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lead to underestimation of the severity of aortic stenosis, as decreased stroke volume due to mitral regurgitation lowers the flow across the aortic valve and hence the aortic gradient.453 This underlines the need to combine different measurements, including assessment of valve areas, if possible using methods that are less dependent on loading conditions, such as planimetry.457 • Indications for intervention are based on global assessment of the consequences of the different valve lesions (i.e. symptoms or presence of LV dilatation or dysfunction). Intervention can be considered for non-severe multiple lesions associated with symptoms or leading to LV impairment.453 • The decision to intervene on multiple valves should take into account the age, comorbidities, and risk of combined procedures, and should be made by the Heart Team after precise and comprehensive evaluation of valve lesions and their interactions with each other.453,461 The risk of combined intervention should be weighed against the evolution of untreated valve disease and the inherent risk of subsequent intervention. • The choice of surgical technique/interventional procedure should take into account the presence of the other VHD.453,458,459,461 • When interventional procedures are considered, staged procedures may be preferable in cases with aortic stenosis and mitral regurgitation (see section 5.5). Improved 1-year survival after combined transcatheter treatment of mitral and tricuspid regurgitation has been reported compared to mitral regurgitation alone.263 PMC may delay surgery, in situations such as severe mitral stenosis associated with moderate aortic regurgitation. The management of specific associations of VHD is detailed in the individual sections of this document.

11 Prosthetic valves

11.1 Choice of prosthetic valve

Factors for valve selection are the patient’s life expectancy, lifestyle, and environmental factors, bleeding and thromboembolic risks related to anticoagulation, potential for surgical or transcatheter reintervention, and, importantly, informed patient preference.

Generally, biological heart valves (BHVs) should be preferred in patients with shorter anticipated survival or comorbidities that may lead to further surgical procedures, and those who are at increased risk for bleeding complications. Thromboembolic complications are less frequent in pregnant women with BHVs.

Recommendations for prosthetic valve selection

Recommendations Classa Levelb

Mechanical prostheses A mechanical prosthesis is recommended according to the desire of the informed patient and if there are no contraindications to longterm anticoagulation.c I C A mechanical prosthesis is recommended in patients at risk of accelerated SVD.d I C A mechanical prosthesis should be considered in patients already on anticoagulation because of a mechanical prosthesis in another valve position. IIa C

Continued A mechanical prosthesis should be considered in

patients aged <60 years for prostheses in the aortic position and aged <65 years for prostheses in the mitral position.462, 464 e IIa B A mechanical prosthesis should be considered in patients with a reasonable life expectancy for whom future redo valve surgery or TAVI (if appropriate) would be at high risk.f IIa C A mechanical prosthesis may be considered in patients already on long-term anticoagulation due to the high risk for thromboembolism.f IIb C Biological prostheses A bioprosthesis is recommended according to the desire of the informed patient. I C A bioprosthesis is recommended when goodquality anticoagulation is unlikely (adherence problems, not readily available), contraindicated because of high bleeding risk (previous major bleed, comorbidities, unwillingness, adherence problems, lifestyle, occupation) and in those patients whose life expectancy is lower than the presumed durability of the bioprosthesis.g I C A bioprosthesis is recommended in case of reoperation for mechanical valve thrombosis despite good long-term anticoagulant control. I C A bioprosthesis should be considered in patients for whom there is a low likelihood and/or a low operative risk of future redo valve surgery. IIa C A bioprosthesis should be considered in young women contemplating pregnancy. IIa C A bioprosthesis should be considered in patients aged >65 years for a prosthesis in the aortic position or aged >70 years in a mitral position. IIa C A bioprosthesis may be considered in patients already on long-term NOACs due to the high risk for thromboembolism.466469 f IIb B

AF = atrial fibrillation; NOAC = non-vitamin K antagonist oral anticoagulant; SVD = structural valve deterioration; TAVI = transcatheter aortic valve implantation. aClass of recommendation. bLevel of evidence. cIncreased bleeding risk because of comorbidities, adherence concerns or geographic, lifestyle or occupational conditions. dYoung age (<40 years), hyperparathyroidism, haemodialysis. eIn patients 6065 years of age who should receive an aortic prosthesis and those between 65 and 70 years of age in the case of mitral prosthesis, both valves are acceptable and the choice requires careful analysis of factors other than age. fRisk factors for thromboembolism are AF, previous unprovoked proximal deep venous thromboembolism and/or symptomatic pulmonary embolism, hypercoagulable state, antiphospholipid antibody. gLife expectancy should be estimated at >10 years according to age, sex, comorbidities, and country-specific life expectancy. ESC/EACTS 2021

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