Pathophysiology and management of multivalvular disease

Abstract

Multivalvular disease (MVD) is a common condition with a complex pathophysiology, dependent on the specific combination of valve lesions. Diagnosis is challenging as several echocardiographic methods commonly used for the assessment of stenosis or regurgitation have been validated only in patients with single valve disease. Decisions about the timing and type of treatment should be made by a multidisciplinary heart valve team, on a case-by-case basis. Several factors should be considered, including the severity and consequences of the MVD, the patient’s life expectancy and comorbidities, the surgical risk associated with combined valve procedures, the long-term risk of morbidity and mortality associated with multiple valve prostheses, and the likelihood and risk of reoperation. The introduction of transcatheter valve therapies into clinical practice has provided new treatment options for patients with MVD, and decision-making algorithms on how to combine surgical and percutaneous treatment options are evolving rapidly. In this Review, we discuss the pathophysiology, diagnosis, and treatment of MVD, focussing on the combination of valve pathologies that are most often encountered in clinical practice.

Sudden cardiac death and valvular pathology

“…In the 21st century, Valvular Heart Disease may be isolated or affect multiple valves [5,6]; and its aetiology may include 10 nosologic groups: heritablecongenital, inflammatoryimmunologic, endocardial (infectious or not), myocardial or other organ diseases, neoplastic, degenerative, iatrogenic (even devices for valve repair or replacement), drugs and physical agents, infiltrative, and idiopathic [5,7,8]; all of which may underlie SCD, as showed by the cases reported.…”

Pathophysiology and management of combined aortic and mitral regurgitation

“…The increased operative risk of double valve surgery [25,26] and the increased risk of long-term thrombotic and bleeding complications with multiple mechanical valves [27] should be balanced against the probability of requiring redo surgery and its inherent risk if only one valve is replaced. This decision must therefore take into account many factors, including patient age, comorbidities and frailty [28]. In addition, expertise in cardiac imaging, cardiac surgery, haemodynamic management, geriatrics and anaesthesia, in the setting of a multidisciplinary heart valve team, is required to optimize management [28].…”

“…This decision must therefore take into account many factors, including patient age, comorbidities and frailty [28]. In addition, expertise in cardiac imaging, cardiac surgery, haemodynamic management, geriatrics and anaesthesia, in the setting of a multidisciplinary heart valve team, is required to optimize management [28].…”

A nationwide contemporary epidemiological portrait of valvular heart diseases

“…The management of patients with multiple valve diseases is complex since each combination raises specific challenges with regard to diagnosis and management 9. There are very few data published in the literature with regard to the incidence and impact on outcomes of multiple VHDs.…”