Managing Valvular Heart Disease

Managing Valvular Heart Disease

Guides valve disease severity assessment with intervention criteria and surveillance schedules.

Why This Skill Exists

Valvular heart disease affects approximately 2.5% of the US population, with prevalence increasing with age. The 2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease established evidence-based criteria for severity grading, intervention timing, and surveillance. The critical challenge is identifying the optimal window for intervention — too early exposes patients to unnecessary procedural risk, too late results in irreversible ventricular dysfunction.

The emergence of transcatheter therapies (TAVR, MitraClip, TEER) has transformed the treatment landscape, but appropriate patient selection requires precise severity assessment and multidisciplinary Heart Team evaluation. Failure to apply guideline-concordant criteria for intervention leads to both undertreatment and overtreatment.

Checkpoint A: Pre-Draft Intake (Mandatory)

1. Which valve(s) are affected and what is the lesion — stenosis, regurgitation, or mixed? (default: "Valve not specified")
2. What is the current severity — mild, moderate, or severe? (default: "Severity not graded")
3. Is the patient symptomatic (dyspnea, angina, syncope, exercise intolerance)? (default: "Symptom status not documented")
4. What is the LVEF and LV dimensions? (default: "Echo data not provided")
5. What are the echocardiographic parameters used for grading (velocity, gradient, valve area, regurgitant volume)? (default: "Parameters not listed")
6. Has a prior echo been performed for comparison? (default: "No prior study")
7. Has the patient been evaluated by a Heart Valve Team? (default: "Not yet evaluated")
8. Are there comorbidities affecting surgical risk (STS score, frailty, age)? (default: "Surgical risk not calculated")

Documents to Request

• Current echocardiogram with Doppler assessment
• Prior echocardiograms for trend analysis
• Cardiac catheterization (if hemodynamic confirmation needed)
• Cardiac CT (for TAVR planning or annular sizing)
• STS risk score calculation
• Exercise stress test (for asymptomatic severe disease)
• BNP/NT-proBNP
• Dental clearance (pre-surgery infection risk)
• Coronary angiography (pre-surgical evaluation)

Step 1: Aortic Stenosis Assessment and Management

Severity Grading (ACC/AHA 2020):

Low-Flow, Low-Gradient AS Subtypes:

• Classical (reduced EF): LVEF < 50%, AVA ≤ 1.0, mean gradient < 40 → dobutamine stress echo to differentiate true-severe from pseudo-severe
• Paradoxical (preserved EF): LVEF ≥ 50%, SVi < 35 mL/m², AVA ≤ 1.0, mean gradient < 40 → often elderly, hypertensive, small LV cavity

Intervention Criteria (Class I):

• Symptomatic severe AS → SAVR or TAVR
• Asymptomatic severe AS with LVEF < 50% → intervention
• Asymptomatic severe AS undergoing other cardiac surgery → concomitant AVR

TAVR vs. SAVR Selection:

• Low surgical risk (STS < 3%): SAVR preferred; TAVR acceptable (ACC/AHA 2020)
• Intermediate risk (STS 3–8%): shared decision-making; both acceptable
• High risk (STS > 8%) or prohibitive: TAVR preferred
• Age < 65: SAVR generally preferred (long-term valve durability)
• Age ≥ 80: TAVR generally preferred

Step 2: Mitral Regurgitation Assessment and Management

Primary (Degenerative) MR Severity — ASE Integrated Approach:

Intervention Criteria for Primary Severe MR (Class I):

• Symptomatic severe MR → surgery (repair preferred over replacement)
• Asymptomatic severe MR with LV dysfunction (LVEF 30–60% or LVESD ≥ 40 mm) → surgery

Secondary (Functional) MR:

• Due to LV dilation and tethering in HFrEF or ischemic cardiomyopathy
• Optimize GDMT first (medical therapy improves functional MR)
• COAPT trial: transcatheter edge-to-edge repair (TEER, MitraClip) for severe secondary MR with LVEF 20–50%, LVESD ≤ 70 mm, on maximal GDMT
• MITRA-FR: no benefit when LV dilation is disproportionately large relative to MR severity

