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The heart's valves keep blood flowing in the right direction; valvular heart disease is when a valve becomes too narrow or too leaky. This makes the heart work harder and can cause breathlessness, tiredness, dizziness and swelling. Some valves are simply monitored over time, while others are repaired or replaced by surgery or a keyhole procedure. After cardiac surgery, physiotherapy and cardiac rehabilitation help you breathe well, recover safely and rebuild fitness. This page explains valve disease and recovery after heart surgery.
Valvular heart disease — particularly aortic stenosis in older Australians and mitral regurgitation across all age groups — is a growing source of cardiac morbidity. With transcatheter aortic valve implantation (TAVI) and mitral edge-to-edge repair now established, the population of patients living with treated valvular disease has expanded significantly. Cardiac rehabilitation after valve intervention is a defined physiotherapy role with strong evidence.
Definition
Valvular heart disease describes structural and functional abnormalities of the cardiac valves — stenosis (narrowing), regurgitation (incompetence), or mixed lesions — of the aortic, mitral, tricuspid, or pulmonary valves. Severity is graded by echocardiography as mild, moderate, or severe based on quantitative criteria.
Pathophysiology
Aortic stenosis (AS) most commonly results from age-related calcific degeneration of a tri-leaflet valve or earlier degeneration of a congenitally bicuspid valve. Progressive narrowing imposes pressure overload on the left ventricle with concentric hypertrophy, eventually leading to symptoms and (untreated) heart failure or sudden death.
Mitral regurgitation (MR) is divided into primary (degenerative — Barlow’s disease, fibroelastic deficiency) and secondary (functional — from LV dilatation or atrial enlargement). Both impose volume overload on the LV and atrium. Rheumatic mitral stenosis remains relevant in patients with Aboriginal and Torres Strait Islander heritage and those from rheumatic-fever-endemic countries.
Co-morbidities
Coronary artery disease (often concurrent with calcific AS), atrial fibrillation (particularly with mitral disease and after surgery), heart failure, infective endocarditis risk, anaemia, frailty, chronic kidney disease, and (post-mechanical valve) bleeding from lifelong anticoagulation.
Prevalence
Significant aortic stenosis affects approximately 3% of Australians aged > 65 and 8% aged > 85. Mitral regurgitation of at least moderate severity affects approximately 2% of adults overall, rising with age. Rheumatic heart disease prevalence in Aboriginal and Torres Strait Islander communities is among the highest in the world.
Causes
Calcific degeneration (most common cause of AS), bicuspid aortic valve, rheumatic heart disease, infective endocarditis, mitral valve prolapse, mitral annular calcification, chordal rupture, papillary muscle dysfunction (post-MI), connective tissue disease (Marfan, Loeys-Dietz), and dilated cardiomyopathy with secondary MR.
Symptoms
Severe AS: the classic triad is exertional dyspnoea, angina, and syncope (or near-syncope). Symptoms typically develop late in the disease course and signal a need for urgent intervention.
Severe MR: exertional dyspnoea, fatigue, orthopnoea, paroxysmal nocturnal dyspnoea, and palpitations (often from AF). Acute MR (e.g. chordal rupture or post-MI papillary muscle dysfunction) presents as cardiogenic shock or pulmonary oedema.
Diagnosis
Why diagnosis matters
Severe symptomatic valvular disease carries substantial annual mortality without intervention. Timely diagnosis enables structured surveillance and appropriately timed valve intervention — particularly important now that transcatheter options have expanded the treatable population.1,2
How the diagnosis is made
Auscultation identifies a murmur in most clinically significant lesions. Echocardiography is the principal diagnostic and grading tool: 2D and 3D imaging defines anatomy; Doppler quantifies severity (peak velocity, mean gradient, valve area, regurgitant volume, effective regurgitant orifice area).
Transoesophageal echocardiography is used to refine anatomy where transthoracic imaging is suboptimal and to guide structural interventions. Cardiac MRI and cardiac CT are increasingly used for periprocedural planning, particularly for TAVI.
Assessment for intervention
Decisions about valve intervention are made by a multidisciplinary heart team incorporating cardiology, cardiothoracic surgery, imaging, anaesthesia, and geriatric assessment in older patients. Standard preoperative work-up includes coronary angiography, cardiac CT for TAVI sizing and access, frailty assessment (clinical frailty scale, gait speed, grip strength), pulmonary function testing, and assessment of cognition.3,4
Surveillance of asymptomatic disease
Asymptomatic severe disease is monitored with serial echocardiography and exercise testing to detect occult symptoms or functional decline. Triggers for intervention in the asymptomatic patient include reduced LV systolic function, very severe stenosis, rapid progression, abnormal exercise response, and elevated natriuretic peptides.5
Management
Treatment goals
Goals are to abolish symptoms, prevent heart failure, restore exercise tolerance, and reduce mortality. Medical therapy does not reverse structural valvular disease — definitive treatment for severe symptomatic disease is valve repair or replacement.
