2017 Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease

Authors:
Doherty JU, Kort S, Mehran R, Schoenhagen P, Soman P.
Citation:
ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol 2017;Sep 1:[Epub ahead of print].

Valvular heart disease (VHD) and structural heart disease account for a substantial amount of cardiovascular conditions, and initial diagnosis and subsequent follow-up often rely on more than a single imaging modality. This is one of two companion documents addressing appropriate use criteria (AUC); this document addresses AUC for multimodality imaging in the diagnosis and management of VHD, and the companion document addresses multimodality imaging in the context of structural heart disease. The following are points to remember:

  1. Initial evaluation with no prior imaging:
    1. Asymptomatic patients.
      • Transthoracic echocardiography (TTE) is an appropriate test among patients with unexplained murmur or abnormal heart sounds, reasonable suspicion for VHD, history of rheumatic heart disease, known disease associated with VHD, first-degree relatives of patients with bicuspid aortic valve, or exposure to medications that could result in VHD.
      • Three-dimensional (3D) transesophageal echocardiography (TEE) may be appropriate among patients with reasonable suspicion for VHD, or history of rheumatic heart disease.
    2. Symptomatic patients.
      • TTE is appropriate in many scenarios among symptomatic patients, including patients with syncope and no other symptoms or signs of cardiovascular disease; hypotension with hemodynamic instability and uncertain or suspected cardiac origin or suspected aortic (AR) or mitral regurgitation (MR); respiratory failure of uncertain etiology; new heart failure (HF); suspected infective endocarditis (IE) with positive blood cultures or new murmur; or suspected cardiac mass, tumor, thrombus, or cardiac source of embolus (CSOE).
      • TEE is appropriate among patients with suspected IE with positive blood cultures or new murmur; or suspected cardiac mass, tumor, thrombus, or CSOE.
  2. Additional testing for clarification of a diagnosis:
    1. Among patients with inadequate TTE, TEE is appropriate; and TTE with contrast, cardiac magnetic resonance imaging (CMR), and cardiac computed tomography (CCT) may be appropriate.
    2. Among patients with suspected IE and moderate to high clinical suspicion, TEE is appropriate, and FDG PET or CCT may be appropriate.
    3. Exercise stress echocardiography is appropriate among patients with asymptomatic severe or moderate aortic stenosis (AS); among patients with mitral stenosis (MS) or MR and discrepancy between clinical symptoms and resting echo/Doppler findings; and among patients with moderate or severe AR.
    4. Low-dose dobutamine stress echocardiography (DSE) is appropriate among symptomatic patients with low-flow, low-gradient severe AS and low left ventricular ejection fraction (LVEF).
    5. TEE or CMR are appropriate patients with suspicion of severe MR or AR that is potentially underestimated on TTE.
  3. Follow-up in asymptomatic or stable symptomatic patients:
    1. Routine surveillance TTE is appropriate every 3-5 years among patients with stage A (at risk) or mild (stage B) valve regurgitation; every 1-2 years in patients with moderate (stage B) VHD; every 1 year in asymptomatic severe (stage C1) AS; every 6-12 months in asymptomatic severe (stage C1) MR; and after control of systemic hypertension in patients with low-flow low-gradient severe AS with normal LVEF.
    2. Repeat imaging at an interval <1 year using TTE, CCT, or CMR is appropriate among patients with bicuspid aortic valve (AV) and aortic diameter >4.5 cm; or aortic diameter >4.0 cm and either rapid rate of change in aortic diameter or family history of aortic dissection.
  4. Follow-up in patients with worsening symptoms:
    1. TTE is appropriate among patients with known VHD and change in clinical status or cardiac examination.
    2. TTE or TEE is appropriate, and CMR or CCT may be appropriate, among patients with IE and change in clinical status or cardiac examination.
  5. Postoperative imaging after surgical valve replacement or repair:
    1. Surgical valve replacement with no symptoms or stable symptoms.
      • After valve replacement, TTE is appropriate for initial (6 weeks to 3 months) postoperative assessment; and re-evaluation ≥3 years for mechanical or tissue valves, after the first 10 years for a bioprosthesis, and prior to pregnancy in the absence of an echo within the last year.
    2. Surgical valve replacement with suspicion of valve dysfunction.
      • TTE, TEE, and/or fluoroscopy is appropriate in the setting of a mechanical valve with concern for valve dysfunction.
      • TTE and/or TEE is appropriate, and CMR and/or CCT may be appropriate, in the setting of a tissue valve with concern for valve dysfunction. If inadequate images are obtained using TTE or TEE, then CMR and/or CCT is appropriate for assessment of a bioprosthesis with concern for dysfunction, and CCT and fluoroscopy is appropriate for assessment of a mechanical valve with concern for dysfunction.
      • TTE and/or TEE is appropriate, and CMR and/or CCT and/or fluoroscopy may be appropriate for re-evaluation of known prosthetic valve dysfunction when it would help guide therapy.
    3. Mitral valve repair.
      • After mitral valve repair, TTE is appropriate for initial (6 weeks to 3 months) postoperative assessment, and re-evaluation ≥3 years later in the absence or suspected dysfunction.
      • In the setting of mitral valve repair with suspected dysfunction, TTE is appropriate, and TEE, exercise stress echo, and/or CMR may be appropriate.
  6. Transcatheter aortic valve replacement (TAVR):
    1. Pre-TAVR evaluation.
      • Prior to TAVR, angiography is appropriate for assessment of concomitant coronary artery disease.
      • TEE, CMR, or CCT is appropriate for accurate assessment of annular size and shape.
      • TTE, TEE, or CCT is appropriate for the assessment of the number of aortic valve cusps and degree of calcification.
      • CCT is appropriate for measurement of the distance between the aortic annulus and coronary ostia, for alignment of the implant within the centerline of the aortic valve, for assessment of aortic atherosclerotic burden, and assessment of the iliofemoral vessels.
      • CCT or CMR is appropriate for assessment of aortic dimensions.
    2. Intraprocedural evaluation.
      • TTE, TEE, or fluoroscopy is appropriate during the procedure for assessment of guidewire placement into the LV.
      • TTE, TEE, angiography, or fluoroscopy is appropriate for valve placement; assessment of post-deployment position, function, and regurgitation; and for evaluation for complications including coronary occlusion, LV dysfunction or outflow tract obstruction, MR, prosthesis dislodgement, tamponade, air embolism, and aortic dissection.
    3. Post-procedural evaluation.
      • In the setting of suspicion of post-procedural valve dysfunction, TTE or TEE is appropriate for assessment of AR (central or paravalvular).
      • In the setting of suspicion of valve dysfunction, TTE and/or brain CT/MRI is appropriate for the assessment of stroke.
  7. Percutaneous MV repair:
    1. Evaluation prior to percutaneous MV repair.
      • TTE, TEE with or without 3D, exercise testing, and/or angiography is appropriate to determine eligibility prior to percutaneous MV repair.
      • TEE within 3 days of the procedure is appropriate to exclude the presence of intracardiac mass, thrombus, or vegetation.
    2. Intraprocedural evaluation during percutaneous MV repair.
      • TEE and/or angiography is appropriate to guide alignment of the device to the origin of the MR jet, grasping the leaflets, and to assess for adequacy of MR reduction.
      • TEE is appropriate during the procedure to assess for MS.
    3. Evaluation after percutaneous MV repair.
      • TTE is appropriate prior to discharge, at 1 month, 6 months, 1 year, and annually to 5 years for assessment of MR severity and LV function.

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