Key Points

Treatment

Design and created by Guideline Central in participation with the American College of Cardiology and American Heart Association.

Valvular Heart Disease

American College of Cardiology

American Heart Association

Publication Date: December 21, 2020

Disease stages in patients with valvular heart disease should be classified (Stages A, B, C, and D) on the basis of symptoms, valve anatomy, the severity of valve dysfunction, and the response of the ventricle and pulmonary circulation.
In the evaluation of a patient with valvular heart disease, history and physical examination findings should be correlated with the results of noninvasive testing (i.e., ECG, chest x-ray, transthoracic echocardiogram). If there is discordance between the physical examination and initial noninvasive testing, consider further noninvasive (computed tomography, cardiac magnetic resonance imaging, stress testing) or invasive (transesophageal echocardiography, cardiac catheterization) testing to determine optimal treatment strategy.
For patients with valvular heart disease and atrial fibrillation (except for patients with rheumatic mitral stenosis or a mechanical prosthesis), the decision to use oral anticoagulation to prevent thromboembolic events, with either a vitamin K antagonist or a non–vitamin K antagonist anticoagulant, should be made in a shared decision-making process based on the CHA₂DS₂-VASc score. Patients with rheumatic mitral stenosis or a mechanical prosthesis and atrial fibrillation should receive oral anticoagulation with a vitamin K antagonist.
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.
Treatment of severe aortic stenosis with either a transcatheter or surgical valve prosthesis should be based primarily on symptoms or reduced ventricular systolic function. Earlier intervention may be considered if indicated by results of exercise testing, biomarkers, rapid progression, or the presence of very severe stenosis.
Indications for transcatheter aortic valve implantation are expanding AS a result of multiple randomized trials of transcatheter aortic valve implantation atrioversus surgical aortic valve replacement. 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).
Indications for intervention for valvular regurgitation are relief of symptoms and prevention of the irreversible long-term consequences of left ventricular volume overload. Thresholds for intervention now are lower than they were previously because of more durable treatment options and lower procedural risks.
A mitral transcatheter edge-to-edge repair is of benefit to patients with severely symptomatic primary mitral regurgitation who are at high or prohibitive risk for surgery, AS well AS to a select subset of patients with secondary mitral regurgitation who remain severely symptomatic despite guideline-directed management and therapy for heart failure.
Patients presenting with severe symptomatic isolated tricuspid regurgitation, commonly associated with device leads and atrial fibrillation, may benefit from surgical intervention to reduce symptoms and recurrent hospitalizations if done before the onset of severe right ventricular dysfunction or end-organ damage to the liver and kidney.
Bioprosthetic valve dysfunction may occur because of either degeneration of the valve leaflets or valve thrombosis. Catheter-based treatment for prosthetic valve dysfunction is reasonable in selected patients for bioprosthetic leaflet degeneration or paravalvular leak in the absence of active infection.

Table 1. Evaluation of Patients With Known or Suspected VHD

Test	Indication
Reason Initial evaluation: All patients with known or suspected valve disease
TTE*	Establishes chamber size and function, valve morphology and severity, and effect on pulmonary and systemic circulation
History and physical	Establishes symptom severity, comorbidities, valve disease presence and severity, and presence of HF
ECG	Establishes rhythm, LV function, and presence or absence of hypertrophy
Reason Further diagnostic testing: Information required for equivocal symptom status, discrepancy between examination and echocardiogram, further definition of valve disease, or assessing response of the ventricles and pulmonary circulation to load and to exercise
Test	Indication
Chest x-ray	Important for the symptomatic patient; establishes heart size and presence or absence of pulmonary vascular congestion, intrinsic lung disease, and calcification of aorta and pericardium
TEE	Provides high-quality assessment of mitral and prosthetic valve, including definition of intracardiac masses and possible associated abnormalities (e.g., intracardiac abscess, LA thrombus)
CMR	Provides assessment of LV volumes and function, valve severity, and aortic disease
PET CT	Aids in determination of active infection or inflammation
Stress testing	Gives an objective measure of exercise capacity
Catheterization	Provides measurement of intracardiac and pulmonary pressures, valve severity, and hemodynamic response to exercise and drugs
Reason Further risk stratification: Information on future risk of the valve disease, which is important for determination of timing of intervention
Test	Indication
Biomarkers	Provide indirect assessment of filling pressures and myocardial damage
TTE strain	Helps assess intrinsic myocardial performance
CMR	Assesses fibrosis by gadolinium enhancement
Stress testing	Provides prognostic markers
Procedural risk	Quantified by STS (Predicted Risk of Mortality) and TAVI scores
Frailty score	Provides assessment of risk of procedure and chance of recovery of quality of life
Reason Preprocedural testing: Testing required before valve intervention
Test	Indication
Dental examination	Rules out potential infection sources
CT coronary angiogram or invasive coronary angiogram	Gives an assessment of coronary anatomy
CT: peripheral	Assesses femoral access for TAVI and other transcatheter procedures
CT: cardiac	Assesses suitability for TAVI and other transcatheter procedures

* TTE is the standard initial diagnostic test in the initial evaluation of patients with known or suspected VHD.

Table 2. Stages of Progression of VHD

Stage	Definition	Description
A	At risk	Patients with risk factors for development of VHD
B	Progressive	Patients with progressive VHD (mild-to-moderate severity and asymptomatic)
C	Asymptomatic severe	Asymptomatic patients who meet the criteria for severe VHD: C1: Asymptomatic patients with severe VHD in whom the left or right ventricle remains compensated C2: Asymptomatic patients with severe VHD, with decompensation of the left or right ventricle
D	Symptomatic severe	Patients who have developed symptoms AS a result of VHD

Table 3. Frequency of Echocardiograms in Asymptomatic Patients With VHD and Normal Left Ventricular (LV) Function

Stage	AS*	AR	MS	MR
Progressive (stage B)	Every 3–5 y (mild severity; V_max 2.0–2.9 m/s) Every 1–2 y (moderate severity; V_max 3.0–3.9 m/s)	Every 3–5 y (mild severity) Every 1–2 y (moderate severity)	Every 3–5 y (mitral valve area [MVA] >1.5 cm)	Every 3–5 y (mild severity) Every 1–2 y (moderate severity)
Severe asymptomatic (stage C1)	Every 6–12 mo (V_max ≥4 m/s)	Every 6–12 mo Dilating LV: more frequently	Every 1–2 y (MVA 1.0–1.5 cm) Every year (MVA <1.0 cm)	Every 6–12 mo Dilating LV: more frequently

Patients with mixed valve disease may require serial evaluations at intervals earlier than recommended for single-valve lesions. These intervals apply to most patients with each valve lesion and do not take into consideration the etiology of the valve disease.
* With normal stroke volume.

