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............................................................................................................................................................................. In patients who are severely symptomatic despite medical therapy, BAV for severe aortic stenosis can be undertaken by an experienced operator.557 TAVI is a promising alternative, but experience during pregnancy is very limited.554

Surgery under cardiopulmonary bypass is associated with a foetal mortality rate of 1556%562 and should be restricted to the rare conditions that threaten the mother’s life if transcatheter intervention is not possible or has failed. Valve replacement should be considered after early delivery by caesarean section. Caesarean section is recommended for patients with severe mitral or aortic stenosis, ascending aortic diameter >45 mm, severe pulmonary hypertension, or if delivery starts while treated with a VKA or <2 weeks after discontinuation of a VKA.

13.2.2 Mechanical prosthesis It is recommended to manage pregnancy in patients with MHV in a centre with a pregnancy Heart Team.554 Therapeutic anticoagulation during pregnancy is of utmost importance to avoid complications in these patients, keeping in mind that no anticoagulation regimen is ideal and management will require a careful balance between maternal and foetal risks. In patients requiring <5 mg/day warfarin, oral anticoagulants throughout pregnancy and a change to UFH before delivery is favoured. In patients requiring higher doses, switching to LMWH during the first trimester with strict anti-Xa monitoring (therapeutic range 0.81.2 IU/mL, aortic valve prosthesis; and 1.01.2 IU/mL, mitral and right sided valve prosthesis) and the use of oral anticoagulants afterwards is favoured with a change to UFH before delivery.554

14 Key messages

General comments 1. Precise evaluation of the patient’s history and symptomatic status, as well as proper physical examination, are crucial for the diagnosis and management of VHD. 2. Echocardiography is the key technique to diagnose VHD and assess its severity and prognosis. Other non-invasive investigations such as CMR, CCT, fluoroscopy, and biomarkers provide important additional information in selected patients. Stress testing should be widely used in asymptomatic patients. Invasive investigation, beyond preoperative coronary angiography, is restricted to situations where non-invasive evaluation is inconclusive. 3. Decision making in elderly patients requires the integration of multiple parameters, including estimation of life expectancy and anticipated quality of life, evaluation of comorbidities, and general condition (including frailty). 4. Decision making in asymptomatic patients weighs the risk of intervention against the expected natural history of VHD. Stress testing should be liberally performed. 5. Informed patient’s expectations and values are an important part of the decision-making process. 6. Interventions (surgery or transcatheter) are indicated in symptomatic patients (spontaneous or exercise induced) in the absence of futility. In selected asymptomatic patients, presence of predictors of rapid symptom progression justifies early intervention when procedural risk is low. 7. Heart Valve Centres with multidisciplinary Heart Teams, Heart Valve Clinics, comprehensive equipment, and sufficient volumes of procedures are required to deliver high-quality care and provide adequate training.

8. Careful follow-up of symptomatic status, LV/RV size, and function is mandatory in asymptomatic patients with severe VHD if an intervention is not yet indicated. 9. In patients with AF, NOACs are contraindicated in patients with clinically significant mitral stenosis or mechanical valves. For stroke prevention in patients who are eligible for OAC, NOACs are recommended in preference to VKAs in patients with aortic stenosis, aortic and mitral regurgitation, or aortic bioprostheses >3 months after implantation.

Aortic regurgitation 10. The evaluation of aortic regurgitation requires careful assessment of potentially associated aortic dilatation to guide the timing and type of surgery.

Aortic stenosis 11. Diagnosis of severe aortic stenosis requires integrative evaluation of pressure gradients (the most robust measurements), AVA, extent of valve calcification, flow conditions, and LV function. 12. Selection of the most appropriate mode of intervention by the Heart Team should take into account clinical characteristics (age and estimated life expectancy, general condition), anatomical characteristics, the relative risks of SAVR and TAVI, the feasibility of transfemoral TAVI, local experience and outcome data, as well as informed patient preference.

Mitral regurgitation 13. Regarding imaging, routine quantification of EROA is an important part of the integrative evaluation for quantification and risk stratification in patients with PMR. 3D transoesophageal echocardiography is more accurate than 2D echocardiography for defining the underlying mechanism of PMR. CMR is useful when echocardiographic evaluation of severe PMR grade is inconclusive. 14. Surgical mitral valve repair is the preferred method of treatment in PMR if a durable repair can be achieved. TEER is a safe but less efficacious alternative that may be considered in patients with contraindications for surgery or high operative risk. 15. In patients with severe SMR, GDMT (including CRT if indicated) should be the first step. If the patient remains symptomatic: mitral surgery is recommended concomitantly in patients with an indication for CABG or other cardiac surgery. Isolated valve surgery may be considered in selected patients. TEER should be considered in patients not eligible for surgery and fulfilling criteria indicating an increased chance of responding to the treatment. Circulatory support devices, cardiac transplantation, or palliative care should be considered as an alternative in patients with end-stage LV and/or RV failure.

Mitral stenosis 16. PMC is currently the standard of care in patients with severe rheumatic mitral stenosis and favourable valve anatomy. 17. Decision making as to the type of intervention used in patients with unfavourable anatomy is still a matter of debate and must take into account the multifactorial nature of predicting the results of PMC. Downloaded from academic.oup.com/eurheartj/article/43/7/561/6358470 by guest on 07 October 2026