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Heart valve disease can lead to life-threatening problems such as heart failure, stroke, blood clots, and heart rhythm abnormalities and is a significant factor in the loss of physical function, quality of life, and life expectancy.
1. Marwick T, et al. Our Hidden Aging: Time to Listen to the Heart. 2021.
2. Coffey S, et al. Global epidemiology of valvular heart disease. Nat Rev Cardiol. 2021;18(12):853-864.
3. Coffey S, et al. The OxVALVE population cohort study (OxVALVE-PCS)-population screening for undiagnosed valvular heart disease in the elderly: study design and objectives. Open Heart. 2014;1(1):e000043.
4. Nkomo VT, et al. Burden of valvular heart diseases: a population-based study. Lancet. 2006;368(9540):1005-11.
5. Singh JP, et al. Prevalence and clinical determinants of mitral, tricuspid, and aortic regurgitation (the Framingham Heart Study). Am J Cardiol. 1999;83(6):897-902
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Located between the heart’s two left chambers, the mitral valve has two leaflets that open and close to ensure blood flows in only one direction. When the mitral valve fails to close completely, blood leaks backward – a condition called mitral regurgitation (MR).
Normal functioning mitral valve
Mitral regurgitation
Primary (degenerative) MR is caused by damage to one or more components of the mitral valve apparatus (leaflets or chords) and can be related to age, birth defects, or an underlying heart disease.
Secondary (functional) MR is caused by heart disease that leads to an enlarged left ventricle or disease of the left atrium.
In some cases, patients with MR may never experience symptoms; others may develop signs of heart failure, such as:3-5
Fatigue
Inability to exercise
Fainting
Dry, hacking cough (often worse when lying down)
Shortness of breath (especially at night)
Decrease in appetite
Weight gain from fluid retention
Accumulation of fluid in feet, ankles, and lungs (oedema)
Image adapted from Marwick T, et al. (2021).
MR has poor prognostic outcomes, with a 50% mortality rate over 5 years for severe secondary MR. This is largely attributable to cardiac dysfunction and other co-morbidities.
Severe secondary MR is an independent predictor of mortality
Adapted from Goliasch G et al. (2018).
Graph courtesy of Dr. G Stone.
1. O’Gara T and Mack MJ. Secondary Mitral Regurgitation. N Engl J Med. 2020;383:1458-1467.
2. Nishimura RA, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(22):2438-2488.
3. Nishimura RA, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;136(9):1–123.
4. Baumgartner H, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease: The Task Force for the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2017;00:1-53.
5. Ponikowski P, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016;18(8):891-975.
6. Nkomo VT, et al. Burden of valvular heart diseases: a population-based study. Lancet. 2006;368(9540):1005-11.
7. Marwick T, et al. Our Hidden Aging: Time to Listen to the Heart. 2021.
8. Benjamin E J, et al. Heart disease and stroke statistics—2017 update: A report from the American Heart Association. Circulation. 2017;135(10):e146-e603.
9. Yancy CW, et al. 2013 ACCF/AHA guideline for the management of heart failure: Executive summary. J Am Coll Cardiol. 2013;62(16):1495-1539.
10. Asgar AW, et al. Secondary mitral regurgitation in heart failure: pathophysiology, prognosis, and therapeutic considerations. J Am Coll Cardiol. 2015;65(12):1231-1248.
11. Nieminen MS, et al. EuroHeart Failure Survey II (EHFS II): a survey on hospitalized acute heart failure patients: description of population. Eur Heart J. 2006;27(22):2725-36.
12. Patel JB, et al. Mitral regurgitation in patients with advanced systolic heart failure. J Card Fail. 2004 Aug;10(4):285-91.
13. Enriquez-Sarano M, et al. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med. 2005;352(9):875-883.
14. Cioffi G, et al. Functional mitral regurgitation predicts 1-year mortality in elderly patients with systolic chronic heart failure. Eur J Heart Fail. 2005 Dec;7(7):1112-7.
