Current Advances in Valvular Heart Diseases

Dear Colleagues,

Valvular heart diseases are a major public health problem associated with an increased risk of morbidity and mortality when not treated. Over the last decade, there has been a growing appreciation for the importance of the underlying mechanism of valvular heart disease and imaging, and the independent association of tricuspid valve regurgitation to reduced survival. Early and timely valvular heart disease intervention is associated with improved outcomes. However, due to their silent nature, valvular heart diseases frequently go underdiagnosed or are diagnosed late, often leading to no intervention or delayed intervention.

This Special Issue highlights strategies for the early diagnosis of valvular heart disease, such as machine learning or artificial intelligence, and the broadening understanding of mechanisms of valvular heart disease and their impact on the type and timing of intervention. 

The topics of interest for this Special Issue include, but are not limited to, the following:

1. Machine learning and artificial intelligence applications in valvular heart disease;
2. Evaluation and management of primary and secondary mitral regurgitation;
3. Evaluation and management of primary and secondary tricuspid valve regurgitation;
4. Transcatheter valve therapies for aortic, mitral, and tricuspid valve disease;
5. Minimally invasive surgical strategies for the treatment of valvular heart disease.

Dr. Vuyisile T. Nkomo
Guest Editor

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• valve disease
• aortic valve stenosis
• aortic valve regurgitation
• mitral valve stenosis
• mitral valve regurgitation
• mitral annular calcification
• tricuspid valve regurgitation
• machine learning
• artificial intelligence
• echocardiography

Title 1: Sutureless Aortic Bioprosthesis In Isolated Aortic Valve Replacement By Minimally Invasive Approach: Results From A Prospective International Real-World Registry
Abstract: Objectives: Sutureless valve has been in clinical use for more than 15 years. The aim of this study is to report clinical and haemodynamic performance from a real-world registry in patients who underwent aortic valve replacement (AVR) with a sutureless bioprosthesis, comparing outcomes of ministernotomy versus minithoracotomy settings. Methods: This prospective international registry enrolled 1652 patients implanted with a sutureless aortic valve in 55 Institutions from 2011 to 2021. Postoperative follow-up and echocardiographic outcomes were collected. Patients with isolated AVR were analyzed by minimally invasive (MICS) approache. Preoperative covariates were adjusted with propensity score maching 3:1, reaching a final cohort of .... ministernotomy AVR patients with ..... patients in minithoracotomy approach. Results: In the overall cohort patients mean age was .... years (...% female); mean EuroSCORE II was ...... Isolated AVR was performed in ...% of cases, .... of which were performed via a minimally invasive approach. First successful implantation was achieved in ....% of cases. Within 30 days, ... and ... valve related reinterventions were reported. Pacemaker implant was required in ... of patients. Intraprosthetic regurgitation ≥ 2 was present in ... of cases while paravalvular leak ≥ 2 in ....%. At a maximum follow-up of 8 years, ...% of cardiovascular deaths and ...% of valve-related reintervention occurred. Among the ... cases of structural valve deterioration (mean .... years after implant), ... were treated with a transcatheter valve-in-valve implantation and ... with explant. Mean pressure gradient decreased from .... mmHg preoperatively to ... mmHg at discharge and remained stable during follow-up. Results of the propensity match analysis showed that the ministernotomy approach has/or not ..... effect on survival, disabling stroke, leaks greater than 2, pacemaker rate and hemodynamics, ....... Conclusions: This registry represents the largest prospective real-world cohort of patients treated with a sutureless valve. Our propensity matched analysis demonstrates the in ministernotomy vs minithoracotomy

