Myocardial remodeling in valvular heart disease: pathophysiology, multimodality imaging and treatment implications

Valvular cardiomyopathy has emerged as a key concept linking valvular heart disease (VHD) with myocardial remodeling and the development of heart failure (HF). This state-of-the-art review provides a comprehensive overview of pathophysiological mechanisms, multimodality imaging, and implication for valve interventions across the spectrum of VHD. We systematically address HF in the context of aortic valve disease, including aortic stenosis and aortic regurgitation, mitral valve disease with a particular focus on mitral regurgitation, and tricuspid valve regurgitation. For each valvular lesion, we integrate evidence on pathophysiological mechanisms on myocardial (mal)adaptation leading to myocardial fibrosis and ultimately HF and death. Additionally, we highlight the role of multimodality imaging for early detection of myocardial remodeling and discuss implications for patient selection and timing of valve interventions. Beyond single-valve disease, we further explore the complex interplay of multiple and mixed valvular heart disease and review emerging data on the interaction between VHD and cardiac amyloidosis, an increasingly recognized and clinically relevant overlap. Overall, this state-of-the-art review underscores that outcomes in VHD are not solely determined by severity of valvular lesions but critically depend on the extent of associated myocardial damage. A deeper understanding of valvular cardiomyopathy may improve risk stratification, refine patient selection, and support the implementation of tailored therapeutic strategies.