2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease PDF

2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease Developed in collaboration with and endorsed by the American Association for Thoracic Surgery, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, S...

2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease Developed in collaboration with and endorsed by the American Association for Thoracic Surgery, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons  Citation This slide set is adapted from the 2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease. Published on [DATE], available at: Journal of the American College of Cardiology [(insert full link)] and Circulation [(insert full link)] The full-text guidelines are available on the ACC website here, [(insert full link)] and the AHA website here, [(insert full link)]  2020 Writing Committee Members* Catherine M. Otto, MD, FACC, FAHA, Co-Chair Rick A. Nishimura, MD, MACC, FAHA, Co-Chair Robert O. Bonow, MD, MS, MACC, FAHA Christopher McLeod, MBCHB, PhD, FAHA Blasé A. Carabello, MD, FACC, FAHA Patrick O’Gara, MD, MACC, FAHA† John P. Erwin III, MD, FACC, FAHA Vera H. Rigolin, MD, FACC, FAHA Federico Gentile, MD, FACC Thoralf M. Sundt III, MD, FACC, FAHA Hani Jneid, MD, FACC, FAHA Annemarie Thompson, MD Eric V. Krieger, MD, FACC Christopher Toley Michael Mack, MD, MACC *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. †ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison. 3 Table 2. ACC/AHA Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)* 4 Top 10 Take-Home Messages 2020 Valvular Heart Disease Guidelines 5  Top 10 Take Home Messages 1. Disease stages in patients with valvular heart disease should be classified (Stages A, B, C, and D) on the basis of symptoms, valve anatomy, the severity of valve dysfunction, and the response of the ventricle and pulmonary circulation. 6  Top 10 Take Home Messages 2. In the evaluation of a patient with valvular heart disease, history and physical examination findings should be correlated with the results of noninvasive testing (i.e., ECG, chest x-ray, transthoracic echocardiogram). If there is discordance between the physical examination and initial noninvasive testing, consider further noninvasive (computed tomography, cardiac magnetic resonance imaging, stress testing) or invasive (transesophageal echocardiography, cardiac catheterization) testing to determine optimal treatment strategy. 7  Top 10 Take Home Messages 3. For patients with valvular heart disease and atrial fibrillation (except for patients with rheumatic mitral stenosis or a mechanical prosthesis), the decision to use oral anticoagulation to prevent thromboembolic events, with either a vitamin K antagonist or a non–vitamin K antagonist anticoagulant, should be made in a shared decision-making process based on the CHA2DS2-VASc score. Patients with rheumatic mitral stenosis or a mechanical prosthesis and atrial fibrillation should have oral anticoagulation with a vitamin K antagonist. 8  Top 10 Take Home Messages 4. All patients with severe valvular heart disease being considered for valve intervention should be evaluated by a multidisciplinary team, with either referral to or consultation with a Primary or Comprehensive Valve Center. 9  Top 10 Take Home Messages 5. Treatment of severe aortic stenosis with either a transcatheter or surgical valve prosthesis should be based primarily on symptoms or reduced ventricular systolic function. Earlier intervention may be considered if indicated by results of exercise testing, biomarkers, rapid progression, or the presence of very severe stenosis. 10  Top 10 Take Home Messages 6. Indications for transcatheter aortic valve implantation are expanding as a result of multiple randomized trials of transcatheter aortic valve implantation atrio versus surgical aortic valve replacement. The choice of type of intervention for a patient with severe aortic stenosis should be a shared decision-making process that considers the lifetime risks and benefits associated with type of valve (mechanical versus bioprosthetic) and type of approach (transcatheter versus surgical). 