Referral for echocardiography

1.1.1.

Consider an echocardiogram for adults with a murmur and no other signs or symptoms if valve disease is suspected based on:

• the nature of the murmur
• family history
• age (especially if over 75), or
• medical history (for example, a history of atrial fibrillation).

1.1.2.

Offer an echocardiogram to adults with a murmur if valve disease is suspected (based on the nature of the murmur, family history, age or medical history) and they have:

• signs (such as peripheral oedema) or symptoms (such as angina or breathlessness) or an abnormal ECG, or
• an ejection systolic murmur with a reduced second heart sound but no other signs or symptoms.

Referral for urgent specialist assessment or urgent echocardiography

1.1.3.

If valve disease is suspected (based on the nature of the murmur, family history, age or medical history):

• Offer urgent (within 2 weeks) specialist assessment that includes echocardiogram or if not available an urgent echocardiogram alone to adults with a systolic murmur and exertional syncope.
• Consider urgent (within 2 weeks) specialist assessment that includes echocardiogram for adults with a murmur and severe symptoms (angina or breathlessness on minimal exertion or at rest) thought to be related to valvular heart disease.

1.1.4.

For guidance on referral and assessment for adults with murmur and non-exertional syncope, follow the recommendations in the NICE guideline on transient loss of consciousness (‘blackouts’) in over 16s.

1.1.5.

For guidance on referral and assessment for adults with breathlessness but no murmur, follow the recommendations in the NICE guideline on chronic heart failure in adults.

Referral to a specialist after echocardiography

1.1.6.

Be aware that mild valve disease is common and rarely progresses to become clinically significant.

1.1.7.

Offer referral to a specialist to:

• adults with moderate or severe valve disease of any type
• adults with bicuspid aortic valve disease of any severity (including mild valve disease).

Information, referral and specialist assessment for pregnant women and women considering pregnancy

1.1.8.

Be aware that most women with valve disease can have a pregnancy without complications.

1.1.9.

Offer advice on the implications of treatment choices on any future pregnancy to women who need heart valve intervention.

1.1.10.

Offer advice on family planning to women with severe valve disease, particularly aortic and mitral stenosis.

1.1.11.

Refer pregnant women or women who are considering a pregnancy to a cardiologist with expertise in the care of pregnant women, if they have any of the following:

• moderate or severe valve disease
• bicuspid aortic valve disease of any severity (including mild disease) and associated aortopathy
• a prosthetic valve.

Refer whether they have symptoms or not.

1.1.12.

Consider seeking specialist advice on the choice of replacement valve if heart valve replacement surgery is being considered for women of childbearing potential.

1.1.13.

For guidance on intrapartum care, follow the recommendations on heart disease in the NICE guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies.

Management of heart failure in people with valve disease

1.2.1.

Consider a beta-blocker for adults with moderate to severe mitral stenosis and heart failure.

1.2.2.

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.

Aortic stenosis

1.3.2.

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.

1.3.3.

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.

1.3.4.

Consider measuring aortic valve calcium score on cardiac CT if the severity of symptomatic aortic stenosis is uncertain.

1.3.5.

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

1.3.6.

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

1.3.7.

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.

Decisions about interventions

1.5.1.

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.

1.5.2.

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.

1.5.3.

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.

1.5.4.

Offer TAVI, if suitable, to adults with non-bicuspid severe aortic stenosis who are at high surgical risk or if surgery is unsuitable.

1.5.5.

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.

See NHS England’s clinical commissioning policy on transcatheter aortic valve implantation for aortic stenosis.

Mitral stenosis

1.5.6.

Consider transcatheter valvotomy for adults with rheumatic severe mitral stenosis, if the valve is suitable for this procedure.

1.5.7.

Offer surgical mitral valve replacement to adults with rheumatic severe mitral stenosis if transcatheter valvotomy is unsuitable.

Mitral regurgitation

1. Monitoring when there is no current need for intervention

What is the most clinically and cost-effective monitoring (type and frequency of test) for adults with asymptomatic mild or moderate heart valve disease (aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation and tricuspid regurgitation) and no current need for intervention?

2. Interventions for tricuspid regurgitation

What is the most clinically and cost-effective management strategy for adults with tricuspid regurgitation?

