Acute heart failure (AHF) encompasses a wide spectrum of conditions resulting from the interplay between pre-existing cardiac disease and various precipitating factors. VHD often coexists with AHF, either due to chronic valvular disease exacerbated by one or more triggers or due to newly acquired valvular dysfunction. Clinical presentations vary widely, ranging from mild heart failure decompensation to acute pulmonary edema or cardiogenic shock. Despite the prevalence of this overlap in clinical practice, current heart failure guidelines lack specific recommendations for these patients. They are frequently excluded from clinical trials, and much of the evidence available stems from observational studies. This position paper attempts to clarify this area, reviewing the epidemiology, pathophysiology, diagnosis, and management of VHD in AHF.

Valvular disease accounts for approximately 10-20% of AHF admissions, with aortic stenosis and mitral regurgitation (both primary and secondary) being the most common. The presence of moderate-to-severe VHD and pulmonary hypertension portends a worse prognosis, characterized by higher rates of rehospitalization and mortality. While valvular disease generally progresses gradually, acute decompensation can be triggered by factors such as anemia, renal failure, arrhythmias, or acute coronary syndrome. These precipitating factors may also cause functional valvular conditions, such as secondary mitral and tricuspid regurgitation. Newly acquired valvular diseases, particularly valvular endocarditis and aortic dissection, demand prompt diagnosis and specific management. In some cases, the typical murmur may be absent due to rapid intracardiac pressure equalization, underscoring the importance of transthoracic and especially transesophageal echocardiography for diagnosis. In specific cases, such as prosthetic valve thrombosis, endocarditis, or aortic dissection, computed tomography (CT) plays a key role in diagnosis. Among patients with prosthetic valves, dysfunction due to thrombosis, endocarditis, or degeneration often leads to significant clinical intolerance. Multivalvular involvement, seen in approximately 20% of cases, complicates both diagnosis and prognosis, especially in assessing the severity of individual valve lesions.

Regarding treatment, this position paper reviews the use of medications such as diuretics, vasodilators, inotropes, vasopressors, and antiarrhythmics tailored to each type of valvular lesion. It emphasizes the importance of airway management, oxygenation, and the use of invasive and non-invasive mechanical ventilation when indicated. In patients with refractory heart failure or cardiogenic shock, short-term mechanical circulatory support is preferred to reduce reliance on inotropes and vasopressors, minimizing their adverse effects. However, these devices are contraindicated in patients with significant aortic insufficiency. Finally, the authors discuss invasive treatment options, including surgery versus transcatheter interventions, specific to each valvular pathology. Certain clinical scenarios require surgery as the sole option, sometimes emergently (e.g., aortic dissection, papillary muscle rupture, or endocarditis with AHF). Conversely, transcatheter techniques, especially transcatheter aortic valve implantation (TAVI) and edge-to-edge percutaneous valve repair (mitral and tricuspid), are gaining prominence in acute cases, though supporting evidence remains limited but growing. The authors recommend a multidisciplinary Heart Team approach to evaluate these complex cases.

COMMENTARY:

This document is particularly timely, given the lack of guidance in the 2021 heart failure guidelines regarding VHD in acute heart failure, with current recommendations more suited to chronic scenarios. Until the anticipated update to these guidelines is published, this position paper provides valuable insights. However, while the discussion on pathophysiology is comprehensive, more specific guidelines on the role of various diagnostic techniques would have been beneficial. Additionally, evidence on treatment approaches, both pharmacologic and invasive, remains scarce, especially concerning percutaneous interventions in AHF with VHD. It is hoped that forthcoming studies will provide the foundation for stronger recommendations in future guideline editions. Meanwhile, the article by Chioncel, et al., serves as a useful reference in our clinical practice.

REFERENCE:

Chioncel O, Adamo M, Nikolaou M, Parissis J, Mebazaa A, Yilmaz MB, et al. Acute heart failure and valvular heart disease: a scientific statement of the Heart Failure Association, the Association for Acute CardioVascular Care, and the European Association of Percutaneous Cardiovascular Interventions of the European Society of Ca Eur J Heart Fail. 2023 May 23. doi: 10.1002/ejhf.2918.