11  Top 10 Take Home Messages 7. Indications for intervention for valvular regurgitation are relief of symptoms and prevention of the irreversible long-term consequences of left ventricular volume overload. Thresholds for intervention now are lower than they were previously because of more durable treatment options and lower procedural risks. 12  Top 10 Take Home Messages 8. A percutaneous edge-to-edge mitral repair is of benefit to patients with severely symptomatic primary mitral regurgitation who are at high or prohibitive risk for surgery, as well as to a select subset of patients with severely symptomatic secondary mitral regurgitation despite guideline- directed management and therapy for heart failure. 13  Top 10 Take Home Messages 9. Patients presenting with severe symptomatic isolated tricuspid regurgitation, commonly associated with device leads and atrial fibrillation, may benefit from surgical intervention to reduce symptoms and recurrent hospitalizations if done before the onset of severe right ventricular dysfunction or end-organ damage to the liver and kidney. 14  Top 10 Take Home Messages 10. Bioprosthetic valve dysfunction may occur because of either degeneration of the valve leaflets or valve thrombosis. Catheter-based treatment for prosthetic valve dysfunction is reasonable in selected patients for bioprosthetic leaflet degeneration or paravalvular leak in the absence of active 15 General Principles 16  Table 3. Evaluation of Patients with Known or Suspected VHD Reason Test Indication TTE* Establishes chamber size and function, valve morphology Initial evaluation: All and severity, and effect on pulmonary and systemic patients with known or circulation suspected valve disease History and Establishes symptom severity, comorbidities, valve disease physical presence and severity, and presence of HF ECG Establishes rhythm, LV function, and presence or absence of hypertrophy *TTE is the standard initial diagnostic test in the initial evaluation of patients with known or suspected VHD 17  Table 3. Evaluation of Patients with Known or Suspected VHD Reason Test Indication Further diagnostic testing: Information Chest x-ray Important for the symptomatic patient; establishes heart size and required for equivocal symptom status, presence or absence of pulmonary vascular congestion, intrinsic discrepancy between examination and lung disease, and calcification of aorta and pericardium echocardiogram, further definition of valve TEE Provides high-quality assessment of mitral and prosthetic valve, disease, or assessing response of the ventricles including definition of intracardiac masses and possible associated and pulmonary circulation to load and to abnormalities (e.g., intracardiac abscess, LA thrombus) exercise CMR Provides assessment of LV volumes and function, valve severity, and aortic disease 18  Table 3. Evaluation of Patients with Known or Suspected VHD Reason Test Indication Further diagnostic testing: PET CT Aids in determination of active infection or inflammation Information required for equivocal symptom status, discrepancy between Stress testing Gives an objective measure of exercise capacity examination and echocardiogram, further definition of valve disease, or Catheterization Provides measurement of intracardiac and pulmonary assessing response of the ventricles and pressures, valve severity, and hemodynamic response to pulmonary circulation to load and to exercise and drugs exercise 19  Table 3. Evaluation of Patients with Known or Suspected VHD Reason Test Indication Further risk stratification: Biomarkers Provide indirect assessment of filling pressures and Information on future risk of myocardial damage the valve disease, which is TTE strain Helps assess intrinsic myocardial performance important for determination of timing of intervention CMR Assesses fibrosis by gadolinium enhancement 20  Table 3. Evaluation of Patients with Known or Suspected VHD Reason Test Indication Further risk stratification: Stress testing Provides prognostic markers Information on future risk of the valve disease, which is Procedural risk Quantified by STS (Predicted Risk of Mortality) and important for determination of TAVI scores timing of intervention Frailty score Provides assessment of risk of procedure