Valvular heart disease — assessment and intervention planning

ESC/EACTS valvular heart disease guidelines; ESC pregnancy guidelines

Echocardiography is both the diagnosis and the grading, and the ESC/EACTS pathway assumes it in every patient. Everything beyond it exists to answer one of two narrow questions: CT supplies the annular dimensions and the access route once a transcatheter valve is genuinely being planned, and cardiac MRI supplies a regurgitant volume when the echocardiographic measurements disagree with each other or the window is poor. Neither is a better echocardiogram.

A murmur under investigation, known valve disease under surveillance, or a patient in whom valve intervention — surgical or transcatheter — is being considered.

Referenced decision support — confirm against your local protocol.

Decision support, not a directive. Protocols and timings shown are typical published ones — your local protocol takes precedence, and the vetting radiologist decides.

The request in front of you

Everything is optional. Leave a field alone and the answer assumes nothing — the verdict updates as you go.

Study requested

What the referrer actually asked for. It is evidence of intent, not a constraint on the right answer.

Contrast as written

What the request form says, not what it should say.

Age

Pick a band, or type an exact age if it matters.

years

Pregnancy status

Renal risk factors

The question a vetter can actually answer from the request. An explicit “none known” is a real answer, and it removes checks rather than deferring them.

Previous contrast reaction

The pathway — tap anything already done

Marking a study complete moves the answer on. A patient arrives partway through a pathway far more often than at the start of one.

Accept as requested

Transthoracic echocardiography — standard adult study

Transthoracic echocardiography

What we'd amend, and why

Transthoracic echocardiography is the key examination in the ESC/EACTS pathway, and it is not first-line by convention — it is first-line because it is the only test that measures the thing being graded. Valve severity is a haemodynamic property, and echocardiography measures it directly: transvalvular velocity and gradient, continuity-equation valve area, regurgitant volume and effective orifice area, and the consequences of the lesion in the form of ventricular size, hypertrophy, function, left atrial volume and estimated pulmonary artery systolic pressure. CT can measure the anatomy of a valve exquisitely and cannot tell you what the blood is doing across it; that distinction is the entire reason this card ranks the studies as it does. Echocardiography also establishes the mechanism, which is what decides whether the answer is repair or replacement — a prolapsing posterior mitral leaflet, a rheumatic commissural fusion, a functional regurgitation from annular dilatation and a bicuspid aortic valve are four different operations. And it is what sets the surveillance interval, which for asymptomatic severe disease is the whole management plan.

Nothing needs resolving before this goes ahead. Routine checks below are owned downstream.

How was this decided?

pathwayadult — Adults — valve assessment and intervention planning

Decision support only. Local protocol takes precedence.

Worth asking the referrer (3)

None of these hold the request up. They sharpen the protocol or the plan that follows.

Has a heart team actually decided that valve intervention is being planned, and is it transcatheter or surgical?
It is the single fact that turns a CT from an unjustified study into the correct next one, and it is not inferable from the diagnosis — which is why an unannotated pre-procedural CT request will be met with a suggestion to echocardiogram first.
Is there a specific discordance in the echocardiogram — grade against ventricular size, gradient against valve area — or was the window inadequate?
It is what a cardiac MRI request is answering. Without it the MRI restates the echocardiogram at greater cost.
For transcatheter planning: what is the renal function, and is the whole aortoiliac and femoral segment needed?
The access run is what determines the contrast volume and coverage, and this population is old, frequently with chronic kidney disease, and will often be exposed to a second contrast load at the procedure itself.

Pathways

Big forks are separate pathways; the first whose conditions match is the one used.

Pregnant patient with known or suspected valve disease

Role	Study & protocol	Why this answers the question
First line	Transthoracic echocardiography Transthoracic echocardiography — standard adult study usually appropriate	Echocardiography is not merely the first study in pregnancy, it is very nearly the whole pathway, and the reason is that it can be repeated as often as the pregnancy requires with no ionising radiation and no contrast agent at all. Pregnancy is itself a stress test: cardiac output rises by something like a third to a half by the second trimester, and that rise unmasks lesions that were asymptomatic before and inflates the transvalvular gradients of ones that were already known. The practical consequence for the report is that a gradient measured in pregnancy is not comparable with the pre-pregnancy value, and grading should lean on valve area and on the consequences of the lesion rather than on the gradient alone. Mitral stenosis is the lesion that decompensates most predictably, because a shortened diastole at a higher heart rate is exactly what a fixed mitral orifice cannot accommodate. Serial studies through the pregnancy, and again postpartum when the haemodynamics have settled, are the standard of care in moderate or severe disease.

This fork contains one study on purpose. Neither the transcatheter planning CT nor the gadolinium-enhanced cardiac MRI belongs in a routine pregnancy pathway, and listing them as later steps would imply a ladder that should not be climbed.
Where structural detail genuinely cannot be obtained transthoracically, transoesophageal echocardiography is the next study and remains radiation-free. Non-contrast cardiac MRI is possible after the first trimester where the question cannot be answered any other way, but no non-contrast cardiac protocol exists in this vocabulary, so it must be arranged by direct discussion rather than resolved here.
Pre-pregnancy counselling is where this should have happened. A woman with known moderate or severe valve disease should have been assessed and, where indicated, treated before conceiving — worth saying to the referrer, because the same patient will present again.

