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............................................................................................................... Health professionals are encouraged to take the ESC/EACTS Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies. However, the ESC/ EACTS Guidelines do not override in any way whatsoever the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition and in consultation with that patient or the patient’s caregiver where appropriate and/or necessary. It is also the healthcare professional’s responsibility to verify the rules and regulations applicable in each country to drugs and devices at the time of prescription.

2 Introduction

2.1 Why do we need new guidelines on

valvular heart disease? Since the publication of the previous version of the guidelines on the management of valvular heart disease (VHD) in 2017, new evidence has accumulated, particularly on the following topics: • Epidemiology: the incidence of the degenerative aetiology has increased in industrialized countries while, unfortunately, rheumatic heart disease is still too frequently observed in many parts of the world.13 • Current practices regarding interventions and medical management have been analysed in new surveys at the national and European level. • Non-invasive evaluation using three-dimensional (3D) echocardiography, cardiac computed tomography (CCT), cardiac magnetic resonance (CMR), and biomarkers plays a more and more central role. • New definitions of severity of secondary mitral regurgitation (SMR) based on the outcomes of studies on intervention. • New evidence on anti-thrombotic therapies leading to new recommendations in patients with surgical or transcatheter bioprostheses for bridging during perioperative periods and over the long term. The recommendation for non- vitamin K antagonist oral anticoagulants (NOACs) was reinforced in patients with native valvular disease, except for significant mitral stenosis, and in those with bioprostheses. • Risk stratification for the timing of intervention. This applies mostly to (i) the evaluation of progression in asymptomatic patients based on recent longitudinal studies mostly in aortic stenosis, and (ii) interventions in high-risk patients in whom futility should be avoided. Regarding this last aspect, the role of frailty is outlined. • Results and indication of intervention:

 The choice of the mode of intervention: current evidence

reinforces the critical role of the Heart Team, which should integrate clinical, anatomical, and procedural characteristics beyond conventional scores, and informed patient’s treatment choice.  Surgery: increasing experience and procedural safety

led to expansion of indications toward earlier intervention in asymptomatic patients with aortic stenosis, aortic regurgitation or mitral regurgitation and stress the preference for valve repair when it is expected to be durable. A particular emphasis is put on the need for more comprehensive evaluation and earlier surgery in tricuspid regurgitation.  Transcatheter techniques: (i) Concerning transcath-

eter aortic valve implantation (TAVI), new information from randomized studies comparing TAVI vs. surgery in low-risk patients with a follow-up of 2 years has led to a need to clarify which types of patients should be considered for each mode of intervention. (ii) Transcatheter edge-to-edge repair (TEER) is increasingly used in SMR and has been evaluated against optimal medical therapy resulting in an upgrade of the recommendation. (iii) The larger number of studies on transcatheter valve-in-valve implantation after failure of surgical bioprostheses served as a basis to upgrade its

Table 2 Levels of evidence

Level of evidence A Data derived from multiple randomized clinical trials or meta-analyses.

Level of evidence B Data derived from a single randomized clinical trial or large non-randomized studies.

Level of evidence C Consensus of opinion of the experts and/or small studies, retrospective studies, registries. ©ESC/EACTS 2021 Downloaded from academic.oup.com/eurheartj/article/43/7/561/6358470 by guest on 07 October 2026