The evolution of valvular management: from surgical dogma to multidisciplinary integration
The management of valvular heart disease has undergone, in two decades, a more radical transformation than during the previous half-century. Faced with an increasing prevalence linked to aging populations, the paradigm of systematic open-heart surgery has given way to a complex range of options: minimally invasive repairs, transcatheter implantations, or hybrid strategies. The challenge for the practitioner is no longer only technical, but decisional, requiring precise planning supported by increasingly sophisticated imaging.
The objective of this Research Topic, gathering ten scientific contributions, is to evaluate the current trajectory of the discipline by focusing on the measurable benefit for the patient. The authors analyse whether these innovations — whether new surgical approaches or repair devices — offer real reproducibility in routine clinical practice, beyond the results obtained in restricted expertise centres.
The central hypothesis suggests that the value of a technique lies not in its intrinsic complexity, but in its ability to improve survival, reduce the reoperation rate, and accelerate recovery. This synthesis explores the necessary synergy between surgical technique, long-term risk stratification, and anatomical foundations to achieve personalized and sustainable valvular medicine.
Structure and scope of the Research Topic
This editorial synthesises ten scientific articles selected to illustrate the current trajectory of valvular therapies. The corpus does not constitute a single experimental study, but a review of clinical and translational data organised around four major axes:
- Reconstructive surgery: Comparison of the total endoscopic approach versus conventional minimally invasive surgery, and evaluation of 5-year results of a modified technique for artificial chordae sizing (Nasso et al.).
- Transcatheter and hybrid approaches: Analysis of propensity score-matched single-center data comparing hemodynamic performance (SAPIEN 3 Ultra RESILIA valve), evaluation of TAVR+PCI versus SAVR+CABG in patients with multiple comorbidities, and study of post-mitral repair thrombotic risk under atrial fibrillation (Zhu et al.).
- Risk stratification and durability: 5-year follow-up of the Dafodil pericardial bioprosthesis, measurement of left atrial strain as a predictive biomarker, and trade-off between repair and replacement in rheumatic mitral disease (Hou et al.).
- Imaging and translational foundations: Evolution from 3D scanner to 4D photon-counting CT, complemented by a comparative study of aortic root anatomy between animal models and humans.
The authors state that artificial intelligence is limited here to imaging quantification, excluding any autonomous decision-making application.
Synthesis of advances: from surgical technique to transcatheter innovation
The contributions gathered in this review highlight a transition towards more personalized approaches, supported by long-term follow-ups and high-precision imaging. The authors report evidence on device durability and the optimization of care pathways.
| Field of study | Authors (Year) | Key Results & Observations |
|---|---|---|
| Mitral Surgery | Nasso et al. (2025) | 5-year follow-up validating a modified technique for sizing artificial chordae for anterior leaflet repair. |
| Bioprostheses | Hiremath et al. (2025) | 5-year clinical results confirming the durability of the Dafodil pericardial bioprosthesis. |
| TAVI / TAVR | Krishnareddigari et al. (2026) | Superiority of the SAPIEN 3 Ultra RESILIA valve (propensity score-matched data) on hemodynamic performance and reduction of paravalvular leaks. |
| Dynamic Imaging | Pouch et al. (2025) | Technological transition from 3D scanner to 4D photon-counting CT, allowing for dynamic characterization of the valve. |
Clinical performance and risk stratification
The analysis of hybrid strategies and new prognostic markers provides essential insights for decision-making within the Heart Team:
- TAVR+PCI vs SAVR+CABG Comparison: The study by Fang et al. (2026) highlights the effectiveness of combined transcatheter approaches in patients with concomitant aortic stenosis and coronary artery disease, both in the short and long term.
- New predictors: Chen et al. (2025) demonstrate that left atrial strain is established as a robust predictive parameter of clinical outcomes in significant aortic valve diseases, complementing conventional risk scores.
- Preclinical models: Strauss et al. warn against anatomical discrepancies between the aortic root of large animal models and that of humans, a critical factor for the validation of future devices.
