Optimized strategies for the management of Mitral Valve Disease

Abstract

Mitral valve disease is one of the most prevalent valvular heart diseases. This thesis aims to investigate and optimize the management of mitral valve disease, focusing on the improvement of current diagnostic and treatment strategies. Two central questions are discussed: 1) how can we optimize diagnostics in patients with mitral valve disease to identify the patient that needs (surgical) intervention, and 2) how can we optimize treatment of mitral valve disease including post procedural management in daily practice? Transthoracic echocardiography remains the recommended method to assess severity of mitral regurgitation in daily practice, although its grading remains challenging. The first part of this thesis shows that determining mitral regurgitation severity is improved by a simple scoring index. The practical and accurate nature of this echocardiographic index is confirmed in a larger cohort of patients undergoing transcatheter aortic valve replacement. In addition to resting images, we show that physical stress echocardiography may be of incremental value. Also a new tool for early detection and continuous monitoring of mitral regurgitation is introduced: the Hemodynamic Cardiac Profiler. Non-invasive measurements of volume-time curves by the Hemodynamic Cardiac Profiler may potentially by suitable for early detection and continuous (tele)monitoring of mitral valve diseases. Surgery (preferably mitral valve repair) is often performed in patients with mitral valve disease. However, current guideline recommendations on the optimal treatment strategy may be conflicting or insufficient. The second part of this thesis focuses on controversies in current guidelines regarding the best treatment strategies in mitral valve disease. Challenges and possible solutions for the management of asymptomatic patients, concomitant valve diseases, and postoperative care are discussed. We suggest that improved adherence to the guidelines, timely referral to expertise centers, and a systematic approach to patient management will improve results in research and patient care; in particular for (asymptomatic) patients with severe mitral regurgitation. Data in this thesis also shows that late significant functional tricuspid regurgitation in patients after mitral valve surgery is seldom seen. Postoperatively, exercise echo parameters may be helpful to evaluate recurrent or persistent complaints. The last part of this thesis demonstrates that bridging anticoagulation in patients after implantation of a mechanical heart valve is associated with considerable risk, regardless the bridging strategy (unfractionated heparin versus subcutaneous low-molecular-weight heparin).