Tastet, Lionel

Abstract Valvular heart disease represents a significant global health burden, with an estimated prevalence of 2.5% in high-income countries and projected increases due to population ageing. Randomized controlled trials in valvular heart disease have undergone substantial evolution, shifting from mortality-focused endpoints toward comprehensive assessments integrating imaging parameters and patient-centered outcomes. Cardiovascular imaging modalities, including echocardiography, cardiac computed tomography, and cardiac magnetic resonance, have become pivotal in trial design, patient selection, and endpoint definition. Recent landmark trials in aortic stenosis, including EARLY-TAVR and EVOLVED, have challenged traditional symptom-based intervention thresholds by incorporating imaging biomarkers of subclinical myocardial dysfunction and cardiac damage staging. In aortic regurgitation, the paucity of randomized controlled trials evidence contrasts with emerging transcatheter technologies, highlighting critical knowledge gaps. Mitral regurgitation trials have demonstrated the importance of patient phenotyping, with divergent outcomes between COAPT and MITRA-FR emphasizing the role of imaging in optimal patient selection. The recent TRILUMINATE and TRISCEND trials have transformed tricuspid regurgitation management through transcatheter interventions, prioritizing quality-of-life improvements alongside traditional clinical endpoints. Future directions include standardization of imaging protocols across modalities, development of artificial intelligence-enhanced analysis, and integration of multiparametric biomarkers for personalized risk stratification. The paradigm shift toward imaging-guided, patient-centered trial design represents a fundamental reimagining of therapeutic success in valvular heart disease, moving beyond procedural outcomes toward comprehensive assessment of clinical benefit and improved patient care.

Abstract Aims This study aims to describe the prevalence of discordant mild/moderate aortic stenosis (AS) in a population-based study and to identify the mechanisms that lead to reduced stroke volume (SV) and discordant moderate AS. Methods and results Discordant high-gradient (HG)-mild AS, defined as AVA > 1.5 cm2 and mean pressure gradient (MG) of 20–40 mmHg, and discordant low-gradient (LG) moderate AS, defined as AVA 1.0–1.5 cm2 and MG < 20 mmHg, were assessed in 883 individuals from the DANCAVAS screening study with aortic valve calcification and 257 individuals form the PROGRESSA study excluding those with left ventricular (LV) ejection fraction < 50%. In the DANCAVAS cohort, 150 men had mild/moderate AS of which 34% had discordance between MG and AVA, representing 66% with moderate AS. Among 262 patients in the combined cohort, 39% had discordant LG-moderate AS and 6% discordant HG-mild AS. Compared with concordant mild and moderate AS, individuals with discordant LG-moderate AS were more likely to present with LV concentric remodelling geometry (26 vs. 33 vs. 45%, P < 0.001), increased valvulo-arterial impedance (3.3 ± 0.7 vs. 3.6 ± 0.5 vs. 4.1 ± 0.7 mmHg/mL/m2, P < 0.001), and reduced systemic arterial compliance (SAC) (0.74 ± 0.22 vs. 0.81 ± 0.22 vs. 0.64 ± 0.18 mL/m2/mmHg, P < 0.001). Factors associated with SV index were relative wall thickness, LV end-diastolic diameter index, SAC, and LV remodelling pattern. Conclusion Discordant moderate AS is common, accounting for two-thirds of patients with moderate AS in the general male population. Patients with discordant LG-moderate AS have predominantly a concentric remodelling pattern with reduced SV. Reduced SV index was associated with signs of reduced vascular compliance, suggesting that altered vascular properties drive differences in remodelling patterns and discordant moderate AS.