3. Interventions for a failed valve

What is the clinical and cost effectiveness of transcatheter intervention compared with surgical redo intervention for adults with failing biological prosthetic tricuspid valves or failing repaired native tricuspid valves when either procedure is suitable?

4. Monitoring after an intervention

What is the most clinically and cost-effective timing, nature and frequency of follow up for different types of valve interventions, including repair and replacement with tissue or mechanical valves?

5. Information and advice

What are the information and advice needs of all adult age groups with heart valve disease of all severities and stages?

Indications for interventions – stress testing or echocardiography

What is the prognostic value of severe mitral regurgitation unmasked on exercise echocardiography in adults with symptomatic non-severe mitral regurgitation at rest?

What is the prognostic value of parameters observed on exercise stress testing and exercise stress echocardiography in asymptomatic severe aortic regurgitation?

Indications for interventions – CT or MRI

In adults with aortic or primary mitral regurgitation in whom the need for intervention is unclear after echocardiography, what is the prognostic value and cost effectiveness of cardiac MRI to assess the severity of valvular regurgitation?

In adults with aortic or mitral regurgitation in whom the need for intervention is unclear after echocardiography, what is the prognostic value and cost effectiveness of left ventricular ejection fraction (LVEF) measured on cardiac MRI to assess the need for intervention?

In adults with asymptomatic severe aortic stenosis what is the prognostic value and cost effectiveness of LVEF measured on cardiac MRI to assess the need for intervention?

In adults with asymptomatic severe tricuspid regurgitation what is the prognostic value and cost effectiveness of cardiac MRI for assessment of the right ventricle to assess the need for intervention?

Indications for interventions – global longitudinal strain

In adults with severe heart valve disease what is the prognostic value and cost effectiveness of global longitudinal strain to assess the need for intervention?

In adults with asymptomatic, severe aortic regurgitation or mitral regurgitation what is the prognostic value and cost effectiveness of B-type natriuretic peptide (BNP) to assess the need for intervention?

Pharmacological management for adults with heart valve disease

What is the clinical and cost effectiveness of ACE inhibitors, angiotensin II receptor antagonists, beta-blockers and diuretics for adults with severe aortic stenosis?

What is the clinical and cost effectiveness of ACE inhibitors, angiotensin II receptor antagonists, beta-blockers and calcium channel blockers, including compared with placebo, for adults with aortic regurgitation?

What is the clinical and cost effectiveness of ACE inhibitors, angiotensin II receptor antagonists, beta-blockers and diuretics for adults with primary severe mitral regurgitation?

What is the clinical and cost effectiveness of beta-blockers for adults over 75 years with non-rheumatic/calcific mitral stenosis, in both sinus rhythm and atrial fibrillation?

What is the clinical and cost effectiveness of pharmacological management of heart failure for adults with heart failure and severe aortic stenosis, severe aortic regurgitation or severe mitral regurgitation?

Monitoring when there is no current need for intervention

What is the most clinically and cost-effective monitoring strategy (type and frequency of test) for adults with asymptomatic severe heart valve disease (aortic regurgitation, mitral stenosis, mitral regurgitation or tricuspid regurgitation) and no current indication for intervention?

What is the most clinically and cost-effective monitoring strategy (type and frequency of test) for adults with symptomatic moderate heart valve disease (aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation and tricuspid regurgitation) and no current indication for intervention?

Interventions

What is the most clinically and cost-effective management strategy for adults with calcific mitral stenosis and an indication for intervention?

Anticoagulation and antiplatelet therapy

What is the clinical and cost effectiveness of single or dual antiplatelet therapies or anticoagulants compared with placebo after transcatheter or surgical valve replacement (implantation) with biological prosthesis and after valve repair?

In adults with biological valve replacement, what effect does anticoagulation or antiplatelet therapy have on long-term valve function and outcomes?

Repeat interventions

What is the clinical and cost effectiveness of transcatheter intervention compared with surgical redo intervention for adults with failing biological prosthetic aortic valves when either procedure is suitable?

What is the clinical and cost effectiveness of transcatheter intervention compared with surgical redo intervention for adults with failing biological prosthetic mitral valves when either procedure is suitable?

Why the committee made the recommendations

How the recommendations might affect practice

The recommendations reflect current practice.