Table 4. Secondary Prevention of Rheumatic Fever

Antibiotics for Prevention	Dosage*
Penicillin G benzathine	1.2 million U intramuscularly every 4 wk^†
Penicillin V potassium	250 mg orally twice daily
Sulfadiazine	1 g orally once daily
Macrolide or azalide antibiotic (for patients allergic to penicillin and sulfadiazine)^‡	Varies

* In patients with documented valvular heart disease, the duration of rheumatic fever prophylaxis should be ≥10 y or until the patient is 40 y of age (whichever is longer). Lifelong prophylaxis may be recommended if the patient is at high risk of group A streptococcus exposure. Secondary rheumatic heart disease prophylaxis is required even after valve replacement.
^† Administration every 3 wk is recommended in certain high-risk situations.
^‡ Macrolide antibiotics should not be used in persons taking other medications that inhibit cytochrome P450 3A, such as azole antifungal agents, HIV protease inhibitors, and some selective serotonin reuptake inhibitors.

Table 5. Duration of Secondary Prophylaxis for Rheumatic Fever

Type	Duration After Last Attack*
Rheumatic fever with carditis and residual heart disease (persistent VHD)	10 y or until patient is 40 y of age (whichever is longer)
Rheumatic fever with carditis but no residual heart disease (no valvular disease^†)	10 y or until patient is 21 y of age (whichever is longer)
Rheumatic fever without carditis	5 y or until patient is 21 y of age (whichever is longer)

* Lifelong prophylaxis may be recommended if the patient is at high risk of group A streptococcus exposure. Secondary rheumatic heart disease prophylaxis is required even after valve replacement.
^† Clinical or echocardiographic evidence.

Table 6. Risk Assessment for Surgical Valve Procedures

Criteria	Low-Risk SAVR (Must Meet ALL Criteria in This Column)	Low-Risk Surgical Mitral Valve Repair for Primary MR (Must Meet ALL Criteria in This Column)	High Surgical Risk (Any 1 Criterion in This Column)	Prohibitive Surgical Risk (Any 1 Criterion in This Column)
STS-predicted risk of death*	<3% AND	<1% AND	>8% OR	Predicted risk of death or major morbidity (all-cause) >50% at 1 y OR
Frailty^†	None AND	None AND	≥2 Indices (moderate to severe) OR	≥2 Indices (moderate to severe) OR
Cardiac or other major organ system compromise not to be improved postoperatively^‡	None AND	None AND	1 to 2 Organ systems OR	≥3 Organ systems OR
Procedure-specific impediment^§	None	None	Possible procedure-specific impediment	Severe procedure-specific impediment

* Use of the STS Predicted Risk of Mortality (http://riskcalc.sts.org/stswebriskcalc/#/) to predict risk in a given institution with reasonable reliability is appropriate only if institutional outcomes are within 1 standard deviation of the STS average observed/expected mortality ratio for the procedure in question. The EUROSCORE II risk calculator may also be considered for use and is available at http://www.euroscore.org/calc.html.
^† Seven frailty indices: Katz Activities of Daily Living (independence in feeding, bathing, dressing, transferring, toileting, and urinary continence) plus independence in ambulation (no walking aid or assistance required, or completion of a 5-m walk in <6 s). Other scoring systems can be applied to calculate no, mild, or moderate to severe frailty.
Examples of major organ system compromise include cardiac dysfunction (severe LV systolic or diastolic dysfunction or RV dysfunction, fixed pulmonary hypertension); kidney dysfunction (chronic kidney disease, stage 3 or worse); pulmonary dysfunction (FEV1 <50% or D <50% of predicted); central nervous system dysfunction (dementia, Alzheimer’s disease, Parkinson’s disease, cerebrovascular accident with persistent physical limitation); gastrointestinal dysfunction (Crohn’s disease, ulcerative colitis, nutritional impairment, or serum albumin <3.0); cancer (active malignancy); and liver dysfunction (any history of cirrhosis, variceal bleeding, or elevated INR in the absence of VKA therapy).
^§ Examples of procedure-specific impediments include presence of tracheostomy, heavily calcified (porcelain) ascending aorta, chest malformation, arterial coronary graft adherent to posterior chest wall, and radiation damage.

Table 7. Examples of Procedure-Specific Risk Factors for Interventions Not Incorporated Into Existing Risk Scores

SAVR	TAVI	Surgical MV Repair or Replacement	Transcatheter Edge-to-Edge Mitral Valve Repair
Technical or anatomic
Prior mediastinal radiation Ascending aortic calcification (porcelain aorta may be prohibitive)	Aorto-iliac occlusive disease precluding transfemoral approach Aortic arch atherosclerosis (protuberant lesions) Severe MR or TR Low-lying coronary arteries Basal septal hypertrophy Valve morphology (e.g., bicuspid or unicuspid valve) Extensive LV outflow tract calcification	Prior sternotomy Prior mediastinal radiation Ascending aortic calcification (porcelain aorta may be prohibitive)	Multivalve disease Valve morphology (e.g., thickening, perforations, clefts, calcification, and stenosis) Prior Mitral Valve surgery
Comorbidities
Severe COPD or home oxygen therapy Pulmonary hypertension Severe RV dysfunction Hepatic dysfunction Frailty*	Severe COPD or home oxygen therapy Pulmonary hypertension Severe RV dysfunction Hepatic dysfunction Frailty*	Severe COPD or home oxygen therapy Pulmonary hypertension Hepatic dysfunction Frailty*	Severe COPD or home oxygen therapy Pulmonary hypertension Hepatic dysfunction Frailty*
Futility
STS score >15 Life expectancy <1 y Poor candidate for rehabilitation	STS score >15 Life expectancy <1 y Poor candidate for rehabilitation	STS score >15 Life expectancy <1 y Poor candidate for rehabilitation	STS score >15 Life expectancy <1 y Poor candidate for rehabilitation

* Validated frailty scores include the Katz Activities of Daily Living Score

Table 8. Median Operative Mortality Rates for Specific Surgical Procedures (STS Adult Cardiac Surgery Database, 2019

