradients
• Pulsed-wave Doppler assessing flow velocities and patterns

• Pressure half-time estimating valve areas

• Quantitative measures for stenotic lesions:

• Valve areas calculated by continuity equation or planimetry
• Mean and peak gradients across stenotic valves
• Dimensionless index for aortic stenosis

• Pressure half-time for mitral stenosis

• Quantitative measures for regurgitant lesions:

• Vena contracta width reflecting effective regurgitant orifice
• Proximal isovelocity surface area (PISA) calculations
• Regurgitant volume and fraction
• Supporting parameters including chamber enlargement

Transesophageal echocardiography (TEE) provides enhanced assessment when needed:
– Superior visualization of posterior structures including mitral valve
– Detailed evaluation of valve morphology and pathology
– Assessment of suitability for repair techniques
– Detection of complications such as endocarditis or thrombus
– Guidance during percutaneous interventions or surgery
– Essential for intraoperative assessment of repair results

Three-dimensional echocardiography offers additional insights:
– En-face views of valve orifices
– Precise localization of pathology
– Accurate measurement of annular dimensions
– Enhanced understanding of complex anatomy
– Improved communication with interventionalists and surgeons

Stress echocardiography plays an important role in specific scenarios:
– Low-flow, low-gradient aortic stenosis assessment
– Evaluation of exercise-induced mitral regurgitation
– Assessment of pulmonary pressures with exercise
– Evaluation of symptoms discordant with resting severity

The integration of multiple echocardiographic parameters is essential for:
– Distinguishing primary from secondary valve dysfunction
– Differentiating between severe and pseudo-severe stenosis
– Accurate grading of regurgitation severity
– Assessment of ventricular response to volume or pressure overload
– Evaluation of associated conditions affecting management

While other imaging modalities provide complementary information, echocardiography remains the primary tool for valve assessment due to its wide availability, lack of radiation, real-time imaging capability, and comprehensive hemodynamic assessment, forming the foundation upon which management decisions are based.

Advanced Imaging Modalities

Beyond echocardiography:

While echocardiography remains the cornerstone of valve assessment, advanced imaging modalities provide complementary information valuable for specific clinical scenarios and management decisions:

Cardiac magnetic resonance imaging (CMR) offers several advantages:
– Superior quantification of ventricular volumes and function
Gold standard for ventricular size and ejection fraction
Particularly valuable for right ventricular assessment
Serial measurements with excellent reproducibility
Assessment of ventricular remodeling and recovery

• Flow quantification through phase-contrast techniques
• Direct measurement of regurgitant volumes and fractions
• Particularly valuable when echocardiographic assessment is challenging
• Assessment of complex or multiple valve lesions

• Quantification of shunt flow in associated defects

• Tissue characterization capabilities

• Myocardial fibrosis assessment through late gadolinium enhancement
• Identification of infiltrative processes affecting valves
• Characterization of masses or vegetations

• Detection of myocardial inflammation

• Comprehensive aortic assessment

• Complete visualization of the aorta
• Accurate measurements for intervention planning
• Detection of associated aortopathy
• Flow pattern analysis in the ascending aorta

Computed tomography (CT) provides unique structural information:
– Calcium scoring of valves
Quantification of aortic valve calcification
Correlation with stenosis severity
Prognostic information regarding disease progression
Particularly valuable in low-flow states

• Detailed anatomical assessment for intervention planning
• Annular dimensions and geometry for TAVR
• Coronary ostial height and relationship to annulus
• Access route evaluation including vessel size and tortuosity

• Left atrial appendage assessment for percutaneous mitral procedures

• Concurrent coronary artery evaluation

• Non-invasive coronary assessment before valve intervention
• Particularly valuable in lower-risk patients
• Alternative to invasive angiography in selected cases
• Detection of coronary anomalies relevant to surgical planning

Positron emission tomography (PET) offers specialized applications:
– Identification of valve inflammation or infection
Diagnosis of prosthetic valve endocarditis
Differentiation between thrombus and pannus
Assessment of inflammatory valve disorders
Monitoring response to therapy

