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Clinical Insights and Advances in Structural Heart Disease

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: 25 September 2026 | Viewed by 6644

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Editor

Dr. David Roberts

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Guest Editor

1. Lancashire Cardiac Centre, Blackpool, UK
2. School of Medicine, University of Liverpool, Liverpool, UK
Interests: valvular heart diseases; structural intervention; TAVI; cardiac surgery

Special Issue Information

Dear Colleagues,

Over the last 20 years, structural cardiac intervention procedures have grown exponentially. Research continues at a fast pace and we wish to inform the readership of the treatment options that are now available. The indications for TAVR are continuing to expand, with recent trials showing at least equivalence to surgical aortic valve replacement (SAVR) in lower-risk patients at follow-up. The concept of a ‘valve for life’ is increasingly important. Self-expanding valves appear to show better haemodynamic function to balloon expandable valves in patients requiring a smaller size TAVR. The use of Valve-in-Valve TAVR (for degenerative SAVR and TAVR) also continues to increase, with follow-up reported in clinical trials and registries. Para-valvular regurgitation still occurs following TAVI and further structural intervention is challenging, usually involving detailed transoesophageal imaging and the use of one or more vascular plug devices.

There are several different percutaneous devices for functional mitral and tricuspid regurgitation available. Trials evaluating percutaneous edge-to-edge repair for mitral regurgitation show clinical benefit beyond 5 years. Tricuspid valve procedures are more complex, but early trial results show clinical benefit in carefully selected patients. Trials evaluating percutaneous left atrial appendage occlusion devices show that they reduce stroke rates in patients with atrial fibrillation who have contra-indication to oral anticoagulation, while recent trials of PFO occluder devices appear to show benefit in carefully selected patients over 60 years of age by preventing recurrent stroke. In this Special Issue we will provide updates on the assessment and management of structural disease in all of these areas. We welcome authors to submit papers on these specific topics.

Dr. David Roberts
Guest Editor

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Keywords

TAVR
Mitra-Clip
Tri-Clip
Pascal
TricValve
PFO closure
LAAO closure
cardiac CT
cardiac MRI
transoesopha-geal echocardiography

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Published Papers (6 papers)

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Research

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12 pages, 27323 KB

Open AccessArticle

High-Fidelity MicroCT Reconstructions of Cardiac Devices Enable Patient-Specific Simulation for Structural Heart Interventions

by Zhongkai Zhu, Yaojia Zhou, Yong Chen, Yong Peng, Mao Chen and Yuan Feng

J. Clin. Med. 2025, 14(20), 7341; https://doi.org/10.3390/jcm14207341 - 17 Oct 2025

Viewed by 846

Abstract

Background/Objective: Precise preprocedural planning is essential for the safety and efficacy of structural heart interventions. Conventional imaging modalities, while informative, do not allow for direct and accurate visualization, limiting procedural predictability. We aimed to develop and validate a high-resolution micro-computed tomography (microCT)-based reverse modeling workflow that integrates digital reconstructions of metallic cardiac devices into patient imaging datasets, enabling accurate, patient-specific virtual simulation for procedural planning. Methods: Clinical-grade transcatheter heart valves, septal defect occluders, patent ductus arteriosus occluders, left atrial appendage closure devices, and coronary stents were scanned using microCT (36.9 μm resolution). Agreement was assessed by intra-class correlation coefficients (ICC) and Bland–Altman analyses. Device geometries were reconstructed into 3D stereolithography files and virtually implanted within multislice CT datasets using dedicated software. Results: Devices were successfully reverse-modeled with high geometric fidelity, showing negligible dimensional deviations from manufacturer specifications (mean ΔDistance range: −0.20 to +0.20 mm). Simulated measurements demonstrated excellent concordance with postprocedural imaging (ICC 0.90–0.96). The workflow accurately predicted clinically relevant parameters such as valve-to-coronary distances and implantation depths. Notably, preprocedural simulation identified a case at high risk of coronary obstruction, confirmed clinically and managed successfully. Conclusions: The microCT-based reverse modeling workflow offers a rapid, reproducible, and clinically relevant method for patient-specific simulation in structural heart interventions. By preserving anatomical fidelity and providing detailed device–tissue spatial visualization, this approach enhances preprocedural planning accuracy, risk stratification, and procedural safety. Its resource-efficient digital nature facilitates broad adoption and iterative simulation. Full article

(This article belongs to the Special Issue Clinical Insights and Advances in Structural Heart Disease)

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Review

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18 pages, 7231 KB

Open AccessReview

Transcatheter Aortic Valve Implantation/Replacement (TAVI/TAVR): How It Started, How It’s Going, and Where It’s Going

by Alok Shah, Amr Gamal, Hesham Abdelaziz, Matthew Luckie, Andrew Wiper, Ranjit More and Tawfiq Choudhury

