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............................................................................................................................................................................. summarized in the specific sections of these guidelines. Echocardiography is also key to evaluating the feasibility of a specific intervention.

Indices of left ventricular (LV) enlargement and function are strong prognostic factors. Recent studies suggest that global longitudinal strain has greater prognostic value than LV ejection fraction (LVEF), although cut-off values are not uniform.26,27 Transoesophageal echocardiography (TOE) should be considered when transthoracic echocardiography (TTE) is of suboptimal quality or when thrombosis, prosthetic valve dysfunction, or endocarditis is suspected. TOE is useful when detailed functional valve anatomy is required to assess repairability. Intraprocedural TOE, preferably 3D, is used to guide transcatheter mitral and tricuspid valve procedures and to assess the immediate result of surgical valve operations. Multimodality imaging may be required in specific conditions for evaluation and/or procedural guidance in TAVI and transcatheter mitral interventions.28,29

3.2.3 Other non-invasive investigations 3.2.3.1 Stress testing The primary purpose of exercise testing is to unmask the objective occurrence of symptoms in patients who claim to be asymptomatic. It is especially useful for risk stratification in aortic stenosis.30 Exercise testing will also determine the level of recommended physical activity, including participation in sports. It should be emphasized that stress testing is safe and useful in asymptomatic patients with VHD. Unfortunately, the VHD II survey indicates that it is rarely performed in asymptomatic patients.1 Exercise echocardiography may identify the cardiac origin of dyspnoea. Prognostic impact has been shown mainly for aortic stenosis and mitral regurgitation.31,32 The use of stress tests to detect CAD associated with severe valvular disease is discouraged because of their low diagnostic value and potential risks in symptomatic patients with aortic stenosis.

3.2.3.2 Cardiac magnetic resonance In patients with inadequate echocardiographic quality or discrepant results, CMR should be used to assess the severity of valvular lesions, particularly regurgitant lesions, and to assess ventricular volumes, systolic function, abnormalities of the ascending aorta, and myocardial fibrosis.33 CMR is the reference method for the evaluation of right ventricular (RV) volumes and function and is therefore particularly useful to evaluate the consequences of tricuspid regurgitation.34 It also has an incremental value for assessing the severity of aortic and mitral regurgitation.

3.2.3.3 Computed tomography CCT may contribute to the evaluation of valve disease severity, particularly in aortic stenosis35,36 and possibly associated disease of the thoracic aorta (dilatation, calcification), as well as to evaluate the extent of MAC. CCT should be performed whenever the echocardiographic data indicate an aortic enlargement >40 mm, to clarify aortic diameter and to assess aortic morphology and configuration. CCT is essential in the pre-procedural planning of TAVI and can also be useful to assess patient-prosthesis mismatch (PPM).37 It is also a prerequisite for pre-procedural planning of mitral and tricuspid valve interventions.38 Positron emission tomography (PET)/CCT is useful in patients with a suspicion of endocarditis of a prosthetic valve.39,40

3.2.3.4 Cinefluoroscopy Cinefluoroscopy is particularly useful for assessing the kinetics of the leaflet occluders of a mechanical prosthesis.

3.2.3.5 Biomarkers B-type natriuretic peptide (BNP) serum levels, corrected for age and sex, are useful in asymptomatic patients and may assist selection of the appropriate time point for a given intervention,41 particularly if the level rises during follow-up. Other biomarkers have been tested, with evidence for fibrosis, inflammation, and adverse ventricular remodelling, which could improve decision making.42

3.2.3.6 Multimarkers and staging In patients with at least moderate aortic stenosis and LVEF >50%, staging according to damage associated with aortic stenosis on LV/ RV, left atrium (LA), mitral /tricuspid valve, and pulmonary circulation was predictive of excess mortality after TAVI and SAVR, and may help to identify patients who will benefit from an intervention.43,44

3.2.4 Invasive investigations 3.2.4.1 Coronary angiography Coronary angiography is recommended for the assessment of CAD when surgery or an intervention is planned, to determine if concomitant coronary revascularization is recommended (see recommendations for management of CAD in patients with VHD).45,46 Alternatively, owing to its high negative predictive value, CCT may be used to rule out CAD in patients who are at low risk of atherosclerosis. The usefulness of fractional flow reserve or instantaneous wavefree ratio in patients with VHD is not well established, and caution is warranted in the interpretation of these measurements when VHD, and in particular aortic stenosis, is present.47,48

3.2.4.2 Cardiac catheterization The measurement of pressures and cardiac output or the assessment of ventricular performance and valvular regurgitation by ventricular angiography or aortography is restricted to situations where noninvasive evaluation by multimodality imaging is inconclusive or discordant with clinical findings. When elevated, pulmonary pressure is the only criterion to support the indication for surgery, and confirmation of echo data by invasive measurement is recommended. Right heart catheterization is also indicated in patients with severe tricuspid regurgitation as Doppler gradient may be impossible or underestimate the severity of pulmonary hypertension.

3.2.5 Assessment of comorbidity The choice of specific examinations to assess comorbidity is guided by the clinical evaluation.

3.3 Risk stratification

Risk stratification applies to any sort of intervention and is required for weighing the risk of intervention against the expected natural history of VHD and for choosing the type of intervention. Most experience relates to surgery and TAVI. Downloaded from academic.oup.com/eurheartj/article/43/7/561/6358470 by guest on 07 October 2026