Step 3: Aortic Regurgitation and Right-Sided Valve Disease

Chronic Severe Aortic Regurgitation Intervention Criteria:

• Symptomatic severe AR → surgery (Class I)
• Asymptomatic severe AR with LVEF < 55% → surgery (Class I)
• Asymptomatic severe AR with LVEF ≥ 55% but LV severely dilated (LVESD > 50 mm or indexed > 25 mm/m²) → surgery (Class IIa)

Tricuspid Regurgitation:

• Functional TR (most common): secondary to RV dilation, pulmonary hypertension, or AF
• Severe TR intervention at time of left-sided valve surgery (Class I)
• Isolated severe TR with progressive RV dilation/dysfunction: emerging transcatheter therapies (TVTR)
• Medical management: diuretics, treat underlying cause (PH, left heart disease)

Tricuspid Stenosis (rare):

• Usually rheumatic; mean gradient > 5 mmHg = severe
• Surgical intervention when symptomatic or at time of other valve surgery

Step 4: Surveillance Schedules

Recommended Echo Surveillance Intervals:

Triggering Earlier Reassessment:

• New or worsening symptoms
• Change in exercise tolerance
• Decline in LVEF or increase in LV dimensions
• New atrial fibrillation
• Rising BNP/NT-proBNP trend

Step 5: Prosthetic Valve Management

Prosthetic Valve Types and Anticoagulation:

Prosthetic Valve Dysfunction Surveillance:

• Annual echo with Doppler assessment of gradients and regurgitation
• Rising transvalvular gradient → suspect valve thrombosis, pannus, or patient-prosthesis mismatch
• New paravalvular leak → may require percutaneous closure or reoperation

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is valve disease severity graded with specific echocardiographic parameters?
2. Are intervention criteria applied correctly per ACC/AHA 2020 guidelines?
3. Is the Heart Team evaluation documented or recommended for intervention candidates?
4. Is the surveillance interval appropriate for the severity and symptom status?
5. Is prosthetic valve anticoagulation correctly specified if applicable?

Quality Audit

• Each valve lesion identified and severity graded
• At least three quantitative echo parameters documented for severe disease
• Discordant parameters addressed (low-flow AS, echo vs. cath correlation)
• Symptom status documented and correlated with severity
• LVEF and LV dimensions assessed for intervention thresholds
• ACC/AHA intervention criteria applied with class of recommendation cited
• STS risk score calculated for surgical candidates
• TAVR vs. SAVR discussion documented with rationale
• Heart Team evaluation documented or recommended
• Surveillance interval assigned with next echo date
• Endocarditis prophylaxis indications reviewed
• Prosthetic valve patients: anticoagulation regimen specified
• Exercise testing considered for asymptomatic severe disease

Guidelines

1. Never intervene on moderate valve disease based solely on symptoms — confirm severity with quantitative echocardiographic criteria first.
2. For severe aortic stenosis, LVEF < 50% is an indication for intervention even in asymptomatic patients — do not wait for symptoms.
3. In mitral regurgitation, repair is superior to replacement when feasible — refer to high-volume surgical centers with > 95% repair rates.
4. Low-flow, low-gradient aortic stenosis requires dobutamine stress echo or calcium scoring to distinguish true-severe from pseudo-severe — never operate based on a single resting echo.
5. TEER (MitraClip) for secondary MR requires strict COAPT trial criteria — patients must be on maximal GDMT and meet anatomic and functional criteria.
6. DOACs are currently contraindicated for mechanical heart valves — warfarin is the only acceptable anticoagulant (REALIGN trial harm).
7. Endocarditis prophylaxis is indicated for prosthetic valves, prior endocarditis, unrepaired cyanotic CHD, and repaired CHD with residual defects — for dental procedures involving gingival manipulation or periapical region.
8. All patients with moderate or greater valve disease should receive annual clinical assessment even between scheduled echo surveillance intervals.