• Myocardial viability assessment
• Evaluation of recovery potential before valve intervention
• Identification of hibernating myocardium
• Guidance for combined valve and coronary procedures
• Prognostic information regarding ventricular recovery

Cardiac catheterization retains specific roles despite advanced non-invasive options:
– Coronary angiography before valve surgery in at-risk patients
– Hemodynamic assessment when non-invasive data is inconclusive
– Direct measurement of gradients in complex stenotic lesions
– Evaluation of concomitant coronary and valve disease
– Assessment of pulmonary vascular resistance before left-sided valve intervention

The integration of these advanced imaging modalities with echocardiography provides comprehensive assessment for:
– Clarification of severity when echocardiography is inconclusive
– Detailed pre-procedural planning for transcatheter interventions
– Assessment of complex multi-valve or mixed valve disease
– Evaluation of prosthetic valve dysfunction
– Research applications advancing understanding of valve pathophysiology

The appropriate selection and sequencing of these imaging modalities should be guided by specific clinical questions, with a focus on obtaining information that will impact management decisions while minimizing unnecessary testing.

Management Approaches

Medical Management

Optimizing conditions and delaying progression:

While definitive treatment of significant valve disease typically involves intervention, medical management plays important roles in symptom control, complication prevention, and optimization of conditions for eventual intervention:

Heart failure management in valve-related volume overload:
– Diuretics reducing congestion and symptom burden
Loop diuretics as mainstay therapy
Addition of thiazides for enhanced effect when needed
Careful monitoring of electrolytes and renal function
Particular value in mitral and tricuspid regurgitation

• Neurohormonal antagonists with selective application
• ACE inhibitors/ARBs in functional mitral regurgitation
• Beta-blockers for rate control and remodeling benefits
• Aldosterone antagonists for enhanced diuresis and anti-fibrotic effects

• Limited role in primary valve disease with normal ventricular function

• Vasodilator therapy in specific scenarios

• Acute severe aortic or mitral regurgitation
• Chronic aortic regurgitation with symptoms before surgery
• Limited long-term data supporting routine use
• Potential role in temporizing before definitive intervention

Rhythm management particularly in mitral valve disease:
– Atrial fibrillation control strategies
Rate control ensuring adequate diastolic filling time
Rhythm control consideration in recent-onset arrhythmia
Cardioversion with appropriate anticoagulation precautions
Catheter ablation in selected cases

• Anticoagulation for thromboembolic prevention
• Mandatory in mitral stenosis with atrial fibrillation
• Risk-stratified approach in other valve lesions with arrhythmias
• Consideration of valve-specific risks and bleeding hazards
• Integration with other indications for anticoagulation

Endocarditis prevention with targeted approach:
– Antibiotic prophylaxis for highest-risk procedures and patients
Prosthetic valve recipients
Previous endocarditis history
Unrepaired cyanotic congenital heart disease
Recent valve replacement material

• Emphasis on general preventive measures
• Dental hygiene and regular dental care
• Prompt treatment of infections
• Aseptic technique for invasive procedures
• Avoidance of unnecessary instrumentation

Rheumatic fever prevention where applicable:
– Primary prevention through streptococcal infection treatment
– Secondary prevention with penicillin prophylaxis
– Duration based on disease severity and consequences
– Particular importance in endemic regions

Management of special populations:
– Pregnancy considerations
Pre-conception risk assessment and counseling
Medication adjustments avoiding teratogens
Close monitoring during pregnancy and delivery
Intervention timing considerations

• ผู้ป่วยสูงอายุ
• Balanced assessment of intervention risks and benefits
• Comorbidity management
• Frailty assessment influencing decisions
• การพิจารณาคุณภาพชีวิต

While medical therapy rarely corrects the underlying valve dysfunction, appropriate application of these strategies can:
– Improve symptom burden and quality of life
– Prevent or manage complications
– Optimize conditions for eventual intervention
– Provide temporary stabilization in non-operable patients

The integration of medical management with appropriate timing of intervention represents the optimal approach to valvular heart disease, recognizing both the limitations of medical therapy alone and the importance of comprehensive care beyond mechanical valve correction.

