What are the treatment options for valvular issues?

Treatment Options for Valvular Heart Disease

Surgery is recommended for operable patients with mechanical heart valves with intractable hemolysis or heart failure due to severe prosthetic or paraprosthetic regurgitation. 1

Classification and Evaluation

• Valvular heart disease should be classified into stages (A, B, C, and D) based on symptoms, valve anatomy, severity of dysfunction, and ventricular/pulmonary circulation response 1
• Transthoracic echocardiography (TTE) is the initial diagnostic test of choice for patients with suspected valvular disease to evaluate valve structure, hemodynamic severity, ventricular size/function, and pulmonary pressures 1
• Transesophageal echocardiography (TEE) is essential for evaluation of suspected prosthetic mitral valve regurgitation, as TTE images are often shadowed by the valve prosthesis 1

Treatment Options for Native Valve Disease

Surgical Interventions

• Valve replacement is indicated for symptomatic severe aortic stenosis, mitral stenosis with unfavorable anatomy for percutaneous approaches, and severe mitral or aortic regurgitation with symptoms or ventricular dysfunction 1
• Mitral valve repair is preferred over replacement for primary mitral regurgitation when feasible due to better outcomes 1
• Surgical intervention should be considered in asymptomatic patients with severe MR who have signs of LV dysfunction (LVEF ≤60% and/or end-systolic dimension >45 mm) 1

Percutaneous Interventions

• Percutaneous mitral commissurotomy (PMC) is indicated for symptomatic patients with mitral stenosis who have favorable valve anatomy 1
• Transcatheter aortic valve replacement (TAVR) is an option for patients with severe aortic stenosis at intermediate or high surgical risk 1
• For patients with mixed valve disease, the appropriate interventional therapy is determined by the predominant valve lesion with consideration of the severity of the concomitant valve disease 1

Treatment Options for Prosthetic Valve Issues

Prosthetic Valve Stenosis

• Surgery is primarily needed for bioprosthetic valve degeneration causing stenosis 1
• Mechanical valve stenosis is rare and typically due to valve thrombosis or pannus formation 1
• Transcatheter "valve-in-valve" approaches for treating bioprosthetic valve stenosis are promising but not yet fully validated 1

Prosthetic Valve Regurgitation

• Surgery is recommended for operable patients with mechanical heart valves with intractable hemolysis or heart failure due to severe prosthetic or paraprosthetic regurgitation 1
• Surgery is reasonable for operable patients with severe symptomatic or asymptomatic bioprosthetic regurgitation 1
• Percutaneous repair of paravalvular regurgitation is reasonable in patients with prosthetic heart valves and intractable hemolysis or NYHA class III/IV heart failure who are at high risk for surgery and have suitable anatomy for catheter-based therapy 1

Thrombosed Prosthetic Valves

• Emergency surgery is reasonable for patients with a thrombosed left-sided prosthetic heart valve with a mobile or large thrombus (>0.8 cm²) 1

Medical Management

• No specific medical therapies exist to prevent bioprosthetic valve degeneration 1
• Medical therapy is not effective for treatment of symptoms due to significant prosthetic valve regurgitation, but standard approaches may help stabilize patients before surgical intervention 1
• For patients with mild mitral regurgitation and normal left ventricular function, no specific medical therapy is recommended 2
• Diuretics may be used for symptom relief in patients who develop congestion 2

Follow-up and Monitoring

• Regular clinical and echocardiographic follow-up is essential to monitor disease progression 2
• Asymptomatic patients with moderate valvular disease should be clinically followed-up yearly with echocardiography every 2 years 1
• Asymptomatic patients with severe valvular disease should be seen every 6 months with annual echocardiography 1
• Following valve repair or replacement, baseline ECG, X-ray, and echocardiography should be established for later comparison 1

Special Considerations

• Heart Valve Centers of Excellence with multidisciplinary teams should manage complex valve disease cases, especially when considering early intervention in asymptomatic patients 1
• Mixed valve disease presents special management challenges due to limited data on timing of intervention, particularly with mixed moderate valve disease 1
• Exercise hemodynamic studies should be considered for patients with mixed valve disease whose symptoms seem out of proportion to resting hemodynamic findings 1