Volcano-Hydrothermal Systems Volume October Volcano Geodesy: Recent developments and future challenges Volume September Numerical models of volcanic eruption plumes: inter-comparison and sensitivity Volume October Understanding volcanoes in the Vanuatu arc Volume August Tarawera Eruption Volume March SI: Tolbachik eruption Volume December Merapi eruption Volume July Flank instability at Mt. Etna Volume February From maars to scoria cones: the enigma of monogenetic volcanic fields Volume , Issues April Luhr Volume , Issues November Recent advances on the geodynamics of Piton de la Fournaise volcano Volume , Issues July Recent advances on the geodynamics of Piton de la Fournaise volcano Volume , Issues June Models and products of mafic explosive activity Volume , Issues March Volcanic lakes and environmental impacts of volcanic fluids Volume , Issue 2 December Sheridan Volume , Issue 4 November Explosive volcanism in the central Mediterranean area during the late Quaternary - linking sources and distal archives Volume , Issue 1 October Kimberlite Emplacement Volume , Issues June Volcanic risk perception and beyond Volume , Issues May Gas geochemistry and Earth degassing Volume Issues August Maar-diatreme volcanism and associated processes Volume , Issues January Interaction between volcanoes and their basement Volume , Issues November For the definition of scores see Table 9.
Diuretics, beta-blockers, digoxin or heart rate—regulating calcium channel blockers can transiently improve symptoms. Anticoagulation with a target international normalized ratio INR between 2 and 3 is indicated in patients with either new-onset or paroxysmal atrial fibrillation. Patients with moderate to severe mitral stenosis and persistent atrial fibrillation should be kept on vitamin K antagonist VKA treatment and not receive NOACs.
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Cardioversion is not indicated before intervention in patients with severe mitral stenosis, as it does not durably restore sinus rhythm. If atrial fibrillation is of recent onset and the LA is only moderately enlarged, cardioversion should be performed soon after successful intervention. Management of patients after successful PMC is similar to that of asymptomatic patients. Follow-up should be more frequent if asymptomatic restenosis occurs. When PMC is not successful, surgery should be considered early unless there are definite contraindications.
When restenosis with symptoms occurs after surgical commissurotomy or PMC, reintervention in most cases requires valve replacement, but PMC can be proposed in selected candidates with favourable characteristics if the predominant mechanism is commissural refusion. In the elderly population with rheumatic mitral stenosis when surgery is high risk, PMC is a useful option, even if only palliative.
In other elderly patients, surgery is preferable. As there is no commissural fusion in these cases, degenerative mitral stenosis is not amenable to PMC. In patients with severe mitral stenosis combined with severe aortic valve disease, surgery is preferable when it is not contraindicated. The management of patients in whom surgery is contraindicated is difficult and requires a comprehensive and individualized evaluation by the Heart Team.
In cases with severe mitral stenosis with moderate aortic valve disease, PMC can be performed to postpone the surgical treatment of both valves.
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In patients with severe tricuspid regurgitation, PMC may be considered in selected patients with sinus rhythm, moderate atrial enlargement and functional tricuspid regurgitation secondary to pulmonary hypertension. In other cases, surgery on both valves is preferred. Valve replacement is the only option for the treatment of rare cases of severe mitral stenosis of non-rheumatic origin where commissural fusion is absent. Key points Most patients with severe mitral stenosis and favourable valve anatomy currently undergo PMC.
Decision making as to the type of intervention in patients with unfavourable anatomy is still a matter of debate and must take into account the multifactorial nature of predicting the results of PMC. Gaps in evidence The scores predicting the results and complications of PMC, particularly those of severe mitral regurgitation, must be refined.
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The potential role of transcatheter mitral valve implantation in high-risk patients is to be determined, particularly those with severe degenerative mitral stenosis. Echocardiography is the ideal technique to evaluate tricuspid regurgitation. In primary tricuspid regurgitation, the aetiology can usually be identified from specific abnormalities of the valve structure. Evaluations of RV dimensions and function should be conducted despite the existing limitations of current indices of RV function. In experienced laboratories, 3D measurements of RV volumes can be considered, which may be similar to those obtained by CMR.
Cardiac catheterization is not needed to diagnose tricuspid regurgitation or estimate its severity but should be obtained in patients in whom isolated tricuspid valve surgery is contemplated for secondary tricuspid regurgitation to evaluate haemodynamics, in particular pulmonary vascular resistance. The timing of surgical intervention remains controversial, mostly due to the limited data available and their heterogeneous nature see table of recommendations for indications for tricuspid valve surgery and Figure 6.
Indications for surgery in tricuspid regurgitation. In severe primary tricuspid regurgitation, surgery is not only recommended in symptomatic patients but should also be considered in asymptomatic patients when progressive RV dilatation or decline of RV function is observed. Although these patients respond well to diuretic therapy, delaying surgery is likely to result in irreversible RV damage, organ failure and poor results of late surgical intervention.
In secondary tricuspid regurgitation, adding a tricuspid repair, if indicated, during left-sided surgery does not increase operative risk and has been demonstrated to provide reverse remodelling of the RV and improvement of functional status even in the absence of substantial tricuspid regurgitation when annulus dilatation is present. Reoperation on the tricuspid valve in cases of persistent tricuspid regurgitation after mitral valve surgery carries a high risk, mostly due to the late referral and the consequently poor clinical condition of patients. If possible, valve repair is preferable to valve replacement.
