29 Aug 2021
ESC/EACTS Valvular Heart Disease Guidelines 2021: updates from the 2017 Guidelines
Reported from the European Society of Cardiology ESC Congress 2021
There has been significant expansion in the field of structural heart diseases in the last couple of years, generating an extensive body of evidence and warranting an update to the 2017 Guidelines. Mirvat Alasnag provides an analysis of the updates included in this new document - a joint effort by the European Society of Cardiology and the European Association for Cardiothoracic Surgery and a testament to the fruitful collaboration of the heart team!
Introduction
The field of structural heart diseases has registered significant expansion in the last four years in all areas including imaging, transcatheter therapies and surgical interventions. Parallel to the developments in device technologies and leaner procedures, the body of evidence generated in recent years also warrants new guidelines. The 2021 valvular heart disease guidelines provide updates to the 2017 recommendations.1 One of the most valuable additions to the guidelines is the emphasis on the heart team approach in the evaluation, decision-making and treatment of patients with heart valve diseases.
Aortic Valve Disease:
- Aortic stenosis (AS) is addressed in the newly elaborated guidelines with several valuable revisions:
- The guidelines now call for early intervention in asymptomatic patients with a left ventricular ejection fraction (LVEF) < 55% and a normal exercise test if the stenosis is very severe: mean gradient > 60mmHg or Vmax >5m/sec (The definition of very severe was adopted from the RECOVERY Trial), severe calcification on cardiac computed tomography and Vmax progression >0.3m/sec/year, or markedly elevated BNP that is 3 times age and sex corrected normal range.2 This is awarded a Class IIa level of evidence.
- The guidelines stipulate an age cut off for surgical replacement of less than 75 years with an STS score of <4% (ie low surgical risk) or those with unsuitable transfemoral access (level of evidence I). The transcatheter option is reserved for those older than 75 years, STS score >8% or unsuitable for surgery (level of evidence I). Non-transfemoral TAVR can be considered for those who are inoperable with a level of evidence IIb. The authors clarify that the age cutoff is meant to capture the life expectancy and lifetime management of individuals with AS and is only relevant when considered in the context of the overall surgical risk and frailty. In contradistinction to the European guidelines, the age cut off in the American College of Cardiology/American Heart Association 2020 guidelines is 65 years.3
- Aside from the age cut off, ascribing a IIa indication for aortic valve replacement in severe AS with preserved LVEF and low flow-low gradients is discordant with the ACC/AHA 2020 guidelines.
- What remains consistent with previous guidelines is ascribing a IIIc recommendation for those with severe comorbidities where any intervention is not likely to improve the quality of life or survival beyond one year.
- Aortic Regurgitation (AR) management is further clarified in the new guidelines.
- Surgical replacement is recommended irrespective of the LVEF provided there are no prohibitive risks.
- As for asymptomatic patients, surgery is advised for those with an LVEF ≤50% or left ventricular end-systolic diameter (LVESD) >50 mm whereby an indexed cutoff of 25 mm/m2 body surface area (BSA) for the LVESD was specified. An indexed LVESD is proposed with a lower cutoff of 20 or 22 mm/m² BSA or resting LVEF of 50-55% in those who are deemed to have a low surgical risk
- Aortic valve repair is ascribed a IIb in experienced centers.
- Aortic valve sparing surgery is awarded a class I for young patients with a dilated root at experienced centers.
- Similar to AS, the authors advise more liberal use of exercise stress testing to evaluate patients for symptoms.
Mitral Valve Disease:
Mitral Regurgitation (MR) was defined more clearly in the new guidelines with an emphasis on the distinction between primary and secondary MR (SMR). In SMR, the valve leaflets and chordae are structurally normal and the MR is a result of an imbalance between closing and tethering forces with an altered left atrial and ventricular geometry.
- The revised guidelines advise surgery for asymptomatic patients with a preserved LV function (LVEF >60%), LVESD <40mm and atrial fibrillation (AF) secondary to MR or pulmonary hypertension. The left atrial volume of >60ml/m2 or diameter of >55mm remains key and an emphasis on center experience to ascertain durable results is unchanged.
- Valve surgery is recommended in those undergoing concomitant coronary artery bypass or other cardiac surgery and remains a class I; however, the LVEF of >30% has been removed.
- Valve surgery or intervention is recommended in severe secondary MR for those who remain symptomatic in spite of guideline directed therapy (including cardiac resynchronization) with the heart team decision central to the decision.
- Patients deemed not appropriate for surgery by the heart team, percutaneous revascularization followed by transcatheter edge to edge repair (TEER) is awarded a IIa recommendation in the updated guidelines.
- The role of the heart team to determine suitability for ventricular assist devices or TEER gained a IIb recommendation in the new guidelines.
Other Valvular Heart Disease:
- A new development for the Tricuspid valve is early surgery for asymptomatic or mildly symptomatic patients with isolated primary regurgitation and right ventricular dilatation. It is recognized that delayed intervention yields poor outcomes including durability. This is a class IIa indication that is not applicable to those with left sided disease (recommend early left sided management).
- Left atrial appendage occlusion is now awarded a IIa recommendation for those with AF and a CHA2DS2VASc >2 undergoing valve surgery.
- Patients eligible for oral anticoagulation for AF, novel anticoagulants are preferred over vitamin K antagonists in patients with AS, AR and MR. The level of evidence has been upgraded to I.
- Single antiplatelet therapy is recommended after transcatheter aortic valve replacement (TAVR) in those without an indication for anticoagulation.
- No substantial updates were noted with respect to prosthetic valves or heart disease and pregnancy.
The most important take away: the integral role of the heart team in the management of valvular heart disease!
Given the rapid developments in this field, the guidelines will likely be revised sooner than expected. Areas where new data and experience is mounting include tricuspid valve interventions and percutaneous repair of the mitral valve. With respect to TAVR, although registry data is growing for small annuli, valve in valve and bicuspid valves, randomized controlled trials are still not available. For now, the most important take away from the current guidelines is the integral role of the heart team in the management of valvular heart disease.
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References
- Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W; ESC/EACTS Scientific Document Group. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2021 Aug 28:ehab395. doi: 10.1093/eurheartj/ehab395. Epub ahead of print. PMID: 34453165.
- Kang DH, Park SJ, Lee SA, Lee S, Kim DH, Kim HK, Yun SC, Hong GR, Song JM, Chung CH, Song JK, Lee JW, Park SW. Early Surgery or Conservative Care for Asymptomatic Aortic Stenosis. N Engl J Med. 2020 Jan 9;382(2):111-119. doi: 10.1056/NEJMoa1912846. Epub 2019 Nov 16. PMID: 31733181.
- Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM 3rd, Thompson A, Toly C; ACC/AHA Joint Committee Members, O'Gara PT, Beckman JA, Levine GN, Al-Khatib SM, Armbruster A, Birtcher KK, Ciggaroa J, Deswal A, Dixon DL, Fleisher LA, de Las Fuentes L, Gentile F, Goldberger ZD, Gorenek B, Haynes N, Hernandez AF, Hlatky MA, Joglar JA, Jones WS, Marine JE, Mark D, Palaniappan L, Piano MR, Spatz ES, Tamis-Holland J, Wijeysundera DN, Woo YJ. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg. 2021 Aug;162(2):e183-e353. doi: 10.1016/j.jtcvs.2021.04.002. Epub 2021 May 8. PMID: 33972115.
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