2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

Abstract

HomeCirculationVol. 143, No. 52020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessReview ArticlePDF/EPUB2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines Catherine M. Otto, MD, FACC, FAHA, Co-Chair Rick A. Nishimura, MD, MACC, FAHA, Co-Chair Robert O. Bonow, MD, MS, MACC, FAHA Blase A. Carabello, MD, FACC, FAHA John P. Erwin III, MD, FACC, FAHA Federico Gentile, MD, FACC Hani Jneid, MD, FACC, FAHA Eric V. Krieger, MD, FACC Michael Mack, MD, MACC Christopher McLeod, MBCHB, PhD, FAHA Patrick T. O’Gara, MD, MACC, FAHA Vera H. Rigolin, MD, FACC, FAHA Thoralf M. Sundt III, MD, FACC, FAHA Annemarie Thompson, MD Christopher Toly Catherine M. OttoCatherine M. Otto Search for more papers by this author , Rick A. NishimuraRick A. Nishimura Search for more papers by this author , Robert O. BonowRobert O. Bonow Search for more papers by this author , Blase A. CarabelloBlase A. Carabello Search for more papers by this author , John P. Erwin IIIJohn P. Erwin III Search for more papers by this author , Federico GentileFederico Gentile Search for more papers by this author , Hani JneidHani Jneid Search for more papers by this author , Eric V. KriegerEric V. Krieger Search for more papers by this author , Michael MackMichael Mack Search for more papers by this author , Christopher McLeodChristopher McLeod Search for more papers by this author , Patrick T. O’GaraPatrick T. O’Gara †ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison. Search for more papers by this author , Vera H. RigolinVera H. Rigolin Search for more papers by this author , Thoralf M. Sundt IIIThoralf M. Sundt III Search for more papers by this author , Annemarie ThompsonAnnemarie Thompson Search for more papers by this author , Christopher TolyChristopher Toly Search for more papers by this author Originally published17 Dec 2020https://doi.org/10.1161/CIR.0000000000000923Circulation. 2021;143:e72–e227is corrected byCorrection to: 2020 ACC/AHA Guideline on the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice GuidelinesTable of ContentsTop 10 Take-Home Messages e74Preamble e751. Introduction e761.1. Methodology and Evidence Review e761.2. Organization of the Writing Committee e761.3. Document Review and Approval e761.4. Scope of the Guideline e761.5. Class of Recommendation and Level of Evidence e771.6. Abbreviations e772. General Principles e782.1. Evaluation of the Patient With Known or Suspected Native VHD e782.2. Definitions of Severity of Valve Disease e782.3. Diagnosis and Follow-Up e782.3.1. Diagnostic Testing: Initial Diagnosis 30 e782.3.2. Diagnostic Testing: Changing Signs or Symptoms e802.3.3. Diagnostic Testing: Routine Follow-Up e802.3.4. Diagnostic Testing: Cardiac Catheterization e812.3.5. Diagnostic Testing: Exercise Testing e812.4. Basic Principles of Medical Therapy e812.4.1. Secondary Prevention of Rheumatic Fever e822.4.2. IE Prophylaxis e822.4.3. Anticoagulation for AF in Patients With VHD e832.5. Evaluation of Surgical and Interventional Risk e852.6. The Multidisciplinary Heart Valve Team and Heart Valve Centers e862.7. Management of Patients With VHD After Valve Intervention e882.7.1. Procedural Complications e892.7.2. Primary and Secondary Risk Factor Evaluation and Treatment e892.7.3. Persistent Symptoms After Valve Intervention e892.7.4. Periodic Imaging After Valve Intervention e893. Aortic Stenosis e903.1. Stages of Valvular AS e903.2. Aortic Stenosis e903.2.1. Diagnosis and Follow-Up e903.2.2. Medical Therapy e933.2.3. Timing of Intervention e943.2.4. Choice of Intervention e974. Aortic Regurgitation e1044.1. Acute Aortic Regurgitation e1044.1.1. Diagnosis of AR e1044.1.2. Intervention e1044.2. Stages of Chronic AR e1044.3. Chronic AR e1064.3.1. Diagnosis of Chronic AR e1064.3.2. Medical Therapy e1064.3.3. Timing of Intervention e1075. Bicuspid Aortic Valve e1095.1. BAV and Associated Aortopathy e1095.1.1. Diagnosis and Follow-Up of BAV e1095.1.2. Interventions for Patients With BAV e1096. Mitral Stenosis e1126.1. Stages of MS e1136.2. Rheumatic MS e1136.2.1. Diagnosis and Follow-Up of Rheumatic MS e1136.2.2. Medical Therapy e1156.2.3. Intervention e1166.3. Nonrheumatic Calcific MS e1187. Mitral Regurgitation e1197.1. Acute MR e1197.1.1. Diagnosis of Acute MR e1197.1.2. Medical Therapy e1197.1.3. Intervention e1197.2. Chronic Primary MR e1197.2.1. Stages of Chronic Primary MR e1197.2.2. Diagnosis and Follow-Up of Chronic Primary MR e1207.2.3. Medical Therapy e1237.2.4. Intervention e1247.3. Chronic Secondary MR e1267.3.1. Stages of Chronic Secondary MR e1267.3.2. Diagnosis of Chronic Secondary MR e1277.3.3. Medical Therapy e1287.3.4. Intervention e1298. Tricuspid Valve Disease e1318.1. Classification