Epidemiology of Valvular Heart Disease in Asia Pacific Region

Abstract

Valvular heart disease poses a significant health burden in the Asia-Pacific region, with its epidemiology varying widely across countries caused by diverse socioeconomic and health care situations. Rheumatic heart disease remains prevalent, especially in low- to middle-income areas, while degenerative valvular diseases are emerging in developed regions caused by an aging population. Significant disparities in access to health care and intervention result in variable clinical outcomes. In the past decade, transcatheter interventions have revolutionized the management of patients with valvular heart disease globally. In the Asia-Pacific region, the uptake and development of transcatheter valvular interventions has been slow until recent years. Continued collaboration across the Asia-Pacific region is essential to mitigate the impact of the upcoming surge of valvular heart disease in this diverse and rapidly changing area.

Keywords: Asia Pacific; degenerative valve disease; diagnosis; epidemiology; rheumatic heart disease; valvular heart disease.

Graphical abstract

Central Illustration

Epidemiology of Valvular Heart Disease in the Asia-Pacific Region In the Asia Pacific region (APAC), valvular heart disease has the following features: 1) rheumatic heart disease is still prevalence in low- to middle-income regions; 2) degenerative valvular heart disease is increasing because of the aging population, especially in high-income regions; 3) there are more bicuspid aortic stenosis than reported in North America and Europe; 4) there are more aortic regurgitation than reported in North America and Europe; 5) atrial functional mitral and tricuspid regurgitation are common; 6) Asians have a smaller body built with smaller aortic annulus and mitral valve area; and 7) there is a delay in diagnosis and significant disparity in access to valvular interventions in APAC, leading to different clinical outcomes.

Figure 1

Age-Standardized Prevalence Rate of Rheumatic Heart Disease A significant difference in the prevalence of rheumatic heart disease was observed in the high income vs low- to middle-income Asia Pacific region (APAC) nations in the 2022 Global Burden of Cardiovascular Diseases Report.

Figure 2

Features of Valvular Heart Diseases in the Asia-Pacific Region (A-C) Bicuspid aortic stenosis is commonly observed in the transcatheter aortic valve replacement population in the Asia-Pacific region than in Europe and the United States. In particular, type 1 (C) is found more frequently than type 0 morphology (B). (D) Rheumatic mitral stenosis remains prevalent in low- to middle-income regions. (E) Atrial secondary mitral regurgitation is increasingly recognized because of the high prevalence of chronic atrial fibrillation, which is characterized by late presentation and severe left atrial dilatation. (F) Patients with mitral regurgitation have smaller mitral valve areas caused by smaller body structures and mixed degenerative causes. (G) Aortic regurgitation is reported to be more common in Asia-Pacific region than in the United States and Europe. (H) Late presented atrial secondary tricuspid regurgitation with right atrial dilatation is common. (I) With the increasing use of cardiac implantable electronic devices, lead-related tricuspid regurgitation is increasingly recognized.

Figure 3

Features of Bicuspid Aortic Valve Undergone Transcatheter Aortic Valve Replacement The average age and proportion of bicuspid aortic valve (BAV) undergoing transcatheter aortic valve replacement in each region. (1) Li et al, (2) Datta et al, (3) Miyasaka et al, (4) Yu et al, (5) Yoon et al, (6) Maznyczka et al, and (7) Tang et al.

Figure 4

Selected Devices in Transcatheter Valvular Interventions From Asia Pacific Region (A) Self-expanding Venus-A transcatheter aortic valve replacement system (Venus Medtech).^a (B) Motorized retrievable self-expanding VitaFlow transcatheter aortic valve replacement system (MicroPort).^a (C) Self-expanding HYDRA transcatheter aortic valve replacement system (Vascular Innovations), with CE mark. (D) Self-expanding TaurusOne transcatheter aortic valve replacement system (Peijia).^a (E) Venus-P transcatheter pulmonary valve replacement system (Venus Medtech)^a, with CE Mark. (F) Myval transcatheter aortic valve replacement system (Meril Life Sciences Pvt. Ltd), with CE Mark. (G) Balloon expandable Renatus transcatheter aortic valve replacement system (Balance Medical).^a (H) Balloon expandable Prizvalve transcatheter aortic valve replacement system (NewMed Medical Co).^a (I) J-valve transcatheter aortic valve replacement system for pure aortic regurgitation (JC Medical), apical system approved by China NMPA and transfemoral system under research. (J) ValveClamp Transapical Edge to edge repair system (Hanyu Medical Technology).^a (K) DragonFly Transcatheter Edge-to-Edge Repair system (Valgen MedTech).^a (L) LuX-valve Plus Transcatheter Tricuspid Valve Replacement system (Jenscare), under research. (M) K-Clip Focal Tricuspid Annuloplasty system (Huihe), under research. ^aApproved by China NMPA.

Figure 5

Interactions of Atrial Fibrillation and Valvular Heart Disease Progressive valvular heart disease predisposes individuals to and precipitates the development of atrial fibrillation, which results in worsening heart failure symptoms and an adverse clinical course. This progression increases the need for valvular interventions, while simultaneously promoting the development of persistent or permanent atrial fibrillation. Chronic atrial fibrillation leads to left and right atrial dilatation and mitral and tricuspid annulus dilatation, resulting in atrial secondary mitral regurgitation and tricuspid regurgitation. Nonetheless, mitral regurgitation and tricuspid regurgitation will perpetuate the development of persistent or permanent atrial fibrillation and exacerbate the severity of mitral regurgitation and tricuspid regurgitation.

Figure 6

Proposed Algorithm to Manage Bicuspid Aortic Stenosis in APAC Bicuspid aortic stenosis is common in the transcatheter aortic valve replacement (TAVR) population. Surgical aortic valve replacement (SAVR) is preferred for patients aged <65 years with low surgical risk. For other patients, a preoperative computed tomography (CT) scan is recommended to assess the anatomy of the aortic root complex. If high-risk anatomical features (such as a calcified raphe, excessive, asymmetrical, or left ventricular outflow tract [LVOT] calcium, or concomitant aortopathy) are present, surgery is preferred unless the patient is at high surgical risk. The final decision should take into consideration the patient’s preferences, age, and the feasibility of future transcatheter aortic valve (TAV)-in-TAV procedures. If the patient is young and the likelihood of future TAV-in-TAV is low, surgery should be considered if the patient is a candidate. If the patient is surgically inoperable with high-risk anatomical features, palliative therapy may be considered. APAC = Asia Pacific region.

Figure 7

Multidisciplinary Heart Team in the APAC A multidisciplinary heart team approach to managing valvular heart diseases is advocated in the Asia Pacific region (APAC). The team should consist of interventional cardiologists, cardiac surgeons, diagnostic and interventional imagers, cardiac anesthetists, and heart valve nurse coordinators. Heart failure specialists and electrophysiologists should also be involved, especially in managing atrial fibrillation and cardiac implantable electronic device-related valvular heart disease.