Adults — valve assessment and intervention planning

Matches your inputsDefault

Role	Study & protocol	Why this answers the question
First line	Transthoracic echocardiography Transthoracic echocardiography — standard adult study usually appropriate	Transthoracic echocardiography is the key examination in the ESC/EACTS pathway, and it is not first-line by convention — it is first-line because it is the only test that measures the thing being graded. Valve severity is a haemodynamic property, and echocardiography measures it directly: transvalvular velocity and gradient, continuity-equation valve area, regurgitant volume and effective orifice area, and the consequences of the lesion in the form of ventricular size, hypertrophy, function, left atrial volume and estimated pulmonary artery systolic pressure. CT can measure the anatomy of a valve exquisitely and cannot tell you what the blood is doing across it; that distinction is the entire reason this card ranks the studies as it does. Echocardiography also establishes the mechanism, which is what decides whether the answer is repair or replacement — a prolapsing posterior mitral leaflet, a rheumatic commissural fusion, a functional regurgitation from annular dilatation and a bicuspid aortic valve are four different operations. And it is what sets the surveillance interval, which for asymptomatic severe disease is the whole management plan.
Second line	Cardiac MRI Cardiac MRI — function and late gadolinium enhancement usually appropriate	Cardiac MRI is the arbiter for regurgitation, and the reason is arithmetic rather than image quality. It measures flow directly with a through-plane phase-contrast acquisition, and it measures ventricular volumes directly by planimetry of a short-axis cine stack, so a regurgitant volume can be derived two independent ways and cross-checked — whereas the echocardiographic estimate rests on geometric assumptions, on a jet that is load-dependent and eccentric, and on a proximal isovelocity surface that assumes a hemisphere. Where the two echocardiographic grades disagree with each other, or where a "moderate" regurgitation sits alongside a dilating ventricle, MRI settles it, and because the ventricular volume is what triggers surgery in asymptomatic severe aortic or mitral regurgitation, the measurement is the decision. It is also the answer to a poor acoustic window, which is a real result rather than a failed study. Two limitations belong on the request: phase-contrast quantification is degraded by an irregular rhythm and by turbulent or eccentric jets, and severe stenosis is better assessed by echocardiography and CT than by MRI, so a request that asks MRI to grade an aortic stenosis is asking the wrong modality.
Second line	CT Coronary Angiogram (CCTA) CT Coronary Angiogram — ECG-Synchronised usually appropriate	This is the sizing study, and it is a fundamentally different kind of examination from the two above it: nothing about it grades the valve, and everything about it is a measurement the implanting operator needs. An ECG-synchronised acquisition of the aortic root gives the annular area and perimeter — the numbers the prosthesis is chosen from, and the reason a non-gated chest CT will not do, because the annulus is a dynamic, elliptical structure that changes size through the cardiac cycle and is conventionally measured in systole. The same acquisition gives the height of the coronary ostia above the annulus and the sinus of Valsalva dimensions, which together predict coronary occlusion by a displaced leaflet; the distribution and bulk of leaflet and left ventricular outflow tract calcium, which predicts annular rupture and paravalvular leak; and the optimal fluoroscopic projection angle, which shortens the procedure. Where coronary anatomy is also needed before intervention, this acquisition can supply it in the same sitting, which is the argument for using a coronary-quality protocol rather than a generic cardiac one. The justification for the whole study is the decision to intervene — before that decision it measures things nobody will use.
Second line	CT Angiogram — Aorta CT Aorta — Aneurysm Assessment and Planning	The other half of a transcatheter work-up, and the half that is most often cropped off and then repeated. The delivery sheath has to travel from a femoral puncture to the aortic root, so the planning study has to show the whole route: minimum luminal diameter of the common and external iliac and common femoral arteries, the circumferential extent of calcification, and the tortuosity — a calcified, tortuous iliac segment below the sheath diameter is what converts a transfemoral case into a subclavian, carotid or transapical one, and that decision is made from this acquisition. It is a non-gated run and can usually be added to the same contrast injection as the root study rather than requiring a second one. Coverage must reach below the femoral bifurcation; a study that stops at the aortic bifurcation has not assessed access and will be repeated.