Return to recommendations

Why the committee made the recommendations

Evidence showed that more cases of severe valve disease were picked up when a murmur plus other signs or symptoms were present. The committee agreed that mild and moderate valve disease does not usually present with these symptoms and using these criteria for referral would not result in unnecessary referral for urgent specialist assessment or echocardiography in most cases.

People with exertional syncope and a systolic murmur need an urgent diagnosis because exertional syncope caused by aortic stenosis has a high risk of a poor outcome. The diagnosis must be made quickly to allow appropriate management, which would likely include intervention if severe aortic stenosis is confirmed. Depending on local availability, an echocardiogram may be faster than direct specialist referral, which would include echocardiography, so the committee agreed to recommend either for this group. The committee agreed that the assessment or echocardiogram should be done within 2 weeks.

For people with severe symptoms (New York Heart Association classification III to IV or perceived by the person as severe) and a murmur, but without exertional syncope, the committee agreed that urgent specialist assessment within 2 weeks, which would include echocardiography, should be considered.

How the recommendations might affect practice

The recommendations reflect current practice.

Return to recommendations

Why the committee made the recommendations

Across the included studies, moderate and severe valve disease was consistently associated with more adverse outcomes than ‘mild’ or ‘mild and moderate’ valve disease. Despite limited evidence for each specific type of valve disease, the committee agreed that specialist referral should be offered to those with moderate or severe disease. This is consistent with current practice.

The evidence could not be used to recommend that people with mild valve disease should never be referred to a specialist, because outcomes were not compared with those without valve disease. However, the committee stressed that patients and healthcare professionals should be aware that mild valve disease is very common in people over 70, it seldom causes symptoms and does not progress in most cases. The committee recommended that people with bicuspid aortic valve disease of any severity (including mild disease) should be offered specialist referral because its progression is different to other types of valve disease, it can be associated with aortopathy and in practice is usually referred.

How the recommendations might affect practice

The committee agreed that it is current practice for everyone with moderate or severe valve disease to be referred to a specialist, regardless of the type of disease and whether it is primary or secondary. The recommendation on moderate and severe valve disease would therefore not lead to a change in practice.

For mild valve disease, there is currently variation in specialist referral, with some unnecessary referrals being made. Although the recommendation does not preclude referral for this group, it may reassure individuals with mild valve disease, reduce the number of unnecessary referrals and be cost saving. The recommendations covering bicuspid aortic valve disease were considered to reflect current practice.

Return to recommendations

Why the committee made the recommendations

The committee recognised that the proportion of pregnant women with valve disease is small compared with the number of women with valve disease who may be considering pregnancy. These women need to carefully consider the impact of treatment on any future pregnancy and should be given advice before making a treatment decision. This should include advice on contraception and planned pregnancy for women with severe valve disease, and consideration of the type of valve they receive if surgery is performed. It may be appropriate for their clinician to seek specialist advice to inform this decision from a cardiologist with expertise in the care of pregnant women. The committee noted that healthcare professionals without specialist expertise may inappropriately advise women against becoming pregnant. They agreed that some women with valve disease who may wish to become pregnant or who are pregnant should be referred to a cardiologist with specialist expertise. The committee highlighted that only women with moderate or severe disease on echocardiography, bicuspid aortic valve disease with associated aortopathy or prosthetic valves need referral. Women with mild disease, for example, aortic regurgitation or mitral valve prolapse without regurgitation, do not need a referral. The committee acknowledged that an ejection systolic flow murmur is present in most pregnant women and is not a cause for concern. They also noted that there is no official subspecialty or national accreditation for cardiologists with a specialist interest in pregnancy.

How the recommendations might affect practice

The committee acknowledged that it is not current practice to refer women who are considering pregnancy to a cardiologist with specialist expertise. Although moderate or severe heart valve disease is relatively rare in women of childbearing age, they still represent an important group of patients. Healthcare centres offering specialised support to women considering pregnancy are not widespread, so the committee expect a moderate change in practice in those centres.

Return to recommendations

Why the committee made the recommendations

There was no evidence that pharmacological management can slow the progression of heart valve disease, only evidence that statins improve prognosis in aortic stenosis. The evidence showed that statins reduced cardiac mortality compared with placebo for adults with aortic stenosis. The committee agreed that this benefit is because of an improvement in overall cardiovascular health rather than a direct effect on the aortic stenosis. Therefore, no recommendation was made and statins should be used in line with the NICE guideline on cardiovascular disease: risk assessment and reduction, including lipid modification.