Qualitative observations and technological limitations
Notable fact: despite the technological excitement, the authors highlight the absence of mature clinical applications of artificial intelligence for autonomous decision-making in this series. The digital contribution remains currently confined to the quantification and interpretation of imaging. Furthermore, the management of antithrombotic treatment after transcatheter mitral repair in patients with atrial fibrillation remains a point of vigilance, as the balance between thrombotic and bleeding risks is not yet consensual (Zhu et al., 2026).
Analysis of advancements and clinical integration
This synthesis of recent work highlights a major transition: the shift from the hegemony of open-heart surgery towards a hybrid model where advanced imaging dictates the therapeutic choice. The data reported by Krishnareddigari et al. on the SAPIEN 3 Ultra RESILIA valve confirm this trend, showing a reduction in paravalvular leaks and improved hemodynamic performance, thereby narrowing the gap with conventional surgical bioprostheses. However, the expansion of TAVI to younger and lower-risk populations necessitates increased rigor in the evaluation of long-term durability, as illustrated by the five-year follow-ups of the Dafodil bioprosthesis.
Technically, the debate between the conventional minimally invasive approach and the fully endoscopic technique (Theodosiadis et al.) shows that increased procedural complexity must imperatively translate into a tangible benefit in terms of recovery. Imaging is also reaching a new milestone with the transition from 3D scanning to photon-counting 4D CT (Pouch et al.), allowing for dynamic valve characterization essential for hybrid planning. A crucial point of vigilance is raised by Strauss et al.: the aortic root anatomy of large animal models differs significantly from humans, which could bias the validation of new devices.
Limits and perspectives
The main finding of this review is the lack of mature artificial intelligence applications for autonomous clinical decision-making, with AI remaining confined to imaging quantification. Furthermore, the management of antibiotic therapy after transcatheter mitral repair in patients with atrial fibrillation remains a therapeutic gray area. Finally, the choice between repair and replacement in rheumatic disease remains unresolved, highlighting that technological innovation does not yet replace clinical judgment in complex pathologies.
In concrete terms, for the practitioner:
- Decision-making optimization: Systematically integrate left atrial strain and 4D CT imaging into your planning to refine risk stratification, beyond conventional clinical scores.
- Technical arbitration: For mitral repairs, 5-year durability depends on surgical precision, particularly the rigorous calibration of artificial chords, regardless of the level of minimal-invasiveness (endoscopic or conventional).
- Preclinical vigilance: When evaluating new devices, keep in mind that the anatomy of the aortic root in animal models diverges significantly from that of humans, requiring caution during initial clinical transposition.
Technical lexicon
SAPIEN 3 Ultra RESILIA: Latest generation of transcatheter aortic valve (TAVI) designed to improve haemodynamic performance and reduce paravalvular leak complications.
4D photon-counting CT: Scanner imaging technology allowing for increased spatial resolution and dynamic (temporal) visualization of the valve, facilitating the understanding of its kinetics.
Left atrial strain: Echographic measurement of left atrial myocardial deformation, used as a predictive marker for clinical evolution and cardiac dysfunction.
Artificial chordae: Synthetic sutures (generally made of ePTFE) used in mitral repair surgery to replace ruptured or elongated natural chordae.
Paravalvular leak: Abnormal passage of blood between the wall of the cardiac annulus and the prosthetic valve structure, often targeted by design innovations in transcatheter valves.
Dafodil Bioprosthesis: Specific type of pericardial valve prosthesis whose clinical durability is evaluated over the long term (5 years in the cited studies).
Source
- Original title: Editorial: Future of heart valve surgery: enhancing outcomes with innovative technologies
- Authors: Omer Dzemali, Theodor Fischlein, Héctor Rodríguez Cetina Biefer
- Publication: Frontiers in Cardiovascular Medicine - 2026-09-04
- DOI: https://doi.org/10.3389/fcvm.2026.1974572
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