Diagnostic Testing: Cardiac Catheterization Although TTE is now able to provide the required anatomic and hemodynamic information in most Table 3. Evaluation of Patients With Known or Suspected VHD Reason Test Indication Initial evaluation: All patients with known or suspected valve disease TTE* Establishes chamber size and function, valve morphology and severity, and effect on pulmonary and systemic circulation History and physical Establishes symptom severity, comorbidities, valve disease presence and severity, and presence of HF ECG Establishes rhythm, LV function, and presence or absence of hypertrophy Further diagnostic testing: Information required for equivocal symptom status, discrepancy between examination and echocardiogram, further definition of valve disease, or assessing response of the ventricles and pulmonary circulation to load and to exercise Chest x-ray Important for the symptomatic patient; establishes heart size and presence or absence of pulmonary vascular congestion, intrinsic lung disease, and calcification of aorta and pericardium TEE Provides high-quality assessment of mitral and prosthetic valve, including definition of intracardiac masses and possible associated abnormalities (eg, intracardiac abscess, LA thrombus) CMR Provides assessment of LV volumes and function, valve severity, and aortic disease PET CT Aids in determination of active infection or inflammation Stress testing Gives an objective measure of exercise capacity Catheterization Provides measurement of intracardiac and pulmonary pressures, valve severity, and hemodynamic response to exercise and drugs Further risk stratification: Information on future risk of the valve disease, which is important for determination of timing of intervention Biomarkers Provide indirect assessment of filling pressures and myocardial damage TTE strain Helps assess intrinsic myocardial performance CMR Assesses fibrosis by gadolinium enhancement Stress testing Provides prognostic markers Procedural risk Quantified by STS (Predicted Risk of Mortality) and TAVI scores Frailty score Provides assessment of risk of procedure and chance of recovery of quality of life Preprocedural testing: Testing required before valve intervention Dental examination Rules out potential infection sources CT coronary angiogram or invasive coronary angiogram Gives an assessment of coronary anatomy CT: Peripheral Assesses femoral access for TAVI and other transcatheter procedures CT: Cardiac Assesses suitability for TAVI and other transcatheter procedures *TTE is the standard initial diagnostic test in the initial evaluation of patients with known or suspected VHD. 