There was not enough evidence for the committee to make recommendations on pharmacological management of other conditions (for example, systemic hypertension) in people who also have heart valve disease.

The committee decided to make recommendations for research to inform pharmacological management using common treatments (ACE inhibitors, angiotensin II receptor antagonists, beta-blockers, calcium channel blockers and diuretics) in adults with aortic stenosis, aortic regurgitation or mitral regurgitation. These are important areas of uncertainty in current UK clinical practice.

How the recommendations might affect practice

The recommendation reflects current practice, so the committee agreed there is unlikely to be a significant resource impact.

Why the committee made the recommendation

Some evidence showed that beta-blockers reduced hospital stay for heart failure and increased exercise tolerance compared with usual care in adults with mitral stenosis. As with all other indications for beta-blockers, some adults with mitral stenosis stopped beta-blockers because of adverse events (weakness, dizziness and shortness of breath). But the committee agreed that in their experience these medicines offer overall benefit for people with moderate to severe mitral stenosis and heart failure.

The studies included younger people than in UK clinical practice, with mitral stenosis often being because of rheumatic fever. Patients also had atrial fibrillation. The committee agreed to make a recommendation for research to inform future use of beta-blockers for older adults with non-rheumatic calcific mitral stenosis, which is currently more common in the UK than rheumatic mitral stenosis, in sinus rhythm or atrial fibrillation.

Although a recommendation to consider beta-blockers in people with moderate to severe mitral stenosis and heart failure was made, there was not enough evidence for the committee to make recommendations on the use of beta-blockers in other types of heart valve disease. Similarly, there was not enough evidence to make recommendations on other drugs for the management of heart failure in heart valve disease. They agreed to make a recommendation for research on the pharmacological management of heart failure in adults with severe aortic stenosis, aortic regurgitation, and mitral regurgitation.

How the recommendation might affect practice

The recommendation reflects current practice, so the committee agreed there is unlikely to be a significant resource impact.

Return to recommendations

Why the committee made the recommendation

Severe symptomatic heart valve disease has a poor prognosis and there is no treatment for the symptoms other than an intervention on the valve. Because of this, the committee recommended that an intervention should be offered to this group. The evidence to support this recommendation is discussed under the different types of valve disease in the section on intervention.

How the recommendation might affect practice

The recommendation reflects current practice.

Return to the recommendation

Why the committee made the recommendations

How the recommendations might affect practice

These recommendations largely reflect current best practice, although there is local variation and not all healthcare professionals will know that all of these thresholds should lead to referral for intervention.

However, the threshold of LVEF less than 55% does represent a change from current practice, because some centres use a threshold of less than 50%. However, for most adults this will mean earlier rather than additional intervention, with subsequent improvement in survival and quality of life.

Cardiac MRI is not currently used by all centres to assess aortic stenosis. The recommendation to consider enhanced follow up and further assessment if mid-wall fibrosis is detected by cardiac MRI should not mean a change in practice because it will be implemented only when cardiac MRI data is available.

Return to recommendations

Why the committee made the recommendation

How the recommendation might affect practice

The recommendation is in line with current practice.

Return to recommendation

Why the committee made the recommendation

How the recommendation might affect practice

The recommendation largely reflects current best practice, although there is local variation and not all healthcare professionals will know that all of these thresholds should lead to referral for intervention.

Return to recommendation

Why the committee made the recommendations

A single study from the US suggested that regular monitoring for people with severe asymptomatic aortic stenosis reduced all-cause mortality and hospital admission for heart failure. However, the study had limitations, including lack of applicability to UK clinical practice.

The committee discussed that although frequency of monitoring currently varies in the UK, it is usually every 6 to 12 months. Some adults find 6-monthly monitoring reassuring. For others this leads to anxiety and they would prefer less frequent monitoring (for example, every 12 months). The committee agreed that the exact frequency of monitoring within the 6-month to 12-month timeframe should be determined by echocardiography results and shared decision making with the patient. Monitoring less often than every 12 months would be likely to lead to negative outcomes for the patient because valve changes in this group occur over months rather than years. However, monitoring less often than every 12 months may be suitable for a minority of patients who have demonstrated stability over several years. The recommendation covers all types of asymptomatic severe valve disease.

