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Secondary mitral regurgitation, which results from left ventricular dysfunction or remodeling or atrial disease, is associated with adverse cardiovascular outcomes. Treatment includes guideline-directed medical therapy for heart failure, if present, and in some cases, surgery or transcatheter intervention.

The past two decades have witnessed a renaissance in the evaluation and treatment of patients with valvular heart disease, catalyzed by advances in surgical innovation, transcatheter techniques, and multimodality cardiac imaging. Transcatheter aortic-valve replacement (TAVR) has been accepted as a reasonable alternative to surgical aortic-valve replacement for the treatment of older patients with severe aortic stenosis; mitral transcatheter edge-to-edge repair (M-TEER) can be safely and effectively used to treat select patients with primary or secondary mitral regurgitation. Tricuspid regurgitation has been a more recent focus of intense clinical investigation. New systems for classifying the cause and severity of tricuspid regurgitation . . .

The assessment and management of tricuspid valve disease have evolved substantially during the past several years. Whereas tricuspid stenosis is uncommon, tricuspid regurgitation is frequently encountered and is most often secondary in nature and caused by annular dilatation and leaflet tethering from adverse right ventricular remodelling in response to any of several disease processes. Non-invasive assessment of tricuspid regurgitation must define its cause and severity; advanced three-dimensional echocardiography, MRI, and CT are gaining in clinical application. The indications for tricuspid valve surgery to treat tricuspid regurgitation are related to the cause of the disorder, the context in which it is encountered, its severity, and its effects on right ventricular function. Most operations for tricuspid regurgitation are done at the time of left-sided heart valve surgery. The threshold for restrictive ring annuloplasty repair of secondary tricuspid regurgitation at the time of left-sided valve surgery has decreased over time with recognition of the risk of progressive tricuspid regurgitation and right heart failure in patients with moderate or lesser degrees of tricuspid regurgitation and tricuspid annular dilatation, as well as with appreciation of the high risks of reoperative surgery for severe tricuspid regurgitation late after left-sided valve surgery. However, many patients with unoperated severe tricuspid regurgitation are also deemed at very high or prohibitive surgical risk. Novel transcatheter therapies have begun to emerge for the treatment of tricuspid regurgitation in such patients. Experience with such therapies is preliminary and further studies are needed to determine their role in the management of this disorder.

In a randomized trial involving patients undergoing mitral-valve surgery for degenerative mitral regurgitation, the addition of tricuspid repair resulted in a lower risk of the primary outcome, a composite of reoperation for tricuspid regurgitation, progression of tricuspid regurgitation, or death. Tricuspid repair resulted in more frequent permanent pacemaker implantation.

This clinical trial compared mitral-valve repair with replacement for severe ischemic mitral regurgitation. There were no significant between-group differences in left ventricular remodeling and clinical outcomes, but replacement was associated with more durable correction. Functional ischemic mitral regurgitation affects 1.6 million to 2.8 million patients in the United States and is associated with a doubling in mortality among patients with mild or greater degrees of mitral regurgitation after myocardial infarction. 1 – 3 Ischemic mitral regurgitation is a consequence of adverse left ventricular remodeling after myocardial injury with enlargement of the left ventricular chamber and mitral annulus, apical and lateral migration of the papillary muscles, leaflet tethering, and reduced closing forces. These processes lead to malcoaptation of the leaflets and variable degrees of mitral regurgitation that can fluctuate dynamically as a function of volume status, afterload, . . .

A 55-year-old man had an out-of-hospital cardiac arrest. An evaluation showed 2-mm ST-segment elevations in the inferior leads on electrocardiography, cardiogenic shock, and a new systolic murmur. A diagnosis was made.

Asymptomatic severe aortic stenosis (AS) poses a clinical challenge with variations in recommendations for management. We sought to compare contemporary guidelines focusing on asymptomatic AS management and present a summary of contemporary studies on early intervention in these patients. Systematic search of electronic databases was conducted with guidelines analyzed using a comparative matrix. A pooled random-effects meta-analysis of randomized controlled trial (RCT) data comparing intervention versus clinical surveillance in asymptomatic severe AS was also performed. Four guidelines from ACC/AHA, ESC/EACTS, JCS/JSCS/JATS/JSVS, and NICE were included encompassing 108 recommendations. Consensus was found for intervention thresholds including left ventricular dysfunction and very severe AS while discrepancies existed in the utility of biomarkers, myocardial fibrosis, exercise stress testing and choice of intervention. Despite variation in study inclusion criteria, current RCTs on the management of asymptomatic AS indicated a significant reduction in rates of major adverse cardiovascular events when comparing early intervention to clinical surveillance (hazard ratio [HR] 0.52 [0.42, 0.63]), driven primarily by reductions in unplanned hospitalizations (HR 0.41 [0.32, 0.52]). While there is broad consensus on classic indicators of severity such as left ventricular dysfunction as indication for intervention, guidelines diverge on other high-risk features warranting intervention. Early studies indicate the overall safety of early intervention, although further work is needed to identify whether it can reduce the risk of hard clinical endpoints. This underscores the need for further research and updated guidelines to clarify the optimal thresholds for intervention and harmonize treatment pathways for the growing number of patients with asymptomatic AS.

In this trial, patients with atrial fibrillation undergoing mitral-valve surgery were assigned to surgical ablation of AF or no ablation. At 6 and 12 months, more patients in the ablation group were free from AF, but more patients in that group required permanent pacemakers. Atrial fibrillation, which is associated with reduced survival and increased risk of stroke, is present in 30 to 50% of patients presenting for mitral-valve surgery. 1 , 2 The development of open surgical procedures for the ablation of atrial fibrillation has led to their widespread application during cardiac operations, but their effectiveness and safety have not been rigorously established. It is hypothesized that long-term outcomes can be improved by successful ablation in patients with preexisting persistent or long-standing persistent atrial fibrillation who are undergoing mitral-valve surgery. The Cox maze III operation (sometimes called the “cut-and-sew” maze operation) is a complex surgical procedure . . .

A 27-year-old man presented to the emergency department with a 5-day history of fevers. Test your diagnostic and therapeutic skills at NEJM.org. A 27-year-old man presented to the emergency department with a 5-day history of fevers. One week before presentation, he began to have congestion, rhinorrhea, cough, and fatigue after exposure to a coworker who had an upper respiratory infection. At the same time, he noted an oral ulcer, which subsequently resolved. He then had fevers, . . .

Abstract Background Mitral valve (MV) repair or replacement surgery is indicated for a variety of conditions. Although uncommon, damage to the left circumflex (LCx) coronary artery, which courses in close proximity to the MV annulus, is a devastating complication. Case summary This report describes the case of a 63-year-old woman following re-operative MV replacement. Shortly after being transferred to the surgical intensive care unit after MV replacement, her EKG was notable for persistent inferolateral ST-segment elevations and reciprocal ST-segment depressions. Emergency transthoracic echocardiogram revealed a reduced left ventricular ejection fraction of 35–40% and mid to distal lateral wall motion hypokinesis. She was emergently taken to the cardiac catheterization laboratory where coronary angiography demonstrated complete occlusion of her mid LCx artery. She underwent urgent percutaneous coronary intervention of the lesion and was started on dual antiplatelet treatment, anticoagulation for comorbid atrial fibrillation, as well as guideline directed medical therapy with improvement in her EKG changes and cardiac function. Conclusion Prompt diagnosis and recognition of LCx injury is crucial. Management involves immediate percutaneous recanalization or surgical coronary bypass grafting.