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Asymptomatic valvular disease: Which imaging arguments to operate...Or not?

Session 103

A main session of EuroEcho Imaging 2015 was dedicated to the role of imaging on the management of patients with asymptomatic valvular heart disease.

Julien Magne (Limoges, France) reviewed the guidelines criteria for surgery in asymptomatic patients with primary severe mitral regurgitation, which largely rely on left ventricular ejection fraction (LVEF) and LV dimensions. These criteria were defined in cohort studies that demonstrated their prognostic value on late survival after surgery. The value of these criteria has been challenged due to the difficulties in predicting post-operative LV dysfunction, which may occur even when following thresholds of LVEF or LV dimensions. This is the reason behind one of the rare discrepancies between the ESC/EACTS and AHA/ACC guidelines. The AHA/ACC guidelines comprise a class IIa recommendation for surgery in patients who do not meet the criteria of LVEF and LV dimensions, provided operative risk is low and there is a very high likelihood of valve repair, whereas there is no corresponding recommendation in European guidelines. Other proposed indices for risk assessment are LV ejection index, LV longitudinal function, LV fibrosis as assessed by cardiac magnetic resonance, left atrial volume and function, and systolic pulmonary artery pressure at rest or during exercise echocardiography. A multifactorial approach combining different indices may be suitable to improve prognostic assessment in asymptomatic primary mitral regurgitation and, therefore, refine indications for surgery.

Federico Asch (Washington, USA) addressed asymptomatic aortic stenosis, which is often considered to carry a good prognosis and therefore to require watchful waiting. The first step, however, is to ensure that patients are truly asymptomatic using exercise testing. Standard exercise testing may detect objective dyspnoea or a fall in blood pressure, which are both indications for aortic valve replacement. Indications derived from exercise echocardiography or cardiopulmonary exercise testing rely on lower levels of evidence. Maximum aortic jet velocity also identifies a subgroup of patients who have a high risk of early cardiac events, when it is ≥ 5.0-5.5 m/sec. The results of exercise testing and maximum jet velocity are the two main criteria leading to consider surgery in patients with asymptomatic aortic stenosis in American and European guidelines. Other criteria, such as natriuretic peptides serum levels are more controversial. The usefulness of the detection of early impairment of LV function using strain rate needs further validation. The number of studies assessing prognostic factors contrasts with the small number of comparative studies, whose relevance is limited by their retrospective design and residual confounding factors. Indications for early surgery in asymptomatic aortic stenosis should also take into account the operative risk, which should be low, < 1% according to current risk scores. When a watchful waiting strategy is chosen, close follow-up is needed, every 3 to 6 months.

The evaluation of secondary tricuspid regurgitation was presented by Luigi Badano (Padova, Italy). The severity of tricuspid regurgitation is difficult to evaluate, in particular because of its dependence on loading conditions. In patients undergoing left-sided valvular surgery and having moderate tricuspid regurgitation, guidelines recommend associated tricuspid surgery when the diameter of the tricuspid annulus is ≥ 40 mm. This indication is supported by the risk and the negative prognostic impact of progressive worsening of tricuspid regurgitation after an isolated correction of left-sided valve disease. However, the technique for measuring the tricuspid annulus raises questions due to its complex three-dimensional structure. In addition, no measurement technique for the tricuspid annulus has been validated in terms of its consequences on long-term prognosis. Three-dimensional imaging of the whole geometry of the tricuspid ring is attractive but needs to be evaluated. The consequences of tricuspid regurgitation on right ventricular function may be assessed using indices such as the TAPSE or Tei index, but their reliability is not well established as regards prognosis of tricuspid regurgitation. In practice, specific prospective studies are needed to better define the indications for surgery, using standardized three-dimensional measurements of tricuspid annulus size and right ventricle.

Multivalve diseases are relatively frequent and this contrasts with the lack of clear guidelines for interventions. Philippe Unger (Brussels, Belgium) showed that multivalve disease is a heterogeneous group due to the multiple possible combinations of the different valve diseases and their severity. Therefore, the assessment and decision making for interventions should be individualized according to each combination. Quantitative measurements, in particular of valve area and effective regurgitant orifice, are particularly useful since they are less likely to be influenced by the haemodynamic consequences of other valve diseases. However, all indices of severity of valvular diseases should be interpreted with caution since they have been validated in single-valve diseases. The conjunction of two moderate valve disease may require surgery if it has significant consequences on symptoms and/or on the LV. In practice, decision-making for intervention should take into account the severity of each valve disease, their consequences, the potential progression of moderate valve diseases, and the possibility of improvement of certain valve disease such as mitral regurgitation after the treatment of aortic stenosis. These features should be weighed against the evaluation of the operative risk, which is higher in multi- than in single-valve surgery. The number of determinants in the decision-making process highlights the need for an individualized approach by the Heart Team.

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.