Survival of people with valvular heart disease in a large, English community-based cohort study.

OBJECTIVE: Valvular heart disease (VHD) is present in half the population aged >65 years but is usually mild and of uncertain importance. We investigated the association between VHD and its phenotypes with all-cause and cause-specific mortality. METHODS: The OxVALVE (Oxford Valvular Heart Disease) population cohort study screened 4009 participants aged >65 years to establish the presence and severity of VHD. We linked data to a national mortality registry and undertook detailed outcome analysis. RESULTS: Mortality data were available for 3511 participants, of whom 361 (10.3%) died (median 6.49 years follow-up). Most had some form of valve abnormality (n=2645, 70.2%). In adjusted analyses, neither mild VHD (prevalence 44.9%) nor clinically significant VHD (moderate or severe stenosis or regurgitation; 5.2%) was associated with increased all-cause mortality (HR 1.20, 95% CI 0.96 to 1.51 and HR 1.47, 95% CI 0.94 to 2.31, respectively). Conversely, advanced aortic sclerosis (prevalence 2.25%) and advanced mitral annular calcification (MAC, 1.31%) were associated with an increased risk of death (HR 2.05, 95% CI 1.28 to 3.30 and HR 2.51, 95% CI 1.41 to 4.49, respectively). Mortality was highest for people with both clinically significant VHD and advanced aortic sclerosis or MAC (HR 4.38, 95% CI 1.99 to 9.67). CONCLUSIONS: Advanced aortic sclerosis or MAC is associated with a worse outcome, particularly for patients with significant VHD, but also in the absence of other VHD. Older patients with mild VHD can be reassured about their prognosis. The absence of an association between significant VHD and mortality may reflect its relatively low prevalence in our cohort.

Perioperative risk assessment with Euroscore and Euroscore II in patients with coronary artery or valvular disease.

Nowadays, both the European System for Cardiac Operative Risk Evaluation (EuroSCORE) logistic (ESL) and EuroSCORE II (ESII) models are used worldwide in predicting in-hospital mortality after cardiac operation. However, these scales are based on different populations and represent different medical approaches. The aim of the study was to assess the effectiveness of the ESL and the ESII risk scores in predicting in-hospital death and prolonged hospitalization in intensive care unit (ICU) after coronary artery bypass grafting (CABG), aortic valve replacement (AVR), and mitral valve replacement (MVR) by comparison of an estimated risk and a real-life observation at a reference cardiac surgery unit.This retrospective study was based on medical records of patients who underwent a CABG, AVR, or MVR at a reference cardiac surgery unit in a 2-year period. Primary endpoint was defined as in-hospital death. Secondary endpoint was a prolonged hospitalization at the ICU, defined as longer than 3 days.The study encompassed 586 patients [114 (23.1%) female, mean age 65.8 ±â€Š10.5 years], including 493 patients undergoing CABG, 66 patients undergoing AVR, and 27 patients undergoing MVR. The ESL and ESII risk scores were higher in MVR subgroup (31.7% ±â€Š30.5% and 15.3% ±â€Š19.4%) and AVR subgroup (9.7% ±â€Š11.6% and 3.2% ±â€Š4.2%) than in CABG subgroup (6.9% ±â€Š10.4% and 2.5% ±â€Š4.1%; P < .001). Subgroups of patients were significantly different in terms of clinical, biochemical, and echocardiography factors. Primary endpoint occurred in 36 (6.1%) patients: 21 (4.3%), 7 (10.6%), and 8 (29.7%) in CABG, AVR, and MVR subgroups, respectively. The ESII underestimated the risk of mortality. Secondary endpoint occurred in 210 (35.8%) patients: 172 (34.9%), 22 (33.4%), and 16 (59.3%) in CABG, AVR, and MVR subgroups, respectively.In the study, the perioperative risk estimated with the ESL and the ESII risk scores was compared with a real-life outcome among over 500 patients. Regardless of the type of surgery, result in the ESL was better correlated with the risk of in-hospital death.

