Heart valve disease in the modern era: a call for holistic, long-term management

Heart valve diseases (HVD) are major causes of mortality and reduced quality of life worldwide, with a significant economic and healthcare burden. The rising average age of the population, combined with improved diagnostic strategies, has led to increasing incidence and prevalence of HVD in the recent years. The increasing proportion of individuals over 60 years is projected to grow from 10% to 21%, resulting in a substantial rise in patients requiring valve interventions over the coming decades.1,2 Epidemiologically, degenerative forms (such as calcific aortic stenosis) predominate in high-income countries, while rheumatic disease remains the main challenge in low- and middle-income settings.3 Alongside this growing prevalence, the way clinical outcomes are assessed has also evolved. Traditionally, studies and registries have focused mainly on procedural outcomes—technical success, prosthesis performance, early complications—which do not fully capture the long-term impact of disease and treatment on patients’ lives. The recent paper published by the first International Consortium for Health Outcomes Measurement on HVD aims precisely to overcome this device- and procedure-centric view, moving toward a more comprehensive, standardized evaluation of both clinical and patient-reported outcomes across the entire care pathway.4 Through an international, multi-society collaboration involving 12 scientific societies and patient representatives, a standardized set of outcomes was defined, structured into five main domains: vital status (overall and cardiovascular survival), patient-reported outcomes (quality of life and daily impact), disease progression, cardiac function and treatment durability, and complications. Sixteen clinical outcome measures and two patient-reported outcome measures tools were selected: the EQ-5D-5L to assess health status and quality of life, and the HVD Impact on Daily Life Questionnaire to specifically capture the disease’s impact on patients’ everyday activities. This set represents a concrete effort to harmonize clinical and patient-reported data collection internationally, with the goals of facilitating comparisons across healthcare systems, monitoring guideline implementation, building more accurate risk prediction models, and ultimately improving care quality.4 Indeed, the growing prevalence and impact of HVD on survival and quality of life underscore the urgency of moving beyond a purely technical perspective, embracing a patient-centered approach focused on clinically and personally meaningful outcomes.5 Despite therapeutic success (both conventional and transcatheter) and the improvement of cardiac symptoms,6 there are three key aspects that deserve careful consideration in the long-term management of patients with HVD. These factors have a significant influence on both prognosis and quality of life: Comorbidities are significant determinants of prognosis in patients undergoing valve surgery, influencing both early recovery and long-term survival. From a population-based recently published study from the SWEDEHEART registry, after adjustments for comorbidities, the mortality risk was lower in Transcatheter aortic valve replacement (TAVR) patients, compared with an age- and sex- matched control population. These findings suggest that the high burden of comorbidities in TAVR patients has a strong impact on the risk for mortality and major adverse cardiovascular events after TAVR.7 For example, anaemia is highly prevalent in patients treated with aortic valve replacement (AVR). A nationwide study demonstrated that patients with moderate or severe anaemia (haemoglobin level <6.2 mmol/L) at discharge faced a markedly increased risk of mortality, hospital readmission, and atrial fibrillation compared with those without or with only mild anaemia. Importantly, these findings suggest that anaemia may represent a modifiable risk factor and that targeted interventions to correct it could improve patient outcomes.8 In addition to anaemia, a prospective cohort study showed that individuals with psoriasis, particularly women, have a significantly elevated risk of developing aortic stenosis. This observation underscores the importance of considering chronic inflammatory diseases when evaluating cardiovascular risk profiles in candidates for valve interventions.9 Antithrombotic treatment plays a critical role in preventing thromboembolic events and ensuring valve durability after both surgical and transcatheter valve procedures. TAVR has become an increasingly common treatment option for patients with severe aortic stenosis who are at elevated surgical risk, but meticulous follow-up and optimized medical therapy, including appropriate anticoagulation regimens, remain essential. Indeed, over the years, approaches to the management of antithrombotic therapy have been the subject of numerous studies and have evolved over time, as demonstrated by data from the recently published Danish registry. Antithrombotic therapy patterns post-TAVR have changed over the first 14 years of TAVR in Denmark, with a decrease in the use of dual antiplatelet therapy and oral anticoagulation plus antiplatelet therapy, accompanied by an increase in single antiplatelet therapy and oral anticoagulation alone.10 Additional evidence from the Finnish Anticoagulation in Atrial Fibrillation study has provided important insights into the impact of vitamin K antagonist therapy quality among patients with atrial fibrillation undergoing mechanical AVR.11 In this nationwide registry-based analysis of over 1000 patients, adverse events were frequent, with ten-year cumulative incidence rates of nearly 28% for significant bleeding, 5.8% for intracranial haemorrhage, 12.8% for ischaemic stroke, and 7.2% for myocardial infarction. Critically, suboptimal time in therapeutic range (TTR) for the international normalized ratio was strongly associated with poorer outcomes: TTR below 80% was linked to almost double the risk of major bleeding and significantly higher rates of stroke and mortality. These findings underscore that maintaining adequate anticoagulation control is essential not only to prevent thromboembolic events but also to limit bleeding complications and reduce the overall risk of death. Infectious complications, including bacteraemia and infective endocarditis, remain among the most serious threats to patients undergoing valve surgery. Bacteraemia is relatively frequent in this population, particularly among individuals with advanced age, diabetes, or immunosuppression. Analyses of patients treated with TAVR have shown that while the procedure itself is associated with a relatively low procedural infection rate, the presence of comorbidities substantially increases the risk of developing bacteraemia during follow-up.12 Infective endocarditis is a particularly severe complication in the setting of prosthetic valves, with major implications for long-term survival. A recent evaluation of outcomes in patients who developed endocarditis after valve surgery revealed significantly higher rates of hospital readmission, heart failure, and mortality compared with patients without infection. These findings underline the importance of stringent infection control strategies, timely diagnosis, and the implementation of prophylactic measures such as perioperative antibiotics to mitigate the burden of infectious complications in this high-risk population.13 In conclusion, the rising burden of HVD requires us to look beyond procedural metrics and embrace a holistic, patient-centered approach. Recognising and addressing comorbidities, optimising antithrombotic strategies, and preventing infections are critical steps to improve not only survival but also the quality of life for this growing patient population. Massimo Piepoli (MD PhD FESC FHFA), Gianluigi Guida, Giandomenico Disabato, and Andrea Attanasio. None declared.