Focus on juvenile hypertension, deep learning-qualified body composition for risk stratification, infective endocarditis, and mixed valvular heart disease

This Focus Issue on valvular heart disease and epidemiology, prevention, and healthcare policies contains the State of the Art Review article 'Mixed valvular heart disease: diagnosis and management' by Philippe Unger from the Universit Libre de Bruxelles, Belgium, and colleagues.The authors assess mixed valvular diseases (MVDs) that are common but have received little attention in the literature, especially regarding the mitral valve and the right-sided cardiac valves. 1 Whereas echocardiography plays a pivotal diagnostic role, the diagnosis is made difficult due to haemodynamic interactions that may invalidate common indices of severity used in isolated stenosis or regurgitation.The diagnostic strategy should aim at initially separately assessing stenosis and regurgitation, considering the diagnostic pitfalls, with complementary use of multimodality imaging in cases of persisting diagnostic uncertainties.Unlike aortic stenosis, the calcium score cannot be used as a surrogate for haemodynamic severity of mixed MVD.Severe stenosis and/or severe regurgitation are indicative of severe MVD, and management should follow recommendations on the predominant lesion.However, some patients with the combination of moderate stenosis and moderate regurgitation have a poor prognosis when left untreated.Concordant data suggest that, in patients with mixed aortic or MV disease, transvalvular velocities and pressure gradients are more powerful prognostic indicators than valve area or the severity of regurgitation.The authors conclude that it is essential to consider the global repercussions that indicate poor outcomes in patients with MVD.However, whereas symptoms and/or ventricular dysfunction are considered as clear indications for intervention, imaging cut-offs have not been validated for balanced moderate regurgitation and stenosis.Although emerging evidence tends to support earlier management, further prospective