Correct. AV surgery is recommended in asymptomatic patients with severe AR and resting LVEF≤50%.

Correct. AV surgery is recommended in asymptomatic patients with severe AR and LVESD>50 mm.

Correct. AV surgery is recommended in asymptomatic patients with severe AR and LVESDi>25 mm/m2

Incorrect. When AV surgery is indicated and the predicted surgical risk is low, replacement of the aortic root or ascending aorta should be considered (Class IIa) if the maximal diameter is ≥45 mm.

Incorrect. A sustained fall in BP>20 mmHg during exercise testing supports considering intervention (Class IIa).

Correct. Intervention is recommended (Class I) in asymptomatic patients with severe AS and LVEF<50% without another cause.

Incorrect. Vmax​ progression ≥0.3 m/s/year supports considering intervention (Class IIa)

Incorrect. Markedly elevated BNP/NT-proBNP (more than three times the normal range) supports considering intervention (Class IIa).

Incorrect. No medical therapies have been shown to influence the natural history of AS to date, including statins.

Incorrect. In patients with symptomatic severe AS and HF, initiation of medical therapy or temporary symptom improvement should not delay intervention.

Correct. Coexistent hypertension should be treated to avoid additional afterload, preferably using renin-angiotensin system blockers, although careful titration is required to avoid symptomatic hypotension.

Incorrect. No medical therapies have been shown to influence the natural history of AS.

Correct. BAV anatomy adds complexity to TAVI and favours SAVR.

Correct. Excessive or bulky calcifications of the annulus or LVOT increase the risk of PVL and annular rupture with TAVI, favouring SAVR.

Incorrect. Porcelain aorta is a factor that favours TAVI over SAVR.

Correct. The presence of an aortic root or ascending aortic aneurysm favours SAVR as both can be repaired simultaneously.

Incorrect. Annually is suggested for patients with moderate AS or mild AS with increasing severity.

Incorrect. Mild AS with no significant leaflet calcification may be followed up every 2−3 years.

Correct. Asymptomatic patients with severe AS should be followed up at least every 6 months to allow detection of early symptoms and changes in echocardiographic parameters.

Incorrect. Close active surveillance requires regular follow-up and prompt reporting of symptoms.

Incorrect. It is a parameter that assists evaluation when other parameters are equivocal.

Correct. A VTI ratio (dimensionless index or velocity ratio) of <0.25 suggests that severe AS is highly likely.

Incorrect. The mean pressure gradient is considered the most robust parameter for the echocardiographic grading of AS.

Incorrect. The VTI ratio is useful because it does not require calculation of the LVOT area.

Incorrect. ICA is recommended for patients with a high and very high (>50%) pre-test likelihood of obstructive CAD.

Correct. CCTA is recommended before valve intervention in patients with a moderate or lower (≤50%) pre-test likelihood of obstructive CAD to rule it out.

Incorrect. RHC is for assessing MV disease or severe TR, or estimating AVA when non-invasive findings are inconclusive.

Incorrect. While the guidelines mention SPECT as a modality to detect ischemia or necrosis, it is not recommended as the primary screening tool to rule out obstructive CAD in the pre-TAVI workup. For patients with low-to-intermediate likelihood, CCTA is preferred modality (Class IIa) due to its high sensitivity for excluding significant stenosis.

Incorrect. BNP is an indicator of cardiac wall stress, not a specific indicator of calcification.

Correct. The natriuretic peptide ratio has been shown to be a powerful, independent, and incremental predictor of mortality in patients with VHD.

Incorrect. Biomarkers help monitor VHD progress and determine the appropriate timing of intervention, but the mean pressure gradient is the most robust parameter for AS severity.

Incorrect. Biomarkers are used in asymptomatic and symptomatic patients to monitor VHD progress.

Correct. Concomitant surgical ablation is recommended (Class I) in patients undergoing MV surgery with AF suitable for a rhythm control strategy.

Incorrect. Catheter ablation is not a core part of AF management during MV surgery.

Correct. Surgical closure of the LA appendage is also recommended (Class I) as an adjunct to OAC in patients with AFundergoing valve surgery to prevent stroke.

Incorrect. Surgical ablation concomitant with valve surgery is recommended. Antiarrhythmic therapy is not the method of choice.

Incorrect. CABG is recommended (Class I) only for stenosis ≥70%.