and Stages of TR e1318.2. Tricuspid Regurgitation e1318.2.1. Diagnosis of TR e1318.2.2. Medical Therapy e1328.2.3. Timing of Intervention e1339. Pulmonic Valve Disease e13510. Mixed Valve Disease e13510.1. Diagnosis of Mixed VHD e13510.2. Timing of Intervention for Mixed VHD e13610.2.1. Intervention for Mixed AS and AR e13610.2.2. Intervention for Mixed AS and MR e13610.2.3. Intervention for Mixed MS and MR e13710.2.4. Intervention for Mixed MS and AR e13710.2.5. Intervention for Mixed MS and AS e13711. Prosthetic Valves e13711.1. Evaluation and Selection of Prosthetic Valves e13711.1.1. Diagnosis and Follow-Up of Prosthetic Valves e13711.1.2. Selection of Prosthetic Valve Type: Bioprosthetic Versus Mechanical Valve e13911.2. Antithrombotic Therapy e14211.3. Bridging Therapy e14611.4. Excessive Anticoagulation and Serious Bleeding With Prosthetic Valves e14811.5. Thromboembolic Events With Prosthetic Valves e14811.6. Acute Mechanical Valve Thrombosis e14911.6.1. Diagnosis of Acute Mechanical Valve Thrombosis e14911.6.2. Intervention e15011.7. Bioprosthetic Valve Thrombosis e15011.7.1. Diagnosis of Bioprosthetic Valve Thrombosis e15011.7.2. Medical Therapy e15011.8. Prosthetic Valve Stenosis e15111.8.1. Diagnosis of Prosthetic Valve Stenosis e15111.8.2. Intervention for Prosthetic Valve Stenosis e15211.9. Prosthetic Valve Regurgitation e15211.9.1. Diagnosis of Prosthetic Valve Regurgitation e15311.9.2. Medical Therapy e15411.9.3. Intervention e15412. Infective Endocarditis e15512.1. Classification of Endocarditis e15512.2. Diagnosis of IE e15612.3. Medical Therapy e16012.4. Intervention e16213. Pregnancy and VHD e16513.1. Initial Management of Women With VHD Before and During Pregnancy e16513.1.1. Medical Therapy for Women With VHD Before and During Pregnancy e16613.1.2. Intervention for Women With Native VHD Before and During Pregnancy e16613.2. Prosthetic Valves in Pregnant Women e16913.2.1. Initial Management e16913.2.2. Anticoagulation for Pregnant Women With Mechanical Prosthetic Heart Valves e17014. Surgical Considerations e17414.1. Evaluation and Management of CAD in Patients With VHD e17414.1.1. Management of CAD in Patients Undergoing TAVI e17414.1.2. Management of CAD in Patients Undergoing Valve Surgery e17614.2. Intervention for AF in Patients With VHD e17715. Noncardiac Surgery in Patients With VHD e17815.1. Diagnosis of Patients With VHD Undergoing Noncardiac Surgery e17815.2. Management of the Symptomatic Patient e17915.3. Management of the Asymptomatic Patient e18016. Evidence Gaps and Future Directions e18116.1. Prevention of Valve Disease: Stage A e18116.2. Medical Therapy to Treat or Prevent Disease Progression: Stage B e18216.3. Optimal Timing of Intervention: Stage C e18216.4. Better Options for Intervention: Stage D e182References e184Appendix 1. Author Relationships With Industry and Other Entities (Relevant) e222Appendix 2. Reviewer Relationships With Industry and Other Entities (Comprehensive) e224Top 10 Take-Home MessagesDisease stages in patients with valvular heart disease should be classified (Stages A, B, C, and D) on the basis of symptoms, valve anatomy, the severity of valve dysfunction, and the response of the ventricle and pulmonary circulation.In the evaluation of a patient with valvular heart disease, history and physical examination findings should be correlated with the results of noninvasive testing (ie, ECG, chest x-ray, transthoracic echocardiogram). If there is discordance between the physical examination and initial noninvasive testing, consider further noninvasive (computed tomography, cardiac magnetic resonance imaging, stress testing) or invasive (transesophageal echocardiography, cardiac catheterization) testing to determine optimal treatment strategy.For patients with valvular heart disease and atrial fibrillation (except for patients with rheumatic mitral stenosis or a mechanical prosthesis), the decision to use oral anticoagulation to prevent thromboembolic events, with either a vitamin K antagonist or a non–vitamin K antagonist anticoagulant, should be made in a shared decision-making process based on the CHA2DS2-VASc score. Patients with rheumatic mitral stenosis or a mechanical prosthesis and atrial fibrillation should receive oral anticoagulation with a vitamin K antagonist.All patients with severe valvular heart disease being considered for valve intervention should be evaluated by a multidisciplinary team, with either referral to or consultation with a Primary or Comprehensive Valve Center.Treatment of severe aortic stenosis with either a transcatheter or surgical valve prosthesis should be based primarily on symptoms or reduced ventricular systolic function. Earlier intervention may be considered if indicated by results