Summary

Comprehensive update replacing the 2014 VHD guideline and 2017 focused update, covering diagnosis, staging (A–D), and management of native and prosthetic valve disease in adults. Key changes include expanded TAVI indications across all surgical risk strata, lower thresholds for intervention in regurgitant lesions, formalized Heart Valve Team/Comprehensive Valve Center referral, updated antithrombotic regimens (NOACs permitted in most VHD with AF except rheumatic MS and mechanical valves), and new recommendations for TEER in primary and selected secondary MR.

Key Recommendations

Stage VHD as A (at risk), B (progressive), C (asymptomatic severe), or D (symptomatic severe) based on symptoms, anatomy, hemodynamics, and ventricular response.
For AF with VHD, use VKA (target INR 2.5) in rheumatic MS or mechanical valves; NOAC or VKA per CHA2DS2-VASc otherwise, including bioprosthetic valves >3 months post-implant.
Refer all patients with severe VHD considered for intervention to a multidisciplinary Heart Valve Team at a Primary or Comprehensive Valve Center.
AVR is indicated for symptomatic severe AS (Stage D) and asymptomatic severe AS with LVEF <50% (Stage C2); consider AVR for asymptomatic severe AS with Vmax ≥5 m/s, abnormal exercise BP, elevated BNP, or rapid progression.
Choose SAVR for AS patients <65 years or life expectancy >20 years; TAVI preferred for patients >80 years or life expectancy <10 years; shared decision-making for ages 65–80 with transfemoral access.
AVR for chronic severe AR is indicated for symptoms, LVEF ≤55%, or LVESD >50 mm (or indexed >25 mm/m2); TAVI is not first-line for AR.
Replace ascending aorta in BAV patients when diameter ≥5.5 cm, or ≥5.0 cm with risk factors (family history dissection, growth ≥0.5 cm/y, coarctation) at a Comprehensive Valve Center.
PMBC is first-line for symptomatic severe rheumatic MS (MVA ≤1.5 cm²) with favorable valve morphology and no LA thrombus or >mild MR; mitral valve replacement only if symptoms refractory and PMBC/repair not feasible.
Mitral valve repair (preferred over replacement) for symptomatic severe primary MR, or asymptomatic severe primary MR with LVEF ≤60% or LVESD ≥40 mm; TEER for high/prohibitive surgical risk with suitable anatomy.
TEER for chronic severe secondary MR is indicated in patients with LVEF 20%–50%, LVESD ≤70 mm, PASP ≤70 mm Hg, and persistent NYHA II–IV symptoms despite optimal GDMT (COAPT criteria).
Tricuspid valve surgery for severe TR at time of left-sided valve surgery; consider isolated tricuspid surgery for severe symptomatic primary or AF-related TR before RV dysfunction or end-organ damage develops.
Mechanical valve favored if age <50 years; bioprosthetic favored if age >65 years; shared decision-making for 50–65 years considering anticoagulation tolerance, durability, and reintervention risk.
All mechanical valve patients require lifelong VKA; NOACs are contraindicated. Add low-dose aspirin in selected patients based on bleeding risk.
Early surgery for IE is indicated for HF from valve dysfunction, paravalvular extension/abscess/heart block, persistent infection despite appropriate antibiotics, recurrent emboli with persistent vegetation, or vegetation >10 mm with severe valve dysfunction.
Avoid NOACs and use dose-adjusted VKA or LMWH (with anti-Xa monitoring) in pregnant women with mechanical valves; switch to UFH/LMWH near delivery to prevent fetal hemorrhage.