In line with current practice, echocardiographic assessment every 3 to 5 years should be considered for adults with mild aortic or mitral stenosis. This would help to identify people with asymptomatic disease that has become more severe and for whom intervention may be appropriate.

How the recommendations might affect practice

The recommendations are in line with current practice.

Return to recommendations

Why the committee made the recommendations

The committee highlighted the importance of shared decision making when discussing interventions. This is to ensure that treatment options are fully explored, along with their risks and benefits. Specifically, the committee highlighted valve durability, the risks associated with the procedure, and the possible need for other cardiac procedures in the future.

The committee agreed that in their clinical experience there was no difference between minimally invasive and standard surgery replacement in terms of outcomes when done by those with expertise in minimally invasive surgery. The decision should be based on patient characteristics and preferences. A lack of expertise in minimally invasive surgery locally should not be used as a reason for not performing a minimally invasive procedure. Adults should be referred to a centre where this expertise is available if the procedure is agreed as most suitable. The evidence to support this recommendation is reported under the different types of valve disease.

How the recommendations might affect practice

The recommendations are expected to have a very small impact on current practice. Minimally invasive surgery will not be suitable for many patients. Those for whom it is suitable may still decide to have standard surgery after considering the possible benefits and risks of both options.

Return to recommendations

Why the committee made the recommendations

How the recommendations might affect practice

Why the committee made the recommendations

Evidence from 7 RCTs comparing transcatheter valvotomy with surgical valvotomy (either by minimally invasive or standard surgery) in people with rheumatic severe mitral stenosis demonstrated very few differences in outcomes. The committee agreed that surgical valvotomy is no longer commonly used in practice because similar results can be achieved with the transcatheter procedure, with less trauma and scarring and at a lower cost to the NHS. The evidence was limited by small studies, often with only a small number of events, and most outcomes being graded as very low quality. The committee agreed that transcatheter valvotomy could be considered for adults with rheumatic severe mitral stenosis who need an intervention and for whom this procedure would be suitable.

No evidence was identified for mitral valve replacement in those with rheumatic mitral stenosis when transcatheter valvotomy is not suitable. The committee agreed this it was important to make a recommendation for these people. Although no evidence was included, the condition would likely deteriorate without an intervention.

It was not appropriate to extrapolate evidence from rheumatic mitral stenosis to calcific mitral stenosis because they are 2 very different pathologies. Because there was no evidence included for calcific mitral stenosis, the committee made a recommendation for research to inform future practice.

How the recommendations might affect practice

The recommendations are in line with current practice.

Return to the recommendations

Why the committee made the recommendations

How the recommendations might affect practice

Why the committee made these recommendations

A single RCT was identified comparing transcatheter repair plus optimal medical management with optimal medical management alone in people with severe, symptomatic tricuspid regurgitation and a high surgical risk score. Patients with associated tricuspid regurgitation have worse prognosis after mitral valve intervention than those with mild or no tricuspid regurgitation. There is strong evidence that secondary functional tricuspid regurgitation that is severe does not improve after fixing the mitral lesion. Moderate tricuspid regurgitation does remain stable in a few patients after mitral correction. However, in a significant number, it does not improve and may get worse. Tricuspid annuloplasty by an experienced surgeon (at the time of mitral surgery) is a quick procedure that reduces the amount of tricuspid regurgitation and may improve prognosis.

Patients with associated tricuspid regurgitation have a worse prognosis after aortic valve intervention than those with mild or no tricuspid regurgitation. There is strong evidence (but not reviewed here) that secondary functional tricuspid regurgitation that is severe does not improve after fixing the left-sided lesion. Tricuspid annuloplasty by an experienced surgeon is a quick procedure that does reduce the amount of tricuspid regurgitation and may improve prognosis of these patients.

The committee made a recommendation for research to inform future guidance.

How the recommendations might affect practice

These recommendations are in line with current practice.

Return to recommendations

Why the committee made the recommendation

No evidence was identified comparing surgery with medical management for people with failing biological prosthetic aortic valves. However, the committee agreed that surgery should be considered in this group because their condition may deteriorate if left without intervention on medical management.

