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Other cardiac conditions and comorbidities—such as CAD, concomitant multiple valve and aortic disease, and RV dysfunction, as well as chronic kidney disease (CKD)—are not always appropriately captured in risk models, even if they are known to impact outcomes.86 Similarly, specific unfavourable characteristics like porcelain aorta, mobile aortic atheroma, and previous mediastinal radiation therapy increase the surgical risk, and therefore may favour transcatheter treatment options. Frailty, including nutritional state, represents another important determinant of outcomes after valve interventions,87–89a which can be evaluated using appropriate tools as summarized in a recent consensus statement.90 Several methods have been proposed, from the simple Fried Frailty Index to more complex scores91 such as the Hospital Frailty Risk Score, which has been validated in a large cohort of TAVI and M-TEER patients.92 The use of PROMs that engage patients in the co-evaluation of their health and wellbeing is encouraged. Several scoring systems have been proposed and validated for reproducibility and association with clinical outcomes, like the Quality of Recovery 15-item PROM or the Kansas City Cardiomyopathy Questionnaire (KCCQ).93–95

5.3 Biomarkers

Biomarker levels indicating either cardiac wall stress [e.g. brain natriuretic peptide (BNP)] or myocardial damage (e.g. troponin), in asymptomatic and symptomatic patients, may help to monitor VHD progress and determine the most appropriate timing of intervention. In patients with VHD, the natriuretic peptide ratio [the ratio of measured BNP or N-terminal pro-B-type natriuretic protein

  

 


 















	   


Figure 3 Central illustration. Patient-centred evaluation for treatment of valvular heart disease. Downloaded from academic.oup.com/eurheartj/article/46/44/4635/8234488 by guest on 07 October 2026