What is the best management approach for an adult patient with a history of cardiovascular disease and valvular heart disease?

Management of Valvular Heart Disease in Adults with Cardiovascular Disease

All patients with severe valvular heart disease being considered for intervention must be evaluated by a multidisciplinary Heart Valve Team at a Primary or Comprehensive Valve Center, as this approach optimizes patient selection, treatment strategy, and outcomes. 1, 2

Initial Diagnostic Evaluation

Correlate physical examination findings with objective testing to establish diagnosis and severity:

• Perform meticulous history focusing on symptom presence and functional capacity, as treatment decisions are primarily symptom-driven 1
• Document specific findings: heart murmurs (location, timing, radiation), signs of heart failure (orthopnea, paroxysmal nocturnal dyspnea, peripheral edema), and exercise tolerance 1
• Obtain 12-lead ECG to identify arrhythmias, ventricular hypertrophy, or conduction abnormalities 2, 3
• Order chest x-ray to assess cardiomegaly, pulmonary congestion, and valve calcification 1
• Transthoracic echocardiography is the single most important diagnostic test and must be performed to quantify valve severity, assess ventricular function, and guide management 1, 2, 3

When physical examination conflicts with initial noninvasive testing, proceed to advanced imaging:

• Consider cardiac CT, cardiac MRI, or stress testing for discordant findings 1, 2
• Use transesophageal echocardiography or cardiac catheterization when non-invasive methods are inadequate 1, 2

Disease Staging Framework

Classify disease severity using the Stage A-D system to guide management decisions:

• Stage A: At risk for VHD (e.g., bicuspid aortic valve, rheumatic fever history) - no intervention needed, focus on risk factor modification 1
• Stage B: Progressive VHD (mild-moderate severity, asymptomatic) - serial monitoring with echocardiography 1
• Stage C: Asymptomatic severe VHD - consider intervention based on objective markers 1
• Stage D: Symptomatic severe VHD - intervention indicated 1

Medical Management Strategies

Medical therapy serves primarily as supportive care, not definitive treatment for chronic valvular disease:

• Apply guideline-directed medical therapy (GDMT) for left ventricular systolic dysfunction: ACE inhibitors/ARBs, beta-blockers, diuretics, and aldosterone antagonists 2, 4
• Avoid abrupt blood pressure lowering in stenotic valve lesions to prevent hemodynamic collapse 4
• No rigorous evidence supports pharmacological therapy for preventing progression of most chronic valvular diseases 5
• Medical therapy may serve as a bridge to surgery in severely decompensated patients 5

For rheumatic heart disease specifically:

• Administer benzathine penicillin G 1.2 million units intramuscularly every 4 weeks (or every 3 weeks in high-risk patients) for secondary prophylaxis 4
• Alternative: oral penicillin V 250 mg twice daily or sulfadiazine 1 gram daily for penicillin-allergic patients 4
• Continue secondary prophylaxis even after valve replacement surgery 4

Anticoagulation Management in Atrial Fibrillation

Use shared decision-making based on CHA₂DS₂-VASc score to select anticoagulation strategy:

• For most VHD patients with atrial fibrillation: choose between vitamin K antagonist (warfarin) or non-vitamin K antagonist oral anticoagulant (NOAC) 1, 2
• Target INR 2.0-3.0 for warfarin therapy in non-valvular atrial fibrillation 6

Absolute contraindications to NOACs (warfarin mandatory):

• Rheumatic mitral stenosis with atrial fibrillation 1, 2, 6
• Mechanical prosthetic valves with atrial fibrillation 1, 2, 6
• Target INR varies by mechanical valve type and position: 2.0-3.0 for St. Jude bileaflet aortic valves; 2.5-3.5 for tilting disk or mitral position bileaflet valves; 2.5-3.5 plus aspirin 75-100 mg daily for caged ball/disk valves 6

Timing of Intervention for Aortic Stenosis

Intervention with transcatheter or surgical valve replacement is indicated primarily for:

• Symptomatic severe aortic stenosis (angina, syncope, dyspnea) 1, 2
• Asymptomatic severe aortic stenosis with reduced left ventricular ejection fraction (<50%) 1, 2

Consider earlier intervention in asymptomatic patients when:

• Exercise testing demonstrates objective exercise limitation or abnormal hemodynamic response 1, 2
• Biomarkers (BNP/NT-proBNP) are significantly elevated 1, 2
• Rapid hemodynamic progression documented on serial imaging 1, 2
• Very severe stenosis present (aortic velocity >5 m/s or mean gradient >60 mmHg) 1, 2

Timing of Intervention for Valvular Regurgitation

Thresholds for intervention are now lower than previously recommended due to improved procedural outcomes and valve durability:

• Primary indications: relief of symptoms and prevention of irreversible left ventricular consequences from chronic volume overload 1, 2
• Asymptomatic severe regurgitation warrants intervention when left ventricular systolic dysfunction develops (LVEF <60% for mitral regurgitation, <50% for aortic regurgitation) or left ventricular dilation exceeds specific thresholds 1, 2

Multidisciplinary Heart Valve Team Composition

The Heart Valve Team must include at minimum:

• Cardiologist with valvular heart disease expertise 1, 2
• Cardiovascular surgeon 1, 2
• Structural valve interventionalist when catheter-based therapy is considered 1, 2

Extended team members for complex cases:

• Cardiovascular imaging specialists, anesthesiologists, nurses with VHD expertise 1
• Infectious disease specialists for endocarditis cases 1
• High-risk obstetrics specialists for pregnant patients 1

Surgical Risk Stratification

Society of Thoracic Surgeons (STS) database median mortality rates:

• Isolated aortic valve replacement: 2.2% 2
• Aortic valve replacement with CABG: 4% 2
• Mitral valve repair: 1% 2
• Mitral valve replacement: 5% 2
• Combined aortic and mitral valve replacement: 9% 2
• Mitral valve replacement with CABG: 9% 2

High-risk features increasing operative mortality:

• Severe left or right ventricular dysfunction with fixed pulmonary hypertension 2
• Chronic kidney disease stage 3 or worse 2
• Severe pulmonary disease (FEV₁ <50% or DLCO₂ <50% predicted) 2
• Central nervous system dysfunction 2
• Active malignancy 2
• Cirrhosis with history of variceal bleeding or elevated INR without anticoagulation 2

Transcatheter vs. Surgical Approach Selection

The choice between transcatheter and surgical intervention requires shared decision-making considering:

• Patient age, surgical risk, and comorbidities 1, 2
• Lifetime management implications: mechanical valves require lifelong anticoagulation but offer superior durability; bioprosthetic valves avoid anticoagulation but have limited durability 7
• Transcatheter options expanding based on multiple randomized trials, particularly for aortic stenosis 1, 2
• For patients <60 years without anticoagulation contraindications: mechanical valves recommended for superior durability 7
• For patients >65 years or life expectancy <10 years: bioprosthetic valves recommended 7
• Ages 60-70: patient preference plays larger role 7

Critical Pitfalls to Avoid

• Do not delay referral to a Heart Valve Center until symptoms become severe - outcomes are optimized with timely intervention before irreversible ventricular damage occurs 1, 2
• Do not rely on medical therapy as definitive treatment for severe chronic valvular disease - only mechanical correction removes the hemodynamic burden 5, 8
• Do not assume very elderly or high-risk patients are inoperable - many previously considered inoperable patients benefit substantially from valve surgery when carefully selected 8
• Do not prescribe NOACs for rheumatic mitral stenosis or mechanical valves - warfarin is mandatory 1, 2, 6
• Do not provide routine endocarditis prophylaxis for rheumatic heart disease alone - only indicated for prosthetic valves, prior endocarditis, or prosthetic material used for valve repair 4

Bioprosthetic Valve Dysfunction Management

Catheter-based treatment is reasonable for selected patients with:

• Bioprosthetic valve leaflet degeneration 2
• Paravalvular leak in the absence of active infection 2