and chance of recovery of quality of life 21  Table 3. Evaluation of Patients with Known or Suspected VHD Reason Test Indication Preprocedural testing: Dental examination Rules out potential infection sources Testing required before valve intervention CT coronary angiogram or invasive coronary Provides an assessment of coronary anatomy angiogram CT: peripheral Assess femoral access for TAVI and other transcatheter procedures CT: cardiac Assesses suitability for TAVI and other transcatheter procedures CMR indicates cardiac magnetic resonance; CT, computed tomography; ECG, electrocardiogram; HF, heart failure; LV, left ventricular; PET, positron emission tomography; STS, Society of Thoracic Surgeons; TAVI, transcatheter aortic valve implantation; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography; and VHD, valvular heart disease. 22  Table 4. Stages of VHD Stage Definition Description A At risk Patients with risk factors for development of VHD B Progressive Patients with progressive VHD (mild to moderate severity and asymptomatic) C Asymptomatic Asymptomatic patients who have the criteria for severe VHD: severe C1: Asymptomatic patients with severe VHD in whom the LV or RV remains compensated space C2: asymptomatic patients with severe VHD with decompensation of LV or RV D Symptomatic severe Patients who have developed symptoms as a result of VHD 23 Diagnosis and Follow-up 24  Diagnostic Testing: Routine Follow-up Table 5. Frequency of Echocardiograms in Asymptomatic Patients with VHD and Normal LV Function Type of Valve Lesion Stage Aortic Stenosis* Aortic Regurgitation Mitral Stenosis Mitral Regurgitation Progressive  Every 3–5 y (mild  Every 3–5 y (mild Every 3–5 y  Every 3–5 y (mild severity) (Stage B) severity; Vmax 2.0–2.9 severity) (MV area >1.5 cm2) m/s)  Every 1–2 y moderate  Every 1–2 y (moderate  Every 1–2 y (moderate severity; Vmax 3.0–3.9 severity) severity) m/s) Patients with mixed valve disease may require serial evaluations at intervals earlier than recommended for single-valve lesions. These intervals apply to most patients with each valve lesion and do not take into consideration the etiology of the valve disease. *With normal stroke volume. 25  Diagnostic Testing: Routine Follow-up Table 5. Frequency of Echocardiograms in Asymptomatic Patients with VHD and Normal LV Function Type of Valve Lesion Stage Aortic Stenosis* Aortic Regurgitation Mitral Stenosis Mitral Regurgitation Severe Every 6–12 mo Every 6–12 mo  Every 1–2 y (MV area 1.0– Every 6–12 mo asymptomatic (Vmax ≥4 m/s) 1.5 cm2) (Stage C1) Dilating LV: More  Every year (MV area 3 months ago, a non–vitamin K oral anticoagulant (NOAC) is an effective alternative to 1 A VKA anticoagulation and should be administered on the basis of the patient’s CHA2DS2-VASc score. 2. For patients with AF and rheumatic MS, long-term VKA oral 1 C-EO anticoagulation is recommended. 33  Anticoagulation for AF in Patients With VHD COR LOE Recommendations 3. For patients with new-onset AF  3 months after surgical or transcatheter bioprosthetic valve replacement, anticoagulation 2a B-NR with a VKA is reasonable. 4. In patients with mechanical heart valves with or without AF who require long-term anticoagulation with VKA to prevent 3: Harm B-R valve thrombosis, NOACs are not recommended. 34 Figure 1. Anticoagulati on for AF in Patients With VHD. Colors corresponds to Table 2. 35  Evaluation of Surgical and Interventional Risk COR LOE Recommendation 1. For patients with VHD for whom intervention is contemplated, individual risks should be calculated for specific surgical and/or 1 C-EO transcatheter procedures, using online tools when available, and discussed before the procedure as a part of a shared decision-making process. 