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2021 ESC/EACTS Guidelines on Valvular Heart Disease

Presented by
Dr Victoria Delgado, Leiden University Medical Center, the Netherlands
Conference
ESC 2021

Based on a substantial amount of new evidence, the experts of the European Society of Cardiology (ESC) and the European Association for Cardiothoracic Surgery (EACTS) have developed new guidance for the treatment of valvular heart disease (VHD). Experienced experts in special centres are seen as an indispensable part of decision-making.

The new guidelines on VHD highlight the importance of an integral approach to patients with VHD within a Heart Valve Centre of excellence that is interlinked with a Heart Valve Clinic, able to provide guideline-directed therapy [1,2]. As an overarching principle, decision-making should be in the hands of a Heart Team consisting of various specialists including interventional cardiologists, cardiac surgeons, and cardiovascular anaesthesiologists. Based on clinical and imaging assessments, the Heart Team will consider local resources, risks versus benefits, treatment options, and goals of the individual patients.

 
Aortic valve disease

In severe aortic regurgitation, there is a new recommendation for surgery in asymptomatic patients with a left ventricular end-systolic diameter (LVESD) of >50mm or LVESD >25mm/m2 body surface area (BSA) or resting left ventricular ejection fraction (LVEF) of ≤50% [1,2]. Furthermore, a new class 2b recommendation indicates that surgery may be considered in asymptomatic patients with LVESD >20mm/m2 BSA or resting LVEF ≤55% if surgery is at low risk (see Table).

In aortic stenosis, interventions should now be considered in asymptomatic patients with severe aortic stenosis and an LVEF <55% without any other cause (class 2a). A consideration for intervention should also be given in these cases with an LVEF >55%, a normal exercise test, and low procedural risk if there is either very severe stenosis (mean gradient ≥60mmHg or Vmax ≥5m/sec), or severe calcification and Vmax progression ≥0.3m/sec/year, or markedly elevated BP levels in repeated measurements that do not have other explanations [1–3].

Table: Recommendations on surgery indication in severe aortic regurgitation in 2017 vs 2021. Modified from [1]



When it comes to deciding which surgical approach should be preferred, Prof. Bernard David Prendergast (St Thomas' Hospital, UK) stated that surgical valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) are both excellent treatment options for patients with aortic stenosis. “The choice between the interventions must be based upon Heart Team evaluations of all patients. In straightforward situations, surgery is recommended for younger patients (<75 years) at lower surgical risk and for patients when transfemoral TAVI is not possible, and the patient remains operable. TAVI is preferred in older patients ≥75 years and in those of inoperable or high surgical risk,” he summarised the new recommendations. “The mode of intervention in all scenarios should be determined by a multifactorial assessment in individual patients, followed by a Heart Team recommendation that is discussed with the patient who can make an informed treatment choice,” Prof. Pendergast added.

 
Mitral valve disease

As for mitral regurgitation (MR), the new guidelines make a clear distinction between primary and secondary mitral valve regurgitation [1,2,4]. The revised guidelines advise surgery for asymptomatic patients with a preserved LV function (LVEF >60%), LVESD <40mm (class 1) and atrial fibrillation (AF) secondary to MR or pulmonary hypertension (class 2a) [2]. The left atrial volume of >60ml/m2 or diameter of >55mm remains key and an emphasis on centre experience to ascertain durable results is unchanged.

For secondary MR, the new recommendations are:


    • Valve surgery/intervention is recommended only in patients with severe secondary MR who remain symptomatic despite guideline-directed treatment and has to be decided by structural collaborative Heart Team (class 1).
    • In symptomatic patients with concomitant coronary artery or other cardiac disease requiring treatment who are judged not appropriate for surgery by the Heart Team based on their individual characteristics, percutaneous coronary intervention (and/or TAVI) possibly followed by transcatheter edge-to-edge repair (TEER) should be considered (class 2a).

There also is a revision for the patients without concomitant disease that upgraded TEER from 2b to 2a, as TEER should be considered in selected symptomatic patients not eligible for surgery and fulfilling criteria suggesting an increased chance of responding to therapy.

 
Tricuspid valve 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 recognised that delayed intervention yields poor outcomes including durability. This is a class 2a indication that is not applicable to those with left-sided disease (recommend early left-sided management) [2].

 
Antithrombotic management

Several changes in recommendations concerning the antithrombotic treatment in the perioperative and postoperative period of prosthetic valve implantation or valve repair have been included in the 2021 ESC/EACTS guidelines on VHD [1,5]. Prof. Davide Capodanno (University of Catania, Italy) called attention to the following new entries:


    • In patients with no baseline indications for oral anticoagulation (OAC), low-dose aspirin or OAC using a vitamin K antagonist (VKA) should be considered for the first 3 months after surgical intervention of an aortic biological heart valve (class 2a).
    • For stroke prevention in AF who are eligible for OAC, DOACs are recommended in preference to VKA for patients with aortic stenosis, aortic regurgitation, and mitral regurgitation.
    • Left atrial appendage occlusion should be considered to reduce thromboembolic risk in patients with AF and a CHADVASC 2 ≥2 undergoing valve surgery (class 2a).
    • Direct oral anticoagulants (DOAC) should be considered over VKA after 3 months following surgical implantation of a biological heart valve in patients with atrial fibrillation (class 2a).
    • DOACs may be considered over VKA within 3 months following surgical implantation of a biological heart valve in mitral position in patients with atrial fibrillation (class 2b).

Concerning the postoperative period after TAVI, 4 more management recommendations were added:


    • OAC is recommended lifelong for TAVI patients who have other indications for OAC (class 1).
    • Lifelong single-antiplatelet therapy is recommended after TAVI in patients with no baseline indication for OAC (class 1).
    • Routine use of OAC is not recommended after TAVI in patients without baseline indication for OAC (class 3).
    • Anticoagulation should be considered in patients with leaflet thickening and reduced leaflet motion leading to elevated gradients at least until resolution (class 2a).

 


    1. Vahanian A, et al. Eur Heart J 2021;28 Aug. DOI:1093/eurheartj/ehab395.
    2. Delagado V. Timing and indication of intervention in asymptomatic patients with valvular heart disease. Session: 2021 ESC/EACTS Guidelines for the management of valvular heart disease, ESC Congress 2021, 27–30 August.
    3. Pendergast BD. Mode of intervention in aortic stenosis. Session: 2021 ESC/EACTS Guidelines for the management of valvular heart disease, ESC Congress 2021, 27–30 August.
    4. Praz F. Mode of intervention in mitral regurgitation. Session: 2021 ESC/EACTS Guidelines for the management of valvular heart disease. ESC Congress 2021, 27–30 August.
    5. Capodanno D. Anticoagulation/avoid stroke in patients with valvular heart disease. Session: 2021 ESC/EACTS Guidelines for the management of valvular heart disease, ESC Congress 2021, 27–30 August.

 

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