Surgical Approaches

The gold standard evolves:

Surgical intervention has been the mainstay of definitive treatment for valvular heart disease for decades, with continuous evolution in techniques, devices, and approaches:

Valve repair techniques preserve native valve tissue when feasible:
– Mitral valve repair approaches including:
Leaflet resection for prolapse or flail segments
Artificial chordae implantation restoring support
Annuloplasty rings restoring and stabilizing annular geometry
Edge-to-edge repair for selected pathologies
Commissurotomy for rheumatic fusion

• Aortic valve repair with growing applications:
• Commissural plication for mild prolapse
• Free margin reinforcement preventing further prolapse
• Annular stabilization with external rings or sutures
• Root remodeling or reimplantation preserving native valve

• Decalcification and commissurotomy in selected cases

• Tricuspid valve repair primarily involving:

• Annuloplasty rings or bands reducing dilation
• Edge-to-edge techniques for specific leaflet issues
• Bicuspidization in extensive disease
• Cleft closure when present

Valve replacement options when repair is not feasible:
– Mechanical prostheses offering durability:
Bileaflet designs predominating in contemporary practice
Excellent long-term durability with rare structural deterioration
Requirement for lifelong anticoagulation
Optimal for younger patients without contraindications to anticoagulation

• Biological prostheses avoiding anticoagulation:
• Stented xenografts from porcine or bovine tissue
• Stentless designs with improved hemodynamics
• Limited durability with age-dependent structural valve deterioration

• Preferred for older patients or those with contraindications to anticoagulation

• Homografts and autografts for specific indications:

• Homografts (cadaveric valves) for endocarditis or complex anatomy
• Ross procedure (pulmonary autograft) for younger patients
• Excellent hemodynamics and potential for growth
• Technical complexity limiting widespread application

Surgical approaches balancing exposure and invasiveness:
– Full sternotomy providing optimal exposure
Standard approach for complex or combined procedures
Excellent visualization of all cardiac structures
Well-established technique with predictable outcomes

• Minimally invasive approaches reducing trauma:
• Right mini-thoracotomy for mitral and tricuspid procedures
• Upper mini-sternotomy for aortic valve surgery
• Robotic assistance further reducing incision size
• Potential benefits in recovery time and cosmesis
• Selective application based on patient and pathology factors

Specific considerations for different valve positions:
– Mitral valve surgery:
Repair strongly preferred over replacement when feasible
Preservation of subvalvular apparatus even during replacement
Growing application of minimally invasive techniques
Concurrent management of atrial fibrillation when present

• Aortic valve surgery:
• Increasing options for valve-sparing root procedures
• Consideration of patient age in prosthesis selection
• Management of associated aortopathy when present

• Expanding minimally invasive applications

• Multiple valve surgery:

• Comprehensive approach addressing all significant lesions
• Consideration of functional tricuspid regurgitation during left-sided surgery
• Tailored strategies for combined disease
• Impact on long-term prognosis and reoperation risk

The evidence base supporting surgical intervention is robust:
– Established mortality benefit in symptomatic severe disease
– Improved long-term survival with appropriate timing
– Enhanced quality of life and functional capacity
– Extensive experience with predictable outcomes
– Evolving indications for earlier intervention in selected scenarios

Despite the emergence of transcatheter options, surgical approaches remain the gold standard for many patients, particularly those who are younger, have complex pathology, or require multiple valve interventions, with continuous refinement improving outcomes and expanding applications.