of exercise testing, biomarkers, rapid progression, or the presence of very severe stenosis.Indications for transcatheter aortic valve implantation are expanding as a result of multiple randomized trials of transcatheter aortic valve implantation versus surgical aortic valve replacement. The choice of type of intervention for a patient with severe aortic stenosis should be a shared decision-making process that considers the lifetime risks and benefits associated with type of valve (mechanical versus bioprosthetic) and type of approach (transcatheter versus surgical).Indications for intervention for valvular regurgitation are relief of symptoms and prevention of the irreversible long-term consequences of left ventricular volume overload. Thresholds for intervention now are lower than they were previously because of more durable treatment options and lower procedural risks.A mitral transcatheter edge-to-edge repair is of benefit to patients with severely symptomatic primary mitral regurgitation who are at high or prohibitive risk for surgery, as well as to a select subset of patients with secondary mitral regurgitation who remain severely symptomatic despite guideline-directed management and therapy for heart failure.Patients presenting with severe symptomatic isolated tricuspid regurgitation, commonly associated with device leads and atrial fibrillation, may benefit from surgical intervention to reduce symptoms and recurrent hospitalizations if done before the onset of severe right ventricular dysfunction or end-organ damage to the liver and kidney.Bioprosthetic valve dysfunction may occur because of either degeneration of the valve leaflets or valve thrombosis. Catheter-based treatment for prosthetic valve dysfunction is reasonable in selected patients for bioprosthetic leaflet degeneration or paravalvular leak in the absence of active infection.PreambleSince 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, which are based on systematic methods to evaluate and classify evidence, provide a foundation for the delivery of quality cardiovascular care. The ACC and AHA sponsor the development and publication of clinical practice guidelines without commercial support, and members volunteer their time to the writing and review efforts. Guidelines are official policy of the ACC and AHA. For some guidelines, the ACC and AHA partner with other organizations.Intended UseClinical practice guidelines provide recommendations applicable to patients with or at risk of developing cardiovascular disease. The focus is on medical practice in the United States, but these guidelines are relevant to patients throughout the world. Although guidelines may be used to inform regulatory or payer decisions, the intent is to improve quality of care and align with patients’ interests. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances, and should not replace clinical judgment.Clinical ImplementationManagement, in accordance with guideline recommendations, is effective only when followed by both practitioners and patients. Adherence to recommendations can be enhanced by shared decision-making between clinicians and patients, with patient engagement in selecting interventions on the basis of individual values, preferences, and associated conditions and comorbidities.Methodology and ModernizationThe ACC/AHA Joint Committee on Clinical Practice Guidelines (Joint Committee) continuously reviews, updates, and modifies guideline methodology on the basis of published standards from organizations, including the Institute of Medicine,1,2 and on the basis of internal reevaluation. Similarly, presentation and delivery of guidelines are reevaluated and modified in response to evolving technologies and other factors to optimally facilitate dissemination of information to healthcare professionals at the point of care.Numerous modifications to the guidelines have been implemented to make them shorter and enhance “user-friendliness.” Guidelines are written and presented in a modular “knowledge chunk” format, in which each chunk includes a table of recommendations, a brief synopsis, recommendation-specific supportive text and, when appropriate, flow diagrams or additional tables. Hyperlinked references are provided for each modular knowledge chunk to facilitate quick access and review. Word limit targets and a web supplement for useful but noncritical tables and figures are 2 recent modifications.In recognition of the importance of cost–value considerations, in certain guidelines, when appropriate and feasible, an analysis of value for a drug, device, or intervention may be performed in accordance with the ACC/AHA methodology.3To ensure that guideline recommendations remain current, new data will be reviewed