Treatment of Valvular Heart Disease
The treatment of valvular heart disease requires a multidisciplinary Heart Team approach involving cardiologists, surgeons, and other specialists to determine the optimal intervention based on valve type, disease severity, and patient characteristics. 1
Disease Staging and Evaluation
Valvular heart disease (VHD) is classified into four progressive stages:
- Stage A: At risk for VHD
- Stage B: Progressive VHD
- Stage C: Asymptomatic severe VHD
- Stage D: Symptomatic severe VHD 1, 2
Comprehensive evaluation includes:
- Transthoracic echocardiography (TTE) to assess valve anatomy, hemodynamics, and ventricular function
- Exercise testing for patients with discrepant symptoms
- Advanced imaging (CT, MRI) when TTE findings are inconclusive 1, 2
Treatment by Valve Type
Aortic Stenosis
- Symptomatic severe AS: Aortic valve replacement (AVR) - either surgical (SAVR) or transcatheter (TAVR) based on surgical risk 1, 2
- Asymptomatic severe AS with LVEF <50%: AVR is recommended 2
- Asymptomatic severe AS with normal LVEF: Consider AVR if:
Aortic Regurgitation
- Symptomatic severe AR: AVR regardless of LV function 2
- Asymptomatic severe AR with LVEF ≤55%: AVR indicated 2
- Asymptomatic severe AR with normal LVEF: Surgical AVR when LV dilation occurs 1
Mitral Stenosis
- Symptomatic severe MS with favorable valve morphology: Percutaneous mitral balloon commissurotomy (PMBC) 2
- Symptomatic severe MS with unfavorable valve morphology: Mitral valve surgery 2
- Asymptomatic MS with pulmonary artery pressure >50 mmHg: Consider PMBC before any non-cardiac surgery 1
Mitral Regurgitation
Primary (degenerative) MR:
Secondary (functional) MR:
- Optimize guideline-directed medical therapy for heart failure
- Consider TEER for selected patients with persistent severe symptoms despite optimal medical therapy 1
Tricuspid Regurgitation
- Severe symptomatic TR: Surgical intervention before onset of severe right ventricular dysfunction 1
- Secondary TR: Treat underlying cause and use diuretics for symptom management 2
Medical Therapy
Medical therapy plays a supportive role in VHD management:
- Heart failure with VHD: Standard GDMT including diuretics, ACE inhibitors/ARBs, beta-blockers, and aldosterone antagonists (with careful monitoring in stenotic lesions) 1
- Atrial fibrillation with VHD:
- Rheumatic heart disease: Secondary prevention of rheumatic fever with long-term antibiotic prophylaxis 1
Prosthetic Valve Management
- Mechanical valves: Lifelong anticoagulation with warfarin
- Aortic position: Target INR 2.0-3.0
- Mitral position: Target INR 2.5-3.5 3
- Bioprosthetic valves:
- Consider warfarin for first 3 months (especially mitral position)
- Long-term anticoagulation not required unless other indications exist 3
- Prosthetic valve thrombosis:
- Obstructive thrombosis: Emergency valve replacement for critically ill patients
- Non-obstructive thrombosis: Consider surgery for large thrombi (>10mm) with embolism 1
Special Considerations
- Pregnancy: High-risk in women with severe mitral stenosis, severe symptomatic aortic stenosis, or mechanical valves 1
- Non-cardiac surgery:
- Symptomatic severe AS: Consider AVR before non-cardiac surgery
- Symptomatic severe MS with pulmonary hypertension: Consider PMBC before non-cardiac surgery
- Asymptomatic severe regurgitative lesions: Non-cardiac surgery generally safe with appropriate monitoring 1
Heart Valve Centers of Excellence
Patients with severe VHD should be evaluated at specialized Heart Valve Centers with expertise in all treatment modalities, including complex valve repair, surgical replacement, and transcatheter interventions 1, 2.
The treatment approach should be guided by the patient's symptoms, valve anatomy, disease severity, ventricular function, and surgical risk, with decisions made by a multidisciplinary Heart Team to ensure optimal outcomes.