15. Grigioni F, et al. MIDA Investigators. Outcomes in mitral regurgitation due to flail leaflets: a multicenter European study. JACC Cardiovasc Imaging. 2008;1(2):133-141.
16. Goliasch G, et al. Refining the prognostic impact of functional mitral regurgitation in chronic heart failure. Eur Heart J. 2018;39(1):39-46.
Medical therapies are the primary treatment pathway used to manage the symptoms of MR, but they do not address the underlying pathology.1 Patients with heart failure (HF) and clinically significant MR are on guideline-directed medical therapy (GDMT).2
Surgical management, in the form of mitral valve repair or replacement, is the standard of care for patients with severe primary mitral regurgitation. However, up to 50% of patients with MR may not meet the eligibility criteria due to risks associated with age or the presence of comorbidities.2 For patients with severe secondary mitral regurgitation, GDMT is the current standard of care.
Cardiac resynchronisation therapy is a procedure that involves implanting a device in the chest to assist the heart’s chambers in contracting in a more coordinated way.3 This is an option recommended for select HF patients.4
TMVr is a minimally invasive mitral valve repair option for patients with MR that are not considered suitable candidates for surgery.5
1. Young A, and Feldman T. Percutaneous mitral valve repair. Curr Cardiol Rep. 2014;16:443.
2. Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC); European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J. 2012;33(19):2451-2496.
3. Mayo Clinic. Cardiac resynchronization therapy. Accessed May 2022.
4. Mirabel M, et al. What are the characteristics of patients with severe, symptomatic, mitral regurgitation who are denied surgery? Eur Heart J. 2007;28(11):1358-1365.
5. Nishimura RA, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;136(9):1–123.
For symptomatic patients diagnosed with moderate-severe or severe MR, surgery is generally recommended to repair or replace the mitral valve. This typically involves open-heart surgery with the patient on cardiopulmonary bypass. However, some patients are not eligible for repair or replacement based on surgical risk. See the links below to access guidelines for the management of MR.
TEER should be considered in selected symptomatic patients, not eligible for surgery and fulfilling criteria suggesting an increased chance of responding to the treatment.
In high-risk symptomatic patients not eligible for surgery and not fulfilling the criteria suggesting an increased chance of responding to TEER, the Heart Team may consider in selected cases a TEER procedure or other transcatheter valve therapy if applicable, after careful evaluation for ventricular assist device or heart transplant.
1. Baumgartner H, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease: The Task Force for the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2017;38(21):2739-2791.
2. Heidenreich PA, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145:e895–e1032.
3. Vahanian A, et al. ESC/EACTS Scientific Document Group, 2021 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2022;43(7):561–632.
4. Otto CM, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143:e72–e227.
Aortic Stenosis (AS) occurs when the heart’s aortic valve (located on the left side of the heart) narrows. This prevents the valve from opening completely, reducing blood flow from the heart into the main artery that supplies blood to the body (the aorta).
When blood flow through the aortic valve is reduced or blocked, the heart must work harder than normal to pump sufficient blood to the body. Eventually, this extra work limits the amount of blood the heart can pump, causing symptoms of weakness, chest discomfort, breathing difficulty, and an increased risk of fainting.
Normal
Mild to moderate aortic stenosis
Severe aortic stenosis
Because of the often slow, progressive nature of AS, patients may not recognise symptoms, having only gradually limited their levels of daily activity. Typical initial symptoms are shortness of breath on exertion or decreased exercise tolerance.5 Most patients with aortic stenosis are first diagnosed when a systolic murmur is detected.1,5
Fatigue
Inability to exercise
Fainting
Shortness of breath and/or breathing problems
Chest pain
Heart palpitations
Presence of a heart murmur
Aortic valve disease (AVD) is the most frequent cause of severe valvular heart disease.
Image adapted from Marwick T, et al. (2021).