Similarly, no evidence was identified comparing transcatheter repeat intervention with medical management when surgery is unsuitable for people with failing biological prosthetic aortic valves. However, the committee agreed that repeat transcatheter intervention should be considered in this group because their condition may deteriorate if left without intervention on medical management.

For people who can have surgery, there were no RCTs comparing transcatheter intervention with surgery for repeat intervention and the only included studies were non-randomised. The committee were not able to base recommendations on this because of the limitations with non-randomised evidence. Therefore, they recommended that a shared decision should be based on short- and longer-term benefits, the type of valve dysfunction and prosthesis, the risks associated with the procedure and the possible need for other cardiac procedures. The term ‘degenerated’ refers to progressive degeneration and does not include failure of the valve due to endocarditis or thrombosis. The recommendation was limited to those with symptoms because this was considered to be an indication for repeat intervention.

The committee also made recommendations for research for repeat intervention for failing biological prosthetic aortic, mitral and tricuspid valves because the only available evidence was non-randomised.

How the recommendation might affect practice

When both transcatheter and surgical procedures are options for repeat intervention, the choice of procedure is usually based on individual patient characteristics although surgery may be done more often. When surgery is not an option, transcatheter intervention is used as the only alternative to medical management. The recommendation will therefore not represent a change in practice.

Return to recommendation

Why the committee made the recommendations

How the recommendations might affect practice

Why the committee made the recommendation

No evidence was found for the frequency of monitoring after an intervention for valve disease. Current practice is variable and depends on patient factors, such as comorbidities, other cardiac disease or previous heart surgery, as well as the type of procedure performed (repair or replacement). Follow up also depends on the type of valve used for a replacement. The committee agreed that mechanical valves have good durability with a low risk of failure. In contrast, biological valves have lower durability with deterioration possible within 10 years. The committee noted that, although practice varies, mechanical valves may be monitored over the first 12 months and then only checked if problems develop. Monitoring is usually more frequent for biological valves – with some centres offering annual follow up starting from the year of the operation and others starting annual follow up after 5 years. Any concerns about abnormal valve function may also affect the frequency of monitoring, with more frequent follow up if there are concerns.

The committee agreed that frequency of follow up should be discussed with the patient. Some people find more frequent monitoring reassuring whereas for others this leads to increased anxiety. People should be encouraged to seek advice if they feel that their condition has deteriorated. There is a higher risk of endocarditis in replacement valves and people should be encouraged to report symptoms.

How the recommendation might affect practice

The recommendation reflects current practice, which is variable and depends on various factors, such as valve durability and patient comorbidities and preferences.

Return to recommendation

Why the committee made the recommendations

Clear and consistent evidence outlined the negative impact of symptoms of valve disease and loss of control that led to feelings of despair and insecurity. In this context, a single point of contact for some people may increase the hope and security afforded between appointments.

The committee also agreed that it was useful to list areas of information and advice that are important to people with valve disease to ensure that their expectations accurately match the likely course of their condition. Having this information will be beneficial for planning, reducing anxiety and supporting shared decision making. This may include relevant information for patients and carers (when appropriate) about the possibility of delirium after valve surgery, in line with the NICE guideline on delirium.

From the evidence and their experience, the committee noted the psychological impact of valve disease on a person, whether or not the person currently has symptoms. They agreed that clinicians should be aware of the potential psychological impact of receiving a diagnosis of heart valve disease and consider providing additional advice and support.

The committee stressed the importance of individualised care and shared decision making and referenced the relevant NICE guidelines. Specific advice and support at the point of transition from paediatric to adult services was also agreed to be important to ensure young adults are given appropriate information on the likely progression of their valve disease and referrals to adult valve clinics.

The committee noted the limitations of the available evidence, which was mostly from those being considered for TAVI. These people typically have more complex comorbidities, and their older age means that their hopes and fears are different from those of younger adults. Therefore, the committee made a recommendation for research on the information and advice needs of all adult age groups with valve disease of all severities and stages. Studies should include patient-reported outcomes and experiences of decision aids.

How the recommendations might affect practice

Currently not all adults with valve disease have a point of contact between appointments or psychological support, and so these recommendations will need a change by some providers.

Return to recommendations