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MV anatomy (often with 3D TOE), identification of the mechanism (PMR, ventricular SMR, or atrial SMR), and evaluation of cardiac damage. • Surgical MV repair is the preferred method of treatment in severe PMR. Transcatheter edge-to-edge repair is recommended in patients who are inoperable or high risk according to the Heart Team. • Surgical MV repair is the procedure of choice for asymptomatic patients with primary MR and signs of cardiac damage, including moderate or more TR. • In patients with ventricular SMR, GDMT (including CRT if indicated) is the initial and essential treatment step. In symptomatic patients without CAD needing revascularization, M-TEER is recommended. In patients with concomitant complex CAD and those not suitable for TEER, mitral surgery may be considered. • In patients with atrial SMR, MV surgery, AF ablation if indicated, and LAAO should be considered after optimization of medical therapy. Transcatheter edge-to-edge repair may be considered in patients at high surgical risk.

Mitral stenosis • Most patients with severe rheumatic MS and favourable valve anatomy should undergo PMC, which is the standard of care. Surgery is recommended for symptomatic patients with contraindications or unfavourable anatomical and clinical characteristics for PMC. • Decision-making in patients with unfavourable anatomy should take into account local PMC experience. • In selected patients with clinically severe degenerative MS and MAC, transcatheter intervention or surgery may improve symptoms.

Tricuspid regurgitation • Concomitant TV repair is the preferred method for patients with left-sided valve pathology and associated moderate or severe TR. • The use of risk scores for the assessment of RV and secondary organ dysfunction should be strongly encouraged in patients with isolated severe TV disease. • In isolated severe TR without severe RV dysfunction, surgery should be performed at an early stage in patients at low operative risk. • In isolated severe TR patients at increased surgical risk, tricuspid TEER or transcatheter replacement should be considered to improve quality of life and RV remodelling, in the absence of severe RV dysfunction or pre-capillary PH.

Tricuspid stenosis • TS is a very rare manifestation of acquired VHD in high-income countries. • TS is mainly associated with rheumatic valve disease, carcinoid syndrome, or enzymatic disorders such as Fabry’s or Whipple’s disease. • Treatment of symptomatic TS mainly involves surgical TV replacement.

Multiple and mixed valvular heart disease • Transvalvular gradients and velocities reflect the combined burden of regurgitation and stenosis in mixed aortic and mitral disease. • Treatment decisions should be based on the assessment of symptom and functional status, cardiac damage, anatomical suitability, and the risk–benefit ratio of intervention and lifetime management considerations. • Patients with mixed moderate AS and AR have similar detrimental outcomes compared with those with severe isolated AS. • In transcatheter procedures, which allow a sequential approach, downstream lesions should be treated first to prevent potential haemodynamic deterioration and allow improvement of upstream lesions due to changing loading conditions and reverse remodelling.

Antithrombotic treatment in patients with a mechanical heart valve • International normalized ratio therapeutic range should be balanced to the type and anatomical site of MHV, as well to the thrombotic risk profile of the individual patient. • Patient training, self-monitoring, and education can increase INR stability and TTR. • Minor or minimally invasive NCS procedures do not require VKA interruption in patients with an MHV. • In patients with an MHV undergoing elective major NCS, bridging may be omitted if the thromboembolic risk is low.

Non-cardiac surgery • The risk of peri-operative cardiovascular complications related to surgery and to patient-specific factors should be evaluated and communicated to the patient and surgical team. • In patients with symptomatic severe AS requiring urgent high-risk NCS, BAV or TAVI should be considered prior to surgery. In patients planned for elective NCS, AV intervention is recommended prior to NCS.

Pregnancy • In women with VHD, decisions regarding management before and during pregnancy should be taken after discussion by the multidisciplinary Pregnancy Heart Team. Unplanned pregnancies should be discouraged. • The following conditions should be corrected prior to considering pregnancy: – clinically severe MS (MVA <1.5 cm2), even when asymptomatic – severe symptomatic AS, or asymptomatic patients with impaired LV function or a pathological exercise test – heritable aortic disorders and high risk of aortic dissection. • Vaginal delivery is the first choice for the majority of patients. Indications for Caesarean section include pre-term labour in patients on OAC, severe MS or AS, aggressive aortic pathology, acute intractable HF, and severe PH. • Women with MHVs should be managed in expert centres.

19 Gaps in evidence

General aspects • Patient-reported outcome measures are infrequently reported in VHD studies. Patient-reported outcome measure-oriented studies are required to improve quality of life and patient satisfaction. • Methods to address underdiagnosis and undertreatment of VHD need to be identified and implemented.

ESC Guidelines                                                                                                                                                                                          4705

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