1. Ren X. Aortic stenosis. MedScape. https://emedicine.medscape.com/article/150638-overview. Published March 23, 2017.
2. Marwick T, et al. Our Hidden Aging: Time to Listen to the Heart. 2021.
3. American Heart Association. Roles of Your Four Heart Valves. https://www.heart.org/en/health-topics/heart-valve-problems-and-disease/about-heart-valves/roles-of-your-four-heart-valves. Accessed May 2022.
4. Faggiano P, et al. Epidemiology and cardiovascular risk factors in aortic stenosis. Cardiovasc Ultrasound. 2006;4:27.
5. Nishimura RA, et al. 2014 AHA/ACC Guideline for the management of patients with valvular heart disease. Circulation. 2014;129(23):2440-2492.
6. Benjamin EJ, et al. Heart disease and stroke statistics—2018 update: a report from the American Heart Association. Circulation. 2018;137(12):e67-e492.
7. Yadgir S, et al. Global, regional, and national burden of calcific aortic valve and degenerative mitral valve diseases, 1990–2017. Circulation. 2020;141(21):1670-80.
There are several treatment options for patients with AS:
Medical therapy is the primary treatment pathway used to manage the symptoms of AS when a patient is not a candidate for surgery or for transcatheter aortic valve implantation (TAVI).
Surgical management, in the form of aortic valve replacement may be used in patients with severe aortic AS that have been identified as candidates for surgery.7 Patients may be denied surgery due to risks associated with age or the presence of co-morbidities.6
TAVI is an effective minimally invasive therapy for those who are denied surgery or who are considered high-risk patients.8
The NavitorTM valve is an option indicated for transcatheter delivery in high surgical risk patients with symptomatic severe AS.9
1. Bouma BJ, et al. To operate or not on elderly patients with aortic stenosis: the decision and its consequences. Heart. 1999;82:143-148.
2. Iung B, et al. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. Eur Heart J. 2003;24:1231-1243.
3. Pellikka A, et al. Outcome of 622 Adults with Asymptomatic, Hemodynamically Significant Aortic Stenosis During Prolonged Follow-Up. Circulation. 2005;111:3290–3295.
4. Charlson E, et al. Decision-making and outcomes in severe symptomatic aortic stenosis. J Heart Valve Dis. 2006;15:312-321.
5. Osnabrugge RLJ, et al. Aortic Stenosis in the Elderly: Disease Prevalence and Number of Candidates for Transcatheter Aortic Valve Replacement: A Meta-Analysis and Modeling Study. J AM Coll Cardiol. 2013;62(11):1002-12.
6. Nishimura RA, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143(5):e35-e71.
7. Nishimura RA, et al. 2014 AHA/ACC Guideline for the management of patients with valvular heart disease. Circulation. 2014;129(23):2440-2492.
8. Reinöhl J, et al. Effect of availability of transcatheter aortic-valve replacement on clinical practice. N Engl J Med. 2015;373(25):2438-2447.
9. Navitor™ TAVI System Instructions for Use.
Due to poor prognostic outcomes, early intervention is highly recommended for all patients with severe symptomatic AS. This is unless intervention is unlikely to improve their quality of life or survival (i.e., patients with severe comorbidities or concomitant conditions that have a survival rate of less than one year). See the links below to access treatment guidelines.
1. Vahanian A, et al. ESC/EACTS Scientific Document Group, 2021 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2022;43(7):561–632.
2. Otto CM, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143:e72–e227.
3. Heidenreich PA, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145:e895–e1032.
The tricuspid valve sits between the heart’s two right chambers. It has three leaflets that open and close to ensure blood flows in only one direction. Tricuspid regurgitation (TR) is caused by the leaflets of the tricuspid valve not closing properly.
Normal functioning tricuspid valve
Improperly functioning tricuspid valve allowing blood to flow back into tricuspid valve and right atrium (tricuspid regurgitation)
If combined with symptoms of congestive heart failure or other related heart conditions, disease may be classified as significant, symptomatic tricuspid regurgitation.
