Valvular Heart Disease: Evidence-Based Practice Update (NEJM 2026) Valvular_Heart_Disease.pdf
Valvular Heart Disease: Evidence-Based Practice Update (NEJM 2026) Valvular_Heart_Disease.pdf
Source: NEJM Group. Valvular Heart Disease: Evidence-Based Practice Update. Received via NEJM email on 14 July 2026.
Tricuspid Regurgitation (TR):
* TR is no longer considered the “forgotten valve”; severe TR is independently associated with increased mortality.
* Early diagnosis is essential, as symptoms are often mistaken for normal aging or right heart failure.
* Secondary TR accounts for ~80% of cases, while primary TR represents only 5–10%. Valvular_Heart_Disease.pdf
* Secondary TR is classified into:
* Atrial TR: annular/right atrial dilation (often AF, HFpEF).
* Ventricular TR: RV remodeling from pulmonary hypertension or RV disease.
* CIED-related TR: pacemaker/ICD lead interference.
* Echocardiography remains the first-line imaging modality; cardiac MRI and CT are increasingly important for quantification and transcatheter planning.
* For patients considered for transcatheter intervention, advanced TR is graded as severe (3+), massive (4+), or torrential (5+) to better define disease severity and assess treatment outcomes.
* Medical therapy focuses on diuretics and treatment of the underlying cause; rhythm control for AF may reduce TR severity.
* Surgery is recommended when severe TR accompanies left-sided valve surgery; transcatheter therapies are expanding for high-risk patients.
Secondary Mitral Regurgitation:
* Optimize guideline-directed medical therapy (GDMT) before intervention.
* Heart Team evaluation is essential.
* TEER is recommended for selected symptomatic patients despite optimal medical therapy.
* The landmark COAPT trial enrolled patients with LVEF 20–50%. Patient selection for TEER should always be individualized by a multidisciplinary Heart Team.
Asymptomatic Severe Aortic Stenosis
* Two management strategies have been evaluated: early intervention (TAVR or SAVR) versus clinical surveillance.
* EARLY-TAVR (2025): Early TAVR reduced the composite of death, stroke, or unplanned cardiovascular hospitalization compared with clinical surveillance.
* AVATAR 10-year follow-up (2026): Early surgical AVR improved long-term outcomes compared with conservative management.
*The decision to intervene, and the choice of TAVR or SAVR, should remain individualized by the Heart Team, considering age, surgical risk, life expectancy, valve anatomy, comorbidities, and patient preferences.
TAVR vs SAVR
* Seven-year follow-up (2025): Both TAVR and SAVR demonstrated durable long-term outcomes.
* Treatment choice should be individualized based on:
* Age and life expectancy.
* Surgical risk.
* Valve anatomy.
* Need for concomitant cardiac surgery.
* Patient preferences.
Practical Messages
* Earlier recognition and referral improve outcomes across valvular diseases.
* Multimodality imaging is increasingly central to diagnosis and procedural planning.
* Management should be individualized through a multidisciplinary Heart Team.
* Transcatheter valve therapies continue to expand beyond aortic stenosis into mitral and tricuspid disease.