Correct. CABG should be considered (Class IIa) in patients with a primary indication for valve surgery and coronary artery stenosis of ≥50%−70%, given the opportunity of concomitant full revascularization.

Incorrect. CABG should be considered for this range of stenosis, not considered unnecessary.

Incorrect. The recommendations for CABG in the context of valve surgery are primarily based on the degree of stenosis (≥70% for Class I and ≥50%−70% for Class IIa)

Incorrect. While TAVI requires expertise, standard low-risk cases are not the primary target for 'highest volume' concentration compared to complex repairs.

Correct. All tricuspid procedures (surgical or transcatheter) are classified as complex and should be concentrated in high-volume centres to ensure optimal outcomes.

Incorrect. While rheumatic disease can be complex, isolated replacement is a standard procedure; repair would be the complex one.

Incorrect. Standard SAVR is a routine procedure.

Correct. TAVI may be considered for the treatment of severe AR in symptomatic patients ineligible for surgery according to the Heart Team, if the anatomy is suitable (Class IIb).

Incorrect. Surgery is recommended (Class I) for symptomatic patients with severe AR unless the anticipated surgical risk is prohibitive. If the patient is ineligible, this Class I indication is overridden.

Incorrect. Medical therapy may provide symptomatic improvement for patients for whom surgery is not feasible or contraindicated, but its value in delaying surgery is not established. It is not a Class I recommendation for this specific clinical situation where an alternative intervention (TAVI) is available.

Incorrect. VSARR is recommended (Class I) in young patients with aortic root dilatation at experienced centers, but the patient is 68 and, most importantly, is deemed ineligible for surgery (prohibitive risk).

Incorrect. Regional wall motion abnormalities are characteristic of Ventricular SMR, typically ischaemic.

Correct. Atrial SMR is defined by preserved LVEF and lack of tethering.

Correct. Annular dilatation is a key mechanism in Atrial SMR.

Correct. In Atrial SMR, leaflets usually have normal morphology and the jet is central, unlike the tethered leaflets in Ventricular SMR.

Incorrect. This is too low for severe PMR.

Incorrect. The threshold is higher (≥60 mL)

Correct. EROA≥40 mm2 is the standard quantitative cut-off for severe MR (≥30 mm2 may apply if the orifice is elliptical).

Incorrect. Vena contracta <3 mm indicates mild MR. ≥7 mm indicates severe.

Incorrect. Class I is reserved for surgery in operable patients or TEER in select SMR patients.

Correct. TEER should be considered (Class IIa) in symptomatic patients with severe PMR who are anatomically suitable and at high surgical risk.

Incorrect. It is a stronger recommendation than IIb.

Incorrect. It is a valid option for high-risk patients.

Correct. The Class I recommendation is explicitly for patients who remain symptomatic despite maximized medical therapy (including CRT).

Incorrect. For patients with severe SMR and preserved ejection fraction (HFpEF), TEER is currently a Class IIb recommendation ('may be considered') due to limited evidence, unlike the Class I recommendation which is specific to patients with reduced LVEF (20–50%).

Incorrect. Severe RV dysfunction or severe uncontrolled pulmonary hypertension are considered unfavourable predictors/exclusion criteria, not indications for Class I TEER.

Incorrect. Intervention in secondary MR is driven by symptoms. There is no Class I recommendation for asymptomatic SMR patients.

Correct. MV surgery is recommended (Class I) in symptomatic patients with severe PMR who are considered operable by the Heart Team.

Correct. MV surgery is recommended (Class I) in asymptomatic patients with LV dysfunction, defined as LVEF≤60%.

Correct. MV surgery is recommended (Class I) in asymptomatic patients with LV dilatation, defined as LVESD≥40 mm.

Incorrect. While intervention is indicated, for high-risk patients suitable for TEER, the recommendation is Class IIa ("should be considered"), not Class I. Only surgery in operable patients holds a Class I recommendation for PMR.

Correct. Presence of SPAP>50 mmHg at rest is a criterion for considering surgery in asymptomatic patients.

Correct. The onset of AF is a strong marker of disease progression and an indication for surgery.

Correct. Significant LA dilatation (LAVI≥60 mL/m2 or diameter ≥55 mm) combined with a high likelihood of durable repair supports intervention.

Incorrect. While increased BNP is a predictor of mortality, the guidelines specifically mention specific anatomical and haemodynamic triggers (AF, SPAP, LA size) for the Class IIa indication in this context.

