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Moreover, in patients with regurgitant lesions, particularly AR, CMR has gained key value in clinical practice. 4.2 Associated diseases and conditions Imaging plays a crucial role in identifying associated diseases and conditions. The presence of concomitant left ventricular (LV) systolic or diastolic dysfunction, RV systolic dysfunction, red flags indicating cardiomyopathies (e.g. amyloidosis, hypertrophic cardiomyopathy), and aortopathy should prompt further examinations to ensure optimal risk stratification and VHD management. In addition to TTE, advanced imaging modalities, like CCT, may be required to assess the aorta, single-photon emission computed tomography (CT) for detection of ischaemia/necrosis, positron emission tomography (PET) for inflammation, nuclear scintigraphy for cardiac amyloidosis, or CMR for tissue characterization. 4.3 Evaluation of valvular heart disease dynamics and variability Serial imaging studies to detect changes over time, or variability due to haemodynamic conditions or initiation/up-titration of medical therapy, are of utmost importance to guide decisions. The dynamic pattern of VHD may convey additional prognostic information. Exercise echocardiography helps to identify the cause of dyspnoea, unveil symptoms in apparently asymptomatic patients, identifies dynamic changes of VHD severity, and can contribute to refinement of the indication for an intervention, especially for AS and mitral regurgitation (MR).52 4.4 Assessment of extravalvular cardiac consequences from valvular heart disease Several studies investigating different valve lesions have established the relevance of extravalvular cardiac damage in terms of prognosis,53–55 recovery after intervention,56 and quality of life.57 The presence of LV hypertrophy, left atrium (LA) dilatation, LV or RV dysfunction and/or remodelling, myocardial fibrosis, and pulmonary hypertension (PH) provide important prognostic information, and may influence the timing and type of treatment. Although not necessarily chronological in their order of appearance, the understanding of cardiac damage, particularly damage involving the LV, is essential to guide appropriate medical therapy before and after any intervention. Transthoracic echocardiography (TTE) including global longitudinal strain (GLS) and CMR can be particularly useful in that regard.58–60 4.5 Evaluation of eligibility, planning, and guiding of interventions Transoesophageal echocardiography (TOE) (preferentially 3D) is the preferred tool for the assessment of suitability for aortic, mitral, and TV repair.45,49,61–63 Risk stratification for an intervention should integrate all the points mentioned above. Transoesophageal echocardiography (TOE), including standard 3D views, is also the modality of choice to guide atrioventricular transcatheter interventions and should be performed by specially trained interventional echocardiographers.61,64 Cardiac computed tomography (CCT) is frequently used to evaluate the relationship of the valve with adjacent structures [e.g. coronary arteries and left ventricular outflow tract (LVOT)], the extension of calcification [e.g. in mitral annular calcification (MAC)], and for sizing of the prosthesis. CT angiography is frequently employed to evaluate the anatomy of surgical, arterial, or venous access routes and detect cardiac or extracardiac complications (e.g. bleeding or embolic events). Coronary CT angiography (CCTA) is increasingly utilized to assess the presence of CAD. 5 Clinical evaluation of patients with valvular heart disease 5.1 Clinical examination Patients with VHD can be either asymptomatic or present with a wide spectrum of symptoms, including acute or chronic HF. An initial meticulous history and a comprehensive physical examination of the patient with auscultation, documentation of clinical signs of HF such as dyspnoea, impaired physical capacity and fatigue, peripheral oedema, and pleural effusion, as well as a systematic frailty assessment, are crucial.65 In addition, comorbidities and coexisting cardiac conditions should be documented (Figure 3). Particular attention should be given to recent changes in symptoms or physical findings indicating a potential worsening of the valve lesion or ventricular function. 5.2 Assessment of comorbidities and risk stratification Risk stratification of patients with VHD has been mainly developed based on surgical populations. The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II)66,67 (https://www. euroscore.org) and the Society of Thoracic Surgeons predicted risk of mortality (STS-PROM) score68 (http://riskcalc.sts.org/ stswebriskcalc/calculate) are the most commonly used scoring systems to estimate surgical risk. Both risk scores have been calibrated to predict post-operative outcomes.69–71 The STS-PROM score is dynamic to account for changes in patient risk profiles, the type of procedure (aortic, mitral, and tricuspid), and outcomes over time. The outdated (logistic) EuroSCORE I model systematically overestimated surgical mortality.70,72 In patients considered for TAVI, surgical risk scores have lower accuracy and tend to overestimate the risk of events.73–75 Discrepancies between observed and predicted peri-procedural mortality after TAVI using surgical risk scores point towards a need for TAVI-specific scores. Models predicting short- and medium-term survival specifically designed for TAVI are rarely used in daily clinical practice due to limitations of their predictive performance.76–79 Specific scores have also been developed for patients undergoing mitral TEER (M-TEER),80–82 but the high heterogeneity of the population with MR limits their external validity and therefore routine clinical use so far.83 Recently, a dedicated clinical score has been calibrated and validated to stratify the risk associated with first-time and repeat isolated TV surgery (TRI-SCORE; https://www.tri-score.com/), and its use should be encouraged for patients with TV disease,84,85 as an alternative to the more complex Society of Thoracic Surgeons (STS) score for isolated TV surgery (https://isolatedtvsurgcalc.research.sts. org/). ESC Guidelines 4653 Downloaded from academic.oup.com/eurheartj/article/46/44/4635/8234488 by guest on 07 October 2026