Procedure	Mortality Rate (%)
AVR	2.2
AVR and CABG	4
AVR and Mitral Valve replacement	9
Mitral Valve replacement	5
Mitral Valve replacement and CABG	9
Mitral Valve repair	1
Mitral Valve repair and CABG	5

Table 9. Structure of Primary and Comprehensive Valve Centers

Comprehensive (Level I) Valve Center	Primary (Level II) Valve Center
Interventional Procedures*
TAVI–transfemoral	TAVI–transfemoral
Percutaneous aortic valve balloon dilation	Percutaneous aortic valve balloon dilation
TAVI–alternative access, including transthoracic (transaortic, transapical) and extrathoracic (e.g., subclavian, carotid, caval) approaches
Valve-in-valve procedures
Mitral transcatheter edge-to-edge repair
Prosthetic valve paravalvular leak closure
Percutaneous mitral balloon commissurotomy
Surgical Procedures*
SAVR	SAVR
Valve-sparing aortic root procedures
Aortic root procedures for aneurysmal disease
Concomitant septal myectomy with AVR
Root enlargement with AVR
Mitral repair for primary MR	Mitral repair for posterior leaflet primary MR
Mitral valve replacement^‡	Mitral valve replacement^‡
Multivalve operations
Reoperative valve surgery
Isolated or concomitant tricuspid valve repair or replacement	Concomitant tricuspid valve repair or replacement with mitral surgery
Imaging Personnel
Echocardiographer with expertise in valve disease and transcatheter and surgical interventions	Echocardiographer with expertise in valve disease and transcatheter and surgical interventions
Expertise in CT with application to valve assessment and procedural planning	Expertise in CT with application to valve assessment and procedural planning
Interventional echocardiographer to provide imaging guidance for transcatheter and intraoperative procedures
Expertise in cardiac MRI with application to assessment of VHD
Criteria for Imaging Personnel
A formalized role/position for a “valve echocardiographer” who performs both the pre- and postprocedural assessment of valve disease	A formalized role/position for a “valve echocardiographer” who performs both the pre- and postprocedural assessment of valve disease
A formalized role/position for the expert in CT who oversees the preprocedural assessment of patients with valve disease	A formalized role/position for the expert in CT who oversees the preprocedural assessment of patients with valve disease
A formalized role/position for an interventional echocardiographer
Institutional Facilities and Infrastructure
MDT	MDT
A formalized role/position for a dedicated valve coordinator who organizes care across the continuum and system of care	A formalized role/position for a dedicated valve coordinator who organizes care across the continuum and system of care
Cardiac anesthesia support	Cardiac anesthesia support
Palliative care team	Palliative care team
Vascular surgery support	Vascular surgery support
Neurology stroke team	Neurology stroke team
Consultative services with other cardiovascular subspecialties
Consultative services with other medical and surgical subspecialties
Echocardiography–3D TEE; comprehensive TTE for assessment of valve disease	Echocardiography–comprehensive TTE for assessment of valve disease
Cardiac CT	Cardiac CT
ICU	ICU
Temporary mechanical support (including percutaneous support devices such AS intra-aortic balloon counterpulsation, temporary percutaneous ventricular assist device or ECMO)	Temporary mechanical support (including percutaneous support devices such AS intra-aortic balloon counterpulsation, temporary percutaneous ventricular assist device or ECMO)
Left/right ventricular assist device capabilities (on-site or at an affiliated institution)
Cardiac catheterization laboratory, hybrid catheterization laboratory, or hybrid OR laboratory^§	Cardiac catheterization laboratory
PPM and ICD implantation	PPM and ICD implantation
Institutional Facilities and Infrastructure
IAC echocardiography laboratory accreditation	IAC echocardiography laboratory accreditation
24/7 intensivist coverage for ICU

* A Primary (Level II) Center may provide additional procedures traditionally offered at a Comprehensive (Level I) Center as long as the criteria for competence and outcomes are met.
^† If intraoperative imaging and surgical expertise exist.
^‡ If mitral valve anatomy is not suitable for valve repair.
^§ Equipped with a fixed radiographic imaging system and flat-panel fluoroscopy, offering catheterization laboratory-quality imaging and hemodynamic capability. Used with permission from Nishimura et al. J Am Coll Cardiol. 2019;73:2609-35.

Table 10. Timing of Periodic Imaging After Valve Intervention

Imaging Follow-Up*

Valve Intervention	Minimal Imaging Frequency^†	Location
Mechanical valve (surgical)	Baseline	Primary Valve Center
Bioprosthetic valve (surgical)	Baseline, 5 and 10 y after surgery,^‡ and then annually	Primary Valve Center
Bioprosthetic valve (transcatheter)	Baseline and then annually	Primary Valve Center
Mitral valve repair (surgical)	Baseline, 1 y, and then every 2–3 y	Primary Valve Center
Mitral valve repair (transcatheter)	Baseline and then annually	Comprehensive Valve Center
Bicuspid aortic valve disease	monitoring of aortic size if aortic diameter is ≥4.0 cm at time of AVR, AS detailed in Section 5.1	Primary Valve Center

* Initial postprocedural TTE is recommended for all patients, ideally 1 to 3 months after the procedure. Annual clinical follow-up is recommended annually for all patients after valve intervention at a Primary or Comprehensive Valve Center.
^† Repeat imaging is appropriate at shorter follow-up intervals for changing signs or symptoms, during pregnancy, and to monitor residual or concurrent cardiac dysfunction.
^‡ Imaging may be done more frequently in patients with bioprosthetic surgical valves if there are risk factors for early valve degeneration (e.g., younger age, renal failure, diabetes)

