Valvular Heart Disease

The answer first

Valvular heart disease is driven by one of two questions: is there enough haemodynamic burden to warrant intervention, and if so, repair or replace, surgical or transcatheter? The two pivotal principles that govern everything below: ^[1]

1. For stenotic left-sided valves, symptoms are the trigger. Once a patient with severe aortic stenosis or severe mitral stenosis develops symptoms, the risk of sudden death climbs steeply and intervention is indicated. Waiting is harmful.
2. For regurgitant lesions, intervene before irreversible ventricular damage. Surgery in chronic aortic and mitral regurgitation is timed on symptoms and on echocardiographic thresholds of ventricular size and function — the goal is to operate before the ventricle has decompensated, because operating on a depressed ejection fraction carries much higher operative mortality and worse long-term outcome. ^[1]

The modern framework is the ACC/AHA stage classification — A (at risk), B (progressive), C (asymptomatic severe), D (symptomatic severe) — applied to every valve. It tells you the patient's position on the surveillance-to-intervention timeline at a glance. ^[1]

DWE high-yield: If you remember one sentence for valvular disease, remember this — the symptomatic patient with severe stenosis needs valve intervention, not medical therapy. No drug slows the progression of calcific aortic stenosis. ^[1]

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References12ShowHide

1. [1]Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery N Engl J Med, 2010.PMID 20961243
2. [2]Mack MJ, Leon MB, Thourani VH, et al. Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low-Risk Patients N Engl J Med, 2019.PMID 30883058
3. [3]Adams DH, Popma JJ, Reardon MJ, et al. Transcatheter aortic-valve replacement with a self-expanding prosthesis N Engl J Med, 2014.PMID 24678937
4. [4]Feldman T, Foster E, Glower DD, et al. Percutaneous repair or surgery for mitral regurgitation N Engl J Med, 2011.PMID 21463154
5. [5]Stone GW, Lindenfeld J, Abraham WT, et al. Transcatheter Mitral-Valve Repair in Patients with Heart Failure N Engl J Med, 2018.PMID 30280640
6. [6]Obadia JF, Messika-Zeitoun D, Leurent G, et al. Percutaneous Repair or Medical Treatment for Secondary Mitral Regurgitation N Engl J Med, 2018.PMID 30145927
7. [7]Rossebø AB, Pedersen TR, Boman K, et al. Intensive lipid lowering with simvastatin and ezetimibe in aortic stenosis N Engl J Med, 2008.PMID 18765433
8. [8]Chan KL, Teo K, Dumesnil JG, et al. Effect of Lipid lowering with rosuvastatin on progression of aortic stenosis: results of the aortic stenosis progression observation: measuring effects of rosuvastatin (ASTRONOMER) trial Circulation, 2010.PMID 20048204
9. [9]Kang DH, Park SJ, Lee SA, et al. Early Surgery or Conservative Care for Asymptomatic Aortic Stenosis N Engl J Med, 2020.PMID 31733181
10. [10]Garg V, Muth AN, Ransom JF, et al. Mutations in NOTCH1 cause aortic valve disease Nature, 2005.PMID 16025100
11. [11]Ross J Jr, Braunwald E. Aortic stenosis Circulation, 1968.PMID 4894151
12. [12]Eikelboom JW, Connolly SJ, Brueckmann M, et al. Dabigatran versus warfarin in patients with mechanical heart valves N Engl J Med, 2013.PMID 23991661