The Bicuspid Aortic Valve Condition: The Critical Role of Echocardiography and the Case for a Standard Nomenclature Consensus.

The bicuspid aortic valve (BAV) condition is characterized by prominent heterogeneity of its valvular phenotypic expression, of its associated disorders, its complications and its prognosis. Echocardiography serves as the first-line imaging modality in 5 major capacities: (1) BAV diagnosis, (2) valvular phenotyping, (3) assessment of valvular function, (4) measurement of the thoracic aorta and exclusion of aortic coarctation, and (5) assessment of uncommon but serious complications such as infective endocarditis and aortic dissection. This article presents a nosological perspective on the BAV condition, discusses the critical role of echocardiography as it relates to these 5 aforementioned capacities; and makes the case for a unified standard nomenclature for the BAV condition.

Stroke, thromboembolism and bleeding in patients with atrial fibrillation according to the EHRA valvular heart disease classification.

AIMS: We compared thromboembolic (TE) and bleeding risks in patients with atrial fibrillation (AF) according to the new 'Evaluated Heartvalves, Rheumatic or Artificial' (EHRA) valve classification. METHODS: Patients were divided into 3 categories: (i) EHRA type 1 corresponds to the previous 'valvular' AF patients, with either rheumatic mitral valve stenosis or mechanical prosthetic heart valves; (ii) EHRA type 2 includes AF patients with other valvular heart disease (VHD) and valve bioprosthesis or repair; and (iii) 'non-VHD controls' i.e. all AF patients with neither VHD nor post-surgical valve disease. RESULTS: Among 8962 AF patients seen between 2000 and 2010, 357 (4%) were EHRA type 1, 1754 (20%) were EHRA type 2 and 6851 (76%) non-VHD controls. EHRA type 2 patients were older and had a higher CHA2DS2-VASc and HAS-BLED scores than either type 1 and non-VHD patients. After a mean follow-up of 1264 ±â€¯1160 days, the occurrence of TE events was higher in EHRA type 2 than non-VHD patients (HR (95%CI): 1.30 1.09-1.54), p = 0.003; also, p = 0.31 for type 1 vs 2, p = 0.68 for type 1 vs non-VHD controls). The rate of major BARC bleeding events for AF patients was higher in either EHRA type 1 (HR (95%CI): 3.16(2.11-4.72), p < 0.0001) or type 2 (HR (95%CI): 2.19(1.69-2.84), p < 0.0001) compared to non-VHD controls. CONCLUSION: The EHRA valve classification of AF patients with VHD appears useful in categorizing these patients, in terms of TE and bleeding risks. This classification can be used in clinical practice for appropriate choices of oral anticoagulation therapy and follow-up.

Stress echocardiography in patients with native valvular heart disease.

Valve stress echocardiography (VSE) can be performed as exercise stress echocardiography (ESE) or dobutamine stress echocardiography (DSE) depending on the patient's clinical status, severity and type of valve disease. ESE combines exercise testing with two-dimensional grey scale and Doppler echocardiography during exercise. Thus, it provides objective assessment of symptomatic status (exercise test), as well as exercise-induced changes of a series of echocardiographic parameters (different depending on the valve disease type), which yield prognostic information in individual patients and help in a better treatment planning. DSE is useful in symptomatic patients with low-gradient aortic stenosis. It clarifies its severity and helps in assessing surgical risk in patients with severe disease and systolic dysfunction. It can be also used to test valve haemodynamics in asymptomatic patients with significant mitral stenosis unable to perform an exercise test or to test the left ventricle response, namely to test viability, in patients with ischaemic secondary mitral regurgitation. VSE has taught us that history taking, clinical examination and resting echocardiography give an 'incomplete picture' of the disease in patients presenting with a severe valve disease. Therefore, its use should be encouraged in such patients.

Machine-learning phenotypic classification of bicuspid aortopathy.

