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...................................................................................................................................................................... Tricuspid regurgitation

18. Relevant tricuspid regurgitation requires early intervention to avoid secondary damage of the RV. 19. Tricuspid regurgitation should be liberally treated at the time of left-sided valve surgery. Isolated surgery of severe secondary tricuspid regurgitation (with or without previous left-sided valve surgery) requires comprehensive assessment of the underlying disease, pulmonary haemodynamics, and RV function.

Prosthetic valves 20. The choice between a mechanical prosthesis and a bioprosthesis should be patient-centred and multifactorial based on patient characteristics, the indication for lifelong anticoagulation, the potential and risks of a re-intervention, and the informed patient preference. 21. Clinical assessment of prosthetic valves should be performed yearly and as soon as possible if new cardiac symptoms occur.

15 Gaps in evidence

Important gaps in evidence exist in the following aspects of VHD:

General comments 1. Prognostic value of CMR-derived indices in patients with aortic regurgitation, aortic stenosis, and mitral regurgitation. 2. Tools for risk stratification for the decision for intervention (including the avoidance of futile interventions) and the choice of the type of intervention (TAVI vs. SAVR for aortic stenosis, repair vs. replacement for mitral and aortic regurgitation). 3. In asymptomatic patients with aortic regurgitation, aortic stenosis, and mitral regurgitation, identification and evaluation of earlier markers of LV dysfunction (biomarkers, imaging, multimodality) as well as longitudinal and translational studies on progression. 4. Gender issues regarding pathophysiology, indications, and timing of treatment. 5. Minimum volumes of procedures that are required to achieve optimal results of intervention. 6. Safety and efficacy of NOACs in patients with surgical or transcatheter bioprostheses in the first 3 months after implantation. 7. Patient education for shared decision making and timely evaluation. 8. Systematic epidemiological data addressing the burden of rheumatic heart disease.

9. Advocacy of VHD.

Aortic regurgitation 10. Potential differences in the risk of aortic complications depending on subtypes of aortic aneurysms (site and morphology), as well as in patients with bicuspid aortic valves.

11. Further evaluation of surgical aortic valve repair.

Aortic stenosis 12. Pathophysiology of progression and novel therapeutic targets for medical treatment.

13. Further research to evaluate the role of intervention: a. Long-term durability of transcatheter heart valves in comparison

with surgical bioprostheses. b. Role of intervention (SAVR or TAVI) in asymptomatic patients. c. Role of TAVI in younger low-risk patients, patients with aortic stenosis affecting bicuspid valves, and patients with moderate aortic stenosis and LV impairment. d. Results of re-intervention (valve or coronary) after TAVI or SAVR. e. The role of revascularization in patients with severe aortic stenosis

and asymptomatic concomitant CAD.

Mitral regurgitation 14. Association between PMR and sudden cardiac death and ventricular arrhythmias.

15. Role of genetic testing to mitral valve prolapse. 16. Further evaluation of the role of intervention:

a. Long-term results of transcatheter intervention. b. Indications of transcatheter intervention in patients with severe PMR at lower surgical risk. c. Potential impact of mitral valve intervention (surgery and catheter intervention) on survival in patients with SMR. d. Selection of criteria to identify responders to TEER for SMR (severity criteria, concept of ‘disproportionate mitral regurgitation’). e. The role of newer transcatheter treatment options (annuloplasty,

combined repair techniques, valve replacement).

Mitral stenosis 17. Scores predicting the results and complications of PMC, particularly that of severe mitral regurgitation. 18. Role of transcatheter mitral valve implantation in high-risk patients, particularly in patients with severe degenerative mitral stenosis and MAC.

Tricuspid regurgitation 19. Quantification of tricuspid regurgitation severity and evaluation of RV function.

20. Further research to evaluate the role of intervention:

a. Criteria for optimal timing of surgery in primary tricuspid regurgitation. b. Evidence on the clinical impact, timing, and treatment modality of isolated severe secondary tricuspid regurgitation. c. Criteria for concomitant tricuspid valve surgery at the time of leftsided surgery in patients without severe tricuspid regurgitation. d. Results and indications of transcatheter tricuspid valve treatment.

Combined and multi-valve diseases 21. Further evaluation of the impact on outcomes and modalities of transcatheter intervention to better define the indications for intervention. Pregnancy 22. Optimal management of pregnant women with MHVs regarding antithrombotic regimens. Non-cardiac surgery 23. Evaluation of the role of ‘urgent TAVI’ in the management of patients with severe aortic stenosis undergoing NCS. Downloaded from academic.oup.com/eurheartj/article/43/7/561/6358470 by guest on 07 October 2026