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 Cardiology

• Published in: European journal of heart failure Vol. 25; no. 7; pp. 1025 - 1048
• Main Authors: Chioncel, Ovidiu, Adamo, Marianna, Nikolaou, Maria, Parissis, John, Mebazaa, Alexandre, Yilmaz, Mehmet Birhan, Hassager, Christian, Moura, Brenda, Bauersachs, Johann, Harjola, Veli‐Pekka, Antohi, Elena‐Laura, Ben‐Gal, Tuvia, Collins, Sean P., Iliescu, Vlad Anton, Abdelhamid, Magdy, Čelutkienė, Jelena, Adamopoulos, Stamatis, Lund, Lars H., Cicoira, Mariantonietta, Masip, Josep, Skouri, Hadi, Gustafsson, Finn, Rakisheva, Amina, Ahrens, Ingo, Mortara, Andrea, Janowska, Ewa A., Almaghraby, Abdallah, Damman, Kevin, Miro, Oscar, Huber, Kurt, Ristic, Arsen, Hill, Loreena, Mullens, Wilfried, Chieffo, Alaide, Bartunek, Jozef, Paolisso, Pasquale, Bayes‐Genis, Antoni, Anker, Stefan D., Price, Susanna, Filippatos, Gerasimos, Ruschitzka, Frank, Seferovic, Petar, Vidal‐Perez, Rafael, Vahanian, Alec, Metra, Marco, McDonagh, Theresa A., Barbato, Emanuele, Coats, Andrew J.S., Rosano, Giuseppe M.C.
• Format: Journal Article
• Language: English
• Published: Oxford, UK John Wiley & Sons, Ltd 01.07.2023
• Subjects: Acute heart failure; Management; Medicin och hälsovetenskap; Valvular heart disease; Valvular heart disease; Acute heart failure; Management
• ISSN: 1388-9842; 1879-0844; 1879-0844
• DOI: 10.1002/ejhf.2918

Acute heart failure (AHF) represents a broad spectrum of disease states, resulting from the interaction between an acute precipitant and a patient's underlying cardiac substrate and comorbidities. Valvular heart disease (VHD) is frequently associated with AHF. AHF may result from several precipitants that add an acute haemodynamic stress superimposed on a chronic valvular lesion or may occur as a consequence of a new significant valvular lesion. Regardless of the mechanism, clinical presentation may vary from acute decompensated heart failure to cardiogenic shock. Assessing the severity of VHD as well as the correlation between VHD severity and symptoms may be difficult in patients with AHF because of the rapid variation in loading conditions, concomitant destabilization of the associated comorbidities and the presence of combined valvular lesions. Evidence‐based interventions targeting VHD in settings of AHF have yet to be identified, as patients with severe VHD are often excluded from randomized trials in AHF, so results from these trials do not generalize to those with VHD. Furthermore, there are not rigorously conducted randomized controlled trials in the setting of VHD and AHF, most of the data coming from observational studies. Thus, distinct to chronic settings, current guidelines are very elusive when patients with severe VHD present with AHF, and a clear‐cut strategy could not be yet defined. Given the paucity of evidence in this subset of AHF patients, the aim of this scientific statement is to describe the epidemiology, pathophysiology, and overall treatment approach for patients with VHD who present with AHF. Assessing severity of acute heart failure (AHF) in parallel with evaluation of the aetiology, mechanism and severity of valvular heart disease (VHD). Management follows Heart Team discussion to decide emergency/urgent/elective interventions or palliation. Three possible scenarios should be considered. First, if there is no emergent indication to intervention, patients must receive medical therapy (MT). MT may be appropriate as bridge to early in‐hospital or elective intervention or as destination therapy if intervention is contraindicated because of the comorbidities. Second, patients presenting with cardiogenic shock or AHF refractory to medical treatment require interventions on an urgent/emergency basis, when VHD represents the main contributor to the immediate life‐threatening haemodynamic deterioration. Third, early use of percutaneous mechanical circulatory support (MCS) may help bridge patients to a decision of delayed VHD repair, left ventricular assist device (LVAD) and/or heart transplantation (HTX). The second and third scenarios are more likely to be considered as patients with AHF and VHD may require emergent surgery, especially in case of valve endocarditis or acute aortic regurgitation caused by aortic dissection or acute mitral regurgitation caused by papillary muscle rupture. ACS, acute coronary syndrome; AF, atrial fibrillation; AMI, acute myocardial infarction; CIED, cardiac implantable electronic device; PE, pulmonary embolism; RV, right ventricular. *AHF phenotypes: cardiogenic shock, acute pulmonary oedema, acute decompensated heart failure; right heart failure.