BACKGROUND: Bicuspid aortic valves (BAV) are associated with incompletely characterized aortopathy. Our objectives were to identify distinct patterns of aortopathy using machine-learning methods and characterize their association with valve morphology and patient characteristics. METHODS: We analyzed preoperative 3-dimensional computed tomography reconstructions for 656 patients with BAV undergoing ascending aorta surgery between January 2002 and January 2014. Unsupervised partitioning around medoids was used to cluster aortic dimensions. Group differences were identified using polytomous random forest analysis. RESULTS: Three distinct aneurysm phenotypes were identified: root (n = 83; 13%), with predominant dilatation at sinuses of Valsalva; ascending (n = 364; 55%), with supracoronary enlargement rarely extending past the brachiocephalic artery; and arch (n = 209; 32%), with aortic arch dilatation. The arch phenotype had the greatest association with right-noncoronary cusp fusion: 29%, versus 13% for ascending and 15% for root phenotypes (P < .0001). Severe valve regurgitation was most prevalent in root phenotype (57%), followed by ascending (34%) and arch phenotypes (25%; P < .0001). Aortic stenosis was most prevalent in arch phenotype (62%), followed by ascending (50%) and root phenotypes (28%; P < .0001). Patient age increased as the extent of aneurysm became more distal (root, 49 years; ascending, 53 years; arch, 57 years; P < .0001), and root phenotype was associated with greater male predominance compared with ascending and arch phenotypes (94%, 76%, and 70%, respectively; P < .0001). Phenotypes were visually recognizable with 94% accuracy. CONCLUSIONS: Three distinct phenotypes of bicuspid valve-associated aortopathy were identified using machine-learning methodology. Patient characteristics and valvular dysfunction vary by phenotype, suggesting that the location of aortic pathology may be related to the underlying pathophysiology of this disease.

Performance of a Simplified Dichotomous Phenotypic Classification of Bicuspid Aortic Valve to Predict Type of Valvulopathy and Combined Aortopathy.

BACKGROUND: A simplified classification of bicuspid aortic valve (BAV) morphology using only the orientation of fused cusps was recently proposed. The aim of this study was to test whether it is useful for showing an association with the type of valvulopathy or aortopathy. METHODS: BAV phenotype was retrospectively classified in 681 patients (mean age, 59 ± 12 years; 424 men) who underwent aortic valve surgery. Each BAV was classified using both dichotomous (right and left coronary cusp fusion [CCF] vs mixed cusp fusion [MCF]) and conventional methods, and its association with the dominant valvulopathy (aortic stenosis [AS] vs regurgitation) and concomitant aortic surgery was analyzed. Four cardiologists individually reviewed transthoracic echocardiographic images of 100 randomly selected patients to compare the feasibility and accuracy of the two classification methods. RESULTS: The frequencies of BAV CCF and MCF were 53% (n = 361) and 47% (n = 320), respectively. AS was the predominant cause of surgery (n = 546 [80%]), and concomitant aortic surgery was done in 31% (n = 214). Patients with BAV MCF showed a higher frequency of AS (89% vs 73%, P < .001) and aortic surgery (38% vs 26%, P < .001) than those with BAV CCF. There were independent associations between BAV MCF and AS (odds ratio, 3.32; 95% CI, 1.99-5.54; P < .001) as well as aortic surgery (odds ratio, 1.76; 95% CI, 1.26-2.45; P = .001). The feasibility of the classification methods did not differ, but dichotomous classification revealed higher accuracy than conventional (87% [95% CI, 84.1%-90.7%] vs 70% [95% CI, 65.0%-74.3%]) for all four examiners, with higher κ coefficients representing interrater agreement (κ = 0.73 ± 0.06 to 0.83 ± 0.06 [dichotomous method] vs 0.51 ± 0.06 to 0.73 ± 0.06 [conventional method]). CONCLUSIONS: The dichotomous classification method is useful for showing the association with the type of valvulopathy or aortopathy, with better diagnostic performance than the conventional method.

Valvular Heart Disease in Adults: Etiologies, Classification, and Diagnosis.