Surgical aortic valve replacement (SAVR)
Open surgical valve replacement remains the standard for younger patients (typically < 65–75 with low surgical risk) and where concurrent cardiac surgery is indicated. Choice between mechanical (durable but requires lifelong warfarin) and bioprosthetic (no long-term anticoagulation but limited durability) is made jointly with the patient.
Transcatheter aortic valve implantation (TAVI)
TAVI is now the standard for patients with severe symptomatic AS who are at intermediate-to-high surgical risk, and is increasingly used in low-risk patients with appropriate anatomy. Recovery is markedly faster than SAVR and many patients are home within days, with early mobilisation and outpatient cardiac rehabilitation as standard.
Mitral valve repair, replacement, and edge-to-edge repair
For primary MR, surgical mitral valve repair is preferred over replacement where feasible. Mitral transcatheter edge-to-edge repair (TEER) is established for selected patients with severe primary MR at prohibitive surgical risk and for symptomatic severe secondary MR despite optimal medical therapy (COAPT-aligned indication).6
Medical therapy
Medical therapy is supportive: heart failure-directed therapy for symptomatic patients awaiting or unsuitable for intervention; blood pressure control (cautiously in severe AS to maintain perfusion); rate and rhythm control of concurrent AF; anticoagulation for AF or mechanical valves; endocarditis prophylaxis for selected high-risk patients per current guidelines.
Cardiac rehabilitation after intervention
Cardiac rehabilitation after valve intervention is recommended in current Australian and international guidelines, with consistent evidence for improved functional capacity, quality of life, and reduced hospital re-admission. Programmes include supervised exercise (with attention to sternal precautions after open surgery, generally for 6–8 weeks), education on lifelong anticoagulation where applicable, endocarditis prevention, and management of co-morbidities.7,8
At Inspire Clinic, individualised post-valve rehabilitation is offered, with attention to the specific procedure (open surgical, mini-thoracotomy, transcatheter), patient comorbidity profile, and goals.
Medications
Anticoagulation
Mechanical valves require lifelong warfarin with INR target dependent on valve type and position (typically 2.5–3.5 for mitral and 2.0–3.0 for aortic). DOACs are contraindicated for mechanical valves. Bioprosthetic valves require limited duration anticoagulation post-implant (typically 3 months) per current guidelines, with longer therapy in selected high-risk situations.
Anticoagulation for concurrent AF follows standard AF guidance; DOACs are appropriate for AF with bioprosthetic valves.
Heart failure therapy
For secondary MR and post-procedural patients with reduced LV function, guideline-directed heart failure therapy applies (see Heart Failure section).
Endocarditis prophylaxis
Antibiotic prophylaxis before dental and selected procedures is recommended for patients with prosthetic valves, prior endocarditis, certain congenital heart disease, and rheumatic heart disease in Aboriginal and Torres Strait Islander populations per Australian Therapeutic Guidelines.
Multi-system manifestations
Atrial fibrillation
AF is particularly common with mitral disease (atrial dilatation) and after cardiac surgery (transient or persistent). Management follows AF principles with attention to anticoagulation choice (DOAC vs warfarin) based on valve type and severity.
Pulmonary hypertension
Chronic severe mitral disease and severe AS can produce secondary pulmonary hypertension. This usually improves after valve intervention but may persist and warrants follow-up echocardiography.
Bleeding and thromboembolism
Lifelong warfarin for mechanical valves carries cumulative bleeding risk; thromboembolism risk persists despite anticoagulation. Patient education, INR self-monitoring where available, and bleeding-risk reassessment are core.
Sternal and wound complications
After median sternotomy, sternal wound dehiscence, sternal instability, and deep sternal infection are uncommon but serious. Sternal precautions and graduated upper-body loading are part of standard rehabilitation.
Living with valvular disease
Sternal precautions
After open cardiac surgery, upper-limb activity is now guided rather than forbidden. The historical “nothing over 5 kg” rule has no identifiable biomechanical derivation, and over-restriction carries its own harms — deconditioning, shoulder stiffness, dependence and loss of confidence. Contemporary practice (“Keep Your Move in the Tube”) is pain-guided functional movement kept close to the body, progressed as the sternum unites over roughly eight to twelve weeks. Our guide to sternal precautions sets out what is safe and when.