Transcatheter Interventions

Revolutionizing valve therapy:

Transcatheter valve interventions have revolutionized the management of valvular heart disease over the past two decades, providing less invasive options for patients across the risk spectrum:

Transcatheter aortic valve replacement (TAVR) has transformed aortic stenosis management:
– Procedural fundamentals including:
Valve delivery via transfemoral, transapical, or alternative access
Balloon-expandable or self-expanding valve platforms
Rapid deployment under fluoroscopic and echocardiographic guidance
Conscious sedation increasingly utilized for transfemoral approach
Typically performed in hybrid operating rooms or catheterization laboratories

• Evidence base supporting expanding indications:
• Initial proof of concept in inoperable patients
• Subsequent non-inferiority to surgery in high-risk patients
• Recent trials demonstrating equivalence or superiority in intermediate-risk
• Emerging data supporting application in low-risk populations

• Ongoing refinement of patient selection criteria

• Specific considerations influencing outcomes:

• Anatomical assessment including annular sizing and calcification
• Access route evaluation and selection
• Coronary height and risk of obstruction
• Conduction system proximity and pacemaker risk

• Cerebral embolic protection consideration

• Limitations and challenges:

• Uncertain long-term durability beyond 10 years
• Paravalvular leak more common than with surgery
• Higher permanent pacemaker rates with certain designs
• Limited options for future coronary access in some cases
• Valve-in-valve considerations for future interventions

Transcatheter mitral interventions addressing diverse pathologies:
– Edge-to-edge repair (MitraClip and similar devices):
Percutaneous adaptation of surgical Alfieri technique
Creation of double-orifice mitral valve
Primary application in degenerative and functional regurgitation
Growing evidence base supporting use in selected patients
Particular value in high surgical risk populations

• Transcatheter mitral valve replacement:
• Emerging technology with various designs
• Challenges including anchoring, left ventricular outflow tract obstruction
• Early experience in native valve disease
• More established for valve-in-valve procedures

• Ongoing evolution of device design and implantation techniques

• Annuloplasty approaches:

• Direct annuloplasty devices mimicking surgical rings
• Indirect annuloplasty via coronary sinus
• Complementary role with other repair techniques
• Variable anatomical suitability limiting application

Transcatheter tricuspid interventions as an emerging frontier:
– Edge-to-edge repair adaptation from mitral experience
– Dedicated tricuspid devices addressing unique anatomy
– Annuloplasty approaches via various mechanisms
– Caval valve implantation for severe, inoperable cases
– Early clinical experience with promising initial results
– Particular value given high risk of isolated tricuspid surgery

Transcatheter management of prosthetic valve dysfunction:
– Valve-in-valve procedures for bioprosthetic degeneration
Established approach for aortic bioprostheses
Growing experience in mitral position
Emerging applications in tricuspid and pulmonary positions
Consideration of future coronary access in aortic position

• Paravalvular leak closure
• Percutaneous approaches using occluder devices
• Application for both mechanical and bioprosthetic valves
• Technical challenges in accessing certain defects
• Significant reduction in repeat surgery for this complication

The integration of transcatheter approaches into comprehensive valve centers has:
– Expanded treatment options for previously untreatable patients
– Provided less invasive alternatives across the risk spectrum
– Facilitated earlier intervention before significant deterioration
– Created need for heart team collaboration in decision-making
– Driven innovation in both transcatheter and surgical approaches

These revolutionary technologies continue to evolve rapidly, with expanding indications, improving outcomes, and new devices continuously entering clinical evaluation, fundamentally changing the management landscape for valvular heart disease.

