The following are key points to remember from the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) about the 2021 Guidelines for the Management of Valvular Heart Disease (VHD):

1. Meticulous evaluation of the patient’s history and symptomatic status, as well as proper physical examination, are crucial for the diagnosis and management of VHD.
2. Echocardiography is the key technique to diagnose VHD and assess its severity and prognosis. Other noninvasive investigations such as cardiac magnetic resonance, cardiac computed tomography, fluoroscopy, and biomarkers provide important additional information in selected patients. Stress testing should be widely used in asymptomatic patients. Invasive investigation, beyond preoperative coronary angiography, is limited to situations where noninvasive evaluation is inconclusive.
3. Decision making in elderly patients requires the integration of multiple parameters, including estimation of life expectancy and anticipated quality of life, evaluation of comorbidities, and general condition (including frailty). Informed patient expectations and values are an important part of the decision-making process.
4. Heart Valve Centers with multidisciplinary Heart Teams, Heart Valve Clinics, comprehensive equipment, and sufficient volumes of procedures are required to deliver high-quality care and provide adequate training.
5. In patients with atrial fibrillation, nonvitamin K antagonist oral anticoagulants (NOACs) are contraindicated in patients with clinically significant mitral stenosis or mechanical valves. For stroke prevention in patients who are eligible for oral anticoagulation, NOACs are recommended in preference to VKAs in patients with aortic stenosis, aortic and mitral regurgitation, or aortic bioprostheses >3 months after implantation.
6. Selection of the most appropriate mode of intervention for severe aortic stenosis by the Heart Team should take into account clinical characteristics (age and estimated life expectancy, general condition), anatomical characteristics, the relative risks of surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI), the feasibility of transfemoral TAVI, local experience and outcome data, as well as informed patient preference.
7. Surgical mitral valve repair is the preferred method of treatment in primary mitral regurgitation (MR) if a durable repair can be achieved. Transcatheter edge-to-edge repair (TEER) is a safe but less efficacious alternative that may be considered in patients with contraindications for surgery or high operative risk.
8. On the other hand, in patients with severe secondary MR, guideline-directed medical therapy (including ardiac resynchronization therapy if indicated) should be the first step. If the patient remains symptomatic, mitral surgery is recommended concomitantly in patients with an indication for coronary artery bypass grafting or other cardiac surgery. Isolated valve surgery may be considered in selected patients. TEER should be considered in patients not eligible for surgery and fulfilling criteria indicating an increased chance of responding to the treatment. Circulatory support devices, cardiac transplantation, or palliative care should be considered as an alternative in patients with end-stage left ventricular and/or right ventricular (RV) failure.
9. Tricuspid regurgitation should be liberally treated at the time of left-sided valve surgery. Isolated surgery of severe secondary tricuspid regurgitation (with or without previous left-sided valve surgery) requires comprehensive assessment of the underlying disease, pulmonary hemodynamics, and RV function.
10. The choice between a mechanical prosthesis and a bioprosthesis should be patient-centerd and multifactorial based on patient characteristics, the indication for lifelong anticoagulation, the potential and risks of a re-intervention, and the informed patient preference. Clinical assessment of prosthetic valves should be performed yearly and as soon as possible if new cardiac symptoms occur.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Heart Transplant, Interventions and Imaging, Interventions and Structural Heart Disease, Angiography, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Nuclear Imaging, Mitral Regurgitation

Keywords: ESC Congress, ESC21, Anticoagulants, Aortic Valve Stenosis, Atrial Fibrillation, Bioprosthesis, Cardiac Surgical Procedures, Coronary Angiography, Coronary Artery Bypass, Diagnostic Imaging, Echocardiography, Fluoroscopy, Frail Elderly, Geriatrics, Heart Transplantation, Heart Valve Diseases, Mitral Valve Insufficiency, Mitral Valve Stenosis, Magnetic Resonance Imaging, Palliative Care, Quality of Life, Secondary Prevention, Stroke, Tomography, Transcatheter Aortic Valve Replacement, Tricuspid Valve Insufficiency

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