This specialist Guidelines summary covers investigation and management of heart valve disease presenting in adults. It aims to improve quality of life and survival for people with heart valve disease through timely diagnosis and appropriate intervention. This summary is intended for use by specialists in a secondary care setting.
Please refer to the full guideline for information on referral for echocardiography and specialist assessment.
For NHS England and NHS Improvement’s position on transcatheter aortic valve implantation for people at low or intermediate surgical risk, see the implementation strategy for transcatheter aortic valve implantation.
Pharmacological Management
Management of Heart Failure in People With Valve Disease
- Consider a beta-blocker for adults with moderate to severe mitral stenosis and heart failure.
- When adults with heart valve conditions and heart failure also have left ventricular dysfunction, refer to the NICE guideline on chronic heart failure in adults.
Indications for Interventions
- Offer an intervention to adults with symptomatic severe heart valve disease.
Aortic Stenosis
- Consider referring adults with asymptomatic severe aortic stenosis for intervention, if suitable, if they have any of the following:
- Vmax (peak aortic jet velocity) more than 5 m/s on echocardiography
- aortic valve area less than 0.6 cm2 on echocardiography
- left ventricular ejection fraction (LVEF) less than 55%
- B‑type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) level more than twice the upper limit of normal
- symptoms unmasked on exercise testing.
- Consider referring adults with symptomatic low‑gradient aortic stenosis with LVEF less than 50% for intervention if during dobutamine stress echocardiography the aortic stenosis is shown to be severe by:
- a mean gradient across the aortic valve that increases to more than 40 mmHg and
- an aortic valve area that remains less than 1 cm2.
- Consider measuring aortic valve calcium score on cardiac CT if the severity of symptomatic aortic stenosis is uncertain.
- Offer enhanced follow up (for example, more frequent reviews) and further assessment (for example, stress echocardiography) to monitor the need for intervention if mid‑wall fibrosis is detected on cardiac MRI in adults with severe aortic stenosis.
Aortic Regurgitation
- Consider referring adults with asymptomatic severe aortic regurgitation for intervention, if suitable, if they have either of the following:
- LVEF less than 55% or
- end systolic diameter (ESD) of more than 50 mm or end systolic diameter index (ESDI) more than 24 mm/m2 on echocardiography.
Mitral Regurgitation
- Consider referring adults with asymptomatic severe primary mitral regurgitation for intervention, if suitable, if they have any of the following:
- LVEF less than 60%
- ESD more than 45 mm or ESDI more than 22 mm/m2 on echocardiography or
- an increase of systolic pulmonary artery pressure to more than 60 mmHg on exercise testing.
When making decisions about referral for surgery, take into account the suitability of the valve for repair and the presence of atrial fibrillation or systolic pulmonary artery pressure of more than 50 mmHg on echocardiography at rest.
Monitoring When There is No Current Need for Intervention
- Offer clinical review every 6 to 12 months, with an echocardiogram, to adults with asymptomatic severe valve disease if an intervention is suitable but not currently needed. Base the frequency of the review on echocardiography findings and shared decision making with the patient.
- Consider echocardiographic assessment every 3 to 5 years for adults with mild aortic or mitral stenosis.
Interventions
See the recommendations on indications for interventions.Decisions about Interventions
- Discuss the possible benefits and risks of interventions with adults who have an indication for valve intervention. Include in the discussion:
- the benefits to quality of life (both in the short and long term)
- prosthetic valve durability
- the risks associated with the procedures
- the type of access for surgery (median sternotomy, minimally invasive surgery or, for people at high surgical risk, transcatheter)
- the possible need for other cardiac procedures in the future.
Follow the recommendations in the NICE guidelines on shared decision making and patient experience in adult NHS services and base decisions on the type of intervention on patient characteristics and preferences.
- When surgery is agreed, base the decision on the type of surgery (median sternotomy or minimally invasive surgery) on patient characteristics and preferences. If minimally invasive surgery is the agreed option and is not available locally, refer the person to another centre.
Aortic Valve Disease
For NHS England and NHS Improvement's position on transcatheter aortic valve implantation for people at low or intermediate surgical risk, see the implementation strategy for transcatheter aortic valve implantation.- Offer surgery, if suitable (by median sternotomy or minimally invasive surgery), as first-line intervention for adults with severe aortic stenosis, aortic regurgitation or mixed aortic valve disease and an indication for surgery who are at low or intermediate surgical risk. TAVI is not cost effective for people at low or intermediate surgical risk at the current list price.
- Offer TAVI, if suitable, to adults with non-bicuspid severe aortic stenosis who are at high surgical risk or if surgery is unsuitable.
- See the recommendations on using TAVI in the NICE interventional procedures guidance on transcatheter aortic valve implantation for aortic stenosis, including entering the details of all people undergoing TAVI into the UK TAVI registry. See also the NICE interventional procedures guidance on sutureless aortic valve replacement in aortic stenosis and balloon valvuloplasty for aortic valve stenosis.
Mitral Stenosis
- Consider transcatheter valvotomy for adults with rheumatic severe mitral stenosis, if the valve is suitable for this procedure.
- Offer surgical mitral valve replacement to adults with rheumatic severe mitral stenosis if transcatheter valvotomy is unsuitable.
Mitral Regurgitation
Primary mitral regurgitation
- Offer surgical mitral valve repair (by median sternotomy or minimally invasive surgery) to adults with severe primary mitral regurgitation and an indication for repair, if surgery is suitable.