on an ongoing basis by the writing committee and staff. Going forward, targeted sections or knowledge chunks will be revised dynamically after publication and timely peer review of potentially practice-changing science. The previous designations of “full revision” and “focused update” will be phased out. For additional information and policies on guideline development, readers may consult the ACC/AHA guideline methodology manual4 and other methodology articles.5–7Selection of Writing Committee MembersThe Joint Committee strives to ensure that the guideline writing committee members have requisite content expertise and are representative of the broader cardiovascular community. Experts are selected across a spectrum of backgrounds, representing different geographic regions, sexes, races, ethnicities, intellectual perspectives or biases, and clinical practice settings. Organizations and professional societies with related interests and expertise are invited to participate as partners or collaborators.Relationships With Industry and Other EntitiesThe ACC and AHA have rigorous policies and methods to ensure that documents are developed without bias or improper influence. The complete policy on relationships with industry and other entities (RWI) can be found at https://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy. Appendix 1 of the guideline lists writing committee members’ relevant RWI; for the purposes of full transparency, their comprehensive disclosure information is available online (https://www.ahajournals.org/doi/suppl/10.1161/CIR.0000000000000923). Comprehensive disclosure information for the Joint Committee is also available at https://www.acc.org/guidelines/about-guidelines-and-clinical-documents/guidelines-and-documents-task-forces.Evidence Review and Evidence Review CommitteesIn developing recommendations, the writing committee uses evidence-based methodologies that are based on all available data.4–5 Literature searches focus on randomized controlled trials (RCTs) but also include registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinion. Only key references are cited.An independent evidence review committee is commissioned when there are one or more questions deemed of utmost clinical importance that merit formal systematic review to determine which patients are most likely to benefit from a drug, device, or treatment strategy, and to what degree. Criteria for commissioning an evidence review committee and formal systematic review include absence of a current authoritative systematic review, feasibility of defining the benefit and risk in a time frame consistent with the writing of a guideline, relevance to a substantial number of patients, and likelihood that the findings can be translated into actionable recommendations. Evidence review committee members may include methodologists, epidemiologists, clinicians, and biostatisticians. Recommendations developed by the writing committee on the basis of the systematic review are marked “SR.”Guideline-Directed Management and TherapyThe term guideline-directed management and therapy (GDMT) encompasses clinical evaluation, diagnostic testing, and both pharmacological and procedural treatments. For these and all recommended drug treatment regimens, the reader should confirm dosage with product insert material and evaluate for contraindications and interactions. Recommendations are limited to drugs, devices, and treatments approved for clinical use in the United States.Patrick T. O’Gara, MD, MACC, FAHAChair, ACC/AHA Joint Committee on Clinical Practice Guidelines1. Introduction1.1. Methodology and Evidence ReviewThe recommendations listed in this document are, whenever possible, evidence based. An extensive review was conducted on literature published through March 1, 2020. Searches were extended to studies, reviews, and other evidence involving human subjects that were published in English and indexed in PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected databases relevant to this guideline. Key search words included but were not limited to the following: valvular heart disease, aortic stenosis, aortic regurgitation, bicuspid aortic valve, mitral stenosis, mitral regurgitation, tricuspid stenosis, tricuspid regurgitation, pulmonic stenosis, pulmonic regurgitation, prosthetic valves, anticoagulation therapy, infective endocarditis, cardiac surgery, transcatheter aortic valve replacement or implantation, and percutaneous mitra-clip. Additionally, the committee reviewed documents related to the subject matter previously published by the ACC and AHA. The references selected and published in this document are representative and not all-inclusive.1.2. Organization of the Writing CommitteeThe writing