The Culprit Valve: A New Concept for Reducing the Risk of Intervention in Patients with Severe Valve Disease

In clinical practice, it is not unusual to come across two relatively serious clinical conditions that occur concomitantly and may justify the patient’s symptoms. For example, associations between aortic stenosis and coronary artery disease, or between aortic stenosis and primary or secondary mitral regurgitation, both moderate to severe, are common in the real world. In the case of patients with low surgical risk, combined treatment is a consensus at the time of surgical intervention despite the consequences of these combined procedures, such as increased cardiovascular morbidity and mortality. For example, aortic valve (AV) replacement, when combined with coronary artery bypass graft surgery, increases the risk of mortality by almost twofold, just as AV replacement, when combined with mitral valve (MiV) surgery, increases this risk by more than threefold. However, in patients with high perioperative risk, especially when a less invasive isolated procedure can be used, the decision to indicate a broader treatment but with higher morbidity and mortality versus an isolated treatment but with lower morbidity and mortality is not trivial.

Recently, in Heart Team (HT) discussions, thanks to the advent of AV treatment by transcatheter aortic valve implantion (TAVI) or even MiV “edge-to-edge” repair and “valve in valve” procedure, the idea that the isolated treatment of the most severe lesion, which is likely the main cause of the patient’s symptoms, can optimize the patient’s outcome, reducing the expected morbidity and mortality and substantially improving the patient’s quality of life, has gained momentum.

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