Significant valvular heart disease (VHD) is a growing public health problem, due to increasing life expectancy and the lack of effective prevention strategies for valve disease of degenerative etiology.1 The characteristics of patients with severe VHD have changed considerably in the last 15 years: they are now older, with more comorbidities, and are more likely to have multivalvular disease.2,3 This rapid change means that cardiology departments must make adjustments in order to respond to the rising numbers of these particularly challenging patients.

In this issue of the Journal, Esteves et al.4 present a snapshot of patients admitted with a primary or secondary diagnosis of VHD to the cardiology department of Hospital Santa Maria in Lisbon over a period of nearly two years in 2014 and 2015.

The study population consisted of 287 patients with significant VHD or prior heart valve intervention, most (67.9%) with calcified aortic and/or mitral valve disease, 66.9% of whom were admitted as acute cases. Etiology was rheumatic in only 8% of cases, far fewer than the 22% reported by the Euro Heart Survey on Valvular Heart Disease.2 Approximately 14% had been hospitalized in the previous year for VHD.

The mean age of the study population was around 75 years, which is older than in the 2001 Euro Heart Survey on Valvular Heart Disease2 but similar to the more recent (2017) Valvular Heart Disease II (VHDII) Survey of the European Society of Cardiology's EURObservational Research Programme.3 Multiple comorbidities were found in 53% of patients, the most common of which were coronary artery disease (28.2%), chronic kidney disease (20.9%) and chronic anemia (26.5%). This combination of older patients and multiple comorbidities greatly increases the risks associated with intervention, and raises the question of how to select patients for treatment in such situations.5,6 The expectations of patients and their caregivers frequently conflict with those of their physicians, further complicating the calculation of risks versus potential benefits, especially the degree of dependence, worsening of cognitive deficits, and relief of symptoms.9

Some aspects of this study merit particular attention due to the impact they may have on the organization of hospital care.

The large number of admissions for elective valve procedures (33.1%) is a measure of increases not only in percutaneous interventions but also, more generally, in referrals for treatment of VHD, in line with the international guidelines.7,8 Treating these old and frequently frail patients with multiple comorbidities requires specialist support in intensive care units and prolonged hospital stay, and this in turn complicates the management of beds in cardiology wards, which are usually reserved for urgent cases. There is a pressing need for reorganization of the supporting structures for these interventions, and for redefinition of outcomes using patient-reported outcome measures.9

The high all-cause (9.8%) and cardiovascular (8.7%) in-hospital mortality in Esteves et al. illustrates the challenges of managing VHD in these patients and the need for the involvement of multidisciplinary teams that include not only clinical cardiologists, interventional cardiologists and thoracic surgeons but also anesthetists, geriatricians, physiatrists and nutritionists, among others. The work of such a heart valve unit will be crucial not only in selecting patients for intervention but also for monitoring them after the procedure in order to ensure an optimal result and rapid functional recovery, in accordance with the patient's expectations.

The picture of the VHD patient hospitalized in the cardiology department is changing rapidly, but hospital structures are not keeping up with these changes. What are we waiting for?