- Offer surgical mitral valve replacement (by median sternotomy or minimally invasive surgery) to adults with severe primary mitral regurgitation and an indication for surgery, if the valve is not suitable for repair and surgery is suitable.
- Consider transcatheter edge-to-edge repair, if suitable, for adults with severe primary mitral regurgitation and symptoms, if surgery is unsuitable.
Secondary Mitral Regurgitation
- Consider surgical mitral valve repair (by median sternotomy or minimally invasive surgery) for adults with severe secondary mitral regurgitation who are having cardiac surgery for another indication, if surgery is suitable.
- Consider surgical mitral valve replacement (by median sternotomy or minimally invasive surgery) for adults with severe secondary mitral regurgitation who are having cardiac surgery for another indication, if the valve is not suitable for repair and surgery is suitable.
- Offer medical management to adults with heart failure and severe secondary mitral regurgitation, if surgery is unsuitable.
- Consider transcatheter mitral edge-to-edge repair for adults with heart failure and severe secondary mitral regurgitation, if surgery is unsuitable and they remain symptomatic on medical management.
Tricuspid Regurgitation
- Consider surgical tricuspid valve repair at the time of mitral valve surgery when tricuspid regurgitation is moderate or severe.
- Consider surgical tricuspid valve repair at the time of aortic valve surgery when tricuspid regurgitation is severe.
Repeat Intervention
- Consider transcatheter or redo surgical intervention for adults with severe aortic degeneration of a biological prosthetic valve and symptoms. Take into account the following factors to inform a shared decision about the choice of intervention:
- the short- and long-term benefits
- type of valve dysfunction and prosthesis
- the risks associated with the procedure
- the possible need for other cardiac procedures in the future.
See the NICE interventional procedures guidance on using transapical transcatheter mitral valve-in-valve implantation for a failed surgically implanted mitral valve bioprosthesis, transapical transcatheter mitral valve-in-ring implantation after failed annuloplasty for mitral valve repair and valve-in-valve TAVI for aortic bioprosthetic dysfunction.
Anticoagulation and Antiplatelet Therapy
- Do not offer anticoagulation after surgical biological valve replacement unless there are other indications for anticoagulation.
- Consider aspirin, or clopidogrel if aspirin is not tolerated, after TAVI.
- If people have other indications for anticoagulation or antiplatelet therapy, follow the recommendations in the NICE guidelines on atrial fibrillation and acute coronary syndromes.
Monitoring After an Intervention
- Base decisions on the frequency and type of monitoring for adults who have had an intervention (valve repair or replacement) for valve disease on:
- durability of the prosthetic valve or durability of the repair
- the presence of another condition, including other heart disease
- residual valve abnormality or consequences of the procedure, for example, paravalvular leak
- concerns about abnormal function of the prosthetic valve
- the patient's wishes.
Advise people and their family members or carers (as appropriate) to seek advice if the heart condition deteriorates.
Information and Advice
- Follow the NICE guideline on shared decision making and the recommendations in the NICE guideline on patient experience in adult NHS services on:
- involvement of family members and carers
- communication
- information
- tailoring healthcare services.
- Consider providing a point of contact for accessing specialist advice between appointments.
- Be aware of the psychological impact on the person receiving a diagnosis of valve disease, whether or not they have symptoms. Consider the person's needs for additional information and support.
- Provide information and advice to adults with valve disease about:
- the expected progression and prognosis of their condition, including the likely length of an asymptomatic stage
- any need for intervention, including the type of intervention
- pregnancy, if appropriate
- the possible effects of other conditions on long-term outcomes
- rehabilitation and long‑term outcomes
- palliative care, if appropriate, including how to access this.
- Provide information and support to young adults about transition from paediatric to adult services, in line with the NICE guideline on transition from children's to adults' services for young people using health or social care services.
Terms Used in This Guideline
This section defines terms that have been used in a particular way for this guideline.Degenerated
Degenerated covers progressive degeneration and does not include failure of the valve due to endocarditis or thrombosis.
Risk of Surgery
This is calculated using EuroSCORE II. People have low surgical risk if they score less than 4%, intermediate risk if they score between 4% and 8% and high risk if they score more than 8%.
Severe Valve Disease
Severity of valve disease is defined in line with the British Society of Echocardiography guidelines on the assessment of aortic stenosis, the tricuspid and pulmonary valves, and mitral valve disease.
Specialist Assessment and Advice
This could include assessment and advice from a cardiologist with expertise in heart valve disease, a multidisciplinary team or a heart valve clinic.
Suitability for Transcatheter Aortic Valve Implantation
Suitability for transcatheter aortic valve implantation (TAVI) depends on:
- an appropriate access for inserting the TAVI catheter
- the morphology of the valve, aortic root and ascending aorta
- the degree and distribution of calcium in the aortic valve.
- All people expected to have an unacceptably high risk of mortality or morbidity as a result of surgery (for example, because of a risk of infection in people who are immunosuppressed). See also the definition of high risk of surgery according to EuroSCORE II.
- All people expected to have unacceptably strenuous and prolonged recovery from surgery and an extended need for rehabilitation because of frailty, reduced mobility, or musculoskeletal conditions.
- All people with low life expectancy, either because of their age or because they have life-limiting comorbidities.
Suitability for Transcatheter Edge-To-Edge Repair
Suitability for transcatheter edge-to-edge repair depends on:- the morphology of the person's valve
- the feasibility of using transoesophageal echocardiography to guide the procedure
- the person's fitness for general anaesthesia.
References
References