Driving and activity
Austroads guidance generally permits private driving from 4 weeks after uncomplicated valve surgery and earlier after TAVI in uncomplicated cases. Commercial driving has longer restrictions.9
Anticoagulation education
For patients on warfarin, education covers consistent vitamin K intake, drug interactions, alcohol moderation, INR monitoring (point-of-care or pathology), bleeding signs, and what to do if a dose is missed.
Endocarditis awareness
Lifelong attention to oral hygiene, dental review at least annually, and seeking medical review for unexplained fevers or systemic illness. Patients should carry a card or wear identification noting prosthetic valve status.10
Prognosis
Prognosis following valve intervention is excellent in low-comorbidity patients, with most achieving near-normal life expectancy. Frailty, comorbidity profile, and concurrent cardiac disease are the principal determinants of long-term outcome.
Psychological dimension
Post-cardiac surgery depression and anxiety are common and often under-recognised. Routine screening at cardiac rehabilitation entry and referral for psychological support is part of comprehensive care.
Role of the physiotherapist
Around valve repair or replacement the physiotherapist provides prehabilitation and post-surgical rehabilitation, and delivers graded cardiac rehabilitation tailored to the lesion and repair, monitoring symptoms and educating on safe, progressive activity.
Warning signs
Part 1 · References
- Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J 2022;43(7):561–632.
- Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease. Circulation 2021;143(5):e72–e227.
- Mack MJ, Leon MB, Thourani VH, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients (PARTNER 3). N Engl J Med 2019;380(18):1695–1705.
- Popma JJ, Deeb GM, Yakubov SJ, et al. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients (Evolut Low Risk). N Engl J Med 2019;380(18):1706–1715.
- Kang DH, Park SJ, Lee SA, et al. Early surgery or conservative care for asymptomatic aortic stenosis (RECOVERY). N Engl J Med 2020;382(2):111–119.
- Stone GW, Lindenfeld J, Abraham WT, et al. Transcatheter mitral-valve repair in patients with heart failure (COAPT). N Engl J Med 2018;379(24):2307–2318.
- Sibilitz KL, Berg SK, Tang LH, et al. Exercise-based cardiac rehabilitation for adults after heart valve surgery. Cochrane Database Syst Rev 2016;(3):CD010876.
- Ribeiro GS, Melo RD, Deresz LF, Dal Lago P, Pontes MR, Karsten M. Cardiac rehabilitation programme after transcatheter aortic valve implantation versus surgical aortic valve replacement: systematic review and meta-analysis. Eur J Prev Cardiol 2017;24(7):688–697.
- Pelliccia A, Sharma S, Gati S, et al. 2020 ESC guidelines on sports cardiology and exercise in patients with cardiovascular disease. Eur Heart J 2021;42(1):17–96.
- Delgado V, Ajmone Marsan N, de Waha S, et al. 2023 ESC guidelines for the management of endocarditis. Eur Heart J 2023;44(39):3948–4042.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Supervised exercise, breathing technique and self-management education are the mainstay of cardiorespiratory physiotherapy for this condition.
Clinical evidence
Part 1 covers the same condition without the technical detail. What follows is the evidence base behind it, written for clinicians — the literature, the reasoning and the gaps.
For clinicians: this summary supports clinical reasoning and is not a protocol. Check current guidelines and local policy before applying it, and read it alongside the key references and guidelines directory.
Framing. Valve disease is a mechanical problem with a timing decision at its centre: severity thresholds, symptoms and ventricular consequences determine when to intervene, and the intervention itself has been transformed by transcatheter techniques.1,2 For physiotherapy this creates two distinct tasks — exercising safely in the presence of a significant lesion, and rehabilitating the very large number of patients who now have valves replaced or repaired late in life.
