2017 ESC/EACTS Guidelines for Management of Valvular Heart Disease

Authors:
Baumgartner H, Falk V, Bax JJ, et al.
Citation:
2017 ESC/EACTS Guidelines for the Management of Valvular Heart Disease: The Task Force for the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2017;Aug 26:[Epub ahead of print].

The 2017 European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) Guidelines for the Management of Valvular Heart Disease document is an important update of the 2012 guidelines. The following are key points that represent new or substantially changed recommendations anticipated to most impact clinical practice:

  1. Aortic stenosis (AS):
    • The diagnosis of severe AS requires consideration of aortic valve area, flow rate, pressure gradients, left ventricular (LV) function, the degree of valve calcification, and blood pressure.
    • The strongest indication for intervention remains symptoms (spontaneous or on exercise testing).
    • Predictors of rapid symptom development can justify early surgery in asymptomatic patients, particularly when surgical risk is low.
    • Although current data favor transcatheter aortic valve replacement (TAVR) in elderly patients who are at increased risk for surgery (particularly if transfemoral access is feasible), the decision between TAVR and surgical AVR (SAVR) should be made by a Heart Team after careful, comprehensive evaluation of the patient, weighing individual risks and benefits.

  2. Aortic valve repair:
    • A Heart Team discussion is recommended in selected patients in whom aortic valve repair may be a feasible alternative to valve replacement. When performed by an experienced surgeon, aortic valve repair with re-implantation or remodeling techniques is recommended in young patients with a tricuspid aortic valve and aortic root dilation.

  3. Mitral regurgitation (MR):
    • Intervention for primary MR is guided by symptoms and risk stratification that includes the assessment of LV size and function, pulmonary artery pressure, left atrial size, and the presence of atrial fibrillation.
    • Mitral valve repair is the preferred intervention, but mitral valve replacement should be considered in patients with unfavorable valve characteristics.
    • Outcomes of mitral valve repair depend on surgeon experience and center-related volume.
    • If pulmonary hypertension (pulmonary artery systolic pressure >50 mm Hg) is the only indication for surgery in severe primary MR, the finding should be confirmed on invasive testing.
    • In secondary MR, there is no conclusive evidence for a survival benefit after mitral valve intervention. Concomitant mitral surgery is recommended in patients with an indication for coronary artery bypass grafting, and may be considered in patients who are symptomatic despite optimal medical therapy (including cardiac resynchronization therapy if indicated) or who have a low surgical risk when revascularization is not indicated.
    • Percutaneous edge-to-edge repair may be considered in patients at high surgical risk, avoiding futility.

  4. Imaging after transcatheter or surgical valve replacement:
    • After transcatheter or surgical valve replacement, echocardiography should be routinely performed within 30 days (preferably around 30 days) to establish baseline valve function, 1 year after implantation, and annually thereafter.

  5. Direct oral anticoagulants (DOACs) in heart valve disease:
    • DOACs may be used in patients with atrial fibrillation and AS, aortic regurgitation, MR, or a bioprosthesis >3 months after implantation; but are contraindicated in patients with mitral stenosis or a mechanical valve.

  6. Mechanical valve antiplatelet therapy:
    • Aspirin 75-100 mg is not routinely recommended in addition to a vitamin K antagonist (VKA) among patients with a mechanical valve, but should be considered among patients with a mechanical valve who experience a thromboembolic event despite therapeutic international normalized ratio (INR).

  7. Among patients with a mechanical valve who undergo percutaneous coronary intervention (PCI), antithrombotic therapy should be guided by assessment of relative risks of ischemia versus bleeding:
    • With a dominant concern for ischemic risk (after acute coronary syndrome, or due to anatomic/procedural factors), triple therapy (a VKA, aspirin, and clopidogrel) should be used for 1 month and up to 6 months, followed by dual therapy (a VKA and either aspirin or clopidogrel) for 6 months; followed by a VKA alone.
    • With a dominant concern for hemorrhagic risk, either triple therapy for 1 month followed by dual therapy for up to 12 months, or dual therapy for 12 months, should be used before returning to single therapy with a VKA.

  8. Bioprosthetic valve thrombosis:
    • In the setting of bioprosthetic valve thrombosis, therapy with a VKA and/or unfractionated heparin is recommended before reintervention.

  9. Paraprosthetic leak:
    • Reoperation is recommended if paraprosthetic leak is caused by infective endocarditis, causes hemolysis requiring blood transfusion, or results in severe symptoms.
    • Transcatheter closure may be considered for paraprosthetic leaks with clinically significant regurgitation in patients at high surgical risk.

  10. Valve-in-valve TAVR:
    • Valve-in-valve TAVR in the aortic position should be considered by the Heart Team, depending on the risk of reoperation and the type and size of the implanted prosthesis.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Anticoagulation Management and ACS, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Pulmonary Hypertension, Interventions and ACS, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound, Mitral Regurgitation

Keywords: Acute Coronary Syndrome, Anticoagulants, Aortic Valve Insufficiency, Aortic Valve Stenosis, Aspirin, Atrial Fibrillation, Bioprosthesis, Blood Pressure, Cardiac Resynchronization Therapy, Cardiac Surgical Procedures, Coronary Artery Bypass, Dilatation, Echocardiography, Endocarditis, Fibrinolytic Agents, Heart Valve Diseases, Hemolysis, Heparin, Hypertension, Pulmonary, Mitral Valve Insufficiency, Mitral Valve Stenosis, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Risk Assessment, Thromboembolism, Thrombosis, Transcatheter Aortic Valve Replacement, Vitamin K


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