committee was composed of clinicians, which included cardiologists, interventionalists, surgeons, anesthesiologists, and a patient representative. Members were required to disclose all RWI relevant to the data under consideration.1.3. Document Review and ApprovalThis document was reviewed by 2 official reviewers each nominated by the ACC and the AHA, as well as content reviewers nominated by the ACC and AHA. Reviewers’ RWI information was distributed to the writing committee and is published in this document (Appendix 2).1.4. Scope of the GuidelineThe focus of this guideline is the diagnosis and management of adult patients with valvular heart disease (VHD). A full revision of the original 1998 VHD guideline was made in 2006, and an update was made in 2008.1 Another full revision was made in 2014,2 with an update in 2017.3 There was an additional statement of clarification specifically for surgery for aortic dilation in patients with bicuspid aortic valves (BAV) in 2016.4 The present guideline will replace the 2014 guideline and 2017 focused update. Some recommendations from the earlier VHD guidelines have been updated as warranted by new evidence or a better understanding of earlier evidence, whereas others that were inaccurate, irrelevant, or overlapping were deleted or modified. Throughout, our goal was to provide the clinician with concise, evidence-based, contemporary recommendations and the supporting documentation to encourage their use. Where applicable, sections were divided into subsections of 1) diagnosis and follow-up, 2) medical therapy, and 3) intervention. The purpose of these subsections is to categorize the Class of Recommendation according to the clinical decision-making pathways that caregivers use in the management of patients with VHD.The document recommends a combination of lifestyle modifications and medications that constitute components of GDMT. For both GDMT and other recommended drug treatment regimens, the reader is advised to confirm dosages with product insert material and to carefully evaluate for contraindications and drug–drug interactions. Table 1 is a list of associated guidelines that may be of interest to the reader.Table 1. Associated Guidelines and Related ReferencesTitleOrganizationPublication Year (Reference)Recommendations for Evaluation of the Severity of Native Valvular Regurgitation With Two-Dimensional and Doppler EchocardiographyASE20175European Association of Echocardiography Recommendations for the Assessment of Valvular Regurgitation, Part 2: Mitral and Tricuspid Regurgitation (Native Valve Disease)EAE20106Guidelines for the Management of Patients With Atrial FibrillationACC/AHA/ESC2006, 2008, 20197–9Guidelines for the Management of Adults With Congenital Heart DiseaseACC/AHA201810Echocardiographic Assessment of Valve Stenosis: EAE/ASE Recommendations for Clinical PracticeEAE/ASE200911Recommendations on the Echocardiographic Assessment of Aortic Valve Stenosis: A Focused Update from the European Association of Cardiovascular Imaging and the American Society of EchocardiographyEACI/ASE201712Guidelines for the Evaluation of Valvular Regurgitation After Percutaneous Valve Repair or Replacement: A Report from the American Society of EchocardiographyASE201913Recommendations for Evaluation of Prosthetic Valves With Echocardiography and Doppler UltrasoundASE200914Guideline for the Diagnosis and Treatment of Hypertrophic CardiomyopathyACCF/AHA201115202016Guidelines on the Management of Cardiovascular Diseases During PregnancyESC2011, 201817, 18Antithrombotic and Thrombolytic Therapy for Valvular Disease: Antithrombotic Therapy and Prevention of ThrombosisACCP201219Guidelines on the Management of Valvular Heart DiseaseESC/EACTS201220201721Guideline for the Management of Heart FailureACCF/AHA201722ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; ACCP, American College of Chest Physicians; AHA, American Heart Association; ASE, American Society of Echocardiography; EACI, European Association of Cardiovascular Imaging; EACTS, European Association of Cardio Thoracic Surgery; EAE, European Association of Echocardiography; and ESC, European Society of Cardiology.Table 2. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*Table 2. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*1.5. Class of Recommendation and Level of EvidenceThe Class of Recommendation (COR) indicates the strength of recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The Level of Evidence (LOE) rates the quality of scientific evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 2).11.6. AbbreviationsAbbreviationMeaning/Phrase2D2-dimensional3D3-dimensionalACEangiotensin-converting enzymeAFatrial fibrillationARBangiotensin receptor blockeraPTTactivated partial thromboplastin timeARaortic regurgitationASaortic stenosisAVRaortic valve replacementBAVbicuspid aortic valveBNPB-type natriuretic peptideCABGcoronary artery bypass graft surgeryCADcoronary artery diseaseCMRcardiac magnetic resonanceCORClass of RecommendationCTcomputed tomographyECGelectrocardiogramGDMTguideline-directed management and therapyHFheart failureIEinfective endocarditisINRinternational normalized ratioLAleft atrium (left atrial)LMWHlow-molecular-weight heparinLOELevel of EvidenceLVleft ventricle (left ventricular)LVEDDleft ventricular end-diastolic dimensionLVEFleft ventricular ejection fractionLVESDleft ventricular end-systolic dimensionMDTmultidisciplinary teamMRmitral regurgitationMSmitral stenosisNOACnon–vitamin K oral anticoagulantNYHANew York Heart AssociationPCIpercutaneous coronary interventionPETpositron emission tomographyPMBCpercutaneous mitral balloon commissurotomyRCTrandomized controlled trialRVright ventricle (right ventricular)SAVRsurgical aortic valve replacementTAVItranscatheter aortic valve implantationTEEtransesophageal echocardiography (echocardiogram)TEERtranscatheter edge-to-edge repairTRtricuspid regurgitationTTEtransthoracic echocardiography (echocardiogram)UFHunfractionated heparinVHDvalvular heart diseaseViVvalve-in-valveVKAvitamin K antagonist2. General Principles2.1. Evaluation of the Patient With Known or Suspected Native VHDPatients with VHD may present with a heart murmur, symptoms, or incidental findings of valvular abnormalities on noninvasive testing. Irrespective of the presentation, all patients with known or suspected VHD should undergo an initial meticulous history and physical examination. A detailed physical examination should be performed to diagnose and assess the severity of valve lesions. An electrocardiogram (ECG) to confirm heart rhythm and a chest x-ray to assess the presence or absence of pulmonary congestion or other lung pathology may be helpful in the initial assessment of patients with known or suspected VHD. A comprehensive transthoracic echocardiogram (TTE) with 2-dimensional (2D) imaging and Doppler interrogation should be performed for diagnosis and evaluation of known or suspected VHD. The TTE also provides additional information, such as the effect of the valve lesion on the cardiac chambers and great vessels, as well as an assessment of other valve lesions. To determine the optimal treatment for a patient with VHD, ancillary testing may be required, such as transesophageal echocardiography (TEE), computed tomography (CT), cardiac magnetic resonance (CMR) imaging, stress testing, Holter monitoring, diagnostic hemodynamic cardiac catheterization, or positron emission tomography (PET) combined with CT imaging. If intervention is contemplated, surgical or procedural risk should be estimated and other factors also considered, including comorbidities, frailty, and patient preferences and values (Table 3).Table 3. Evaluation of Patients With Known or Suspected VHDReasonTestIndicationInitial evaluation: All patients with known or suspected valve diseaseTTE*Establishes chamber size and function, valve morphology and severity, and effect on pulmonary and systemic circulationHistory and physicalEstablishes symptom severity, comorbidities, valve disease presence and severity, and presence of HFECGEstablishes rhythm, LV function, and presence or absence of hypertrophyFurther diagnostic testing: Information required for equivocal symptom status, discrepancy between examination and echocardiogram, further definition of valve disease, or assessing response of the ventricles and pulmonary circulation to load and to exerciseChest x-rayImportant for the symptomatic patient; establishes heart size and presence or absence of pulmonary vascular congestion, intrinsic lung disease, and calcification of aorta and pericardiumTEEProvides high-quality assessment of mitral and prosthetic valve, including definition of intracardiac masses and possible associated abnormalities (eg, intracardiac abscess, LA thrombus)CMRProvides assessment of LV volumes and function, valve severity, and aortic diseasePET CTAids in determination of active infection or inflammationStress testingGives an objective measure of exercise capacityCatheterizationProvides measurement of intracardiac and pulmonary pressures, valve severity, and hemodynamic response to exercise and drugsFurther risk stratification: Information on future risk of the valve disease, which is important for determination of timing of interventionBiomarkersProvide indirect assessment of filling pressures and myocardial damageTTE strainHelps assess intrinsic myocardial performanceCMRAssesses fibrosis by gadolinium enhancementStress testingProvides prognostic markersProcedural riskQu