HEART VALVE DISEASE










  • Reference [1,2,3]
STAGES OF AORTIC STENOSIS AND MONITORING RECS
Stage ECHO findings Recommended monitoring
Normal
  • Aortic valve area (AVA): 3 - 4 cm²
  • Aortic valve pressure gradient (A△P): very small (a few mmHg)
  • Maximum aortic velocity (AVmax): < 2 m/s
N/A
Mild
  • Aortic valve area (AVA): >1 cm²
  • Aortic valve pressure gradient (A△P): < 20 mmHg
  • Maximum aortic velocity (AVmax): 2 - 2.9 m/s
ECHO every 3 - 5 years
Moderate
  • Aortic valve area (AVA): >1 cm²
  • Aortic valve pressure gradient (A△P): 20 - 39 mmHg
  • Maximum aortic velocity (AVmax): 3 - 3.9 m/s
ECHO every 1 - 2 years
Severe
  • Aortic valve area (AVA): <1 cm²
  • Aortic valve pressure gradient (A△P): ≥ 40 mmHg
  • Maximum aortic velocity (AVmax): ≥ 4 m/s

Patients with significant LV dysfunction (e.g. reduced EF, reduced stroke volume) may not meet criteria for A△P or AVmax even though they have severe stenosis
ECHO every 6 - 12 months
RATE OF PROGRESSION:
  • There is wide patient variability in the rate of AS progression. Once moderate AS is present, the average rate of progression is an increase in velocity of 0.3 m/s per year, an increase in mean pressure gradient of 7 mmHg/year, and a decrease in valve area of 0.1 cm²/year.





  • Reference [1,2,3,7]
STAGES OF AORTIC REGURGITATION AND MONITORING RECS
Stage ECHO findings Recommended monitoring
Mild
  • Jet width: < 25% of LVOT
  • Vena contracta: < 0.3 cm
  • Regurgitant volume (RVol): < 30 ml/beat
  • Regurgitant fraction (RF): < 30%
  • Effective regurgitant orifice area (EROA): < 0.10 cm²
  • LV volume: normal or mild dilation
ECHO every 3 - 5 years
Moderate
  • Jet width: 25 - 64% of LVOT
  • Vena contracta: 0.3 cm - 0.6 cm
  • Regurgitant volume (RVol): 30 - 59 ml/beat
  • Regurgitant fraction (RF): 30% - 49%
  • Effective regurgitant orifice area (EROA): 0.10 - 0.29 cm²
  • LV volume: normal or mild dilation
ECHO every 1 - 2 years
Severe
  • Jet width: ≥ 65% of LVOT
  • Vena contracta: > 0.6 cm
  • Regurgitant volume (RVol): > 60 ml/beat
  • Regurgitant fraction (RF): ≥ 50%
  • Effective regurgitant orifice area (EROA): ≥ 0.3 cm²
  • LV volume: abnormal (LVESD > 50 mm)
ECHO every 6 - 12 months
RATE OF PROGRESSION:
  • In one study, patients with moderate AR had the following progression rates to severe AR:
    • Patients with valve leaflet pathology - 1.4%/year
    • Patients with aortic dilation - 3.7%/year





  • Reference [1,2,3]
STAGES OF MITRAL STENOSIS AND MONITORING RECS
Stage ECHO findings Recommended monitoring
Normal
  • Mitral valve area (MVA): 4 - 6 cm²
N/A
Mild to moderate
  • Mitral valve area (MVA): 1.6 - 4 cm²
  • Diastolic pressure half-time: < 150 ms
ECHO every 3 - 5 years
Severe
  • Mitral valve area (MVA): ≤ 1.5 cm²
  • Diastolic pressure half-time: ≥ 150 ms
MVA: 1.0 - 1.5 cm²
ECHO every 1 - 2 years
MVA: < 1.0 cm²
ECHO yearly
RATE OF PROGRESSION:
  • There is wide patient variability in the rate of MS progression. In general, stenosis progresses at a rate of 0.1 - 0.3 cm²/year.





  • Reference [1,3,10,11,12]
STAGES OF PRIMARY MITRAL REGURGITATION AND MONITORING RECS
Stage ECHO findings Recommended monitoring
Mild to moderate
  • Central jet: 20 - 40% of LA
  • Vena contracta: < 0.7 cm
  • Regurgitant volume (RVol): < 60 ml
  • Regurgitant fraction (RF): < 50%
  • Effective regurgitant orifice (ERO): < 0.40 cm²
  • LA and LV: mild LA enlargement; no LV enlargement
Mild: ECHO every 3 - 5 years
Moderate: ECHO every 1 - 2 years
Severe
  • Central jet: > 40% of LA
  • Vena contracta: ≥ 0.7 cm
  • Regurgitant volume (RVol): ≥ 60 ml
  • Regurgitant fraction (RF): ≥ 50%
  • Effective regurgitant orifice (ERO): ≥ 0.40 cm²
  • LA and LV: moderate or severe LA enlargement; LV enlargement
ECHO every 6 - 12 months
RATE OF PROGRESSION:
  • In one study, the rate of progression of primary MR was as follows:
    • RVol - 7.4 ml/year
    • RF - 2.9%/year
    • ERO - 0.059 cm²/year

