What are the current management guidelines for valvular heart disease?

Current Management Guidelines for Valvular Heart Disease (2025)

Valvular heart disease management should follow a stage-based classification system (Stages A-D) with treatment decisions guided by symptom status, valve anatomy, severity of dysfunction, and ventricular response, as recommended by the most recent guidelines. 1

Disease Classification and Evaluation

• 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

• Initial evaluation requires:

  • 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

Management of Specific Valve Lesions

Aortic Stenosis

• Symptomatic severe AS: Aortic valve replacement (AVR) is indicated, either surgical (SAVR) or transcatheter (TAVR)
  • TAVR vs. SAVR decision based on surgical risk, age, and valve anatomy
• Asymptomatic severe AS: AVR recommended if:
  • LVEF <50%
  • Very severe AS (aortic velocity >5 m/s)
  • Abnormal exercise test
  • Rapid progression of stenosis

Aortic Regurgitation

• Symptomatic severe AR: AVR recommended regardless of LV function
• Asymptomatic severe AR: AVR indicated when LVEF ≤55%
• Medical therapy with vasodilators may be considered in patients not suitable for surgery

Mitral Stenosis

• Symptomatic severe MS with favorable valve morphology: Percutaneous mitral balloon commissurotomy (PMBC) recommended
• Asymptomatic MS with pulmonary artery pressure >50 mmHg: PMBC should be considered before non-cardiac surgery

Mitral Regurgitation

• Primary (degenerative) MR:

  • Symptomatic severe MR with LVEF >30%: Mitral valve repair (preferred) or replacement
  • Asymptomatic severe MR: Surgical intervention recommended with LV dysfunction or dilation
  • Transcatheter edge-to-edge repair (TEER) beneficial for severely symptomatic patients at high surgical risk

• Secondary (functional) MR:

  • Optimize guideline-directed medical therapy for heart failure
  • TEER may benefit select patients with persistent symptoms despite optimal medical therapy

Tricuspid Valve Disease

• Severe symptomatic TR: Surgical intervention recommended before severe right ventricular dysfunction
• Tricuspid stenosis: Intervention recommended for symptomatic severe cases
• Diuretics useful for symptom management in secondary TR

Anticoagulation and Antiplatelet Therapy

• Mechanical valves: Lifelong warfarin with target INR:

  • Aortic position: INR 2.0-3.0
  • Mitral position: INR 2.5-3.5

• Bioprosthetic valves: Warfarin should be considered for first 3 months, especially in mitral position

• VHD with atrial fibrillation: Anticoagulation based on CHA₂DS₂-VASc score; warfarin required for rheumatic mitral stenosis

Heart Team Approach and Follow-up

• Multidisciplinary Heart Team approach recommended for all patients with severe VHD
• Evaluation at specialized Heart Valve Centers when intervention is considered
• Post-procedural baseline TTE recommended for all patients
• Periodic monitoring based on intervention type, time since intervention, ventricular function, and concurrent conditions

Special Considerations

• Pregnancy: High-risk management for severe mitral stenosis, severe symptomatic aortic stenosis, or mechanical valves
• Non-cardiac surgery: Consider AVR before surgery for symptomatic severe AS; consider PMBC before surgery for symptomatic severe MS with pulmonary hypertension
• Prosthetic valve choice: Shared decision-making based on age, contraindications to anticoagulation, and patient preference

Emerging Trends

• Expanding role of transcatheter interventions beyond TAVR to include mitral and tricuspid valve procedures
• Valve-in-valve procedures for failed bioprosthetic valves
• Two-tier heart valve center model: Comprehensive (Level I) and Primary (Level II) Valve Centers

By following these guidelines, clinicians can optimize outcomes for patients with valvular heart disease through appropriate timing of interventions and selection of optimal treatment strategies.