Ring annuloplasty, preferably with prosthetic rings, is key to surgery for secondary tricuspid regurgitation. Percutaneous repair techniques are in their infancy and must be further evaluated before any recommendations can be made.
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Indications for tricuspid valve surgery. Percutaneous balloon valvuloplasty can be attempted as a first approach if tricuspid stenosis is isolated. Tricuspid stenosis is often combined with tricuspid regurgitation, most frequently of rheumatic origin. It is therefore almost always associated with left-sided valve lesions, particularly mitral stenosis, that usually dominate the clinical presentation. Echocardiography provides the most useful information.
Tricuspid stenosis is often overlooked and requires careful evaluation. Echocardiographic evaluation of the anatomy of the valve and its subvalvular apparatus is important to assess valve reparability. The lack of pliable leaflet tissue is the main limitation for valve repair.
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Even though this is still a matter of debate, biological prostheses for valve replacement are usually preferred over mechanical ones because of the high risk of thrombosis carried by the latter and the satisfactory long-term durability of the former in the tricuspid position. Percutaneous balloon tricuspid dilatation has been performed in a limited number of cases, either alone or alongside PMC, but frequently induces significant regurgitation. There is a lack of data on long-term results. Intervention on the tricuspid valve is usually carried out at the time of intervention on the other valves in patients who are symptomatic despite medical therapy.
The choice between repair or valve replacement depends on valve anatomy and surgical expertise. Balloon commissurotomy can be considered in the rare cases with anatomically suitable valves when tricuspid stenosis is isolated, or additional mitral stenosis can also be treated interventionally see table of recommendations in section 7. Key points Tricuspid stenosis is a rare condition, whereas tricuspid regurgitation is more common, especially in its secondary form.
For appropriate management, secondary tricuspid regurgitation has to be clearly distinguished from primary tricuspid regurgitation. Similar to mitral regurgitation, primary tricuspid regurgitation requires intervention sufficiently early to avoid secondary damage of the RV, which is associated with poor outcome. Secondary tricuspid regurgitation should be liberally treated at the time of left-sided valve surgery. Consideration of isolated surgery of secondary tricuspid regurgitation after previous left-sided valve surgery requires comprehensive assessment of the underlying disease, pulmonary haemodynamics and RV function.
Gaps in evidence Criteria for optimal timing of surgery in primary tricuspid regurgitation require refinement. Criteria for concomitant tricuspid valve surgery at the time of left-sided surgery in patients without severe tricuspid valve disease require refinement. The potential role of transcatheter tricuspid valve treatment in high-risk patients needs to be determined.
Significant stenosis and regurgitation can be found on the same valve. Disease of multiple valves may be encountered in several conditions, particularly in rheumatic and congenital heart disease, but also less frequently in degenerative valve disease. There is a lack of data on combined or multiple-valve diseases. This does not allow for evidence-based recommendations. The general principles for the management of combined or multiple-valve disease are as follows: When either stenosis or regurgitation is predominant, management follows the recommendations concerning the predominant VHD.
When the severity of both stenosis and regurgitation is balanced, indications for interventions should be based on symptoms and objective consequences rather than on the indices of severity of stenosis or regurgitation.
In this setting, consideration of the pressure gradient that reflects the haemodynamic burden of the valve lesion becomes more important than valve area and measures of the regurgitation for the assessment of disease severity. Besides the separate assessment of each valve lesion, it is necessary to take into account the interaction between the different valve lesions.
As an illustration, associated mitral regurgitation may lead to underestimation of the severity of aortic stenosis, as decreased stroke volume due to mitral regurgitation lowers the flow across the aortic valve and hence the aortic gradient.
This underlines the need to combine different measurements, including assessment of valve areas, if possible using methods that are less dependent on loading conditions, such as planimetry. Indications for intervention are based on global assessment of the consequences of the different valve lesions i. Intervention can be considered for non-severe multiple lesions associated with symptoms or leading to LV impairment.
The decision to intervene on multiple valves should take into account the extra surgical risk of combined procedures. The choice of surgical technique should take into account the presence of the other VHD; repair remains the ideal option. The management of specific associations of VHD is detailed in the individual sections of this document. Key points In combined VHD, pathology is considered severe even if both stenosis and regurgitation are only of moderate severity and pressure gradients become of major importance for assessment.
Gaps in evidence More data on the natural history and the impact of intervention on outcome are required to better define the indications for intervention. Every valve prosthesis introduces a new disease process. In practice, the choice is between a mechanical and a biological prosthesis. Randomized trials comparing both prostheses consistently found similar survival, no significant difference in rates of valve thrombosis and thromboembolism, higher rates of bleeding with mechanical prostheses and higher rates of reintervention with bioprostheses.
Rather than setting arbitrary age limits, prosthesis choice should be discussed in detail with the informed patient, cardiologists and surgeons, taking into account the factors detailed below see tables of recommendations in section Bioprostheses should be considered in patients whose life expectancy is lower than the presumed durability of the bioprosthesis, particularly if comorbidities may necessitate further surgical procedures, and in those with increased bleeding risk.
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