There has been concern that patient with severe aortic stenosis treated with transcatheter aortic valve implantation (TAVI) might be at higher risk of infective endocarditis (IE) compared with patients undergoing surgical aortic valve replacement (SAVR). Cahill and colleagues1 used data from the National Institute for Cardiovascular Outcomes Research (NICOR) TAVI and Adult Cardiac Surgery databases, linked to the NHS Hospital Episode Statistics database, that included 91 962 patients undergoing SAVR (21% mechanical valves) and 14 195 patients undergoing TAVI between 2007 and 2016. The incidence of IE per 1000 person-years after SAVR was 4.81 (95% CI 4.61 to 5.03) compared with 3.57 (95% CI 3.00 to 4.21) with TAVI, with a higher cumulative incidence of IE after SAVR compared with TAVI (2.4% (95% CI 2.3 to 2.5) versus 1.5% (95% CI 1.3 to 1.8), HR 1.60, p<0.001) (figure 1). After multivariable adjustment, risk factors for IE included SAVR, younger age, male sex, atrial fibrillation and dialysis.

Cumulative incidence of IE in patients after surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI).

In the accompanying editorial, Raisi-Estabragh, Bagur and Mamas2 discuss general IE risk factors and then focus on risk factors specific to a bioprosthetic aortic valve, including potential differences between patients undergoing valve replacement by a transcatheter versus surgical route and differences in the valves themselves (figure 2). They point out that, despite efforts by Cahill et al 1 to adjust for patient characteristics, other confounding differences between patients undergoing TAVI versus SAVR cannot be excluded with certainty. For example, competing risks for death in the older patients with greater comorbidity undergoing TAVI might mask the true risk of IE. However, as this study illustrates: ‘Big data epidemiology facilitated by linkage of high-quality routine datasets can allow rapid characterisation of large populations, providing valuable insights into the burden and determinants of disease and evaluation of key clinical questions in a time and cost-efficient manner.’

Summary of key risk factors for prosthetic valve endocarditis including general factors and those specific to SAVR and TAVI. CABG, coronary artery bypass grafting; CHD, congenital heart disease; CKD, chronic kidney disease; CPB, cardiopulmonary bypass; IE, infective endocarditis; SAVR, surgical aortic valve replacement; TAVI, transcatheter aortic valve implantation.

Rheumatic heart disease (RHD) is the most common cause of significant valve dysfunction worldwide, with a younger age at clinical presentation in low-income, compared with higher-income, countries. In a study of 612 cases of RHD among children in Uganda3 between 2010 and 2018, median patient age was 12.8 years (37% men) with a very high mortality rate of 31% and a short median time to death of less than 8 months. Multivariable predictors of mortality were baseline complications (HR 1.78, 95% CI 1.31 to 2.41), severe RHD (HR 4.58, 95% CI 1.87 to 11.23) and, most importantly, whether an intervention for valve disease was performed (HR 0.05, 95% CI 0.01 to 0.21) (figure 3).

(A) Kaplan-Meier survival curve for children with RHD, with and without a prior cardiac intervention. (B) Kaplan-Meier survival curve for children with RHD, early (2010–2014) versus late (2015–2018) enrolment periods. (C) Kaplan-Meier survival curve for children with RHD, with mild, moderate or severe disease at baseline. RHD, rheumatic heart disease.

As Iung points out in an editorial,4 ‘Unlike for degenerative heart valve disease, the prevalence of RHD does not increase with age but peaks between 25 and 50 years, resulting in a substantial burden of premature deaths. The prevalence of RHD varies considerably across regions and is particularly high in Sub-Saharan Africa. However, specific data are frequently lacking in these countries due to limited resources in healthcare system and even more in clinical research.’ In addition, the burden of RHD in low-income countries is exacerbated by limited availability of surgical intervention and suboptimal primary and secondary prevention of RHD. Iung recommends that ‘Dedicated registries should be developed in countries where rheumatic fever remains endemic since they may contribute to improve resources, allowing for more frequent interventions at an earlier stage of heart valve disease.’

Another important study in this issue of Heart is a prospective longitudinal observational cohort study of 604 patients with dilated cardiomyopathy (DCM), of whom 16% had a history of moderate alcohol consumption.5 Compared with the rest of the study group, those with moderate alcohol consumption had a greater degree of left and right ventricular systolic dysfunction, larger chamber dimensions and more ventricle hypertrophy (figure 4). However, moderate alcohol consumption was more common in men (23%) than women (2%) and after adjustment for biological sex, excess alcohol consumption was not associated with adverse cardiac anatomic changes.

Box plots demonstrating variations in cardiac structure and function in patients with dilated cardiomyopathy stratified by previous alcohol intake. Patients with a history of moderate alcohol excess have lower biventricular function (left and right ventricular ejection fraction (LVEF/RVEF)) and more dilated ventricles (left and right ventricular end diastolic volume (LVEDVi/RVEDVi); left and right ventricular end systolic volume (LVESVi/RVESVi)), as well as increased left ventricular mass (LVMi) and dilated left atria (left atrial volume (LAVi)). These differences were not robust to adjustment for age, sex and clinical covariates (titin truncating variant status, medication use including beta blockers, ACE inhibitors, aldosterone antagonists and diuretics). Adjusted p values shown.

The Education in Heart article6 in this issue summarised the current indications for the timing and completeness of revascularisation in patients with an acute coronary syndrome, including non-ST elevation acute coronary syndromes, ST-elevation myocardial infarction and cardiogenic shock. All the Education in Heart articles can be found in our online library of 24 articles each year (https://heart.bmj.com/pages/collections/education_in_heart/) with an option for CME credits via our BMJ Learning platform.

The Image Challenge 7 in this issue asks you to make the diagnosis based on a cardiac magnetic resonance image of a large intramural septal cardiac mass in a young woman with a dry cough (figure 5). Do you know what this is? Over 150 of our Image Challenge multiple choice questions are archived online so that trainees and clinicians can accelerate their diagnostic imaging skills (https://heart.bmj.com/pages/collections/image_challenges/).

Cardiac magnetic resonance tissue images: (A) T2-weighted image, (B) fat suppressed T1-cardiac image and (C) late gadolinium enhancement.

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