How do we categorize valvular heart diseases?

From the Guidelines

Valvular heart diseases should be categorized into stages A, B, C, and D based on symptoms, valve anatomy, the severity of valve dysfunction, and the response of the ventricle and pulmonary circulation. This categorization is crucial for determining the optimal treatment strategy and has been recommended by the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines 1.

Key Considerations for Categorization

• The affected valve (mitral, aortic, tricuspid, or pulmonary)
• The type of dysfunction (stenosis or regurgitation/insufficiency)
• The severity of valve disease (mild, moderate, or severe)
• The etiology of the valve disease (congenital, acquired, or functional)
• The hemodynamic consequences of the valve disease

Staging of Valvular Heart Disease

The staging of valvular heart disease is based on the following criteria:

• Stage A: Patients at risk for valvular heart disease
• Stage B: Patients with progressive valvular heart disease
• Stage C: Patients with asymptomatic severe valvular heart disease
• Stage D: Patients with symptomatic severe valvular heart disease

This staging system helps guide clinical decision-making regarding monitoring frequency, medical therapy, and timing of interventional or surgical treatment, with the goal of improving morbidity, mortality, and quality of life for patients with valvular heart disease 1.

Importance of Multidisciplinary Evaluation

All patients with severe valvular heart disease being considered for valve intervention should be evaluated by a multidisciplinary team, with either referral to or consultation with a Primary or Comprehensive Valve Center 1. This ensures that patients receive comprehensive care and that treatment decisions are made based on a thorough evaluation of their condition.

Treatment Considerations

Treatment of valvular heart disease depends on the stage and severity of the disease, as well as the presence of symptoms and other comorbidities. The decision to use oral anticoagulation to prevent thromboembolic events should be made in a shared decision-making process based on the CHADS-VASc score 1. Additionally, the choice of type of intervention for a patient with severe aortic stenosis should be a shared decision-making process that considers the lifetime risks and benefits associated with type of valve (mechanical versus bioprosthetic) and type of approach (transcatheter versus surgical) 1.

From the Research

Categorization of Valvular Heart Diseases

Valvular heart diseases can be categorized based on the type of valve affected and the nature of the lesion. The main categories include:

• Stenotic valvular lesions, where the valve opening is narrowed, restricting blood flow 2, 3
• Regurgitant valvular lesions, where the valve does not close properly, allowing blood to flow backward 2, 3

Types of Valvular Heart Diseases

The most common types of valvular heart diseases include:

• Mitral regurgitation (MR), where the mitral valve does not close properly 4
• Aortic stenosis (AS), where the aortic valve opening is narrowed 4
• Aortic regurgitation (AR), where the aortic valve does not close properly 4
• Mitral stenosis, most often caused by rheumatic fever, although this is uncommon in the United States 4

Diagnosis and Evaluation

The diagnosis and evaluation of valvular heart diseases typically involve:

• Echocardiography, which is the gold standard for diagnosis and periodic assessment of patients with valvular heart disease 2, 3, 5
• Transthoracic echocardiography, which should be obtained first when valvular heart disease is suspected 4
• Other tests, such as transesophageal echocardiography, computed tomography scan, magnetic resonance imaging study, and cardiac catheterization, which may be used in special situations to obtain more detailed diagnostic information 4
• Cardiac magnetic resonance (CMR) imaging, which can provide a more accurate and valid quantification of cardiac function, mass, and regurgitant volumes than echocardiography 6

Management and Treatment

The management and treatment of valvular heart diseases depend on the severity of the valve dysfunction and the presence of symptoms. Generally:

• Patients with stenotic valvular lesions can be monitored clinically until symptoms appear 3
• Patients with regurgitant valvular lesions require careful echocardiographic monitoring for left ventricular function and may require surgery even if no symptoms are present 2, 3
• Surgery or intervention is recommended when symptoms dictate or when changes in left ventricular function occur 5
• Medical therapy has a limited role in the treatment of valvular heart disease, although afterload reduction may be beneficial in cases of severe aortic insufficiency 2