The prevalence of valvular heart disease (VHD) in the United States was estimated to be approximately 2.5% in the 1990s. The prevalence currently is thought to be increasing because of more accurate diagnostic methods and aging of the population. Mitral regurgitation (MR) is the most common valve defect, followed by aortic stenosis (AS) and aortic regurgitation (AR). Degenerative disease is the most common etiology of MR, AS, and AR, though these forms of VHD also can be caused by congenital valve defects, systemic inflammatory diseases, endocarditis, and many other conditions. Mitral stenosis, most often caused by rheumatic fever, is uncommon in the United States. When VHD is suspected, transthoracic echocardiography should be obtained first. Other tests, including transesophageal echocardiography, computed tomography scan, magnetic resonance imaging study, and cardiac catheterization, are used in special situations to obtain more detailed diagnostic information. Guidelines for VHD management recommend interval monitoring with echocardiography. The exact interval recommended depends on the severity of the valve dysfunction and whether the patient is symptomatic. Monitoring of asymptomatic patients is important because early intervention, when valve function worsens or symptoms develop, is associated with better outcomes.

Comprehensive 4-stage categorization of bicuspid aortic valve leaflet morphology by cardiac MRI in 386 patients.

Bicuspid aortic valve (BAV) disease is heterogeneous and related to valve dysfunction and aortopathy. Appropriate follow up and surveillance of patients with BAV may depend on correct phenotypic categorization. There are multiple classification schemes, however a need exists to comprehensively capture commissure fusion, leaflet asymmetry, and valve orifice orientation. Our aim was to develop a BAV classification scheme for use at MRI to ascertain the frequency of different phenotypes and the consistency of BAV classification. The BAV classification scheme builds on the Sievers surgical BAV classification, adding valve orifice orientation, partial leaflet fusion and leaflet asymmetry. A single observer successfully applied this classification to 386 of 398 Cardiac MRI studies. Repeatability of categorization was ascertained with intraobserver and interobserver kappa scores. Sensitivity and specificity of MRI findings was determined from operative reports, where available. Fusion of the right and left leaflets accounted for over half of all cases. Partial leaflet fusion was seen in 46% of patients. Good interobserver agreement was seen for orientation of the valve opening (κ = 0.90), type (κ = 0.72) and presence of partial fusion (κ = 0.83, p < 0.0001). Retrospective review of operative notes showed sensitivity and specificity for orientation (90, 93%) and for Sievers type (73, 87%). The proposed BAV classification schema was assessed by MRI for its reliability to classify valve morphology in addition to illustrating the wide heterogeneity of leaflet size, orifice orientation, and commissural fusion. The classification may be helpful in further understanding the relationship between valve morphology, flow derangement and aortopathy.

Quadricuspid aortic valve: a comprehensive review

Abstract Quadricuspid aortic valve (QAV) is a rare congenital heart disease. The functional status of QAV is predominantly a pure aortic regurgitation. Clinical manifestations of patients with a QAV depend on the functional status of the QAV and the associated disorders. Significant valvular regurgitation and (or) stenosis is often present with subsequent operation performed at the fifth to sixth decade of life. The functional status of QAV is predominantly regurgitant; whereas pure stenotic QAV can be as few as in only 0.7% of the patients. QAV is usually an isolated anomaly, but other congenital heart defects can be present in 18-32% of the patients. About one-fifth of them require a surgical operation. Tricuspidalization is a preferred technique for QAV repair. As not all the patients with a QAV necessarily warrant a surgical operation, decision-making in patient selection and surgical procedure of choice are crucial. Antibiotic prophylaxis against infective endocarditis is necessary in the QAV patients with unequal-sized cusps.

Fluoroscopic "heart chamber" anatomy - the case for imaging modality-independent terminology.

