Professor Alfieri, you are a world-renowned expert in the surgical treatment of heart valves. Sometimes the heart valve problem with the aortic valve, with the mitral valve, with the tricuspid valve could be a sign of systemic disease. It's important to diagnose the systemic disease as early as possible, perhaps based on the heart valve symptoms. Would you please discuss some systemic diseases that may manifest as heart valve problems?

Yeah, they're quite common nowadays. Patients present with some oncologic problems which are treated with drugs or radiation. Of course, radiation and drugs can influence the function of heart valves. And so this is a common situation nowadays to have post-radiotherapy valvular problems. You can also have specific tumors, like the carcinoid heart valve, which can affect the heart valves, particularly the right-side heart valves, the tricuspid, and a pulmonary valve. You can have Marfan syndrome, for instance. It is quite often associated with the genetic disease of the mitral valve and also with aortic valve insufficiency. You can have systemic lupus erythematosus, for instance. You can have rheumatoid arthritis and antiphospholipid syndrome. And you can have all these systemic diseases which can be associated with heart valve diseases.

So, a cardiac surgeon and a cardiologist should be very aware of the systemic diseases and work in concert with other multidisciplinary teams and other specialists.

Exactly! Particularly if some symptoms are typical of heart valve disease is present. In those particular subsets of patients, you have to be aware that valves can be involved.

From a surgical perspective, are you as aggressive in treating their heart valve disease that's caused by systemic disease? Are there other differences in your approach?

No, I think that you have to be similarly aggressive with this heart valve disease. The important thing is to avoid situations that are becoming irreversible. For instance, the left side of the heart is becoming too dilated, fibrotic, and the wall of the left ventricle is becoming thinner. And then it is something with this situation that was lost there. So we have to avoid being in this terminal stage of heart valve disease. We have to do things earlier.