Incorrect. DOACs are contraindicated (Class III) in rheumatic MS with MVA ≤2.0 cm2 due to trial data showing inferiority to VKA.

Correct. VKA is the Class I recommendation for stroke prevention in patients with rheumatic MS and AF.

Incorrect. Antiplatelet therapy is insufficient for stroke prevention in the high-risk setting of rheumatic MS.

Incorrect. LAAO is not a first-line strategy; it is reserved for patients with contraindications to anticoagulation.

Incorrect. Severe stenosis (MVA<1.0−1.5 cm2) is the primary indication for intervention, not a contraindication.

Correct. LA thrombus is a major contraindication due to the high risk of systemic embolization during the procedure.

Correct. PMC typically increases regurgitation; therefore, pre-existing moderate-to-severe MR is a contraindication.

Correct. Severe or bi-commissural calcification predicts poor outcomes and complications, making it a contraindication for PMC.

Correct. Causes include infective endocarditis, rheumatic fever, carcinoid syndrome, trauma, and drug-induced or CIED-induced damage.

Correct. Causes include infective endocarditis, rheumatic fever, carcinoid syndrome, trauma, and drug-induced or CIED-induced damage.

Incorrect. AF is a mechanism of Secondary (Atrial) TR.

Correct. Causes include infective endocarditis, rheumatic fever, carcinoid syndrome, trauma, and drug-induced or CIED-induced damage.

Correct. It is a qualitative criterion.

Correct. It is a semi-quantitative criterion.

Incorrect. An EROA ≥40mm2 indicates severe TR, whereas 20-39mm2 is moderate

Incorrect. RV dilatation is supportive but not specific for severity grade alone.

Correct. CMR allows for more accurate evaluation of LV volumes and LVEF than 2D echocardiography and is useful in borderline cases.

Correct. The quantitative criteria for severe AR are RF>50% (echo) and RF>40% (CMR).

Correct. Vena contracta >6 mm is listed as a semi-quantitative criterion for severe AR.

Incorrect. Echocardiography is the first-line modality. Acute decompensation or shock requires rapid assessment, for which Echocardiography is key. CMR is generally a second-line modality used in non-acute settings or for specific parameter measurements.

Correct. 3D Echo is the method of choice to assess morphology.

Correct. RHC should be performed in symptomatic patients to assess pulmonary haemodynamics.

Correct. CMR is the method of choice to assess RV volumes and function.

Incorrect. Biopsy is not routinely indicated.

Correct. Atrial secondary TR is caused by annular dilatation (often with AF).

Correct. Atrial secondary TR is often asociated with AF.

Correct. Ventricular secondary TR is caused by RV dilatation and dysfunction leading to leaflet tethering.

Incorrect. Leaflet tethering/restriction is a hallmark of Ventricular, not Atrial, TR.

Correct. Surgery is recommended (Class I) in patients with severe TR undergoing left-sided valve surgery.

Correct. Surgery is recommended (Class I) in symptomatic patients with severe primary TR.

Incorrect. For asymptomatic primary TR with RV dilatation, surgery is a Class IIa recommendation, not Class I.

Incorrect. For isolated severe secondary TR (symptomatic), surgery is a Class IIa recommendation.

Incorrect. Balloon valvuloplasty can be attempted in selected cases, but it is not the Class I standard.

Correct. Surgery (usually replacement) is recommended (Class I) in symptomatic patients with severe TS.

Incorrect. Medical therapy such as diuretics can improve symptoms and can be used as a bridge to surgery or transcatheter intervention.

Incorrect. TTVI is an emerging field with limited experience for TS, not a Class I recommendation.

Correct. The guidelines state that intervention is recommended in symptomatic patients with mixed moderate AV disease if gradients are high (mean ≥40 mmHg or Vmax​≥4.0 m/s).

Correct. Intervention is recommended in asymptomatic patients with mixed moderate disease if gradients are high AND LVEF is <50%.

Incorrect. A mean gradient of 20 mmHg is too low to trigger a Class I recommendation for intervention in mixed disease without other criteria.

Incorrect. Elevated BNP alone is not a Class I trigger for intervention in mixed valve disease in current guidelines, though it adds prognostic value.

Correct. MHV is preferred in younger patients (<60 for aortic) due to durability.

Correct. MHV is preferred in younger patients (<65 for mitral) due to durability.