Interventional cardiologists have traditionally relied upon fluoro-scopic imaging for percutaneous coronary interventions. Transcatheter structural heart interventions, however, require additional imaging modalities such as echocardiography and multislice computed tomography (MSCT) for pre-, intra- and post-procedural assistance. MSCT has emerged as the critical imaging modality for patient and device selection prior to transcatheter structural heart interventions. MSCT is unique as it provides a complete 3-dimensional (3D) dataset of the heart and vasculature that is amenable to multiplanar reconstruction for 2-dimensional (2D) or volume-rendered interpretations. Herein, we present a modality-independent terminology for understanding volumetric images in the context of transcatheter heart valve therapies. The goal of this system is to allow physicians to readily interpret the orientation of fluoroscopic, MSCT, echocardiographic and MRI images, thus generalising their understanding of cardiac anatomy to all imaging modalities.

A Bicuspid Aortic Valve Imaging Classification for the TAVR Era.

OBJECTIVES: This study sought to evaluate transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve (BAV) aortic stenosis (AS), with a particular emphasis on TAVR-directed bicuspid aortic valve imaging (BAVi) of morphological classification. BACKGROUND: TAVR has been used to treat BAV-AS but with heterogeneous outcomes and uncertainty regarding the relevance of morphology. METHODS: In 14 centers in the United States, Canada, Europe, and Asia, 130 BAV-AS patients underwent TAVR. Baseline cardiac computed tomography (CT) was analyzed by a dedicated Corelab. Outcomes were assessed in line with Valve Academic Research Consortium criteria. RESULTS: Bicommissural BAV (vs. tricommissural) accounted for 68.9% of those treated in North America, 88.9% in Europe, and 95.5% in Asia (p = 0.003). For bicommissural bicuspids, non-raphe type (vs. raphe type) BAV accounted for 11.9% of those treated in North America, 9.4% in Europe, and 61.9% in Asia (p < 0.001). Overall rates of 30-day mortality (3.8%) and cerebrovascular events (3.2%) were favorable and similar among anatomical subsets. The rate of new permanent pacemaker insertion was high (26.2%) and similar between balloon-expandable (BE) and self-expanding (SE) designs (BE: 25.5% vs. SE: 26.9%; p = 0.83); there was a trend to greater permanent pacemaker insertion in BE TAVR in the presence of coronary cusp fusion BAV morphology. Paravalvular aortic regurgitation (PAR) ≥ moderate was 18.1% overall but lower at 11.5% in those with pre-procedural CT. In the absence of pre-procedural CT, there was an excess of PAR in BE TAVR that was not the case in those with a pre-procedural CT; SE TAVR required more post-dilation. Predictors of PAR included intercommissural distance for bicommissural bicuspids (odd ratio [OR]: 1.37; 95% confidence interval [CI]: 1.02 to 1.84; p = 0.036) and lack of a baseline CT for annular measurement (OR: 3.03; 95% CI: 1.20 to 7.69; p = 0.018). CONCLUSIONS: In this multicenter study, TAVR achieved favorable outcomes in patients with pre-procedural CT, with the exception of high permanent pacemaker rates for all devices and shapes.

Prevalence and correlates of valvular heart diseases in the elderly population in Hubei, China.

We sought to determine the prevalence and correlates of valvular heart diseases (VHD) in the elderly population. The participants' personal information, medical history, behavioral habits and clinical status were assessed by questionnaire, while the left ventricular dimensions, function and the presence and severity of VHD were evaluated by transthoracic echocardiography. This study analyzed the data of 3948 participants who were older than 60 years. Significant VHD was present in 1.93% of participants; the standardized prevalence of VHD among the elderly population in Hubei was 2.05% (95% CI: 1.61-2.49). The most frequent VHD was aortic regurgitation, followed by tricuspid regurgitation, mitral regurgitation and multiple valve diseases. Univariate analysis results indicated that compared with participants without VHD, those with VHD were older (p < 0.001), with a higher body mass index (BMI) (p < 0.001), were more likely to smoke (p = 0.04), and had higher rates of coronary artery disease (CAD) (p < 0.001) and arrhythmia (p < 0.001). The results of multinomial regression analysis of complex sampling indicated that combined mitral and aortic valve diseases were related to older age, male sex and smoking; CAD was associated with single left-sided VHD.

Quadricuspid Aortic Valve: A Comprehensive Review.

