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Fast Facts

A brief refresher with useful tables, figures, and research summaries

Valvular Disease

In this section, we provide an overview of the most common types of valvular heart disease encountered on the general inpatient service:

Aortic Stenosis
Mitral Regurgitation
Infective Endocarditis

Aortic Stenosis

The central issue in the management of aortic stenosis (AS) is when to intervene. Intervention involves either surgical aortic valve replacement (AVR) or percutaneous transcatheter aortic valve replacement (TAVR). TAVR has replaced surgical AVR for patients at high or prohibitive surgical risk. Studies also have shown that, in the short term, TAVR is noninferior to surgery for patients at intermediate or low surgical risk, although longer-term outcomes for such patients are still being evaluated.

The decision to intervene can be made based on the following findings:

Symptoms: The most common are dyspnea on exertion, chest pain, and syncope. AVR is not generally recommended for asymptomatic patients (except in patients with very severe AS). In sedentary patients, exercise stress testing may be indicated to confirm the absence of symptoms.
Maximum aortic velocity (V_max) on Doppler echocardiogram: AVR should be considered in symptomatic patients with V_max ≥4.0 m/sec.
Aortic valve area (AVA) calculated from the patient’s echocardiogram: The AVA should be ≤1.0 cm² to confirm the diagnosis of severe AS.
Ejection fraction (EF): Patients with reduced EF (<50%) may have severe AS without a V_max ≥4.0 m/sec.
Dobutamine stress echocardiography (DSE): For patients with reduced EF, an increase in V_max ≥4.0 m/sec with an AVA remaining ≤1.0 cm² on DSE is consistent with severe AS.

[Image] — **Aortic Stenosis Disease Stages**

Mitral Regurgitation

The following factors are taken into consideration when evaluating a patient for mitral-valve surgery (repair or replacement):

Severity of disease: Generally, mitral-valve surgery is indicated only in patients with severe mitral regurgitation (MR), as defined by Doppler echocardiography.
Symptoms: Mitral-valve surgery is indicated in patients with dyspnea or fatigue who have severe MR.
Left ventricular (LV) dilatation or dysfunction: Mitral-valve surgery is recommended for asymptomatic patients with severe MR if they have an EF ≤60%, an LV end-systolic dimension (LVESD) ≥40 mm, or both.
Severely reduced LV function or severe LV dilatation (LVESD >55 mm): Patients with severely reduced LV function (EF <30%) or severe LV dilatation (LVESD >55 mm) may not benefit from mitral-valve surgery.
Pulmonary hypertension: Consider mitral-valve surgery in the asymptomatic patient with severe MR and a pulmonary artery systolic pressure >50 mm Hg at rest.
New-onset atrial fibrillation (AF): In asymptomatic patients with severe MR, AF is an indication for surgery if it is known to be new or if it is present at the time of diagnosis of severe MR.

Transcatheter mitral-valve repair, using the percutaneous mitral-valve clip, has been compared to medical therapy in two trials in patients with moderate-to-severe MR and heart failure; the trials came to different conclusions regarding clinical outcomes, and as a result, the role of the procedure in patients with MR remains uncertain. Transcatheter mitral-valve repair can be considered in patients with an indication for mitral-valve repair who are at high surgical risk.

See the research section in this rotation guide for more details to inform decisions about surgery for patients with AS and MR.

Infective Endocarditis

The Duke criteria are used to diagnose infective endocarditis (IE). For patients with IE who are not acutely ill, obtain blood culture data and await culture results before deciding which therapy is appropriate. For acutely ill patients, empiric therapy may be necessary; vancomycin is usually recommended for such patients.

Early surgery for IE should be considered for patients with the following conditions:

heart failure
annular or aortic abscess
heart block
recurrent emboli on appropriate antibiotic therapy
infections resistant to antibiotic therapy
fungal endocarditis
persistent infection (>5-7 days)

Research

Landmark clinical trials and other important studies

Research

Five-Year Outcomes of Transcatheter or Surgical Aortic-Valve Replacement

Makkar RR et al. N Engl J Med 2020.

Patients with severe symptomatic aortic stenosis at intermediate operative risk were randomized to either TAVR or surgical aortic-valve replacement. At 5 years, the incidence of death or disabling stroke did not differ significantly between groups. However, more patients in the TAVR group had at least mild paravalvular aortic regurgitation, and repeat hospitalizations.

