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Radiotherapy may lead to aortic and/or valvular calcification, CAD of proximal segments, restrictive cardiomyopathy, pericardial adhesions and calcifications with constriction, restrictive lung disease, chest wall scarring, and impaired wound healing, especially in patients who underwent radiation by means of older techniques (>20 years ago). The above factors complicate any surgical approach and increase the operative risk, which is underestimated by traditional risk scores.179–181 TAVI is proposed as an alternative for patients presenting with radiation-induced AS in the 2022 ESC Guidelines on cardio-oncology182 based on favourable, but limited, observational data,183,184 because this category of patients has been excluded from RCTs.183,184 Furthermore, M-TEER in patients presenting with radiation-induced MV disease with MR is often limited by thickened leaflets with restricted movement and subsequent risk of iatrogenic stenosis. In patients with active or stable cancer and severe AS, both TAVI and SAVR can be considered based on life expectancy, age, prognosis, and disability following cancer treatment, with a trend towards more TAVI utilization.185 TAVI procedural complication rates appear similar compared with those of control subjects without cancer.186 To avoid futility, treatment decisions discussed by the Heart Team should involve the treating oncologists.5,182

6.4 Prophylaxis of rheumatic fever

Rheumatic heart disease remains the most common cause of death from VHD worldwide.187 Prevention should preferentially target the first occurrence of acute rheumatic fever. Correct diagnosis and early antibiotic treatment of group A Streptococcus throat or skin infection is key for primary prevention. Large-scale screening combined with prophylaxis in children or adolescents with latent RHD appears to be an effective strategy to reduce the risk of disease progression and RHD prevalence.188–190 In patients with established RHD, secondary long-term prophylaxis with benzathine benzyl penicillin 1.2 million international units (IU) every 3–4 weeks over 10 years is recommended to prevent recurrent episodes, especially in children and adolescents. Long-term prophylaxis into adulthood should be considered in high-risk patients according to the severity of VHD and exposure to group A Streptococcus.191,192

6.5 Cardiogenic shock and acute heart

failure Acute presentation or decompensation of VHD can result in cardiogenic shock due to rapid haemodynamic deterioration and altered cardiac function. Alternatively, pre-existing VHD can be a bystander of an acute cardiovascular condition further exacerbating circulatory impairment until the occurrence of cardiogenic shock. In this setting, assessment of the severity of VHD, as well as its contribution to acute HF, may be difficult. Evidence concerning acute VHD management in this context is scarce and only exists for the MV and AV.193,194 Hospital admission for acute decompensated AS is a frequent problem seen in up to 25% of AS hospitalizations.195,196 However, only a minority of these patients (1.6%–3.2%) present with cardiogenic shock.197,198 While intensive care treatment remains the cornerstone of haemodynamic stabilization and support, an intervention should be considered early, because it represents the only way to reverse progressive organ dysfunction due to low cardiac output. Balloon aortic valvuloplasty has been used in this context in the past, but has been largely replaced by TAVI in recent years, due to the high risk of severe AR and mortality in the acute setting.199–201 Several large observational studies have established the feasibility of TAVI in patients with cardiogenic shock with similar device success, even if LVEF is low, although 30-day mortality remains higher (13%–19%) compared with routine TAVI.194,197,198 Surgery represents the preferred treatment in patients with acute AR, while TAVI has only been described in individual cases or patients with a failed surgical valve (valve-in-valve). Fast pacing over a temporary pacemaker lead shortens the diastole and may temporarily improve haemodynamics until the intervention.5,8

Except for papillary muscle rupture, acute PMR rarely leads to cardiogenic shock and may be best treated by surgical valve repair or replacement. In contrast, increasing evidence supports the use of M-TEER in patients with acute ventricular SMR, particularly following acute myocardial infarction, due to lower mortality compared with surgery or medical treatment in propensity-matched analyses.194,202,203 This strategy might also be helpful to facilitate weaning from mechanical circulatory support.

6.6 Palliative care

In some patients with advanced VHD not qualifying for surgical or transcatheter therapies, medical HF treatment remains the only, and sometimes best, available option. These patients usually present late, have extensive cardiac damage, develop terminal HF during the natural evolution of VHD, and are ineligible for mechanical circulatory support or heart transplantation (HTx). Early implementation of expert multidisciplinary palliative and end-of-life care, with the support of HF specialists,204–206 reduces the number of hospitalizations and improves quality of life and symptom burden, in particular dyspnoea, pain, and anxiety.207 Continuous co-ordination between all involved subspecialties, and transparent communication with the patient and their relatives, are key to ensure high quality of care.

7 Aortic regurgitation

7.1 Prevalence and aetiology

Chronic AR is mainly due to intrinsic abnormalities of the AV cusps and/ or secondary to progressive dilatation of the aortic root and/or ascending aorta. In high-income countries, degenerative changes are the leading cause of AR, while RHD is more frequent in middle- and low-income countries.12 Acute presentations are usually related to infective endocarditis or extension of aortic dissection into the aortic root. Chronic pure severe AR is more frequent in men and is associated with BAV and concomitant dilatation of the aorta in more than one-half of cases.208

7.2 Evaluation

During stepwise AR evaluation, the following aspects should be addressed: the severity of AR, its mechanism, and aetiology; the haemodynamic impact on LV function and pulmonary pressure; and evaluation of the ascending aorta. While echocardiography is the firstline modality, CMR and CCT are more accurate for the measurement of specific parameters (Figure 4). The results of the evaluation need to take into consideration the haemodynamic condition of the patient, particularly the blood pressure (BP), since high pressures can lead to overestimation of the regurgitant volume (RVol). Assessment of AR severity with TTE follows an integrative approach considering qualitative, semi-quantitative, and quantitative parameters, but remains challenging.45 Consequences of AR on LV size and function must be carefully assessed. Cut-offs for intervention are mostly based on two-dimensional (2D) echocardiographic measurements. However, 3D echocardiography and CMR allow more accurate Downloaded from academic.oup.com/eurheartj/article/46/44/4635/8234488 by guest on 07 October 2026