Fatigue
Declining exercise capacity
Light-headedness
Shortness of breath
Swollen feet, ankles, abdomen, or neck
Projected number of Australians with tricuspid valve regurgitation to 2051
1. Topilsky Y, et al. Burden of tricuspid regurgitation in patients diagnosed in the community setting. JACC Cardiovasc Imaging. 2019;12:433442.
2. Nath J, et al. Impact of tricuspid regurgitation on long-term survival. J Am Coll Cardiol. 2004;43:405409.
3. Chorin E, et al. Tricuspid regurgitation and long-term clinical outcomes. Eur Heart J Cardiovasc Imaging. 2020;21:157-165.
4. Benfari G, et al. Excess mortality associated with functional tricuspid regurgitation complicating heart failure with reduced ejection fraction. Circulation. 2019;140:196-206.
5. Topilsky Y, et al. Clinical presentation and outcome of tricuspid regurgitation in patients with systolic dysfunction. Eur Heart J. 2018;39:3584-3592.
6. Kadri AN, et al. Outcomes of patients with severe tricuspid regurgitation and congestive heart failure. Heart. 2019;105:1813-1817.
7. Stuge O, Liddicoat J. Emerging opportunities for cardiac surgeons within structural heart disease. J Thorac Cardiovasc Surg. 2006;132:1258-1261.
8. Kilic A, et al. Trends and outcomes of tricuspid valve surgery in North America: an analysis of more than 50,000 patients from the Society of Thoracic Surgeons database. Ann Thorac Surg. 2013;96:1546-1552.
9. Dreyfus J, et al. Timing of referral of patients with severe isolated tricuspid valve regurgitation to surgeons (from a French nationwide database). Am J Cardiol. 2018;122:323-326.
10. CSANZ 2021: Tricuspid regurgitation prevalent, severe, and lethal. An Australian national database was used to assess prevalence and outcomes. Cardiology. 2021;6(4).
11. Wang N, et al. Tricuspid regurgitation is associated with increased mortality independent of pulmonary pressures and right heart failure: a systematic review and meta-analysis. Euro Heart J 2019;40:476-484.
12. Marwick T, et al. Our Hidden Aging: Time to Listen to the Heart. 2021.
Medical therapy is the primary treatment pathway used to manage the symptoms of TR. Of note, this option does not address the underlying problem with the tricuspid valve and has been shown to have a limited impact on survival.
Tricuspid valve repair or tricuspid valve replacement are two types of surgery used to treat TR. This is often performed when surgery is being done on the left side of the heart.
Of note, the timing of surgery is important as there is an increased operative risk if performed late (i.e., the patient has become symptomatic with right-sided heart failure or has end-organ damage).
This option is often denied to patients, it is high risk, has limited clinical evidence, higher mortality rates, and TR can still recur.
Transcatheter tricuspid valve repair (TTVR) is a minimally invasive procedure that may be an option for patients considered too high risk for surgery. Unlike surgery, this procedure does not require opening of the chest cavity and temporarily stopping the heart.
TriClip™ is a transcatheter device option for tricuspid valve repair.
1. D’Agostino RS, et al. The STS Adult Cardiac Surgery Database: 2018 Update. Ann Thorac Surg. 2018;205:15-23.
2. Vahanian A, et al. ESC/EACTS Scientific Document Group, 2021 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2022;43(7):561–632.
3. Otto CM, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143:e72–e227.3. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines Catherine M. Otto, et al. https://doi.org/10.1161/CIR.0000000000000923 Circulation. 2021;143:e72–e227.
Treatment for TR is dependent on the disease severity and comorbidities. While there are medications available to address symptoms, the medication does not treat the underlying problem with the tricuspid valve. Options for TR treatment include both tricuspid valve surgery or transcatheter tricuspid valve repair. See the links below to access treatment guidelines.
1. Vahanian A, et al. ESC/EACTS Scientific Document Group, 2021 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2022;43(7):561–632.
2. Heidenreich PA, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145:e895–e1032.
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