Read the NEJM Journal Watch Summary

Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low-Risk Patients

Mack MJ et al. N Engl J Med 2019.

Among patients with severe aortic stenosis who were at low surgical risk, the rate of the composite of death, stroke, or rehospitalization at one year was significantly lower with TAVR than with surgery.

Read the NEJM Journal Watch Summary

Transcatheter Aortic-Valve Replacement with a Self-Expanding Valve in Low-Risk Patients

Popma JJ et al. N Engl J Med 2019.

In patients with severe aortic stenosis who were at low surgical risk, TAVR with a self-expanding supraannular bioprosthesis was noninferior to surgery with respect to the composite end point of death or disabling stroke at 24 months.

Read the NEJM Journal Watch Summary

Transcatheter Mitral-Valve Repair in Patients with Heart Failure

Stone GW et al. N Engl J Med 2018.

Among patients with heart failure and moderate-to-severe or severe secondary mitral regurgitation who remained symptomatic despite the use of maximal doses of guideline-directed medical therapy, transcatheter mitral-valve repair resulted in a lower rate of hospitalization for heart failure and lower all-cause mortality within 24 months of follow-up than medical therapy alone.

Read the NEJM Journal Watch Summary

Percutaneous Repair or Medical Treatment for Secondary Mitral Regurgitation

Obadia JF et al. N Engl J Med 2018.

Among patients with severe secondary mitral regurgitation, the rate of death or unplanned hospitalization for heart failure at one year did not differ significantly between patients who underwent percutaneous mitral-valve repair in addition to receiving medical therapy and those who received medical therapy alone.

Read the NEJM Journal Watch Summary

Two-Year Outcomes of Surgical Treatment of Severe Ischemic Mitral Regurgitation

Goldstein D et al. for the CTSN. N Engl J Med 2015.

The CTSN Severe Ischemia MR Trial showed a significantly greater rate of recurrence of moderate-to-severe mitral regurgitation in patients who underwent mitral repair versus replacement but found no significant differences in adverse cardiovascular events at one-year follow-up. In this 2-year update, the mitral repair group continued to have a greater mitral regurgitation recurrence rate but, in contrast with the one-year follow-up, also had more heart-failure-related events and cardiovascular admissions.

Read the NEJM Journal Watch Summary

Percutaneous Repair or Surgery for Mitral Regurgitation

Feldman T et al. for the EVEREST II Investigators. N Engl J Med 2011.

In the EVEREST II trial, patients with moderately severe or severe mitral regurgitation underwent percutaneous mitral-valve repair with the mitral-valve clip or mitral-valve surgery. Although percutaneous repair was less effective at reducing mitral regurgitation than conventional surgery, the procedure was associated with superior safety and similar improvements in clinical outcomes.

Read the NEJM Journal Watch Summary

Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients

Leon MB et al. N Engl J Med 2016.

The PARTNER 2 trial randomized patients with severe aortic stenosis and intermediate surgical risk to TAVR or open surgery. TAVR was similar to surgical aortic-valve replacement with respect to the primary end point of death or disabling stroke.

Read the NEJM Journal Watch Summary

Two-Year Outcomes after Transcatheter or Surgical Aortic-Valve Replacement

Kodali SK et al. for the PARTNER Trial Investigators. N Engl J Med 2012.

In the PARTNER A trial, patients with severe aortic stenosis (AS) at high surgical risk were randomized to either surgical AVR or TAVR. At 2 years, all-cause mortality and cardiovascular mortality did not differ significantly between groups. TAVR was associated with a higher rate of stroke or TIA. In the parallel PARTNER B trial, patients with severe AS deemed to be inoperable were randomized to best medical therapy or TAVR; TAVR significantly reduced rates of all-cause and cardiovascular mortality.

Read the NEJM Journal Watch Summary

Early Surgery versus Conventional Treatment for Infective Endocarditis

Kang D-H et al. N Engl J Med 2012.

In the EASE trial, patients with left-sided native-valve endocarditis, severe aortic or mitral-valve disease, and large vegetations (diameter, >10 mm) were randomized to surgery within 48 hours or conservative management with surgery only for complications or persistence of symptoms after completion of antibiotic therapy. Early surgery was associated with a significant reduction in embolic events.

Read the NEJM Journal Watch Summary