Valvular Heart Disease
Definition
Valvular heart disease (VHD) encompasses acquired structural abnormalities of the cardiac valves — aortic, mitral, tricuspid, and pulmonary — leading to stenosis, regurgitation, or both. The 2025 ESC/EACTS guidelines focus on acquired VHD and exclude congenital valve disease, endocarditis, and aortic disease as primary topics.
Key Concepts
Epidemiology
- VHD prevalence is rising due to the ageing population; degenerative aetiology now dominates in high-income countries
- Rheumatic heart disease remains the most common cause of death from VHD worldwide, predominantly in low- and middle-income countries
- Underdiagnosis and undertreatment remain important concerns even in high-income countries sources/vhd-esc-2025
very high
Heart Team and Heart Valve Centre
- A multidisciplinary Heart Team working within a regional Heart Valve Network is the standard of care
- Complex procedures (MV repair, TAVI in high anatomical risk, concomitant procedures) should be concentrated at high-volume Heart Valve Centres
- Patient-centred shared decision-making is explicitly mandated throughout management sources/vhd-esc-2025
very high - See also: concepts/Heart-Valve-Centre
Imaging Assessment
- Echocardiography (TTE/TOE) is the first-line modality for all VHD
- CCT is mandatory for TAVI planning; provides annulus sizing, coronary ostia distance, vascular access assessment
- CMR provides accurate LV/RV volumes, regurgitant quantification, and myocardial fibrosis assessment
- Strain imaging (GLS) detects subclinical LV/RV dysfunction before conventional thresholds are met sources/vhd-esc-2025
very high
Associated Conditions
- CAD: CCTA before valve intervention if pre-test CAD likelihood ≤50%; CABG Class I with ≥70% stenosis if undergoing valve surgery; PCI Class IIa before TAVI for ≥90% stenosis ≥2.5 mm vessels
- AF: DOACs preferred for AF with AS/AR/MR; VKA (not DOACs) for rheumatic MS with MVA ≤2.0 cm²; surgical LAAO Class I B during valve surgery; surgical AF ablation Class I A for MV surgery
- Radiation-induced VHD: Screen TTE 10 years after radiotherapy, every 5 years thereafter; operative risk underestimated by standard scores
- Cardiogenic shock: TAVI now largely replaces balloon valvuloplasty for decompensated AS; M-TEER supported for acute ventricular SMR post-MI sources/vhd-esc-2025
very high
Sex-Specific Considerations
- Women have lower AVA for equivalent AS haemodynamic severity; sex-specific flow thresholds proposed
- Atrial SMR driven by HFpEF/AF more common in women
- Women underrepresented in VHD RCTs; outcome differences after TAVI and SAVR documented sources/vhd-esc-2025
very high
Antithrombotic Principles
- MHV: lifelong VKA, DOACs contraindicated (Class III A) sources/vhd-esc-2025
very high - After TAVI (no OAC indication): lifelong single ASA Class I A; routine OAC not recommended (Class III A) sources/vhd-esc-2025
very high - After surgical BHV or MV/TV repair: short-term VKA or ASA for 3 months, then reassess sources/vhd-esc-2025
very high - ACC/AHA 2020: mechanical bileaflet AVR + no risk factors → VKA INR target 2.5; mechanical AVR + risk factors (AF, prior thromboembolism, LV dysfunction) or mechanical MVR → INR 3.0; DOACs Class III:Harm for all mechanical valves sources/VHD-AHA-2020
very high - See: concepts/TAVI, concepts/Structural-Valve-Deterioration
AF Anticoagulation in VHD
- ACC/AHA 2020: For most VHD with AF, anticoagulation decision based on CHA2DS2-VASc score; either VKA or NOAC acceptable except for rheumatic mitral stenosis or mechanical prosthesis → VKA required sources/VHD-AHA-2020
very high - ESC 2024: Uses CHA2DS2-VA (sex removed as a risk factor); otherwise similar VKA requirement for rheumatic MS and MHV sources/vhd-esc-2025
very high
Disease Staging (ACC/AHA Framework)
- Stage A: At risk; normal valve anatomy/function
- Stage B: Progressive mild-moderate VHD; asymptomatic
- Stage C1: Asymptomatic severe; compensated LV/RV
- Stage C2: Asymptomatic severe; LV/RV decompensation
- Stage D: Symptomatic severe VHD
- This A–D framework was introduced by ACC/AHA 2020 and has been widely adopted sources/VHD-AHA-2020
very high
Contradictions / Open Questions
- Lifetime durability of transcatheter valves (TAVI, TMVI) remains unknown beyond 5–8 years — long-term valve-in-valve outcomes are the key unknown for younger patients
- Atrial SMR: no RCT evidence to guide surgical vs transcatheter intervention; both modalities supported by observational data only
- Mixed/multiple VHD recommendations largely based on expert consensus and extrapolation from single-valve data
- Optimal timing and mode of CAD treatment before TAVI remains debated (NOTION-3 vs ACTIVATION divergent results)
- ACC/AHA 2020 vs ESC 2024 AF anticoagulation divergence: ACC/AHA 2020 uses CHA2DS2-VASc (sex included as a risk factor); ESC 2024 uses CHA2DS2-VA (sex removed) — different stroke risk thresholds result sources/VHD-AHA-2020
very highvs sources/vhd-esc-2025very high
Connections
- Related to concepts/Aortic-Stenosis
- Related to concepts/Aortic-Regurgitation
- Related to concepts/Primary-Mitral-Regurgitation
- Related to concepts/Secondary-Mitral-Regurgitation
- Related to concepts/Mitral-Stenosis
- Related to concepts/Tricuspid-Regurgitation
- Related to concepts/TAVI
- Related to concepts/Heart-Valve-Centre
- Related to concepts/Structural-Valve-Deterioration
- Related to entities/Atrial-Fibrillation
- Related to entities/Heart-Failure
- Related to entities/Pulmonary-Hypertension
- Related to entities/ATTR-Amyloidosis