Mitral valve surgery in patients with chronic severe heart failure carries a high perioperative risk. Life-threatening complications such as intraoperative left ventricular rupture, severe postoperative ventricular dysfunction, and subsequent mechanical valve thrombosis remain challenging and require urgent multidisciplinary management.

Globally, around 1 in 2 patients with left heart disease (LHD) has pulmonary hypertension (PH). The prevalence of PH associated with heart failure, mitral regurgitation, aortic valve disease, hypertrophic cardiomyopathy, and cardiac amyloidosis has mainly been investigated in high-income countries, especially the United States and Europe, by transthoracic echocardiography without right heart catheterization confirmation. It is estimated that around 80% of patients with hypertrophic cardiomyopathy or cardiac amyloidosis, around 65% of patients with heart failure or mitral regurgitation, and around 40% of patients with aortic valve disease have PH. In contrast, data about PH associated with mitral stenosis and rheumatic heart disease are primarily from low-income countries. The prevalence is around 80% in mitral stenosis-as determined by right heart catheterization in candidates for surgery or balloon valvuloplasty-and around 45% in rheumatic heart disease based on transthoracic echocardiography screening. PH associated with LHD (PH-LHD) clinical trials have focused on PH secondary to heart failure and have most often been performed in the United States and Europe (sites from these countries in 53.3% and 43.3% of the trials, respectively). The heterogeneous epidemiology of PH-LHD may reflect actual differences in the frequency of the underlying types of LHD, but it may also be the consequence of detection and reporting biases. Regional health authority choices, diagnostic capacity, and socio-economic factors likely influence the selection of the sites of PH-LHD trials. Efforts are needed to better characterize the worldwide burden of PH-LHD and to conduct truly global clinical trials.

Background and Objectives: Transcatheter aortic valve implantation (TAVI) is the standard therapy for patients with severe aortic stenosis at intermediate or high surgical risk. Mitral annular calcification (MAC) is frequently observed in this population and has been linked to adverse cardiovascular outcomes. This study evaluated the association between MAC and TAVI-related complications and mortality, and identified predictors of all-cause mortality and permanent pacemaker implantation (PPI) following TAVI. Materials and Methods: Patients undergoing self-expanding TAVI between January 2010 and June 2020 were retrospectively analyzed. Outcomes included TAVI-related complications, in-hospital and long-term mortality, and predictors of all-cause mortality and PPI. Results: A total of 245 patients (98 men [40%], mean age 76.3 ± 8.3 years) were included. Mean left ventricular ejection fraction was 54.8 ± 11.4%, and aortic valve area was 0.74 ± 0.14 cm2. MAC was present in 148 patients (60.4%). Pericardial effusion (26.4% vs. 12.4%, p = 0.013) and acute kidney injury (21.6% vs. 7.2%, p = 0.005) were significantly more frequent in patients with MAC. PPI was required in 42 patients (17.8%). In-hospital mortality occurred in 14 patients (5.7%), and all-cause mortality was observed in 89 patients (36.3%) during a median follow-up of 23.1 months (IQR, 11.6-44.3). MAC extension into the left ventricular outflow tract was the only independent predictor of PPI (OR: 3.32, p = 0.002). Independent predictors of all-cause mortality included use of renin-angiotensin-aldosterone system blockers (HR: 0.54, p = 0.012), hemoglobin level (HR: 0.79, p = 0.006), severe MAC (HR: 1.94, p = 0.024), and post-TAVI atrial fibrillation (HR: 2.39, p = 0.002). Conclusions: MAC is common in TAVI patients and is associated with increased procedural complications, including higher rates of pericardial effusion and acute kidney injury. Greater MAC severity independently predicts higher all-cause mortality. In addition, MAC extension into the left ventricular outflow tract is an independent predictor of PPI following self-expanding TAVI, emphasizing the importance of comprehensive pre-procedural imaging.

Heart failure with preserved ejection fraction (HFpEF) is associated with reduced functional capacity and quality of life, as well as with high rates of heart failure hospitalisation and mortality. Valvular heart disease (VHD) is frequently encountered in patients with HFpEF, and both conditions share common risk factors, such as age, hypertension, diabetes and coronary artery disease, which may contribute to their shared pathogenesis and progression. With recent advances in percutaneous therapies for VHD and an improved understanding of HFpEF, there is a growing interest in the relationship between VHD and HFpEF. In this review, we provide an overview of the pathophysiology, epidemiology and management strategies of tricuspid regurgitation, mitral regurgitation, aortic stenosis and aortic regurgitation in the setting of HFpEF.

A 47-year-old female with severe mitral stenosis underwent open mitral valve replacement. Preoperative and intraoperative transesophageal echocardiography (TEE) suggested a left atrial appendage thrombus, but no thrombus was found when the atrium was opened. While TEE is the gold standard for left atrial appendage thrombus diagnosis, its accuracy can be affected by artifacts, as well as normal anatomical structures, such as the coumadin ridge or pectinate muscle trabeculations, which may mimic thrombus, and by spontaneous echogenic contrast. Adjunct imaging techniques, including 3D TEE, left atrial appendage outflow velocity, and contrast-enhanced imaging, can improve accuracy. Cardiac CT is also a valuable alternative. In this case, the mass may have resulted from blood stasis rather than a true thrombus, highlighting the diagnostic challenges in such scenarios.

Severe aortic stenosis presents substantial anesthetic risk because fixed left ventricular outflow obstruction limits the ability to compensate for perioperative hemodynamic changes. These risks are further amplified in elderly patients with additional valvular disease and limited physiologic reserve who require urgent noncardiac surgery. We report the anesthetic management of a 96-year-old woman with critical aortic stenosis and concomitant mitral valve disease who required urgent hip fracture repair. Preoperative echocardiography demonstrated severe valvular calcification with a markedly reduced aortic valve area and elevated transvalvular gradients consistent with critical aortic stenosis. General anesthesia was induced with etomidate and fentanyl, with invasive arterial monitoring and phenylephrine infusion utilized to maintain coronary perfusion pressure and hemodynamic stability throughout the procedure. Multimodal postoperative pain management and close postoperative monitoring were employed to facilitate recovery while minimizing cardiovascular stress. The patient tolerated the procedure without intraoperative hemodynamic instability and experienced an uncomplicated postoperative recovery. This case illustrates key physiologic principles in the anesthetic management of severe aortic stenosis and highlights the importance of multidisciplinary decision-making and shared informed consent when high-risk patients require urgent surgical intervention.

Computed tomography (CT) calcium scoring is used to adjudicate paradoxical low-flow, low-gradient (LFLG) severe aortic stenosis (AS). However, its reliability may be limited in rheumatic disease.