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Patients with dilated cardiomyopathy and functional mitral regurgitation (MR) have a very poor prognosis. Surgical correction of MR in this setting is controversial because survival benefit has not been proven; however, patients who have undergone mitral repair often show substantial symptomatic improvement and reverse left ventricular remodeling. Here, Michele De Bonis and Ottavio Alfieri argue that these 'end-stage' patients should not be denied surgery, and that mitral repair should be performed before irreversible deterioration occurs.

To mark the 10^th anniversary of Nature Reviews Cardiology, five of our Advisory Board members were invited to consider a topic within cardiology about which we know too little. The key opinion leaders from around the globe also suggest ways in which future research could be targeted to address the deficits in our understanding, with the aim of preventing cardiovascular disease, improving patient care, and reducing morbidity and mortality.

The severity of left ventricular dilatation and remodeling represents one of the strongest predictors of mortality. Prevention, reversal, or both of left ventricular remodeling therefore constitute crucial parts of therapy in many cases. Along with pharmacologic therapies various surgical procedures are available. In this Review, the most common surgical options for left ventricular remodeling are discussed.

A number of papers published in 2018 have provided important information expected to influence clinical practice, particularly for the management of functional mitral regurgitation in patients with heart failure caused by ischaemic or non-ischaemic cardiomyopathy and for the treatment of severe aortic stenosis in patients at low surgical risk.

In this state-of-the-art Review, Michele De Bonis and colleagues discuss the optimal management of patients with degenerative or function mitral regurgitation, from established surgical techniques to new percutaneous technologies. They also provide an overview of the use of echocardiography in the assessment of MR.

In this Review, Alfieri and colleagues focus on new concepts on mitral valve pathophysiology and patient risk profile assessment to guide the indication and timing of the management of mitral valve regurgitation. The authors also describe new imaging modalities and contemporary surgical and transcatheter techniques, highlighting the need for a multidisciplinary approach.

Atrial fibrillation is characterized by structural remodeling of the atrial myocardium—a slow process that comprises morphological changes that affect atrial myocardial architecture and atrial ultrastructure. Here Corradi et al. examine the morphological changes that characterize the fibrillating atrial myocardium at histological and ultrastructural levels, and explore how the pathogenetic mechanisms involved in AF could lead to new treatments.

Blood motion in the heart features vortices, the stability of which is vital to the dynamic balance between rotating blood and myocardial tissue and to the development of cardiac dysfunction. In this Perspectives article, Pedrizzetti et al. examine cardiac vortex flow as a sensitive pathogenetic indicator and modulator of left ventricular remodelling towards heart failure, and the role of cardiac vortices for risk stratification of patients following cardiac surgery or device therapy.

Transcatheter aortic valve implantation (TAVI) is increasingly used to treat patients with aortic stenosis for whom the risks associated with surgery are very high. In this Review, the new generation of TAVI devices are discussed, many of which have features that allow repositioning of the device and reduce paravalvular leakage.