Title 2: Single centre experience with the balloon-expandable Myval transcatheter aortic valve system with the first 200 patients: 30-day and 1-year follow-up.
Abstract: Abstract Aims: To report our single centre, 30-day and 1 year outcome data, regarding the first 200 patients who underwent TAVR procedure using the MYVAL THV system. Methods: From November 2019 to October 2022, 200 consecutive patients underwent TAVR procedure. Outcomes were analyzed accordign to the Valve Academic Research Consortium-2 (VARC-2) definitions and device performance assessed via transthoracic echocardiography. Data collection was allowed by the Local Ethical Committee. Results: In the total cohort, the mean age was 75.3±6.9 years, 122 (61%) were male. The mean Euroscore II and STS score were 5.4±5.4 and 5.8±3.8, respectively. The proportion of patients with bicuspid aortic valve was 18%. Transfemoral access was the most common (surgical vs. percutaneous 1% vs. 98%) and in two patients surgical subclavian access was used. VARC-2 outcomes were as follows: device success 99%, STROKE 2%, major and minor vascular complication was 5% and 4.5%, respectively, the rate of new permanent pacemaker implantation was 29.5%. At discharge, the incidence of aortic regurgitation grade II or above was 5.5% without relevant PVL (grade II or above 0.5%). In-hospital mortality was only 1%. At one year, the all-cause mortality rate was 8.5% (cardiac origin in 3 cases) and two patients had valve-related dysfunction requiring surgical aortic replacement. Conclusions: Based on our results, excellent 30-day and 1-year outcomes regarding patient survival, technical success and valve-related adverse events were achieved using the MYVAL transcatheter heart valve system. The limitations of our study comprise a single centre study with retrospective data collection.

Title 3: Prevalence, pathophysiological role and determinants of mitral annular disjunction among patients with mitral valve prolapse: a systematic review
Abstract: Background: Over the last two decades, a number of imaging studies have evaluated the characteristics and clinical implications of mitral annular disjunction (MAD) among patients with mitral valve prolapse (MVP). The present systematic review has been primarily designed to summarize the main findings of these studies and to examine the overall impact of MAD in MVP patients. Methods: All imaging studies assessing the prevalence, pathophysiological role and determinants of MAD in MVP individuals, selected from PubMed and EMBASE databases, were included. There was no limitation of time period. The risk of bias was assessed by using the National Institutes of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Results: The full-texts of 21 studies with 4504 MVP individuals were analyzed. The overall pooled prevalence of MAD in MVP individuals was 42.8% (range 14.9-90%). When considering the different imaging modalities for assessing MAD, the average MAD prevalence was 20% for cardiac computed tomography studies, 31.3% for transthoracic echocardiography (TTE) studies, 44.7% for transesophageal echocardiography studies and 58.7% for cardiac magnetic resonance studies. MAD presence was more commonly associated with female sex, young age, narrow antero-posterior thoracic diameter, symptoms of palpitations and syncope, T-wave inversion in inferolateral leads and frequent and/or complex ventricular arrhythmias (VAs) on electrocardiogram, myxomatous leaflets, bileaflet prolapse, larger mitral valve annulus and non-severe mitral regurgitation on TTE. A total of 12 studies (57.1%) provided follow-up data. Over a median follow-up time of 3.9 yrs (range 1-10.3 yrs), MVP individuals with MAD showed increased risk of clinical arrhythmic events, no difference in survival rate and good surgical outcome. Conclusions: MAD was present in more than one-third of MVP patients. A multimodality imaging approach comprehensive of noninvasive chest shape assessment might improve the MAD detection among MVP individuals. Careful serial monitoring for VAs appears as mandatory for MAD patients.

Title 4: Long-Term Outcomes of Surgical and Transcatheter Interventions for Tricuspid Regurgitation: A Comprehensive Review
Abstract: Impacting more than 70 million people worldwide, tricuspid regurgitation (TR) refers to the retrograde flow of blood from the right ventricle to the right atrium due to improper closure of the tricuspid valve. Depending on the severity of TR, signs and symptoms can range from asymptomatic to features of right heart failure, including dyspnea, exercise intolerance, peripheral edema, and ascites. Severe features as such necessitate treatment. In recent years, advancements in management including surgical and transcatheter interventions have taken prominence, leading to improved short-come outcomes in this patient population. However, there is still a dearth of evidence regarding long-term outcomes of surgical and transcatheter interventions for TR. This comprehensive review aims to present clinicians with recent findings from pivotal clinical studies on interventional clinical outcomes, in an effort to help guide their judgment when it comes to deciding the best course of treatment for their patients. Keywords: tricuspid regurgitation, repair, replacement, transcatheter devices, surgery