Incorrect High bleeding risk favours a Biological valve to avoid the need for high-intensity anticoagulation.

Correct. If a patient already requires long-term OAC (e.g., for AF), the downside of MHV (anticoagulation) is negated.

Incorrect. Routine OAC is not recommended after TAVI without a specific indication (e.g., AF)

Incorrect. Routine DAPT is not recommended (Class III) as it increases bleeding without ischemic benefit compared to SAPT.

Correct. Lifelong single antiplatelet therapy (SAPT) is recommended (Class I) after TAVI in patients without OAC indication.

Incorrect. Routine NOACs after TAVI without AF are not recommended (Class III) based on the GALILEO trial.

Correct. Intrinsic regurgitation due to leaflet wear/tear is a sign of SVD.

Correct. This gradient increase defines haemodynamic SVD.

Incorrect. HALT without haemodynamic change is subclinical valve thrombosis, distinct from structural deterioration (SVD).

Correct. This is one of the criteria for severe SVD in aortic BHV.

Incorrect. Continuing full VKA for major surgery poses an unacceptable bleeding risk.

Correct. For major surgery, VKA is interrupted to reach INR < 1.5, with heparin bridging for high-risk (mitral) valves.

Incorrect. Vitamin K is reserved for bleeding or urgent reversal, not routine pre-op management.

Incorrect. Aspirin provides insufficient protection against valve thrombosis for a mechanical mitral valve.

Incorrect. Warfarin > 5 mg/day carries a high risk of embryopathy and should be avoided in the 1st trimester if possible.

Correct. Switching to LMWH with monitoring is recommended to avoid teratogenicity while protecting the mother.

Incorrect. Aspirin alone is totally inadequate for a mechanical valve.

Incorrect. DOACs are contraindicated in pregnancy and mechanical valves.

Incorrect. The ESC Guidelines recommend VSARR (Class IIa) over composite valve replacement in young patients at experienced centers. The goal is to spare the native valve and avoid prosthesis-related complications when durable results are expected.

Correct. AV surgery may be considered (Class IIb) in asymptomatic patients with severe AR and LVESVI>45 mL/m2 if the surgical risk is low.

Correct. VSARR has been demonstrated to be superior to the use of a composite valve graft (Bentall procedure) in terms of long-term mortality and overall morbidity (thromboembolism and endocarditis) and should therefore be favoured by experienced centres in patients with root enlargement and good tissue quality.

Correct. When AV surgery is indicated and the predicted surgical risk is low, replacement of the aortic root or ascending aorta should be considered (Class IIa) if the maximal diameter is ≥45 mm.

Correct. Significant MS (<1.5 cm2) is poorly tolerated in pregnancy and should be treated pre-conception.

Incorrect. Mild regurgitation is usually well tolerated due to the physiological volume load and vasodilation.

Correct. Symptomatic severe AS carries high maternal risk and requires intervention before pregnancy.

Correct. Severe aortic dilatation (>50 mm or >45 mm depending on risk factors) carries a risk of dissection and requires surgery pre-pregnancy.

Incorrect. Routine addition increases bleeding risk without proven benefit for everyone.

Correct. Aspirin is added (Class IIa) for specific indications like concomitant CAD or thromboembolism despite VKA.

Incorrect. Clopidogrel carries higher bleeding risk in combination with VKA than Aspirin.

Incorrect. It is permitted and indicated in the specific high-risk scenarios mentioned.

Incorrect. While often asymptomatic, HALT can lead to Reduced Leaflet Motion (RLM) and increased transvalvular gradients (haemodynamic deterioration).

Incorrect. HALT is also observed in 5-20% of patients after SAVR (Surgical Aortic Valve Replacement), it is not exclusive to TAVI.

Correct. HALT is the imaging hallmark of subclinical thrombosis. It can progress to haemodynamic obstruction but is usually reversible with anticoagulation (VKA or NOAC).

Incorrect. HALT is generally a thrombotic/non-structural issue that responds to medical therapy (OAC), unlike Structural Valve Deterioration (SVD) which might require reintervention.

Incorrect. While NCS under strict monitoring is the fallback if bridging is not doable, the guidelines recommend considering a bridge first to reduce the high risk of acute decompensation.

Correct. In patients with symptomatic severe AS requiring urgent high-risk NCS, TAVI or BAV should be considered to reduce the risk of acute decompensation during surgery.

