Valve Disease Management

Introduction to Valve Disease

The presence of multiple moderate valve lesions may accelerate disease progression compared to single valve disease, as noted by the American Heart Association 1
Clinical evaluation every 6 months and echocardiography annually are recommended for patients with multiple valve lesions, according to the European Society of Cardiology 2

Patients with multiple valve lesions should be instructed to promptly report any change in functional status, as advised by the European Society of Cardiology 2
Left ventricular function and dimensions should be tracked, including any decrease in LVEF below 55%, monitor for LV dilation, and assess for changes in diastolic function 2
Valve regurgitation progression should be monitored, including progression from moderate to severe regurgitation and changes in regurgitant volume or effective regurgitant orifice area 2
Development of symptoms such as dyspnea on exertion, decreased exercise tolerance, fatigue, and palpitations should be assessed 2
Pulmonary pressures should be monitored, including the development of pulmonary hypertension (systolic pulmonary pressure >50 mmHg) 2
The following patient populations require closer monitoring:

Exercise echocardiography should be considered if there is discrepancy between symptoms and resting echocardiographic findings, as recommended by the European Society of Cardiology 5
Exercise testing can reveal dynamic changes in regurgitation severity, exercise-induced pulmonary hypertension, and left ventricular contractile reserve 5
Echocardiography is recommended for patients with systemic disease that may affect the heart, family history of genetically transmitted cardiovascular disease, and phenotypic features of Marfan syndrome or related connective tissue diseases (Class IIb recommendation) 6
Echocardiography is indicated before cardioversion in patients requiring urgent cardioversion, those with prior cardioembolic events, contraindications to anticoagulation, and known or suspected intra-atrial thrombus 6
Echocardiography is valuable for diagnosing acute ischemic syndromes, hypotension of unknown cause, cardiac tamponade, aortic dissection, and source of embolism in hemodynamically unstable patients 6
Echocardiography is recommended for patients with syncope and clinically suspected heart disease, periexertional syncope, and syncope in high-risk occupations (e.g., pilots) 6
Baseline and periodic reevaluations with echocardiography are recommended for patients undergoing chemotherapy with cardiotoxic agents 6

Surgical intervention should be considered if symptoms attributable to valve disease develop, left ventricular ejection fraction decreases below 60%, left ventricular end-systolic dimension increases ≥40 mm, development of pulmonary hypertension, or new onset atrial fibrillation, according to the European Society of Cardiology 2
Tricuspid valve repair should be considered only if the regurgitation progresses to severe with right-sided heart failure symptoms 7
The coexistence of multiple valve lesions may accelerate the need for intervention compared to single valve disease 1, 8
Delayed intervention in the setting of progressive LV dysfunction can lead to irreversible myocardial damage 3

There is no indication for vasodilator therapy (including ACE inhibitors) in chronic mitral or aortic regurgitation with normal left ventricular function and no heart failure symptoms, as stated by the European Society of Cardiology 2
If heart failure symptoms develop, ACE inhibitors should be considered, beta-blockers may be appropriate, and diuretics for symptom management 2
The American College of Cardiology and European Heart Journal recommend implementing GDMT for heart failure with preserved ejection fraction, including ACE inhibitors/ARBs, beta-blockers, and mineralocorticoid receptor antagonists, in patients with Grade I diastolic dysfunction, mild left ventricular dilation, and trace mitral and tricuspid regurgitation 8, 7
Overtreatment for trace regurgitation of the mitral and tricuspid valves should be avoided, as current guidelines do not recommend specific intervention for trace regurgitation 8, 7
Vasodilator therapy may be beneficial if there is evidence of functional MR associated with LV dilatation, but currently, there is insufficient evidence to recommend vasodilator therapy for patients with organic mitral regurgitation and preserved LV function 3

Eccentric jets of mitral regurgitation may be underestimated by color flow imaging alone, and comprehensive assessment using multiple parameters is essential, as noted by the American College of Cardiology 9
The coexistence of both mitral and aortic regurgitation may lead to more rapid progression than either lesion alone, and more frequent monitoring may be needed if there are signs of progression, according to the American Heart Association 1
Patients with mitral valve prolapse may have dynamic changes in regurgitation severity that aren't captured on resting echocardiography, as reported by the European Society of Cardiology 5
Right ventricular dysfunction is an independent predictor of poor outcomes in patients with left heart disease, and careful volume management with diuretics is recommended to optimize hemodynamics in patients with right heart strain and IVC dilation 2
Grade I diastolic dysfunction can progress to higher grades and eventually heart failure with preserved ejection fraction (HFpEF), and early intervention with guideline-directed medical therapy (GDMT) may slow this progression 8