Table 11. Stages of AS

Stage	Definition	Valve Anatomy	Valve Hemodynamics	Hemodynamic Consequences	Symptoms
A	At risk of AS	Bicuspid aortic valve (or other congenital valve anomaly) Aortic valve sclerosis	Aortic V_max <2 m/s with normal leaflet motion	None	None
B	Progressive AS	Mild to moderate leaflet calcification/fibrosis of a bicuspid or trileaflet valve with some reduction in systolic motion or Rheumatic valve changes with commissural fusion	Mild AS: Aortic V_max 2.0–2.9 m/s or ∆P_mean <20 mm Hg Moderate AS: Aortic V_max 3.0–3.9 m/s or ∆P_mean 20–39 mm Hg	Early LV diastolic dysfunction may be present Normal left ventricular ejection fraction (LVEF)	None
C: Asymptomatic severe AS
C1	Asymptomatic severe AS	Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening	Aortic V_max ≥4 m/s or ∆P_mean ≥40 mm Hg Aortic valve area (AVA) typically ≤1.0 cm (or AVAi 0.6 cm/m) but not required to define severe AS Very severe AS: Aortic V_max ≥5 m/s or ∆P_mean ≥60 mm Hg	LV diastolic dysfunction Mild LV hypertrophy Normal LVEF	None: Exercise testing is reasonable to confirm symptom status
C2	Asymptomatic severe AS with LV dysfunction	Severe leaflet calcification/fibrosis or congenital stenosis with severely reduced leaflet opening	Aortic V_max ≥4 m/s or ∆P_mean ≥40 mm Hg AVA typically ≤1.0 cm (or AVAi 0.6 cm/m²)	LVEF <50%	None
D: Symptomatic severe AS
D1	Symptomatic severe high- gradient AS	Severe leaflet calcification/fibrosis or congenital stenosis with severely reduced leaflet opening	Aortic V_max ≥4 m/s or ∆P_mean ≥40 mm Hg AVA typically ≤1.0 cm (or AVAi ≤0.6 cm/m) but may be larger with mixed AS/AR	LV diastolic dysfunction LV hypertrophy Pulmonary hypertension (PHTN) may be present	Exertional dyspnea or decreased exercise tolerance Exertional angina Exertional syncope or presyncope
D2	Symptomatic severe low-flow/low-gradient AS with reduced LVEF	Severe leaflet calcification with severely reduced leaflet motion	AVA ≤1.0 cm with resting aortic V_max <4 m/s or ∆P_mean <40 mm Hg Dobutamine stress echocardiography (DSE) shows AVA <1.0 cm with V_max ≥4 m/s at any flow rate	LV diastolic dysfunction LV hypertrophy LVEF <50%	Heart failure (HF) Angina Syncope or presyncope
D3	Symptomatic severe low-gradient AS with normal LVEF or paradoxical low-flow severe AS	Severe leaflet calcification/fibrosis with severely reduced leaflet motion	AVA ≤1.0 cm (indexed AVA ≤0.6 cm/m²) with an aortic V_max <4 m/s or ∆P_mean <40 mm Hg, AND Stroke volume index <35 mL/m² Measured when patient is normotensive (systolic blood pressure <140 mm Hg)	Increased LV relative wall thickness Small LV chamber with low stroke volume Restrictive diastolic filling LVEF ≥50%	HF Angina Syncope or presyncope

Table 12. A Simplified Framework With Examples of Factors Favoring SAVR, TAVI, or Palliation Instead of Aortic Valve Intervention

Favors SAVR	Favors TAVI	Favors Palliation
Age/life expectancy*	Younger age/longer life expectancy	Older age/fewer expected remaining years of life	Limited life expectancy
Valve anatomy	BAV Subaortic (LV outflow tract) calcification Rheumatic valve disease Small or large aortic annulus^†	Calcific AS of a trileaflet valve
Prosthetic valve preference	Mechanical or surgical bioprosthetic valve preferred Concern for patient–prosthesis mismatch (annular enlargement might be considered)	Bioprosthetic valve preferred Favorable ratio of life expectancy to valve durability TAVI provides larger valve area than same size SAVR
Concurrent cardiac conditions	Aortic dilation^‡ Severe primary MR Severe CAD requiring bypass grafting Septal hypertrophy requiring myectomy AF	Severe calcification of the ascending aorta (“porcelain” aorta)	Irreversible severe LV systolic dysfunction Severe MR attributable to annular calcification
Noncardiac conditions		Severe lung, liver, or renal disease Mobility issues (high procedural risk with sternotomy)	Symptoms likely attributable to noncardiac conditions Severe dementia Moderate to severe involvement of ≥2 other organ systems
Frailty	Not frail or few frailty measures	Frailty likely to improve after TAVI	Severe frailty unlikely to improve after TAVI
Estimated procedural or surgical risk of SAVR or TAVI	SAVR risk low TAVI risk high	TAVI risk low to medium SAVR risk high to prohibitive	Prohibitive SAVR risk (>15%) or post-TAVI life expectancy <1 y
Procedure-specific impediments	Valve anatomy, annular size, or low coronary ostial height precludes TAVI Vascular access does not allow transfemoral TAVI	Previous cardiac surgery with at-risk coronary grafts Previous chest irradiation	Valve anatomy, annular size, or coronary ostial height precludes TAVI Vascular access does not allow transfemoral TAVI
Goals of Care and patient preferences and values	Less uncertainty about valve durability Avoid repeat intervention Lower risk of permanent pacer Life prolongation Symptom relief Improved long-term exercise capacity and QOL Avoid vascular complications Accepts longer hospital stay, pain in recovery period	Accepts uncertainty about valve durability and possible repeat intervention Higher risk of permanent pacer Life prolongation Symptom relief Improved exercise capacity and QOL Prefers shorter hospital stay, less postprocedural pain	Life prolongation not an important goal Avoid futile or unnecessary diagnostic or therapeutic procedures Avoid procedural stroke risk Avoid possibility of cardiac pacer

* Expected remaining years of life can be estimated from U.S. Actuarial Life Expectancy tables. The balance between expected patient longevity and valve durability varies continuously across the age range, with more durable valves preferred for patients with a longer life expectancy. Bioprosthetic valve durability is finite (with shorter durability for younger patients), whereas mechanical valves are very durable but require lifelong anticoagulation. Long-term (20-y) data on outcomes with surgical bioprosthetic valves are available; robust data on transcatheter bioprosthetic valves extend only to 5 y, leading to uncertainty about longer-term outcomes. The decision about valve type should be individualized on the basis of patient-specific factors that might affect expected longevity.
^† A large aortic annulus may not be suitable for currently available transcatheter valve sizes. With a small aortic annulus or aorta, a surgical annulus-enlarging procedure may be needed to allow placement of a larger prosthesis and avoid patient–prosthesis mismatch.
^‡ Dilation of the aortic sinuses or ascending aorta may require concurrent surgical replacement, particularly in younger patients with a BAV.

