Perspective:

The following are 10 points to remember about these guidelines on the management of valvular heart disease (VHD):

1. Echocardiography is the key technique used to confirm the diagnosis of VHD, as well as to assess its severity and prognosis. Transesophageal echocardiography should be considered when transthoracic echocardiography is of suboptimal quality or when thrombosis, prosthetic dysfunction, or endocarditis is suspected.

2. The use of stress tests to detect coronary artery disease (CAD) associated with severe VHD is discouraged because of their low diagnostic value and potential risks.

3. Coronary angiography is recommended before valve surgery in patients with severe VHD and any of the following: history of CAD; suspected myocardial ischemia; left ventricular (LV) systolic dysfunction; in men aged over 40 years and postmenopausal women; and ≥1 cardiovascular risk factor.

4. In severe aortic regurgitation, surgery is indicated in symptomatic patients, in asymptomatic patients with resting LV ejection fraction (LVEF) ≤50%, and in patients undergoing coronary artery bypass grafting (CABG) or surgery of ascending aorta, or on another valve.

5. Aortic valve replacement is indicated in patients with severe aortic stenosis (AS) and any symptoms related to AS, in patients with severe AS undergoing CABG, surgery of the ascending aorta or another valve, in asymptomatic patients with severe AS and systolic LV dysfunction (LVEF <50%) not due to another cause, and in patients with severe AS and abnormal exercise test showing symptoms on exercise clearly related to AS.

6. Transcatheter aortic valve implantation (TAVI) should only be undertaken with a multidisciplinary ‘heart team’ including cardiologists and cardiac surgeons and other specialists if necessary, and should only be performed in hospitals with cardiac surgery on-site.

7. TAVI is indicated in patients with severe symptomatic AS who are not suitable for AVR as assessed by a ‘heart team,’ and who are likely to gain improvement in their quality of life, and to have a life expectancy of more than 1 year after consideration of their comorbidities.

8. In severe primary mitral regurgitation, mitral valve repair should be the preferred technique when it is expected to be durable. Surgery is indicated in symptomatic mitral regurgitation patients with LVEF >30% and LV end-systolic dimension (LVESD) <55 mm and in asymptomatic patients with LV dysfunction (LVESD ≥45 mm and/or LVEF ≤60%).

9. Percutaneous mitral commissurotomy is indicated in symptomatic mitral stenosis patients with favorable characteristics, and in symptomatic patients with contraindication or high risk for surgery.

10. For valve replacement, a mechanical prosthesis is recommended according to the desire of the informed patient and if there are no contraindications for long-term anticoagulation, and a bioprosthesis is recommended when good quality anticoagulation is unlikely (compliance problems; not readily available) or contraindicated because of high bleeding risk (e.g., prior major bleed, comorbidities, unwillingness, compliance problems, lifestyle, occupation).