J. Clin. Med. 2026, 15(13), 5242; https://doi.org/10.3390/jcm15135242 - 4 Jul 2026

Viewed by 650

Abstract

Transcatheter Aortic Valve Implantation/Replacement (TAVI/TAVR) has come a long way since the first-in-human implant by Prof Cribier & colleagues in 2002. Initially a consideration for inoperable/high-surgical-risk patients, TAVI is now indicated in patients with severe tricuspid aortic stenosis and suitable anatomy aged 70 or higher. This has been made possible due to improvements in preprocedural planning, performance upgrades to and evolution of transcatheter heart valve (THV) systems and increasing operator experience. Younger age at index implantation, complexities of redo TAVI planning and methods to improve THV durability are the next frontiers. This review summarizes these advancements while emphasizing preprocedural planning, current guidelines, and individualized device selection, with a brief note on polymeric heart valves—developed to overcome the disadvantageous bioprosthetic dysfunction seen with current THVs. Full article

(This article belongs to the Special Issue Clinical Insights and Advances in Structural Heart Disease)

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22 pages, 643 KB

Open AccessReview

Prehabilitation Before Cardiac Surgery and Structural Heart Interventions: An Umbrella Review of Pooled Evidence

by Elen H. Hughes, Robyn Lotto, Ellen A. Dawson, Mohamed Saber, Ethan Richards, Adrian Morris, David Mayhew, Fahmi Faraz, Reza Ashrafi and Julia D. Jones

J. Clin. Med. 2026, 15(10), 3821; https://doi.org/10.3390/jcm15103821 - 15 May 2026

Viewed by 550

Abstract

Background: Prehabilitation aims to optimise patients before cardiac procedures through interventions including exercise training, respiratory conditioning, nutritional support, psychological preparation and multimodal lifestyle programmes. Evidence from systematic reviews and meta-analyses is increasing but remains heterogeneous due to variation in intervention design, patient populations and overlap of primary studies. Methods: We conducted an umbrella review of 17 systematic reviews and meta-analyses evaluating prehabilitation prior to cardiac surgery and structural heart interventions in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Methodological quality of included reviews was assessed using A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2). Outcomes of interest were postoperative pneumonia, hospital length of stay (LOS), and mortality. Results: Across pooled analyses, the most consistent finding was a reduction in postoperative pneumonia, particularly in studies incorporating inspiratory muscle training (IMT), with relative risk reductions of approximately 55–62%, corresponding to a modest absolute risk reduction. Reductions in hospital LOS were also reported, although effect sizes were smaller and more variable. In contrast, no consistent reduction in short-term mortality was demonstrated, likely reflecting low event rates. The evidence base was limited by substantial overlap between reviews and predominantly low or critically low methodological quality. Conclusions: Prehabilitation, particularly when incorporating IMT, is consistently associated with a reduction in postoperative pneumonia and may contribute to modest reductions in hospital LOS. However, the evidence base is constrained by heterogeneity, study overlap and low methodological quality. Further high-quality, adequately powered randomised trials are required to define the role of prehabilitation in contemporary cardiac surgical and structural intervention practice. Full article

(This article belongs to the Special Issue Clinical Insights and Advances in Structural Heart Disease)

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13 pages, 3135 KB

Open AccessReview

Transcatheter Aortic Valve Implantation for Pure Aortic Regurgitation

by Samuel Norman, Noman Ali and Daniel Blackman

J. Clin. Med. 2026, 15(9), 3206; https://doi.org/10.3390/jcm15093206 - 22 Apr 2026

Viewed by 776

Abstract

Transcatheter aortic valve implantation (TAVI) has transformed the management of severe aortic stenosis (AS), evolving from a therapy reserved for inoperable patients to a viable treatment across the spectrum of surgical risk. This success has stimulated innovation in transcatheter therapies for other valvular heart diseases, including aortic regurgitation (AR). In contrast to AS, AR is characterised by heterogeneous aetiologies, absence of annular calcification, larger and more elliptical annular dimensions, and concomitant aortopathy. These challenges have limited the efficacy and safety of conventional transcatheter aortic valves (TAVs), use of which in pure native AR is associated with high rates of valve embolisation, significant residual regurgitation, permanent pacemaker implantation, and mortality. The development of dedicated TAVs designed specifically for the treatment of AR has addressed many of these anatomical challenges. The JenaValve Trilogy and J-Valve systems incorporate leaflet-grasping mechanisms that enable secure anchoring independent of calcification, resulting in transformation of procedural and clinical outcomes. Recent prospective registry data, including the landmark ALIGN-AR trial, demonstrate high technical and procedural success rates, low residual regurgitation, acceptable safety profiles, and meaningful improvements in functional status and ventricular remodelling. These data have informed contemporary guideline updates, with the 2025 European Society of Cardiology (ESC)/European Association of Cardiothoracic Surgery (EACTS) Guidelines for the management of valvular heart disease issuing the first conditional recommendation for TAVI in selected patients with severe AR and the National Institute for Health and Care Excellence (NICE) recommending TAVI for native AR in patients for whom surgical AVR is not available or is high risk. This review summarises the clinical implications of AR, examines current guideline recommendations for management, and critically appraises the evidence supporting transcatheter treatment strategies. Full article

