HEART VALVE DISEASE









  • Reference [17]
AHA stages of valvular heart disease
Stage Definition Description
A At risk Patients with risk factors for development of VHD
B Progressive Patients with progressive VHD (mild to moderate severity and asymptomatic)
C Asymptomatic severe Asymptomatic patients who have the criteria for severe VHD:
  • C1: Asymptomatic patients with severe VHD in whom the LV or RV remains compensated
  • C2: Asymptomatic patients with severe VHD with decompensation of the LV or RV
D Symptomatic severe Patients who have developed symptoms as a result of VHD




  • Reference [1,2,3,17]
STAGES OF AORTIC STENOSIS AND MONITORING RECOMMENDATIONS
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
(Stage B)
  • 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
(Stage B)
  • 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
(Stage C1)
  • 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















  • Reference [1,2,3,7,17]
STAGES OF AORTIC REGURGITATION AND MONITORING RECOMMENDATIONS
Stage ECHO findings Recommended monitoring
Mild
(Stage B)
  • 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
(Stage B)
  • 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
(Stage C1)
  • 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
Dilating LV: more frequently










  • Reference [1,2,3,17]
STAGES OF MITRAL STENOSIS AND MONITORING RECOMMENDATIONS
Stage ECHO findings Recommended monitoring
Normal
  • Mitral valve area (MVA): 4 - 6 cm²
 N/A
Mild to moderate
(Stage B)
  • Mitral valve area (MVA): 1.6 - 4 cm²
  • Diastolic pressure half-time: < 150 ms
 ECHO every 3 - 5 years
Severe
(Stage C1)
  • 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










  • Reference [1,3,10,11,12,17]
STAGES OF PRIMARY MITRAL REGURGITATION AND MONITORING RECOMMENDATIONS
Stage ECHO findings Recommended monitoring
Mild to moderate
(Stage B)
  • 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
(Stage C1)
  • 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
Dilating LV: more frequently

  • Reference [1,3,10,11,12,17]
STAGES OF SECONDARY MITRAL REGURGITATION AND MONITORING RECOMMENDATIONS
Stage ECHO findings Recommended monitoring
Mild to moderate
(Stage B)
  • 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
(Stage C1)
  • 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
Dilating LV: more frequently











  • Reference [1,3,17]
STAGES OF TR AND TS AND MONITORING RECOMMENDATIONS
Stage ECHO findings Recommended monitoring
Mild TR
(Stage B)
  • Central jet area: < 5 cm²
  • Central jet: < 50% RA
  • Vena contracta: < 0.7 cm
  • RV/RA/IVC: no enlargement
 N/A
Moderate TR
(Stage B)
  • Central jet area: 5 - 10 cm²
  • Central jet: < 50% RA
  • Vena contracta: < 0.7 cm
  • RV/RA/IVC: no RV enlargement; no or mild RA/IVC enlargement
 N/A
Severe TR
(Stage C)
  • Central jet area: > 10 cm²
  • Central jet: ≥ 50% RA
  • Vena contracta: ≥ 0.7 cm
  • RV/RA/IVC: all dilated
 N/A
Severe TS
(Stage C)
  • Pressure half-time: ≥ 190 ms
  • Valve area: ≤ 1.0 cm²
  • RA/IVC: enlarged
 N/A











  • Reference [5,17]
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 40 years old - 30%
    • Valve at 20 years old - 50%
Age > 65 years
  • 15-year risk of bioprosthetic valve deterioration:
    • Valve at > 70 years old: <10%
Patient preference (avoid risk of reintervention) Patient preference (avoid risk and inconvenience of anticoagulation)
Low risk of complications with long-term anticoagulation High risk of complications with long-term anticoagulation
Compliant patient with access to INR monitoring Limited access to medical care or inability to regulate VKA
Other indications for anticoagulation (e.g. atrial fib) Access to surgical centers with low reoperation mortality rate
High-risk reintervention (e.g. porcelain aorta, prior radiation therapy) Access to transcatheter valve-in-valve replacement
Small aortic root size for AVR (may preclude valve-in-valve procedure in future) TAVR valves have larger effective orifice areas for smaller valve sizes (avoid patient–prosthesis mismatch)




  • ✝For On-X AVR, use of a VKA targeted to a lower INR (1.5–2.0) may be reasonable starting ≥ 3 months after surgery, with continuation of aspirin 75 to 100 mg daily
  • Reference [17]
AHA recommendations for antithrombotic therapy in patients with mechanical heart valves
Valve type / Patient factors Target INR
(range)
  • 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✝
Antiplatelet therapy
  • For patients with a mechanical surgical AVR or mitral valve replacement who are managed with a VKA and have an indication for antiplatelet therapy, addition of aspirin 75 to 100 mg daily may be considered when the risk of bleeding is low