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(NT-proBNP) to upper limit of normal for age, sex, and assay] has been shown to be a powerful, independent, and incremental predictor of mortality.96–98 In patients undergoing AV replacement, the accumulation of several elevated biomarkers of cardiovascular stress was associated with higher all-cause and cardiovascular mortality, and a higher rate of repeat hospitalization.99,100

5.4 Exercise testing

Because of the slow progression of valve lesions, patients may gradually limit their activity levels over several years and deny having actual symptoms that can be unmasked by exercise testing.12 This is particularly important in cases of AS, because once symptoms occur there is a sharp increase in the risk of sudden cardiac death, unless a valve intervention is performed.101–104 Exercise testing may provide additional information about the haemodynamic severity of VHD and help determine the risk and optimal timing of intervention by objectively evaluating functional capacity.101,103 Cardiopulmonary exercise testing has a prognostic role and can assist decision-making in patients with VHD of intermediate severity, particularly those with asymptomatic AR.101,105,106 Exercise echocardiography is used for the assessment of LV global and segmental function, pulmonary artery pressure, and aortic and mitral pressure gradients.101,107 It also documents exercise-induced increase of MR and TR severity, especially in patients with secondary disease.108,109 Prognostic impact has been shown mainly for AS and MR.110,111 Misconceptions regarding its risk and tolerability contribute to the overall underuse of exercise testing in patients with VHD,12 despite data confirming its safety in most asymptomatic patients.112,113

5.5 Invasive investigations

5.5.1. Coronary angiography Coronary artery assessment is recommended to evaluate the need for revascularization when valve surgery or an intervention is planned. The information regarding the existence of concomitant CAD should be available at the time of Heart Team discussion. CCTA is recommended as an alternative to coronary angiography to rule out CAD in patients who are at low or moderate risk of obstructive CAD. Coronary blood flow and fractional flow reserve (FFR) are altered in the setting of concomitant VHD, and functional haemodynamic assessment of CAD in these patients is not well established.114–118

5.5.2 Cardiac catheterization

Right heart catheterization (RHC) should be performed in patients with equivocal echocardiographic findings, particularly those with MV disease, as well as in all candidates for the treatment of severe TR. In exceptional cases with unclear AS severity, it can be combined with measurements of the transaortic gradients allowing estimation of the aortic valve area (AVA). Right heart catheterization contributes to assess the repercussions of any left-sided VHD or LV impairment on the pulmonary circulation and right side of the heart. It provides information regarding volume state, cardiac output, and vascular resistance, differentiating between pre- and post-capillary PH, and should be ideally performed in euvolaemia. Measurements of the pulmonary capillary wedge pressure v-wave can inform about MR severity, but are neither sensitive nor specific, and may also be increased if the compliance of the LA is reduced or in case of diastolic LV dysfunction, as in patients with MS or chronic HF.119 Similarly, the height of the right atrium (RA) v-wave, and the pressure curve mimicking the RV pattern (‘ventricularization’ of the RA pressure), are signs of relevant TR, which are frequently accompanied by increased RV end-diastolic pressure in case of associated RV dysfunction. In patients with severe TR, pulmonary vascular resistance (PVR) should be calculated to unmask pulmonary vascular disease, which may not be captured by echocardiography due to RV systolic dysfunction or underestimation of pulmonary pressures because of TR.

5.6 Patient-centred care and shared

decision-making Given that treatment of VHD typically involves several modalities and specialities, and may result in a complex and sometimes timeconsuming decision-making process, patient education and information, using online material and face-to-face conversations, are essential at each step. A clearly defined point of contact for all questions relating to the disease or type of treatments should be communicated to the patient and their relatives.120 The symptomatic and prognostic benefits, as well as the advantages and disadvantages of any treatment option, should be presented in an open and evidence-based manner. This includes mortality and risks of reintervention and complications (also over the long term), as well as recovery time and the need for cardiac, and if necessary psychological, rehabilitation until return to physical activity and work. Other issues to be discussed before the procedure include the need for oral anticoagulation (OAC) and its monitoring, as well as the noise generated by mechanical heart valves (MHVs). Information regarding centre experience and volume for a specific procedure should be provided. Misconceptions (e.g. subjective overestimation of the risk of surgery) should be addressed and potential interactions with individual lifestyle factors—including social activities, family and professional life, and hobbies—should be discussed in detail. The Heart Team recommendation regarding the treatment and its modality must be based on evidence and anatomical considerations, balancing the risks and benefits of available treatment options.16 The patient and patient’s relatives need to be well informed about the rationale leading to the Heart Team recommendation, and given ample time to share personal preferences.121 At the end of the process, a shared decision is made between the treating team and the informed patient and relatives (Figure 3).

6 Management of conditions

associated with valvular heart disease

6.1 Diagnosis and management of

coronary artery disease The presence of CAD plays an important role in decision-making regarding the timing and modality of treatment, and should be assessed before Heart Team discussion. In patients with a low or moderate pre-test likelihood of obstructive CAD (≤50%), CCTA is recommended to rule out relevant CAD with high sensitivity.122–124 Several studies have investigated the value of CCT angiography for CAD screening in elderly TAVI candidates. While sensitivity for the detection of obstructive CAD is high (95%–97%), specificity (68%–73%) is

ESC Guidelines                                                                                                                                                                                          4655

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