Incorrect. While prognosis is poor, guidelines suggest considering intervention (BAV/TAVI) before giving up, unless the NCS itself is futile.

Incorrect. Concomitant high-risk NCS and SAVR carries prohibitive mortality risk in an unstable patient with sepsis/perforation.

Correct. Women typically have LESS calcification than men, which makes calcium scoring thresholds lower for women.

Correct. Women often present with distinct pathophysiology: more fibrosis, less calcium, and smaller concentrically hypertrophied ventricles.

Correct. Paradoxical low-flow low-gradient AS is MORE frequent in women due to smaller ventricular cavities.

Incorrect. Women tend to have smaller LV cavities.

Incorrect. TOE can allow morphological evaluation and planimetry , but DSE is specifically mentioned for discriminating true from pseudo-severe AS in this low-flow, low-gradient scenario.

Correct. In patients with low-flow, low-gradient AS with reduced LVEF, DSE can help discriminate between pseudo-severe and true severe AS in the presence of flow reserve (increase in stroke volume of ≥20%).

Incorrect. LV catheterization is not recommended unless non-invasive investigations are inconclusive.

Incorrect. While CCT AVCS is important and provides complementary information to DSE , DSE directly assesses flow reserve which is the key feature for discriminating the two types of AS in this context.

Incorrect. This option describes "classical" low-flow, low-gradient AS with reduced LVEF.

Correct. This is a definition of paradoxical low-flow, low-gradient AS because the gradient is low (<40 mmHg) due to a reduced stroke volume index (≤ 35 mL/m²) despite a preserved ejection fraction (≥ 50%).

Incorrect. This is a definition normal-flow, low-gradient AS with preserved LVEF.

Incorrect. Mean gradient ≥40 mmHg and AVA≤1.0 cm² defines severe high-gradient AS.

Incorrect. SAVR is recommended primarily for patients <70 years of age if surgical risk is low.

Correct. TAVI is recommended (Class I) in patients ≥70 years of age with tricuspid AV stenosis, if the anatomy is suitable.

Incorrect. The Ross procedure is a surgical option generally considered for young patients with prolonged life expectancy in whom anticoagulation is undesirable or contraindicated.

Incorrect. MHVs are generally preferred in patients aged <60 years due to the need for lifelong anticoagulation and associated risks.

Incorrect. This describes Low-flow, Low-gradient AS with reduced LVEF.

Incorrect. This describes Normal-flow, Low-gradient AS with preserved LVEF.

Correct. This category is defined by mean gradient<40 mmHg, AVA≤1 cm2, SVi≤35 mL/m2, and LVEF≥50%.

Incorrect. This describes Discordant high-gradient AS.

Correct. Values of >2000 AU in men and >1200 AU in women indicate severe AS with high sensitivity and specificity.

Correct. Cautious interpretation of AVCS is required in patients who can develop severe AS without pronounced AVcalcification, such as in BAV or predominantly fibrotic stenosis associated with radiation-induced disease.

Correct. Severe AS becomes unlikely in men with AVCS<1600 AU and <800 AU in women.

Correct. In low-flow, low gradient AS with reduced LVEF, CCT AVCS and DSE provide complementary information.

Incorrect. Although TAVI has a quicker recovery, complex CAD is listed as a concomitant condition that favours SAVR (plus CABG) over TAVI.

Correct. Complex CAD is a concomitant condition that favours SAVR. Concomitant non-complex CAD can be addressed by CABG or PCI, while complex CAD favours CABG.

Incorrect. SAVR is the preferred option when complex CAD is present, irrespective of access type.

Incorrect. BAV is rarely considered as a bridge to intervention in unstable patients or those requiring urgent high-risk non-cardiac surgery, not as a definitive strategy for severe AS with CAD.

Incorrect. The criterion for "Very severe AS" (which supports Class IIa intervention) is Vmax​>5.0 m/s or mean gradient ≥60 mmHg. 4.8 m/s is severe, but not "very severe."

Correct. Intervention should be considered (Class IIa) if LVEF<55% without another cause attributable to AS.

Correct. Severe valve calcification (ideally assessed by CCT) and Vmax​ progression ≥0.3 m/s/year is a parameter that supports considering intervention (Class IIa).

Correct. Markedly elevated BNP/NT-proBNP levels (more than three times age- and sex-corrected normal range) is a parameter that supports considering intervention (Class IIa)