(This article belongs to the Special Issue Clinical Insights and Advances in Structural Heart Disease)

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22 pages, 4032 KB

Open AccessReview

Exercise-Induced Desaturation in Patent Foramen Ovale: Mechanisms, Diagnostic Approach, and Resolution After Closure—A Narrative Review with an Illustrative Case

by Martina Podolec, Jiří Dostál, Petr Volf, Aneta Dvořáková and Martin Mates

J. Clin. Med. 2026, 15(4), 1523; https://doi.org/10.3390/jcm15041523 - 14 Feb 2026

Viewed by 1344

Abstract

Exercise-induced desaturation is an uncommon but clinically significant manifestation of patent foramen ovale, which is present in approximately one-quarter of the general population. Although patent foramen ovale is usually asymptomatic, exertion may provoke transient right-to-left shunting when dynamic changes in venous return and intrathoracic pressure favour intermittent right-to-left transit across the interatrial septum. This narrative review synthesises current evidence on exertion-provoked shunting and its contribution to otherwise unexplained dyspnoea and hypoxaemia. To illustrate these concepts, we present an illustrative case with marked exercise-induced desaturation in the absence of pulmonary disease. The evaluation combined contrast transthoracic and transoesophageal echocardiography with cardiopulmonary exercise testing, and the shunt magnitude was quantified invasively using catheter-based thermodilution at rest and during Valsalva provocation. Six months after percutaneous closure, repeat cardiopulmonary exercise testing showed complete resolution of exercise-induced desaturation without a statistically significant change in exercise tolerance (work performed). Notably, normalisation of oxygen saturation during exercise may occur without a measurable increase in maximal exercise capacity. Overall, patent foramen ovale-mediated right-to-left shunting is an under-recognised yet potentially reversible cause of exertional hypoxaemia; diagnosis typically requires deliberate physiological provocation and integrated imaging, and closure can be considered in carefully selected individuals. Full article

(This article belongs to the Special Issue Clinical Insights and Advances in Structural Heart Disease)

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13 pages, 936 KB

Open AccessReview

When Should Physicians Consider Referring Elderly Patients with Suspected PFO-Related Stroke for Device Closure?

by Alisha Varia and David Roberts

J. Clin. Med. 2026, 15(1), 294; https://doi.org/10.3390/jcm15010294 - 30 Dec 2025

Viewed by 1505

Abstract

Background: Guidelines recommend patent foramen ovale (PFO) closure for secondary prevention after cryptogenic stroke in patients aged 18–65 years, but there is limited evidence to guide management of elderly adults. This research aims to assess the efficacy, safety and methodological quality of trials comparing secondary prevention PFO closure with medial therapy alone (MTA) in patients aged ≥ 60 years. Methods: A PubMed search identified four studies comparing PFO closure with MTA in elderly patients—PFOSK (South Korea), PT (Taiwan), DEFENSE (South Korea) and PFOG (Germany). Primary analyses evaluated study quality—patient selection, allocation, crossover and adherence. Secondary analyses compared recurrent cerebral ischaemia, mortality, new-onset atrial fibrillation (AF) and disability. Results: In 644 patients ≥ 60 years old, PFO closure was associated with a 45% (95% CI 0.35–0.86, p = 0.0091) reduction in recurrent cerebral ischaemia and an 85% (95% CI 0.05–0.49, p = 0.0016) reduction in mortality. Lower disability scores and increased incidence of new-onset AF (RR 2.15, 95% CI 1.07–4.32, p = 0.0306) was observed in closure groups. Study quality was limited by heterogeneity in medical regimens and closure protocols, crossover between treatment arms and imbalances in baseline characteristics, with closure groups generally younger and possessing larger shunt sizes. Conclusions: In patients aged ≥ 60 years, PFO closure appears to reduce the risk of the recurrence of ischaemic events and mortality, particularly in those with ‘high-risk’ PFO features. However, variability in study designs and low event rates limit certainty. Large, standardised trials are warranted to provide evidence for guideline recommendations in this population. Full article

(This article belongs to the Special Issue Clinical Insights and Advances in Structural Heart Disease)

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