Table 13. Stages of Chronic Aortic Regurgitation (AR)

Stage	Definition	Valve Anatomy	Valve Hemodynamics	Hemodynamic Consequences	Symptoms
A	At risk of AR	Bicuspid aortic valve (or other congenital valve anomaly) Aortic valve sclerosis Diseases of the aortic sinuses or ascending aorta History of rheumatic fever or known rheumatic heart disease Infective endocarditis (IE)	AR severity: none or trace	None	None
B	Progressive AR	Mild-to-moderate calcification of a trileaflet valve, bicuspid aortic valve (or other congenital valve anomaly) Dilated aortic sinuses Rheumatic valve changes Previous IE	Mild AR: Jet width <25% of left ventricular outflow tract (LVOT); Vena contracta <0.3 cm; RVol <30 mL/beat; RF <30%; Effective regurgitant orifice (ERO) <0.10 cm; Angiography grade Moderate AR: Jet width 25%–64% of LVOT; Vena contracta 0.3–0.6 cm; RVol 30–59 mL/beat; RF 30%–49%; ERO 0.10–0.29 cm; Angiography grade 2	Normal LV systolic function Normal LV volume or mild LV dilation	None
C	Asymptomatic severe AR	Calcific aortic valve disease Bicuspid valve (or other congenital abnormality) Dilated aortic sinuses or ascending aorta Rheumatic valve changes IE with abnormal leaflet closure or perforation	Severe AR: Jet width ≥65% of LVOT; Vena contracta >0.6 cm; Holodiastolic flow reversal in the proximal abdominal aorta; RVol ≥60 mL/beat; RF ≥50%; ERO ≥0.3 cm; Angiography grade 3–4; In addition, diagnosis of chronic severe AR requires evidence of LV dilation	C1: Normal LVEF (>55%) and mild to moderate LV dilation (LVESD <50 mm) C2: Abnormal LV systolic function with depressed LVEF (≤55%) or severe LV dilation (LVESD >50 mm or indexed LVESD >25 mm/m)	None; exercise testing is reasonable to confirm symptom status
D	Symptomatic severe AR	Calcific valve disease Bicuspid valve (or other congenital abnormality) Dilated aortic sinuses or ascending aorta Rheumatic valve changes Previous IE with abnormal leaflet closure or perforation	Severe AR: Doppler jet width ≥65% of LVOT; Vena contracta >0.6 cm; Holodiastolic flow reversal in the proximal abdominal aorta; RVol ≥60 mL/beat; RF ≥50%; ERO ≥0.3 cm; Angiography grade 3–4; In addition, diagnosis of chronic severe AR requires evidence of LV dilation	Symptomatic severe AR may occur with normal systolic function (LVEF >55%), mild to moderate LV dysfunction (LVEF 40%–55%), or severe LV dysfunction (LVEF <40%) Moderate to severe LV dilation is present	Exertional dyspnea or angina or more severe HF symptoms

Table 14. Stages of MS

Stage	Definition	Valve Anatomy	Valve Hemodynamics*	Hemodynamic Consequences	Symptoms
A	At risk of MS	Mild valve doming during diastole	Normal transmitral flow velocity	None	None
B	Progressive MS	Rheumatic valve changes with commissural fusion and diastolic doming of the MV leaflets Planimetered MVA >1.5 cm	Increased transmitral flow velocities Mitral valve area >1.5 cm² Diastolic pressure half-time <150 MS	Mild-to-moderate left atrium (LA) enlargement Normal pulmonary pressure at rest	None
C	Asymptomatic severe MS	Rheumatic valve changes with commissural fusion and diastolic doming of the MV leaflets Planimetered MVA ≤1.5 cm	Mitral valve area ≤1.5 cm² Diastolic pressure half-time ≥150 MS	Severe LA enlargement Elevated PASP >50 mm Hg	None
D	Symptomatic severe MS	Rheumatic valve changes with commissural fusion and diastolic doming of the MV leaflets Planimetered MVA ≤1.5 cm	Mitral valve area ≤1.5 cm² Diastolic pressure half-time ≥150 MS	Severe LA enlargement Elevated PASP >50 mm Hg	Decreased exercise tolerance Exertional dyspnea

* The transmitral ΔPmean should be obtained to further determine the hemodynamic effect of the MS and is usually >5–10 mm Hg in severe MS. However, due to the variability of the ΔP with heart rate and forward flow, it has not been included in the criteria for severity.

Table 15. Stages of Chronic Primary MR

Stage	Definition	Valve Anatomy	Valve Hemodynamics*	Hemodynamic Consequences	Symptoms
A	At risk of MR	Mild MV prolapse with normal coaptation Mild valve thickening and leaflet restriction	No MR jet or small central jet area <20% LA on Doppler Small vena contracta <0.3 cm	None	None
B	Progressive MR	Severe MV prolapse with normal coaptation Rheumatic valve changes with leaflet restriction and loss of central coaptation Prior IE	Central jet MR 20%–40% LA or late systolic eccentric jet MR Vena contracta <0.7 cm RVol <60 mL RF <50% ERO <0.40 cm Angiographic grade 1+ to 2+	Mild LA enlargement No LV enlargement Normal pulmonary pressure	None
C	Asymptomatic severe MR	Severe MV prolapse with loss of coaptation or flail leaflet Rheumatic valve changes with leaflet restriction and loss of central coaptation Prior IE Thickening of leaflets with radiation heart disease	Central jet MR >40% LA or holosystolic eccentric jet MR Vena contracta ≥0.7 cm RVol ≥60 mL RF ≥50% ERO ≥0.40 cm Angiographic grade 3+ to 4+	Moderate or severe LA enlargement LV enlargement PHTN may be present at rest or with exercise C1: LVEF >60% and LVESD <40 mm C2: LVEF ≤60% and LVESD ≥40 mm	None
D	Symptomatic severe MR	Severe MV prolapse with loss of coaptation or flail leaflet Rheumatic valve changes with leaflet restriction and loss of central coaptation Prior IE Thickening of leaflets with radiation heart disease	Central jet MR >40% LA or holosystolic eccentric jet MR Vena contracta ≥0.7 cm RVol ≥60 mL RF ≥50% ERO ≥0.40 cm Angiographic grade 3+ to 4+	Moderate or severe LA enlargement LV enlargement PHTN present	Decreased exercise tolerance Exertional dyspnea