36  Table 8. Risk Assessment for Surgical Valve Procedures Footnote text located on the next slide Criteria Low-Risk SAVR (Must Low-Risk Surgical Mitral High Surgical Risk Prohibitive Surgical Risk Meet ALL Criteria in This Valve Repair for Primary (Any 1 Criterion in This (Any 1 Criterion in This Column) Column) MR (Must Meet ALL Column) Criteria in This Column) STS-predicted risk of 50% at 1 y OR Frailty† None None ≥2 Indices (moderate to ≥2 Indices (moderate to severe) AND AND severe) OR OR Cardiac or other major None None 1 to 2 Organ systems ≥3 Organ systems organ system compromise AND AND OR OR not to be improved postoperatively‡ Procedure-specific None None Possible procedure-specific Severe procedure-specific impediment§ impediment impediment 37  Table 8. Surgical Risk Assessment *Use of the STS Predicted Risk of Mortality (http://riskcalc.sts.org/stswebriskcalc/#/) to predict risk in a given institution with reasonable reliability is appropriate only if institutional outcomes are within 1 standard deviation of the STS average observed/expected mortality ratio for the procedure in question. The EUROSCORE II risk calculator may also be considered for use and is available at http://www.euroscore.org/calc.html. †Seven frailty indices: Katz Activities of Daily Living (independence in feeding, bathing, dressing, transferring, toileting, and urinary continence) plus independence in ambulation (no walking aid or assistance required, or completion of a 5-m walk in 15 Life expectancy Life Life expectancy 40 years of age and postmenopausal women), invasive coronary angiography is indicated before valve intervention. 2. In patients with chronic severe secondary MR, invasive coronary angiography should be 1 C-LD performed as part of the evaluation. 3. In selected patients with a low to intermediate pretest probability of CAD, contrast-enhanced 2a B-NR coronary CT angiography is reasonable to exclude the presence of significant obstructive CAD. 4. In patients undergoing valve repair or replacement with significant proximal CAD (≥70% reduction in luminal diameter in major coronary arteries or ≥50% reduction in luminal 2a C-LD diameter in the left main coronary artery and/or physiologically significance), CABG is reasonable for selective patients. 205  Intervention for AF in Patients With VHD COR LOE Recommendations 1. In patients with VHD and AF for whom surgical intervention is planned, the potential symptomatic benefits and additional procedural risks of adjunctive 1 C-LD arrhythmia surgery at the time of cardiac valvular surgery should be discussed with the patient. 2. For symptomatic patients with paroxysmal or persistent AF who are undergoing valvular surgery, surgical pulmonary vein isolation or a maze procedure can be 2a B-R beneficial to reduce symptoms and prevent recurrent arrhythmias. 3. For patients with AF or atrial flutter who are undergoing valve surgery, LA appendage ligation/excision is reasonable to reduce the risk of thromboembolic 2a B-NR events. 206  Intervention for AF in Patients With VHD COR LOE Recommendations 4. In patients undergoing LA surgical ablation of atrial arrhythmias and/or LA appendage ligation/excision, 2a B-NR anticoagulation therapy is reasonable for at least 3 months after the procedure. 5. For patients without atrial arrhythmias who are undergoing 3: valvular surgery, LA appendage B-NR Harm occlusion/exclusion/amputation is potentially harmful. 207 Figure 20. Intervention for AF in patients with VHD. Colors correspond to Table 2. 208 Noncardiac Surgery in Patients with VHD 209  Diagnosis in Patients With VHD Undergoing Noncardiac Surgery COR LOE Recommendation 1. In patients with clinically suspected moderate or greater degrees of valvular stenosis or regurgitation who are undergoing noncardiac 1 C-EO surgery, preoperative echocardiography is recommended. 210  Management of the Symptomatic Patient With VHD Undergoing Noncardiac Surgery COR LOE Recommendation 1. In patients who meet standard indications for intervention for VHD (replacement and repair) on the basis of symptoms and disease severity, intervention should be performed before elective noncardiac surgery to reduce perioperative 1 C-EO risk if possible, depending on the urgency and risk of the noncardiac procedure. 211  Management of the Asymptomatic Patient With VHD Undergoing Noncardiac Surgery COR LOE Recommendations 1. In asymptomatic patients with moderate or greater degrees of AS and normal LV systolic 2a B-R function, it is reasonable to perform elective noncardiac surgery. 2. In asymptomatic patients with moderate or greater degrees of rheumatic MS with less than severe pulmonary hypertension (pulmonary artery systolic pressure