- For a more detailed guide to diagnosis and management see
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- Mitral valve disease
- Aortic valve disease
- Right sided valve disease
- Prosthetic valves
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- Risk factors
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- Radiotherapy (which can induce VHD)
- AF can be caused by VHD, but can also trigger it (especially in the case of MR and TR)
- Rheumatic fever
- Associated connective tissue disease
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- Complications of valve disease
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- All patient with VHD have an increased risk of IE
- 50% have significant CAD
- HF and pulmonary hypertension
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- Imaging
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- Aims
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- Define the severity of the valvular lesion
- Can suggest a cause
- Can assess the extra-valvular cardiac damage such as LVH, LA dilatation, LV or RV dysfunction, myocardial fibrosis and pulmonary hypertension
- Might suggest associated conditions such as cardiomyopathy, amyloid, aortopathy
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- TOE has a diagnostic role in thrombosis, prosthetic valve dysfunction, IE, MS and assessment of MV or TV valve anatomy (especially if considering valve repair)
- CMR can be especially useful in assessing AR. Also helps quantify regurgitant fraction and degree of any myocardial fibrosis
- Get echo within 2 weeks if systolic murmur and exertional syncope, or murmur plus severe symptoms potentially attributable to valve disease
- Do echo every 3-5 years if mild AS or MS
- Exercise echo useful to identify causes of SOB, unveil symptoms in asymptomatic patients, identify dynamic changes of VHD severity and can help decide on interventions, especially in AS and MR
- Aims
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- Additional assessments
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- Exercise testing is important in assessment of AS (as symptoms tend to occur late) and intermediate severity asymptomatic AR
- Angiography – required if valve surgery planned. All need either an invasive coronary angiogram, or a CTCA (if low or moderate risk)
- Right heart catheter – consider if equivocal finding in MV disease, or in severe TR
- Raised troponin can occur in both NSTEMI and decompensated of VHD – sometimes hard to determine cause
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- General tips for management
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- Refer to a specialist if moderate or severe valve disease, and anybody with bicuspid aortic valve (including mild disease)
- Intervention is usually offered in symptomatic severe valve disease
- Surgery depends on symptoms, LV dysfunction, severity of valve disease (and if acute)
- If prior IE or prosthetic valves – consider prophylactic antibiotics before procedures (see infective endocarditis)
- In stenosis – try to avoid arterial vasodilators like ACE-I and nifedipine
- Diuretics are generally safe in valve disease
- In pregnancy most women with valve disease have no complications, however severe AS or MS present the biggest risks
- If no intervention planned, no symptoms and severe valve disease – echo and clinical review every 6-12 months
- CABG often advised if a patient requires valve surgery and has coronary artery stenosis of >70%
- Anticoagulation for AF – usually DOACs ok. Only exception is severe rheumatic MS with valve area <2cm2
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- Risk stratification
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- STS PROM score commonly used to predict surgical outcomes and risk (though may overestimate risks of TAVI)
- BNP ratio (ratio of measured NT-pro BNP to upper limit of normal for age/sex/assay) is a powerful predictor of mortality in VHD
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- Combined valve lesions
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- Mixed valvular heart disease implies regurgitation and stenosis in the same valve
- Multiple valvular heart disease implies different valves involved
- More common in rheumatic heart disease, cardiomyopathy or due to the late effects of radiotherapy
- Less diagnostic validity of measures established to grade single valve defects (the severity of mixed AV disease is often underestimated for example)
- If treating one valve, usually treat other severe lesions, and moderate AS or TR if present
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- Radiation induced valve disease
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- Presents 5-30 years after radiotherapy (often for conditions such as lymphoma)
- Dose dependent
- Often multivalve
- Often fibrotic pericardium, coronary and aortic disease too
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