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Internal quality assessment (see dedicated document concerning TAVI from the ESC41), systematic recording, and public availability of the volume and outcome data of the performed procedures are essential. Participation in national or international registries should be encouraged. These considerations are of particular importance regarding asymptomatic low-risk patients (where low mortality and procedural safety are paramount), those with multiple comorbidities (where the need for multidisciplinary collaboration is essential), and new techniques with a steep learning curve (where better results may be obtained at experienced centres). There is a pressing need to ensure higher dispersion and adoption of interventions for VHD, especially (but not exclusively) in middle- and lower-income countries where rheumatic heart disease (RHD) remains the principal cause of VHD.42,43 Key strategies include awareness programmes, increased public and medical education, simplified and improved diagnostic tools, and measures to reduce costs and facilitate access to evidence-based treatment options.44
4 Imaging of patients with valvular
heart disease
Multimodality imaging is now the standard approach in VHD management to determine the pathophysiology, assess severity, plan interventions, and identify complications (Figure 2). The use of imaging for the assessment of each specific valve lesion is described in the corresponding sections. The role of imaging is transversal from diagnosis to follow-up and should encompass an integrative assessment.
4.1 Initial valve assessment
Comprehensive transthoracic echocardiography (TTE) is the first-line examination to confirm valve dysfunction, and determine the aetiology, mechanism, and severity of VHD, as well as cardiac chamber anatomy and damage.45,46 It should be performed by properly trained imagers.47–49 Quantitative imaging analysis (as opposed to visual) should be the goal in all patients with relevant VHD, complemented by qualitative and semi-quantitative evaluation. The severity of VHD should be assessed using an integrative approach of all criteria checked for consistency. When TTE is of poor quality or inconclusive, transoesophageal echocardiography (TOE) and/or additional diagnostic imaging modalities should be applied (e.g. calcium scoring and anatomy of the valve using CCT). In specific clinical scenarios [e.g. thrombosis, prosthetic valve dysfunction, endocarditis, mitral stenosis (MS), assessment of MV or TV anatomy], TOE has a central diagnostic role.50,51
Figure 2 Integrative imaging assessment of patients with valvular heart disease. 3D, three-dimensional; CAD, coronary artery disease; CCT, cardiac computed tomography; CMR: cardiac magnetic resonance; TOE; transoesophageal echocardiography; TTE, transthoracic echocardiography; VHD, valvular heart disease. Downloaded from academic.oup.com/eurheartj/article/46/44/4635/8234488 by guest on 07 October 2026