Decision-Making and Heart Team Approach

Collaborative expertise for optimal outcomes:

The growing complexity of valvular heart disease management, with multiple intervention options and diverse patient factors, has led to the heart team approach becoming the standard for decision-making:

The heart team typically includes:
– Cardiac surgeons with valve expertise
– Interventional cardiologists with structural experience
– Imaging specialists focused on valve assessment
– Heart failure cardiologists for ventricular function evaluation
– Cardiac anesthesiologists for perioperative risk assessment
– Additional specialists as needed (geriatrics, palliative care)

Key factors influencing intervention decisions include:
– Valve pathology characteristics
Mechanism of dysfunction (degenerative, functional, etc.)
Anatomical features affecting repair potential
Suitability for transcatheter approaches
Presence of multiple valve involvement

• Patient-specific factors
• Age and life expectancy
• Comorbidities affecting risk and recovery
• Frailty assessment beyond chronological age
• Previous cardiac surgery increasing risk

• Anticoagulation considerations and contraindications

• Institutional factors

• Available expertise in specific techniques
• Volume and outcomes for different approaches
• Access to newer technologies and trials
• Systems for managing complications

Risk assessment tools informing but not determining decisions:
– Surgical risk calculators (STS score, EuroSCORE II)
Valuable for estimating procedural risk
Limited by focus on short-term outcomes
Incomplete capture of frailty and specific comorbidities
Adjunctive rather than definitive role in decision-making

• Frailty assessment tools
• Gait speed and timed up-and-go tests
• Grip strength measurement
• Comprehensive geriatric assessment when indicated

• Cognitive function evaluation

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• Baseline functional status and limitations
• Goals of care and patient preferences
• Anticipated recovery trajectory
• Expected benefit relative to intervention risk

The shared decision-making process involves:
– Comprehensive presentation of options with risks and benefits
– Consideration of patient values and preferences
– Discussion of uncertainty where evidence is limited
– Involvement of family or caregivers when appropriate
– Documentation of rationale for final recommendation

Guidelines provide frameworks while allowing individualization:
– Class of recommendation reflecting evidence strength
– Level of evidence transparency regarding data quality
– Regular updates incorporating new evidence
– Recognition of areas where evidence is limited
– Flexibility for patient-specific factors not captured in trials

The heart team approach has demonstrated benefits including:
– More appropriate patient selection for each intervention
– Reduced variation in care not explained by patient factors
– Improved outcomes through collaborative expertise
– Enhanced patient satisfaction with comprehensive evaluation
– Continuous quality improvement through case review

This collaborative model represents a paradigm shift from individual physician decision-making to a team-based approach, recognizing that optimal management of valvular heart disease requires integration of multiple perspectives and expertise, particularly as intervention options continue to expand and patient populations become increasingly complex.

การปฏิเสธความรับผิดทางการแพทย์

หมายเหตุสำคัญ: This information is provided for educational purposes only and does not constitute medical advice. Valvular heart disease requires evaluation and management by qualified healthcare professionals with appropriate training and expertise in cardiovascular medicine. The selection of diagnostic and therapeutic approaches should be based on patient-specific factors, current guidelines, and shared decision-making between patients and their healthcare teams. This article is not a substitute for professional medical advice, diagnosis, or treatment. If you are experiencing symptoms that may be related to valvular heart disease, please consult with a healthcare provider promptly. Delay in appropriate evaluation and management of significant valve disease may result in preventable complications.

บทสรุป

Valvular heart disease represents a diverse spectrum of conditions with significant impact on quality of life and survival when left untreated. The evolution in understanding of valve pathophysiology, coupled with advances in diagnostic imaging and therapeutic options, has transformed the management landscape, offering effective interventions for patients across the age and risk spectrum.

The contemporary approach to valvular heart disease emphasizes several key principles: early detection through appropriate use of imaging, careful timing of intervention before irreversible consequences develop, selection of the optimal intervention strategy through heart team collaboration, and long-term management addressing both the valve pathology and its systemic effects.

The expanding array of treatment options—from traditional surgery to transcatheter interventions—has created both opportunities and challenges, requiring thoughtful integration of patient factors, valve pathology, and institutional expertise to achieve optimal outcomes. The heart team model provides the framework for this integration, ensuring that patients benefit from collaborative expertise in increasingly complex decision-making.

As research continues to refine our understanding of valvular heart disease and technology expands the intervention options available, management will likely evolve toward earlier, less invasive, and more personalized approaches, further improving outcomes for this common and consequential group of cardiovascular conditions.