No combined transcatheter valve protocol exists in this vocabulary. In practice the two CT steps above are one appointment and often one contrast injection — an ECG-synchronised root acquisition followed immediately by a non-gated run through the abdomen and pelvis to the common femoral arteries — and they are listed separately here only because that is how the protocol library is shaped. A local structural CT protocol should be used where one exists.
Aortic valve calcium scoring, used to resolve low-flow low-gradient aortic stenosis, is an unenhanced ECG-gated acquisition of the aortic valve. There is no dedicated protocol for it here; the coronary calcium acquisition is the closest technique and the request should say explicitly that the aortic valve, not the coronary arteries, is being scored.
Both CT steps carry a real contrast load in a population that is old and frequently has chronic kidney disease, and that will meet a second contrast load at the procedure itself. Volume reduction, hydration and spacing the two exposures are worth planning at vetting rather than discovering afterwards.
Where the request states that the heart team has already decided on intervention and the echocardiogram is complete, the CT is the correct next study and a prompt to echocardiogram first should be read as a request to record that fact, not as an objection.

Pitfalls

Sizing an aortic annulus from a non-gated chest CT. The annulus is elliptical and changes through the cardiac cycle, motion blurs it on an ungated acquisition, and a prosthesis chosen from those numbers is the wrong prosthesis.
Requesting a transcatheter planning CT before the heart team has decided to intervene. The study measures things nobody will use, at a real contrast and radiation cost in an elderly population.
Cropping the planning CT above the femoral bifurcation. The access vessels are half of what the study is for, and the omission forces a repeat with a second contrast load.
Asking cardiac MRI to grade an aortic stenosis. It is the reference method for regurgitation and for ventricular volumes; stenosis severity belongs to echocardiography, with CT calcium scoring as the tie-breaker in the low-flow low-gradient case.
Accepting a low-gradient aortic stenosis at face value. A small valve area with a low mean gradient can mean a genuinely severe stenosis with a failing or small hyperdynamic ventricle, or a moderate stenosis mis-measured — and the two have opposite management. Stroke volume index and aortic valve calcium are what separate them.
Quantifying regurgitation by phase contrast in atrial fibrillation without saying so. An irregular rhythm degrades the flow measurement, and the resulting regurgitant fraction should carry that caveat.
Grading a valve in pregnancy against pre-pregnancy gradients. The physiological rise in cardiac output inflates gradients independently of any change in the valve.
Treating a normal-looking valve on CT as excluding significant disease. CT shows the anatomy; severity is a flow measurement and CT does not make it.
Forgetting the aorta. Bicuspid aortic valve disease is associated with aortopathy, and the ascending aorta should be measured whenever a bicuspid valve is reported — it changes both surveillance and the operation.

Priors — what to pull first

Retrieve every previous echocardiogram, not just the last one. Severe valve disease is diagnosed as much from the trajectory — a valve area falling year on year, a ventricle that has started to dilate — as from any single study.
Where a prosthesis is in place, find the operation note or the implant card. The make, size and expected gradients of the prosthesis are what the current numbers have to be read against.
If a CT has been done for another reason, check whether it was ECG-gated before assuming the root measurements on it are usable.

What makes a good request

Severity grading in the ESC/EACTS guideline is integrative: no single number grades a valve. Aortic stenosis is graded on peak velocity, mean gradient and valve area read together with stroke volume index, and mitral regurgitation on regurgitant volume, effective orifice area and the consequences of the lesion — left atrial and ventricular dimensions, pulmonary pressure. That is why the echocardiogram is the study and the request should state which valve and which question.
The two discordant patterns are where this pathway earns its keep. Low-flow low-gradient aortic stenosis — a small calculated valve area with a low mean gradient — is resolved by stress echocardiography and by quantifying aortic valve calcium on an unenhanced ECG-gated CT, using sex-specific thresholds that are substantially higher in men. And a regurgitant lesion whose echocardiographic grade does not match the ventricular remodelling is the classic indication for cardiac MRI.
A CT for transcatheter valve planning is justified by the decision, not by the diagnosis. It is the right study once a heart team has concluded that intervention is on the table; requested before that, it is an ionising, contrast-loaded study whose measurements nobody is going to use. A request should say the decision has been taken, because this tool cannot infer it and will otherwise suggest the echocardiogram first.
A good request states the valve and the lesion, the echocardiographic severity and any internal inconsistency in it, the acoustic window, the renal function, the rhythm and rate, and — for transcatheter planning — the intended access and whether coronary anatomy is also needed.
Suspected infective endocarditis is a different question with a different pathway: transthoracic then transoesophageal echocardiography, with cardiac CT and nuclear imaging in prosthetic valve disease. This card covers the haemodynamic assessment, not the infection.

Scoring this once it is done

The classification and risk tools this question ends in.

eGFR (CKD-EPI 2021 Creatinine)

How these studies are acquired

Contrast, phases and timing for every study on the pathways above.

Transthoracic echocardiography — standard adult study Cardiac MRI — function and late gadolinium enhancement CT Coronary Angiogram — ECG-Synchronised CT Aorta — Aneurysm Assessment and Planning

Confirm locally

Transthoracic echocardiography — standard adult study: timings are typical — confirm against local protocol.
Timings, contrast volumes and rates above are typical published values. Your department's protocol, scanner and patient population decide the actual numbers.
Safety thresholds and premedication policy follow local policy where it differs from the cited guidance.

References

Implemented from the cited published sources. Educational and workflow support only; confirm against current guidelines and local policy before clinical use.