  • Reference [1,3,10,11,12]
STAGES OF SECONDARY MITRAL REGURGITATION AND MONITORING RECS
Stage ECHO findings Recommended monitoring
Mild to moderate
  • Regurgitant volume (RVol): < 30 ml
  • Regurgitant fraction (RF): < 50%
  • Effective regurgitant orifice (ERO): < 0.20 cm²
  • LV function: LV dilation and systolic dysfunction
Mild: ECHO every 3 - 5 years
Moderate: ECHO every 1 - 2 years
Severe
  • Regurgitant volume (RVol): ≥ 30 ml
  • Regurgitant fraction (RF): ≥ 50%
  • Effective regurgitant orifice (ERO): ≥ 0.20 cm²
  • LV function: LV dilation and systolic dysfunction
ECHO every 6 - 12 months
RATE OF PROGRESSION:
  • The rate of progression of secondary MR is highly variable and dependent on the severity of the underlying condition




  • Reference [1,3]
STAGES OF TR AND TS AND MONITORING RECS
Stage ECHO findings Recommended monitoring
Mild TR
  • Central jet area: < 5 cm²
  • Vena contracta: < 0.7 cm
  • RV/RA/IVC: no enlargement
N/A
Moderate TR
  • Central jet area: 5 - 10 cm²
  • Vena contracta: < 0.7 cm
  • RV/RA/IVC: no RV enlargement; no or mild RA/IVC enlargement
N/A
Severe TR
  • Central jet area: > 10 cm²
  • Vena contracta: > 0.7 cm
  • RV/RA/IVC: all dilated
N/A
Severe TS
  • Pressure half-time: ≥ 190 ms
  • Valve area: ≤ 1.0 cm²
  • RA/IVC: enlarged
N/A
RATE OF PROGRESSION:
  • There is limited data on the rate of progression of TR and TS. Severe, primary TR is has a poor prognosis. The course of secondary TR is highly dependent on the underlying condition. In cases where right ventricular dysfunction is successfully treated, secondary TR may improve or resolve.








  • Reference [5]
Factors to consider when choosing a valve type
Favors Mechanical Valve Favors Bioprosthetic Valve
Age < 50 years
  • 15-year risk of bioprosthetic valve deterioration:
    • Valve at age 40 - 30%
    • Valve at age 20 - 50%
Age > 70 years
  • 15-year risk of bioprosthetic valve deterioration:
    • Valve at age greater than 70 - <10%
Low risk of complications with long-term anticoagulation High risk of complications with long-term anticoagulation
Compliant patient for INR monitoring Noncompliant patient
Other indications for anticoagulation (e.g. atrial fib) Access to surgical centers with low reoperation mortality rate
High-risk reintervention (eg, porcelain aorta, prior radiation therapy)
Small aortic root size for AVR (may preclude valve-in-valve procedure in future)



Antithrombotic therapy recommendations for prosthetic valves
Mechanical heart valves
Valve type/patient factors Target INR
(range)
All mechanical valve patients
  • Aspirin 75 - 100 mg/day is recommended in addition to anticoagulation with VKA in all patients with a mechanical heart valve
N/A
  • Mechanical bileaflet or current-generation single-tilting disc aortic valve and no risk factors for thromboembolism
2.5
(2 - 3)
  • Any mechanical aortic valve + additional risk factors for thromboembolism (e.g. a fib, previous thromboembolism, LV dysfunction, or hypercoagulable conditions)
3
(2.5 - 3.5)
  • Older-generation mechanical aortic valve (such as ball-in-cage)
3
(2.5 - 3.5)
  • Mechanical mitral valve
3
(2.5 - 3.5)
  • On-X® aortic valve replacement and no thromboembolic risk factors
  • On-X® website
Target of 1.5 - 2.0 may be reasonable
Bioprosthetic heart valves
  • Aspirin 75 mg to 100 mg per day is reasonable in all patients with a bioprosthetic aortic or mitral valve
  • Anticoagulation with a VKA to achieve an INR of 2.5 is reasonable for at least 3 months and for as long as 6 months after surgical bioprosthetic mitral or aortic valve replacement in patients at low risk of bleeding.
Transcatheter aortic valve replacement (TAVR)
  • Anticoagulation with a VKA to achieve an INR of 2.5 may be reasonable for at least 3 months after TAVR in patients at low risk of bleeding
  • Clopidogrel 75 mg daily may be reasonable for the first 6 months after TAVR in addition to life-long aspirin 75 mg to 100 mg daily