Thresholds & Doses

Severe AS: aortic Vmax ≥4 m/s or mean gradient ≥40 mm Hg, AVA typically ≤1.0 cm² (or ≤0.6 cm²/m² indexed); very severe AS: Vmax ≥5 m/s or mean gradient ≥60 mm Hg.
Low-flow low-gradient severe AS: AVA ≤1.0 cm² with stroke volume index <35 mL/m² and Vmax <4 m/s or mean gradient <40 mm Hg.
CT aortic valve calcium score thresholds for severe AS: ≥1300 AU in women, ≥2000 AU in men.
Severe AR: jet width ≥65% LVOT, vena contracta >0.6 cm, regurgitant volume ≥60 mL/beat, regurgitant fraction ≥50%, ERO ≥0.3 cm².
AVR for chronic AR triggered by LVEF ≤55% or LVESD >50 mm (indexed >25 mm/m²).
Severe MS: MVA ≤1.5 cm², diastolic pressure half-time ≥150 ms, typical mean gradient 5–10 mm Hg; PMBC reasonable if PASP >50 mm Hg or exercise gradient >15 mm Hg.
Severe MR: vena contracta ≥0.7 cm, regurgitant volume ≥60 mL, regurgitant fraction ≥50%, ERO ≥0.40 cm².
Mitral surgery for primary MR triggered by LVEF ≤60% or LVESD ≥40 mm.
Severe TR: vena contracta ≥0.7 cm, ERO ≥0.40 cm², regurgitant volume ≥45 mL; tricuspid annulus dilation threshold for concomitant repair: >40 mm or >21 mm/m².
INR targets: mechanical AVR with no risk factors = 2.5 (range 2.0–3.0); mechanical AVR with risk factors or mechanical MVR = 3.0 (range 2.5–3.5); On-X AVR after 3 months with no risk factors = 1.5–2.0 plus aspirin 75–100 mg.
VKA reasonable for 3–6 months after bioprosthetic AVR/MVR or mitral repair; lifelong VKA only if other indication.
Rheumatic fever secondary prophylaxis: penicillin G benzathine 1.2 million U IM every 4 weeks (every 3 weeks high-risk); duration ≥10 years or until age 40 with residual VHD.
Endocarditis prophylaxis only for prosthetic valves, prior IE, congenital heart disease with residual defects, repair with prosthetic material, or heart transplant with valvulopathy, before dental procedures involving gingival manipulation.
TAVI procedural mortality benchmark: STS-predicted mortality <3% (low), >8% (high), >15% futile; STS-predicted mitral repair mortality <1% low-risk.
Aortic replacement in BAV: ≥5.5 cm aortic sinuses/ascending aorta; ≥5.0 cm with risk factors; ≥4.5 cm if undergoing concomitant AVR.
Vegetation size >10 mm with severe valve dysfunction is an indication for early surgery in IE; risk of embolization highest first 2 weeks of antibiotic therapy.
Warfarin embryopathy risk >30% if dose >5 mg/d in first trimester; risk <3% if ≤5 mg/d. LMWH dosing requires anti-Xa peak 0.8–1.2 U/mL 4–6 h post-dose with weekly monitoring.
Asymptomatic VHD imaging intervals: severe AS every 6–12 months; moderate AS every 1–2 years; mild AS every 3–5 years; severe AR/MR every 6–12 months.

Citations

Section 1.4 / Table 1 — scope and replacement of 2014 guideline and 2017 focused update
Section 2.4.3 / Figure 1 — anticoagulation for AF with VHD including NOAC vs VKA selection
Section 2.5 / Table 8 — surgical risk stratification thresholds (STS, frailty, organ systems)
Section 3.2.3 / Figure 2 — timing of AVR for aortic stenosis including Stage C2 and very severe AS criteria
Section 3.2.4.2 / Figure 3 / Table 14 — SAVR vs TAVI choice by age and anatomic factors
Section 4.3.3 / Figure 4 — timing of intervention for chronic AR with LVEF/LVESD thresholds
Section 5.1.2 / Figure 6 — aortic replacement size thresholds in BAV
Section 6.2.3 / Figure 7 — PMBC vs surgery decision pathway for rheumatic MS
Section 7.2.4 / Figure 8 — primary MR repair indications and TEER role
Section 7.3.4 / Figure 9 — secondary MR intervention based on COAPT criteria
Section 11.2 / Figure 12 / Table 22 — antithrombotic therapy and prosthetic valve type selection
Section 12.4 / Figure 16 — endocarditis surgical indications and timing after stroke
Section 13.2.2 / Figure 18 — anticoagulation regimens for mechanical valves during pregnancy
Top 10 Take-Home Messages — summary of major guideline shifts