Quadricuspid aortic valve (QAV) is a rare congenital heart disease. The functional status of QAV is predominantly a pure aortic regurgitation. Clinical manifestations of patients with a QAV depend on the functional status of the QAV and the associated disorders. Significant valvular regurgitation and (or) stenosis is often present with subsequent operation performed at the fifth to sixth decade of life. The functional status of QAV is predominantly regurgitant; whereas pure stenotic QAV can be as few as in only 0.7% of the patients. QAV is usually an isolated anomaly, but other congenital heart defects can be present in 18-32% of the patients. About one-fifth of them require a surgical operation. Tricuspidalization is a preferred technique for QAV repair. As not all the patients with a QAV necessarily warrant a surgical operation, decision-making in patient selection and surgical procedure of choice are crucial. Antibiotic prophylaxis against infective endocarditis is necessary in the QAV patients with unequal-sized cusps.

Routine initial exercise stress testing for treatment stratification in comprehensive cardiac rehabilitation.

There is evidence of substantial benefit of cardiac rehabilitation (CR) for patients with low exercise capacity at admission. Nevertheless, some patients are not able to perform an initial exercise stress test (EST). We aimed to describe this group using data of 1094 consecutive patients after a cardiac event (71±7 years, 78% men) enrolled in nine centres for inpatient CR. We analysed sociodemographic and clinical variables (e.g. cardiovascular risk factors, comorbidities, complications at admission), amount of therapy (e.g. exercise training, nursing care) and the results of the initial and the final 6-min walking test (6MWT) with respect to the application of an EST. Fifteen per cent of patients did not undergo an EST (non-EST group). In multivariable analysis, the probability of obtaining an EST was higher for men [odds ratio (OR) 1.89, P=0.01], a 6MWT (per 10 m, OR 1.07, P<0.01) and lower for patients with diabetes mellitus (OR 0.48, P<0.01), NYHA-class III/IV (OR 0.27, P<0.01), osteoarthritis (OR 0.39, P<0.01) and a longer hospital stay (per 5 days, OR 0.87, P=0.02). The non-EST group received fewer therapy units of exercise training, but more units of nursing care and physiotherapy than the EST group. However, there were no significant differences between both groups in the increase of the 6MWT during CR (123 vs. 108 m, P=0.122). The present study confirms the feasibility of an EST at the start of CR as an indicator of disease severity. Nevertheless, patients without EST benefit from CR even if exercising less. Thus, there is a justified need for individualized, comprehensive and interdisciplinary CR.

Structure and function of the tricuspid and bicuspid regurgitant aortic valve: an echocardiographic study.

OBJECTIVES: The emerging new treatment options for aortic valve disease call for more sophisticated diagnostics. We aimed to describe the echocardiographic pathophysiology and characteristics of the purely regurgitant aortic valve in detail. METHODS: Twenty-nine men, with chronic aortic regurgitation without concomitant heart disease referred for aortic valve intervention, underwent 2D transoesophageal echocardiographic (TEE) examination prior to surgery according to a previously published matrix. Measurements of the aortic valve apparatus in long and short axis view were made in systole and diastole and analysed off-line. The aortic valves were grouped as tricuspid (TAV) or bicuspid (BAV), and classified by regurgitation mechanism. RESULTS: Twenty-four examinations were eligible for analysis of which 13 presented TAV and 11 BAV. The regurgitation mechanism was classified as dilatation of the aorta in 6 cases, as prolapse in 11 cases and as poor cusp tissue quality or quantity in 7 cases. The ventriculo-aortic junction (VAJ) and valve opening were closely related (TAV r = 0.5, BAV r = 0.73) but no correlation was found between the VAJ and the maximal sinus diameter (maxSiD) or the sinotubular junction (STJ). However, the STJ and maxSiD were significantly related (TAV vs BAV: systole r = 0.9, r = 0.8; diastole r = 0.9, r = 0.7), forming an entity. The conjoined BAV cusps were shorter than the anterior cusps when closed (P = 0.002); the inter-commissural distances of the cusps in the BAV group were significantly different (P = 0.001 resp. 0.03) in both systole and diastole. CONCLUSIONS: The VAJ was independent of other aortic dimensions and should thereby be considered as a separate entity with influence on valve opening. The detailed 2D TEE measurements of this study add further important information to our knowledge about the function and echocardiographic anatomy of the pathological aortic valve and root either as a stand-alone examination or as a benchmark and complement to 3D echocardiography. This may have an impact on decisions regarding repairability of the native aortic valve.

