Ernesto Greco
Mattia Vinciguerra
Roney Sampaio
Elena Aikawa- 1Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- 2Heart Institute, Clinical Hospital, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
- 3Center for Interdisciplinary Cardiovascular Sciences, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- 4Center for Excellence in Vascular Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
Editorial on the Research Topic
Insights in heart valve disease: 2022
Heart valve disease (HVD) represents a significant burden for health systems around the world. The growing advances in imaging and diagnostics need to be correlated with improvements in management. In total, nine articles have been published in this Research Topic, with interesting new findings summarized in Table 1. The articles have reached significant visibility, with more than 10,000 views so far. In this editorial, we aim to discuss the articles that highlighted the progress that has been made in the field of heart valve disease in 2022.
Table 1. Data regarding the articles published in the research topic “New Insights in Heart Valve Disease”; the number below the authors’ details corresponds to the number of references.
The burden of rheumatic and non-rheumatic valvular disease
The widespread use of penicillin-like drugs and improved access to healthcare reduced the burden of rheumatic heart disease (RHD) in the past century. In some developed countries, the false perception of its under-control burden has diminished alerts in the diagnosis of RHD, worsened by reduced compliance with penicillin treatment. Regional disparities contribute to the vast medical and economic burdens of RHD. It remains the leading cause of severe valvular heart disease with the highest significant cost among cardiovascular diseases, particularly in low-income countries. The valvular involvement frequently leads to heart failure, shortening life expectancy, and is responsible for 320,000 deaths annually. The projections of the global burden in the next decade indicate, mainly in low- and middle-income countries, an increasing trend in incidence, affecting more female subpopulations. The regional disparities may be attributable to the restricted access to healthcare, education, and housing Hu et al.
On the other side of the heart valvular disease spectrum, non-rheumatic, calcific aortic valve and mitral valve diseases are significant causes of public health concern, affecting mainly older adults in Western countries. These are highly treatable diseases and efforts to reduce the burden should be directed to modifiable risk factors, affecting the natural history of the disease, and improving interventional lines of management (1).
New insights need a new classification
The guidelines suggest treatment for severe valvular disease, identifying echocardiographic parameters of severity that professionals in the medical field can refer to in case of asymptomatic disease. A poor prognosis is associated with severe HVD and its surgical correction is mandatory to reverse cardiac remodeling and restore quality of life.
What emerges from recent literature and most of the articles published in this Research Topic is the necessity to revise surgical timing. The diagnostic assessment needs to include the grading of valve disease, a mirror of the altered morphology, and the dynamic response of the overloaded and/or over-pressured heart chambers. The study of the extra-valve cardiac involvement may allow for defining different stages of the disease, with a notable prognostic impact and crucial role for surgical implications.
Aortic stenosis
Pathophysiological changes of the left and right ventricles are induced by aortic valve stenosis. Stöbe et al. focused their research on cardiac involvement in patients affected by moderate aortic stenosis. They differentiated the population study according to the number of pathophysiological changes: increased left ventricular mass index, diastolic dysfunction, and increased right ventricle (RV) load. The study population was homogenous for comorbidities, excluding patients with severe comorbidities as these were not attributable entirely to aortic stenosis. The group with more extent cardiac damage resulted in a significantly lower survival rate without aortic valve replacement (AVR) or progression of aortic stenosis. The extra-valve cardiac involvement may be crucial for clinical outcomes after AVR, with a staging classification that appears to have important prognostic implications (2).
The natural history of aortic valve stenosis proceeds along pathophysiological changes and triggering factors may influence the clinical outcomes. A rapid progression of aortic stenosis associated with diabetes was demonstrated by Han et al. with an annual increase of peak aortic jet velocity (Vmax) >0.3 m/s/year. The systemic inflammatory response and impairing endothelial function are recognized as causes of aortic valve degeneration. The adverse effect of diabetes on left ventricle hypertrophic remodeling with increased left ventricle (LV) filling pressures may accelerate the pathophysiological changes, proceeding along with the staging of cardiac damage extent.
The resulting mechanical forces, such as tensile and shear stress, are powerful promoters of aortic valve pathogenesis, with biological responses typical of aortic valve calcification Salim et al. Overall, this emergent staging classification provides an incremental prognostic value in patients with valve disease.
Mitral regurgitation
The novel classification system was demonstrated to be significantly helpful for risk stratification and timing of surgery for primary mitral regurgitation. Grouping the population study according to the natural history of cardiac involvement in the context of primary mitral regurgitation, for each increase in the group, a 17% higher risk of all-cause mortality was observed (3).
The discussion regarding racial disparities in characteristics and outcomes of patients undergoing mitral transcatheter interventions may lead to full implementation of knowledge of surgical timing Shechter et al. Observations regarding the flow dynamic assessment in the native mitral valve and after surgery may be conducted in a standardized fashion, able to offer valid and crucial results Pugliese et al.
Conclusion
Identifying factors of greater severity in a patient, with the same group of valvular disease, is fundamental for recognizing the differences in early and long-term prognosis. Although our considerations are focused mainly on surgical timing and prognostic implications, the armamentarium of surgical techniques with less invasive access (4) needs to be at the basis of new studies. While surgical procedures improve the quality of a patient's life, thus far, no drug therapy has been developed to treat HVD, and while efforts have been made to improve surgical techniques and management, further innovative research must be focused on developing non-invasive treatments of valvular diseases.
Author contributions
All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's note
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References
1. Yadgir S, Johnson CO, Aboyans V, Adebayo OM, Adedoyin RA, Afarideh M, et al. Global burden of disease study 2017 nonrheumatic valve disease collaborators. Global, regional, and national burden of calcific aortic valve and degenerative mitral valve diseases, 1990-2017. Circulation. (2020) 141(21):1670–80. doi: 10.1161/CIRCULATIONAHA.119.043391
2. Généreux P, Pibarot P, Redfors B, Mack MJ, Makkar RR, Jaber WA, et al. Staging classification of aortic stenosis based on the extent of cardiac damage. Eur Heart J. (2017) 38(45):3351–8. doi: 10.1093/eurheartj/ehx381
3. van Wijngaarden AL, Mantegazza V, Hiemstra YL, Volpato V, van der Bijl P, Pepi M, et al. Prognostic impact of extra-mitral valve cardiac involvement in patients with primary mitral regurgitation. JACC Cardiovasc Imaging. (2022) 15(6):961–70. doi: 10.1016/j.jcmg.2021.11.009
Keywords: valve disease, less invasive approach, phisiopathology, risk stratificacion, guidelines and recommendations
Citation: Greco E, Vinciguerra M, Sampaio R and Aikawa E (2023) Editorial: New insights in heart valve disease 2022. Front. Cardiovasc. Med. 10:1226113. doi: 10.3389/fcvm.2023.1226113
Received: 20 May 2023; Accepted: 13 June 2023;
Published: 21 June 2023.
Edited and Reviewed by: Hendrik Tevaearai Stahel, University Hospital of Bern, Switzerland
© 2023 Greco, Vinciguerra, Sampaio and Aikawa. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Ernesto Greco ernesto.greco@uniroma1.it