Interplay between medical and interventional therapies in valvular heart disease and heart failure: an expert opinion paper

Figures

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  Figure 1. Medical therapy optimization before and after MR correction. The figure shows the necessity of optimize medical therapy (including CRT when indicated) before MR correction due to the possibility of obtaining a MR reduction through LV and LA remodelling. After MR correction, the improvement in haemodynamic favours GDMT optimization, pivotal to maximize MR correction's benefits. Created in BioRender (https://BioRender.com/l1cbytk). ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin-receptor blocker; ARNI, angiotensin receptor-neprilysin inhibitor; CRT, cardiac resynchronization therapy; GDMT, guideline-directed medical therapy; LA, left atrial; LV, left ventricular; MR, mitral regurgitation; MRA, mineralocorticoid receptor antagonist; M-TEER, mitral-transcatheter edge-to-edge repair; SGLT2-I, sodium–glucose co-transporter 2 inhibitor; SMR, secondary mitral regurgitation

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  Figure 2. Medical therapy and AVR in patients with HF and severe AS. The figure shows the suggested management in patients with HFrEF/HFmrEF and HFpEF. AVR, through percutaneous or surgical treatment, remains the pivotal step in AS management. GDMT pre-AVR should be administered with caution for the risk of pre-load reduction and hypotension. Post-AVR, GDMT could be a fundamental step to improve outcomes. Created in BioRender (https://BioRender.com/vif19z2). AS, aortic stenosis; AVR, aortic-valve replacement; GDMT, guideline-directed medical therapy; HFmrEF, heart failure with mildly reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; RASi, renin–angiotensin system inhibitor; RCT, randomized control trial; SBP, systolic blood pressure; SGLT2-I, sodium–glucose co-transporter 2 inhibitor

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  Figure 3. Moderate AS. The figure shows the heterogeneous trajectory of moderate AS. One time considered a benign, slowly progressive state, now it is considered associated with poor outcomes. No drug has yet been shown to reduce the progression of AS in RCTs. TAVR UNLOAD, a RCT, did not shown strong benefit although the procedure was safe. Created in BioRender (https://BioRender.com/40o8ze1). AS, aortic stenosis; CMR, cardiac magnetic resonance; KCCQ-OSS, Kansas city cardiomyopathy questionary–overall summary score; LA, left atrial; LV, left ventricular; RCTs, randomized control trials

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  Figure 4. Aortic regurgitation in patients with LVAD. The figure shows the management of AR in patients with LVAD. Created in BioRender (https://BioRender.com/yc7ghm6). AR, aortic regurgitation; BP, blood pressure; ISHLT, international society for heart and lung transplantation; LVAD, left ventricular assist device; LVEDD, left ventricular end-diastolic diameter; RV, right ventricular; SAVR, surgical aortic-valve replacement; TAVR, transcatheter aortic-valve replacement

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  Figure 5. Management of patients before and after TTVI. The figure shows the suggested management in patients with severe TR and right HF. The first step should be to identified as reversible TR aetiologies, including left VHD, AF, CIED-related TR and pulmonary hypertension. In patients without these aetiologies or after the management of these aetiologies, persistency of TR should be managed with medical therapy, particularly with diuretics to avoid fluid overload without lingering on TTVI, if indicated. After TTVI, diuretics should ideally be continued up to 3 months, if tolerated, to avoid device detachment. GDMT optimization post-TTVI could be useful to improve outcomes, but data are lacking. Created in BioRender (https://BioRender.com/xh2xt8j). AF, atrial fibrillation; CIED, cardiac implantable electronic device; GDMT, guideline-directed medical therapy; RCTs, randomized control trials; TTVI, transcatheter tricuspid valve intervention; VHD, valvular heart disease