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Imaging Multiple Valve Disease

EuroEcho-Imaging 2014 session report

Cardiac imaging specialists call for broader perspectives to identify best practice for evaluation and management of patients with multiple valve lesions.

Professor Guy Van Camp (Aalst, BE) and I co-chaired this interesting session late on Friday morning. The prevalence of valvular heart disease is substantial, related in part to the aging population as well as the numerous causes of valvular heart disease. The strong attendance at this session spoke to the high level of interest in this important topic.

Dr. William Armstrong (Ann Arbor, US) began the session with an overview lecture in which he described the influence of coexisting valve lesions upon each other, and noted that the usual echocardiographic measures may be challenging to interpret when multiple lesions are present. For example, the presence of coexisting AR in a patient with AS will not only alter LV loading conditions, adding volume overload to pressure overload, but will also increase anterograde flow across the valve and elevate the gradients for any given degree of stenosis. Equally complicated changes occur when AS and MR coexist. MS and AR can be seen in patients with rheumatic valvular disease, while TR is a frequent coexisting problem in patients with left sided valvular lesions. Dr. Amstrong, and the subsequent speakers, emphasized that the current European as well as American guidelines on valvular heart disease discuss individual lesions extensively, but include little information on how to evaluate multiple valve disease, especially in the asymptomatic patient.

Following the opening overview, the audience was next fortunate to hear well-illustrated discussions of some of the more common specific situations in which multiple valve diseases presents challenges to the imager. Dr. Saaed Al Ahmari (Riyadh, SA) discussed the combination of AS with AR and the challenges of interpreting transvalvular gradients and LV function in this setting. Next, Dr. Kim O’Connor (Quebec, CA) discussed the combination of AS with MR, which is not uncommon in older patients with valve calcification, and noted that MR can be both functional and related to intrinsic valve lesions in this setting. Finally, Dr. Maria Sofia Cabral (Porto, PT) reviewed the challenge of managing TR at the time of surgery for left-sided valvular lesions, noting that the addition of surgical tricuspid annuloplasty does not appear to prolong cardiopulmonary bypass or lead to excessive perioperative complications.

As Prof. Van Camp and I listened to four excellent presentations, I was reminded that multiple valvular lesions often coexist. Valvular heart disease has attracted a great deal of attention, in part related to high interest in transcatheter therapies for aortic, mitral, tricuspid, and pulmonic valve disorders. While multiple valve disease is not uncommon, scientific studies have tended to focus upon isolated lesions. Cardiac imaging specialists will need to broaden their perspective in order that we might learn how best to evaluate and manage patients with multiple valve lesions.




Imaging Multiple Valve Disease

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.