What are the treatment options for valvular heart disease?

Treatment of Valvular Heart Disease

The management of valvular heart disease requires a multidisciplinary Heart Team approach with all patients with severe valvular heart disease being evaluated at specialized Heart Valve Centers when intervention is considered. 1, 2

Disease Classification and Evaluation

• Valvular heart disease is classified into four progressive stages 2:

  • Stage A: At risk for valvular heart disease
  • Stage B: Progressive valvular heart disease
  • Stage C: Asymptomatic severe valvular heart disease
  • Stage D: Symptomatic severe valvular heart disease

• Comprehensive evaluation includes:

  • Transthoracic echocardiography (TTE) to assess valve anatomy, hemodynamics, and ventricular function
  • Exercise testing for patients with discordant symptoms
  • Advanced imaging (CT, MRI) when TTE findings are inconclusive

Treatment Options by Valve Type

Aortic Stenosis (AS)

• Symptomatic severe AS:

  • Aortic valve replacement (AVR) is recommended, either surgical (SAVR) or transcatheter (TAVR)
  • Choice between SAVR and TAVR based on surgical risk, patient age, and valve anatomy 1, 2

• Asymptomatic severe AS:

  • AVR recommended if LVEF <50%
  • AVR reasonable if very severe AS (aortic velocity >5 m/s)
  • AVR reasonable if abnormal exercise test or rapid progression 1

Aortic Regurgitation (AR)

• Symptomatic severe AR:

  • AVR recommended regardless of LV function 2

• Asymptomatic severe AR:

  • AVR indicated when LVEF ≤55%
  • AVR indicated when LV end-systolic dimension >50 mm or indexed dimension >25 mm/m² 2

Mitral Stenosis (MS)

• Symptomatic severe MS with favorable valve morphology:

  • Percutaneous mitral balloon commissurotomy (PMBC) recommended 2
  • Surgical intervention for unfavorable valve morphology or when PMBC unavailable

• Asymptomatic MS:

  • PMBC considered for pulmonary artery pressure >50 mmHg 2

Mitral Regurgitation (MR)

• Primary (degenerative) MR:

  • Symptomatic severe MR with LVEF >30%: Mitral valve repair (preferred) or replacement 1, 2
  • Asymptomatic severe MR: Surgery recommended with LV dysfunction (LVEF ≤60%) or LV dilation (end-systolic dimension >45 mm) 1
  • Transcatheter edge-to-edge repair (TEER) for severely symptomatic patients at high surgical risk 1, 2

• Secondary (functional) MR:

  • Optimize guideline-directed medical therapy for heart failure
  • TEER beneficial in select patients with severe MR who remain symptomatic despite optimal medical therapy 1

Tricuspid Valve Disease

• Severe symptomatic tricuspid regurgitation (TR):

  • Surgical intervention recommended before onset of severe right ventricular dysfunction 1
  • Intervention during left-sided valve surgery for moderate-to-severe TR or tricuspid annular dilation >40 mm 1

• Tricuspid stenosis (TS):

  • Intervention recommended for symptomatic severe TS
  • Percutaneous balloon tricuspid dilatation may be considered as first approach in isolated TS 1

Medical Therapy

• Heart failure with valvular disease:

  • Standard guideline-directed medical therapy including diuretics, ACE inhibitors/ARBs, beta-blockers with careful monitoring in stenotic lesions 2

• Atrial fibrillation with valvular disease:

  • Anticoagulation based on CHA₂DS₂-VASc score for most valve conditions
  • Vitamin K antagonist (warfarin) required for rheumatic mitral stenosis and mechanical prostheses 1, 2

Anticoagulation for Prosthetic Valves

• Mechanical valves:

  • Lifelong warfarin with target INR 2.0-3.0 for aortic position
  • Target INR 2.5-3.5 for mitral position 2

• Bioprosthetic valves:

  • Warfarin for first 3 months, especially in mitral position
  • Long-term antiplatelet therapy thereafter 2

Follow-up and Monitoring

• Baseline post-procedural TTE recommended for all patients
• Regular echocardiographic follow-up based on valve type, disease severity, and ventricular function
• More frequent monitoring for patients with prosthetic valves or after valve repair 2

Special Considerations

• Pregnancy:

  • High-risk management for women with severe MS, severe symptomatic AS, or mechanical valves 2

• Non-cardiac surgery:

  • Consider valve intervention before elective non-cardiac surgery for symptomatic severe AS or MS with pulmonary hypertension 2

• Valve selection:

  • Mechanical valves generally recommended for patients <50 years without contraindication to anticoagulation
  • Bioprosthetic valves recommended when anticoagulation is contraindicated or undesired 2

Emerging Treatments

• Transcatheter interventions expanding beyond TAVR to include:
  • Transcatheter mitral valve repair and replacement
  • Transcatheter tricuspid valve interventions
  • Valve-in-valve procedures for failed bioprosthetic valves 1, 3

The treatment of valvular heart disease has evolved significantly with advances in imaging, surgical techniques, and transcatheter interventions, allowing for more individualized approaches to improve morbidity, mortality, and quality of life.