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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References10ShowHide

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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