Table 16. Stages of Secondary MR

Stage	Definition	Valve Anatomy	Valve Hemodynamics*	Associated Cardiac Findings	Symptoms
A	At risk of MR	Normal valve leaflets, chords, and annulus in a patient with coronary disease or cardiomyopathy	No MR jet or small central jet area <20% LA on Doppler Small vena contracta <0.30 cm	Normal or mildly dilated LV size with fixed (infarction) or inducible (ischemia) regional wall motion abnormalities Primary myocardial disease with LV dilation and systolic dysfunction	Symptoms due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy
B	Progressive MR	Regional wall motion abnormalities with mild tethering of mitral leaflet Annular dilation with mild loss of central coaptation of the mitral leaflets	ERO <0.40 cm Regurgitant volume <60 mL Regurgitant fraction <50%	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction due to primary myocardial disease	Symptoms due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy
C	Asymptomatic severe MR	Regional wall motion abnormalities and/or LV dilation with severe tethering of mitral leaflet Annular dilation with severe loss of central coaptation of the mitral leaflets	ERO ≥0.40 cm Regurgitant volume ≥60 mL^‡ Regurgitant fraction ≥50%	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction due to primary myocardial disease	Symptoms due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy
D	Symptomatic severe MR	Regional wall motion abnormalities and/or LV dilation with severe tethering of mitral leaflet Annular dilation with severe loss of central coaptation of the mitral leaflets	ERO ≥0.40 cm Regurgitant volume ≥60 mL^‡ Regurgitant fraction ≥50%	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction due to primary myocardial disease	HF symptoms due to MR persist even after revascularization and optimization of medical therapy Decreased exercise tolerance Exertional dyspnea

* Several valve hemodynamic criteria are provided for assessment of MR severity, but not all criteria for each category will be present in each patient. Categorization of MR severity as mild, moderate, or severe depends on data quality and integration of these parameters in conjunction with other clinical evidence.
The measurement of the proximal isovelocity surface area by 2DTTE in patients with secondary MR underestimates the true ERO because of the crescentic shape of the proximal convergence.
^‡ May be lower in low-flow states.

Table 17. Classification of TR

Primary	Secondary
Rheumatic Infective endocarditis Iatrogenic (device leads, endomyocardial biopsy) Congenital (e.g., Ebstein’s, levo-transposition of the great arteries) Other (trauma, carcinoid, drugs, irradiation, etc.)	Pulmonary hypertension with RV remodeling (primary or secondary to left-sided heart disease) Dilated cardiomyopathy Annular dilation (associated with AF)* RV volume overload (shunts/ high output)

* Isolated TR is associated with AF and has LVEF >60%, pulmonary artery systolic pressure <50 mm Hg, and no left-sided valve disease, with normal-appearing tricuspid valve leaflets.

Table 18. Stages of Tricuspid Regurgitation (TR)

Stage	Definition	Valve Hemodynamics	Hemodynamic Consequences	Clinical Symptoms and Presentation
B	Progressive TR	Central jet <50% RA Vena contracta width <0.7 cm ERO <0.40 cm Regurgitant volume <45 mL	None	None
C	Asymptomatic severe TR	Central jet >50% RA Vena contracta width >0.7 cm ERO>0.40 cm Regurgitant volume >45 mL Dense continuous wave signal with triangular shape Hepatic vein systolic flow reversal	Dilated RV and RA Elevated RA with “c-V” wave	Elevated venous pressure No symptoms
D	Symptomatic severe TR	Central jet ≥50% RA Vena contracta width ≥0.7 cm ERO ≥0.40 cm Regurgitant volume ≥45 mL Dense continuous wave signal with triangular shape Hepatic vein systolic flow reversal	Dilated RV and RA Elevated RA with “c-V” wave	Elevated venous pressure Dyspnea on exertion, fatigue, ascites, edema

Table 19. AS/MR Mixed Valve Disease

Severe AS	Severe MR	Surgical Risk	Procedure
SAVR candidate	Primary MR Repairable valve	Low intermediate	SAVR Surgical MV repair
SAVR candidate	Primary MR Valve not repairable	Low intermediate	SAVR Surgical mitral valve replacement
TAVI candidate	Primary Repairable valve	High prohibitive	TAVI Mitral TEER*
SAVR candidate TAVI candidate	Secondary MR	Low intermediate	SAVR Surgical mitral valve repair/mitral valve replacement or TAVI Mitral TEER*
TAVI candidate	Secondary MR	High prohibitive	TAVI Mitral TEER*

* Consider TEER as a later staged procedure if symptoms and severe MR persist after treatment of the AS.

Table 20. Selected Factors That May Impact Shared Decision-Making for the Choice of Prosthetic Valve

Favor Mechanical Prosthesis	Favor Bioprosthesis
Age <50 y Increased incidence of structural deterioration with bioprosthesis (15 y risk: 30% for age 40 y, 50% for age 20 y) Lower risk of anticoagulation complications	Age >65 y Low incidence of structural deterioration (15 y risk: <10% for age >70 y) Higher risk of anticoagulation complications
Patient preference (avoid risk of reintervention)	Patient preference (avoid risk and inconvenience of anticoagulation)
Low risk of long-term anticoagulation	High risk of long-term anticoagulation
Compliant patient with either home monitoring or close access to INR monitoring	Limited access to medical care or inability to regulate VKA
Other indication for long-term anticoagulation (e.g., AF)	Access to surgical centers with low reoperation mortality rate
High-risk reintervention (e.g., porcelain aorta, prior radiation therapy)	Access to transcatheter ViV replacement
Small aortic root size for AVR (may preclude ViV procedure in future)	TAVI valves have larger effective orifice areas for smaller valve sizes (avoid patient–prosthesis mismatch)

Table 21. Systemic Fibrinolysis Versus Surgery for Prosthetic Valve Thrombosis

Favor Surgery	Favor Fibrinolysis
Readily available surgical expertise	No surgical expertise available
Low surgical risk	High surgical risk
Contraindication to fibrinolysis	No contraindication to fibrinolysis
Recurrent valve thrombosis	First-time episode of valve thrombosis
NYHA class IV	NYHA class I, II, or III
Large clot (>0.8 cm²)	Small clot (≤0.8 cm²)
LA thrombus	No LA thrombus
Concomitant CAD in need of revascularization	No or mild CAD
Other valve disease	No other valve disease
Possible pannus	Thrombus visualized
Patient choice	Patient choice

Table 22. Diagnosis of IE According to the Proposed Modified Duke Criteria

Definite IE
Pathological criteria
Microorganisms demonstrated by culture or histological examination of a vegetation, a vegetation that has embolized, or an intracardiac abscess specimen; or Pathological lesions: vegetation or intracardiac abscess confirmed by histological examination showing active endocarditis
Clinical criteria
2 major criteria; or 1 major criterion and 3 minor criteria; or 5 minor criteria
Possible IE
1 major criterion and 1 minor criterion; or 3 minor criteria
Rejected
Firm alternative diagnosis explaining evidence of IE; or Resolution of IE syndrome with antibiotic therapy for <4 d; or No pathological evidence of IE at surgery or autopsy, with antibiotic therapy for <4 d; or Does not meet criteria for possible IE AS listed above