Food and Drug Administration criteria for the diagnosis of drug-induced valvular heart disease in patients previously exposed to benfluorex: a prospective multicentre study.

AIMS: The Food and Drug Administration (FDA) criteria for diagnosis of drug-induced valvular heart disease (DIVHD) are only based on the observation of aortic regurgitation ≥ mild and/or mitral regurgitation ≥ moderate. We sought to evaluate the diagnostic value of FDA criteria in a cohort of control patients and in a cohort of patients exposed to a drug (benfluorex) known to induce VHD. METHODS AND RESULTS: This prospective, multicentre study included 376 diabetic control patients not exposed to valvulopathic drugs and 1000 subjects previously exposed to benfluorex. Diagnosis of mitral or aortic DIVHD was based on a combined functional and morphological echocardiographic analysis of cardiac valves. Patients were classified according to the FDA criteria [mitral or aortic-FDA(+) and mitral or aortic-FDA(-)]. Among the 376 control patients, 2 were wrongly classified as mitral-FDA(+) and 17 as aortic-FDA(+) (0.53 and 4.5% of false positives, respectively). Of those exposed to benfluorex, 48 of 58 with a diagnosis of mitral DIVHD (83%) were classified as mitral-FDA(-), and 901 of the 910 patients (99%) without a diagnosis of the mitral DIVHD group were classified as mitral-FDA(-). All 40 patients with a diagnosis of aortic DIVHD were classified as aortic-FDA(+), and 105 of the 910 patients without a diagnosis of aortic DIVHD (12%) were classified aortic-FDA(+). Older age and lower BMI were independent predictors of disagreement between FDA criteria and the diagnosis of DIVHD in patients exposed to benfluorex (both P ≤ 0.001). CONCLUSIONS: FDA criteria solely based on the Doppler detection of cardiac valve regurgitation underestimate for the mitral valve and overestimate for the aortic valve the frequency of DIVHD. Therefore, the diagnosis of DIVHD must be based on a combined echocardiographic and Doppler morphological and functional analysis of cardiac valves.

The definition of valvular and non-valvular atrial fibrillation: results of a physicians' survey.

AIMS: To assess different aspects of the definition of valvular/non-valvular atrial fibrillation (AF) used in clinical practice by physicians who usually treat this condition. METHODS AND RESULTS: We prospectively conducted a web-based survey including cardiologists and internists who attended continuing medical education courses on cardiovascular medicine. A questionnaire was drawn up, containing 17 questions clustered into five main topics: (A) known rheumatic aetiology; (B) site/type of valve involvement; (C) prosthetic heart valve; (D) haemodynamic relevance; (E) miscellaneous. The overall response rate was 22.4% (21.1% for cardiologists and 24% for internists). Coexistence of both medical history of rheumatic disease and clinical signs of valvular involvement were considered as essential prerequisites for the diagnosis of rheumatic AF by half of the respondents, and one-third assumed that lone aortic valve disease was sufficient for AF to be defined as valvular. A similar proportion of respondents considered that in the presence of mitral regurgitation, AF had to be defined as valvular. The majority of responding physicians considered the degree of valvular defect of lesser importance for the definition of valvular or non-valvular origin of AF. CONCLUSION: We found important heterogeneity and uncertainties in the answers given by physicians who usually treat patients with AF, as evidence of the lack of precise and unique definitions of the origin of AF (valvular/non-valvular). It is urgent to issue clear widely accepted definitions of the origin of AF, which should improve clinical practice and research.