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AS and Class I indications for SAVR, a significantly higher proportion of men than women are referred for evaluation by a cardiac surgeon.994,995 Male patients derive a clearer benefit from SAVR compared with women, who have higher in-hospital and long-term mortality and morbidity,987,996 possibly explained by more severe concentric hypertrophy991 and a smaller aortic annulus predisposing to PPM.997 Conversely, in a randomized trial (RHEIA) that compared TAVI with SAVR in 443 women with a mean age of 73 years, TAVI was superior in reducing the primary endpoint composed of death, stroke, or rehospitalization at 1 year, predominantly driven by a reduction in rehospitalization for valve- or procedure-related symptoms or worsening HF.998 Several observational studies suggest that elderly women have lower mortality after TAVI,999 even if the rates of major vascular complications and bleeding tend to be higher.997 Indexed cut-offs to indicate treatment of AR are validated, but only partially account for sex differences. Newer studies using echocardiographic volumes1000 and CMR1001 suggest that women may experience higher event rates at lower cut-offs compared with men, but this requires further investigation.

17.2 Mitral valve disease

Patients with RHD are often young women and have a high prevalence of major cardiovascular complications with far-reaching impacts on reproductive health and access to care.282 Although women experience favourable outcomes compared with men when treated by percutaneous balloon valvuloplasty, access to these procedures is still limited in low-income countries.662 Fibroelastic disease with MV prolapse is also more frequent in women, and may be accompanied by morphological abnormalities of the MA associated with fibrosis of the papillary muscles or the inferobasal LV that may act as the substrate for sudden cardiac death, even in the absence of severe MR.1002 Recent evidence has supported considering lower women-specific cut-offs for intervention with regard to LVESD (36 mm; indexed LVESD, 1.8 cm/m2), while the LVEF cut-off was similar to men (58%), albeit with higher mortality.548 Ventricular SMR associated with low LVEF is more frequent in men with HF,1003 while atrial SMR due to chronic AF and/or HFpEF affects more women (58% vs 42% male).579 Female sex is a risk factor for the development of MAC and was reported to account for 68% of the patients included in a large-scale transcatheter MV replacement in MAC registry.1004 Furthermore, women present with a faster disease progression.1005

17.3 Tricuspid valve disease

Tricuspid regurgitation is more prevalent in women,208 and female sex is associated with accelerated disease progression.1006–1008 Hypotheses to explain these observations include the overall higher prevalence of HFpEF and AF in women.1009 Women are usually diagnosed at an older age and the cause of TR is most frequently a consequence of left valvular disease or annular dilatation attributable to RA dilatation.1010 No differences have been detected to date in terms of adverse events after surgery1011 or transcatheter TV interventions.1012,1013 18 Key messages

Heart Team and Heart Valve Centre

• An integrated regional Heart Valve Network incorporating outpatient Heart Valve Clinics and specialist Heart Valve Centres allows optimal patient care. • Heart Valve Centres should fulfil institutional and local statutory requirements, and strive for high procedural volume and excellent clinical outcomes. • Heart Team recommendations should be based upon these guideline recommendations, relevant updated evidence, key medical considerations, and patient preferences. • Core members of the Heart Team include the primary clinical cardiologist, cardiologists with subspecialty expertise in VHD, specialists in advanced cardiovascular imaging and peri-procedural imaging guidance, and surgeons and interventional cardiologists with training and expertise in valve interventions. • A network approach that distinguishes between higher- and lower-volume centres is appropriate, with more complex procedures focused in the most experienced (i.e. upper quartile) centres. Information on the network organization should be communicated to patients, as well as referring cardiologists and general practitioners.

Aortic regurgitation

• Assessment of AR severity with TTE remains challenging and current cut-offs for intervention are mostly based on 2D measurements, although 3D echocardiography and CMR allow more accurate evaluation of LV volumes and LVEF. • Mechanisms of AR may be closely related to the aortic diameters that should be measured accurately at all levels of the aortic root (annulus, sinuses, and sinotubular junction). • Indication for operation is based on symptoms, LV volumes, LVEF, and aortic diameters. Although valve replacement remains the standard treatment, AV repair (or AV sparing when associated with root aneurysm) is being increasingly used to avoid prosthesis-related complications, especially in experienced centres. • Current transcatheter options for AR are limited and applicable only in patients who are ineligible for surgery.

Aortic stenosis

• Diagnosis of severe AS requires integrative evaluation of pressure gradients (the most robust measurements), AVA, flow conditions, the extent of valve calcification, and LV function. • Selection of the most appropriate mode of intervention should take into account clinical characteristics (age and estimated life expectancy, concomitant conditions), access and valve anatomy (particularly the feasibility of transfemoral TAVI and calcification patterns), and surgical risk, as well as repeat procedure options and risks (lifetime management).

Mitral regurgitation

• The echocardiographic diagnostic workup of patients with MR includes multiparametric assessment of MR severity, evaluation of Downloaded from academic.oup.com/eurheartj/article/46/44/4635/8234488 by guest on 07 October 2026