Table 23. Major and Minor Criteria in the Modified Duke Criteria for the Diagnosis of IE

Major Criteria
Blood culture positive for IE
ypical microorganisms consistent with IE from 2 separate blood cultures: Viridans streptococci, Streptococcus bovis, HACEK group (Haemophilus spp., Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella spp., and Kingella kingae), S. aureus; or community-acquired enterococci, in the absence of a primary focus; or Microorganisms consistent with IE from persistently positive blood culture results, defined AS follows: At least 2 positive culture results of blood samples drawn 12 h apart; or All of 3 or most of ≥4 separate culture samples of blood (with first and last samples drawn at least 1 h apart) Single positive blood culture result for Coxiella burnetii or antiphase I IgG antibody titer >1:800
Evidence of endocardial involvement
Echocardiogram positive for IE defined AS follows: Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation Abscess; or New partial dehiscence of prosthetic valve New valvular regurgitation (worsening or changing of preexisting murmur not sufficient)
Minor Criteria
Predisposition, predisposing heart condition, or injection drug use Fever, temperature >38°C (100.4°F) Vascular phenomena, major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions Immunological phenomena: glomerulonephritis, Osler’s nodes, Roth’s spots, and rheumatoid factor Microbiological evidence: positive blood culture but does not meet a major criterion AS noted above* or serological evidence of active infection with organism consistent with IE

* Excludes single positive cultures for coagulase-negative staphylococci and organisms that do not cause IE.

Class of Recommendations and Level of Evidence

Class (Strength) of Recommendation
CLASS I (STRONG)Benefit >>> Risk
Suggested phrases for writing recommendations: Is recommended Is indicated/useful/effective/beneficial Should be performed/administered/other Comparative-Effectiveness Phrases^†: Treatment/strategy A is recommended/indicated in preference to treatment B Treatment A should be chosen over treatment B
CLASS IIa (MODERATE) Benefit >> Risk
Suggested phrases for writing recommendations: Is reasonable Can be useful/effective/beneficial Comparative-Effectiveness Phrases^†: Treatment/strategy A is probably recommended/indicated in preference to treatment B It is reasonable to choose treatment A over treatment B
CLASS IIb (WEAK) Benefit ≥ Risk
Suggested phrases for writing recommendations: May/might be reasonable May/might be considered Usefulness/effectiveness is unknown/unclear/uncertain or not well established
CLASS III: No Benefit (MODERATE) (Generally, LOE A or B use only) Benefit = Risk
Suggested phrases for writing recommendations: Is not recommended Is not indicated/useful/effective/beneficial Should not be performed/administered/other
CLASS III: Harm (STRONG) Risk > Benefit
Suggested phrases for writing recommendations: Potentially harmful Causes harm Associated with excess morbidity/mortality Should not be performed/administered/other

Level (Quality) of Evidence^‡
LEVEL A
High-quality evidence^‡ from more than 1 RCT Meta-analyses of high-quality RCTs One or more RCTs corroborated by high-quality registry studies
LEVEL B-R (Randomized)
Moderate-quality evidence^‡ from 1 or more RCTs Meta-analyses of moderate-quality RCTs
LEVEL B-NR (Nonrandomized)
Moderate-quality evidence^‡ from 1 or more well-designed, well-executed nonrandomized studies, observational studies, or registry studies Meta-analyses of such studies
LEVEL B
Limited populations evaluated Data derived from a single randomized trial or nonrandomized studies
LEVEL C-LD (Limited Data)
Randomized or nonrandomized observational or registry studies with limitations of design or execution Meta-analyses of such studies Physiological or mechanistic studies in human subjects
LEVEL C-EO (Expert Opinion)
Consensus of expert opinion based on clinical experience
LEVEL C
Very limited populations evaluated Only consensus opinion of experts, case studies, or standards of care

COR and LOE are determined independently (any COR may be paired with any LOE).

A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

* The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information).
^† For comparative-effectiveness recommendations (COR I and IIa; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.
^‡ The method of assessing quality is evolving, including the application of standardized, widely used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee.

COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE, Level of Evidence; NR, nonrandomized; R, randomized; RCT, randomized controlled trial.