Intervention evidence
- Transcatheter aortic valve implantation is at least as good as surgery in low-risk patients: PARTNER 3 and Evolut Low Risk both showed non-inferiority or superiority for death, stroke and rehospitalisation, which is why the age and risk profile of the rehabilitation caseload has shifted.3,4
- Early surgery in asymptomatic very severe aortic stenosis reduced cardiac death compared with conservative care in the RECOVERY trial, supporting earlier intervention in selected patients.5
- Transcatheter mitral repair reduced heart-failure hospitalisation and mortality in secondary mitral regurgitation with heart failure in COAPT, adding a large new post-procedural rehabilitation population.6
- Severity thresholds and intervention triggers — symptoms, ventricular dilatation or dysfunction, pulmonary hypertension, atrial fibrillation — are guideline-defined and worth knowing, because the physiotherapist often sees the first symptom.1,2
Exercise and rehabilitation
- Exercise-based cardiac rehabilitation after heart valve surgery improves exercise capacity, with uncertain mortality effect and a small evidence base; referral is recommended and frequently omitted.7
- Rehabilitation after TAVI is under-utilised despite an older, frailer population in whom function, balance and independence are the outcomes that matter most.8
- Sports cardiology guidance frames exercise by lesion and severity: mild lesions with normal ventricular function tolerate normal activity, while severe symptomatic stenotic lesions restrict vigorous exercise pending intervention.9
- In severe aortic stenosis, vigorous exercise is contraindicated once symptomatic, because cardiac output is fixed and exertional syncope, arrhythmia and sudden death are the recognised risks.9
Physiotherapy implications
- Know the lesion, the severity and the ventricular function before you prescribe. Stenotic and regurgitant lesions behave differently: stenosis limits output and tolerates tachycardia and hypovolaemia poorly, while regurgitation tolerates afterload reduction better.1,9
- Avoid maximal isometric loading and Valsalva in significant stenotic lesions, in aortopathy and on anticoagulation with a mechanical valve; substitute graded low-load, high-repetition resistance work with continuous exhalation.
- In significant mitral stenosis, control the rate of progression carefully — tachycardia shortens diastolic filling and raises left atrial pressure, producing rapid breathlessness.
- After surgery, apply the local sternal management protocol, progress upper-limb loading gradually, and refer to cardiac rehabilitation as the default rather than the exception.7
- After TAVI, prioritise function, gait, balance and independence alongside aerobic work, and screen for delirium, deconditioning and new conduction disease or pacing.8
- On anticoagulation, avoid contact and high-fall-risk activity, reassess falls risk, and report unexplained bruising or bleeding.
- Escalate exertional syncope or pre-syncope, angina, new or worsening breathlessness or orthopnoea, new palpitations, and any fever with a prosthetic valve (endocarditis).10
Clinical reasoning
- A new exertional symptom in known severe valve disease is an intervention trigger, not a training variable — report it promptly.1,2
- Distinguish valve-related limitation from deconditioning, anaemia, atrial fibrillation and lung disease; several usually coexist in older patients.
- Exertional syncope in aortic stenosis is a red-flag emergency, not a hydration issue.9
- Patients often normalise a slowly progressive limitation; ask what they have stopped doing rather than whether they are breathless.
Evidence gaps
- Rehabilitation evidence after valve intervention is small, heterogeneous and mostly surgical rather than transcatheter.7,8
- Safe exercise thresholds in moderate and asymptomatic severe lesions are consensus-based rather than trialled.9
- Optimal timing and content of prehabilitation before valve intervention have not been established.
- Whether rehabilitation improves survival or readmission after TAVI is unknown.8
References for the clinical evidence summary
- Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J 2022;43(7):561–632.
- Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease. Circulation 2021;143(5):e72–e227.
- Mack MJ, Leon MB, Thourani VH, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients (PARTNER 3). N Engl J Med 2019;380(18):1695–1705.
- Popma JJ, Deeb GM, Yakubov SJ, et al. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients (Evolut Low Risk). N Engl J Med 2019;380(18):1706–1715.
- Kang DH, Park SJ, Lee SA, et al. Early surgery or conservative care for asymptomatic aortic stenosis (RECOVERY). N Engl J Med 2020;382(2):111–119.
- Stone GW, Lindenfeld J, Abraham WT, et al. Transcatheter mitral-valve repair in patients with heart failure (COAPT). N Engl J Med 2018;379(24):2307–2318.
- Sibilitz KL, Berg SK, Tang LH, et al. Exercise-based cardiac rehabilitation for adults after heart valve surgery. Cochrane Database Syst Rev 2016;(3):CD010876.
- Ribeiro GS, Melo RD, Deresz LF, Dal Lago P, Pontes MR, Karsten M. Cardiac rehabilitation programme after transcatheter aortic valve implantation versus surgical aortic valve replacement: systematic review and meta-analysis. Eur J Prev Cardiol 2017;24(7):688–697.
- Pelliccia A, Sharma S, Gati S, et al. 2020 ESC guidelines on sports cardiology and exercise in patients with cardiovascular disease. Eur Heart J 2021;42(1):17–96.
- Delgado V, Ajmone Marsan N, de Waha S, et al. 2023 ESC guidelines for the management of endocarditis. Eur Heart J 2023;44(39):3948–4042.
Corrections: If something on this page is wrong, out of date or unclear, we want to know. Email reception@inspireclinic.au with the page name and what you believe is incorrect. Substantive corrections are made promptly, and the guide’s version and last-updated date are changed to reflect it.