Abbreviations

2D: 2-dimensional

3D: 3-dimensional

ACE: angiotensin-converting enzyme

AF: atrial fibrillation

aPTT: activated partial thromboplastin time

AR: aortic regurgitation

ARB: angiotensin receptor blocker

AS: aortic stenosis

ASA: aspirin

AVA: aortic valve area

AVAi: aortic valve area indexed to body surface area

AVR: aortic valve replacement

BAV: bicuspid aortic valve

BID: two times a day

BNP: B-type natriuretic peptide

BP: blood pressure

CABG: coronary artery bypass graft

CAD: coronary artery disease

CKD: chronic kidney disease

CMR: cardiac magnetic resonance

CNS: central nervous system

COR: Class of Recommendation

CRT: cardiac resynchronization therapy

CT: computed tomography

CW: continuous wave

DLCO2: diffusion capacity for carbon dioxide

DOAC: direct oral anticoagulants

DSE: dobutamine stress echocardiography

ECG: electrocardiogram

EF: ejection fraction

ERO: effective regurgitant orifice

ETT: exercise treadmill test

FEV1: forced expiratory volume in 1 second

GDMT: guideline determined medical therapy

GI: gastrointestinal

HF: heart failure

ICD: implantable cardioverter defibrillator

IE: infective endocarditis

INR: international normalized ratio

IV: intravenous

IVC: inferior vena cava

LA: left atrium

LMWH: low molecular weight heparin

LOE: Level of Evidence

LV: left ventricle

LVEDD: left ventricular end-diastolic dimension

LVEF: left ventricular ejection fraction

LVESD: left ventricular end-systolic dimension

LVOT: left ventricular outflow tract

MDT: multidisciplinary team

MI: myocardial infarction

MR: mitral regurgitation

MS: mitral stenosis

MV: mitral valve

MVA: mitral valve area

MVR: mitral valve replacement

NOAC: non–vitamin K oral anticoagulant

NVE: native valve endocarditis

NYHA: New York Heart Association

PA: pulmonary artery

PASP: pulmonary artery systolic pressure

PCI: non–vitamin K oral anticoagulant

PET: positron emission tomography

PHTN: pulmonary hypertension

PMBC: percutaneous mitral balloon commissurotomy

PO: by mouth

PR: pulmonic regurgitation

PROM: predicted risk of mortality

PVE: prosthetic valve endocarditis

QD: once daily

RA: right atrium

RCT: randomized controlled trial

RF: regurgitant fraction

RV: right ventricular

RVH: right ventricular hypertrophy

RVol: regurgitant volume

RVOT: right ventricular outflow tract

Rx: therapy

S. aureus: Staphylococcus aureus

SAVR: surgical aortic valve replacement

SC: subcutaneous

spp: species

STS: Society of Thoracic Surgeons

T 1/2: half-life

TA: tricuspid annular

TAVI: transcatheter aortic valve implantation

TAVR: transcatheter aortic valve replacement

TEE: transesophageal echocardiography

TEER: transcatheter aortic valve implantation

TR: tricuspid regurgitation

TS: tricuspid stenosis

TTE: transthoracic echocardiography/echocardiogram

TV: tricuspid valve

TVR: tricuspid valve replacement

UFH: unfractionated heparin

V max: maximal velocity

VHD: valvular heart disease

VKA: vitamin K antagonist

ΔP: pressure gradient

Source Citation

Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM 3rd, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Feb 2;143(5):e72-e227. doi: 10.1161/CIR.0000000000000923. Epub 2020 Dec 17. Erratum in: Circulation. 2021 Feb 2;143(5):e229. PMID: 33332150.

Disclaimer

This resource is for informational purposes only, intended as a quick-reference tool based on the cited source guideline(s), and should not be used as a substitute for the independent professional judgment of healthcare providers. Practice guidelines are unable to account for every individual variation among patients or take the place of clinician judgment, and the ultimate decision concerning the propriety of any course of conduct must be made by healthcare providers after consideration of each individual patient situation. Guideline Central does not endorse any specific guideline(s) or guideline recommendations and has not independently verified the accuracy hereof. Any use of this resource or any other Guideline Central resources is strictly voluntary.

Valvular Heart Disease

Key Points

Treatment

Table 1. Evaluation of Patients With Known or Suspected VHD

Table 2. Stages of Progression of VHD

Table 3. Frequency of Echocardiograms in Asymptomatic Patients With VHD and Normal Left Ventricular (LV) Function

Table 4. Secondary Prevention of Rheumatic Fever

Table 5. Duration of Secondary Prophylaxis for Rheumatic Fever

2.4.1. Secondary Prevention of Rheumatic Fever

2.4.2. IE Prophylaxis

2.4.3. Anticoagulation for AF in Patients With VHD

Figure 1. Anticoagulation for AF in Patients With VHD

2.5. Evaluation of Surgical and Interventional Risk

Table 6. Risk Assessment for Surgical Valve Procedures

Table 7. Examples of Procedure-Specific Risk Factors for Interventions Not Incorporated Into Existing Risk Scores

Table 8. Median Operative Mortality Rates for Specific Surgical Procedures (STS Adult Cardiac Surgery Database, 2019

2.6. The Multidisciplinary Heart Valve Team and Heart Valve Centers

Table 9. Structure of Primary and Comprehensive Valve Centers

2.7.4. Periodic Imaging After Valve Intervention

Table 10. Timing of Periodic Imaging After Valve Intervention

Imaging Follow-Up*

Table 11. Stages of AS

3.2.1.1. Diagnostic Testing: Initial Diagnosis

3.2.1.5. Diagnostic Testing: Exercise Testing

3.2.2. Medical Therapy

3.2.3. Timing of Intervention

Figure 2. Timing of Intervention for AS

3.2.4.1. Choice of Mechanical Versus Bioprosthetic AVR

3.2.4.2. Choice of SAVR Versus TAVI for Patients for Whom a Bioprosthetic AVR Is Appropriate

Figure 3. Choice of SAVR Versus TAVI When AVR is Indicated for Valvular AS

Table 12. A Simplified Framework With Examples of Factors Favoring SAVR, TAVI, or Palliation Instead of Aortic Valve Intervention

Aortic Regurgitation

Table 13. Stages of Chronic Aortic Regurgitation (AR)

4.3.1. Diagnosis of Chronic AR

4.3.2. Medical Therapy

4.3.3. Timing of Intervention

Figure 4. Timing of Intervention for AR

Bicuspid Aortic Valve

5.1.1.1. Diagnostic Testing: Initial Diagnosis

Figure 5. Intervals for Imaging the Aorta in Patients With a BAV

5.1.1.2. Diagnostic Testing: Routine Follow-Up

5.1.2.1. Intervention: Replacement of the Aorta in Patients with BAV

Figure 6. Intervention for Replacement of the Aorta in Patients With a BAV

5.1.2.2. Intervention: Replacement of the Aortic Valve

Mitral Stenosis

Table 14. Stages of MS

Rheumatic MS

6.2.1.1. Diagnostic Testing: Initial Diagnosis

6.2.1.5. Diagnostic Testing: Exercise Testing

6.2.2. Medical Therapy

6.2.3. Intervention

6.3. Nonrheumatic Calcific MS

Figure 7. Intervention for MS

Mitral Regurgitation

Table 15. Stages of Chronic Primary MR

7.2.2.1. Diagnostic Testing: Initial Diagnosis

7.2.2.2. Diagnostic Testing: Changing Signs or Symptoms

7.2.2.3. Diagnostic Testing: Routine Follow-Up

7.2.2.5. Diagnostic Testing: Exercise Testing

7.2.3. Medical Therapy

7.2.4. Intervention

Figure 8. Primary MR

Table 16. Stages of Secondary MR

7.3.2. Diagnosis of Chronic Secondary MR

7.3.3. Medical Therapy for Secondary MR

7.3.4. Intervention for Secondary MR

Figure 9. Secondary MR

Table 17. Classification of TR

Tricuspid Regurgitation

8.2.1. Diagnosis of TR

Table 18. Stages of Tricuspid Regurgitation (TR)

8.2.2. Medical Therapy for TR

8.2.3. Timing of Intervention

Figure 10. Tricuspid Regurgitation

9. Pulmonic Valve Disease

10. Mixed Valve Disease

10.1. Diagnosis of Mixed VHD

10.1.2. Intervention for Mixed AS and AR

Table 19. AS/MR Mixed Valve Disease

11. Prosthetic Valves