New Guidelines on Echocardiographic Timing of Periodic Imaging After Valvular Intervention

2020	Prior Recommendations
Guidelines for post-intervention echocardiographic surveillance follow:1 Surgical mechanical valve at baseline Surgical bioprosthetic valve at baseline, 5 years, 10 years, and then annually Transcatheter bioprosthetic valve at baseline and then annually Surgical mitral valve repair at baseline, 1 year, and then every 2-3 years Transcatheter mitral valve repair at baseline and then annually	2018: Suggestion from the Valve Academic Research Consortium for post-TAVR echocardiographic imaging to occur at baseline, 1 month, 6 months, 12 months, and yearly thereafter.4 TAVR guidelines suggest echocardiography at 30 days after TAVR and then at least annually. This is to comply with current requirements for following TAVR patients in a registry, monitoring for complications of TAVR, and guiding medical therapy of concurrent cardiac conditions. Also, durability of TAVR valves is not yet known, requiring frequent surveillance of complications.6
	2017: Proposed algorithm for increased need for early surveillance of bioprosthetic valve replacement with yearly transthoracic echocardiography (TTE).2
	2014: Prosthetic valve implantation should receive a baseline TTE (Class I, Level of Evidence [LOE] B) and a TTE/TEE at any time after if there is a change in clinical symptoms or signs suggesting valve dysfunction (Class I, LOE C).3 Annual TTE is reasonable in patients with a bioprosthetic valve after the first 10 years, even in the absence of a change in clinical status (Class IIa, LOE C).

Additional TEE Monitoring Prior to Switching of Antibiotics for IE

2020

Prior Recommendations

Patients being considered for an early change to oral antibiotic therapy for the treatment of stable IE should have a baseline TEE before switching to oral therapy. A repeat TEE 1-3 days before completion of the oral antibiotic regimen should also be performed (Class IIb, LOE B).1 This is taken from the Partial Oral Treatment of Endocarditis (POET) trial, which showed non-inferiority of early oral antibiotic therapy to long-term intravenous therapy in patients with stable left-sided IE.5

2014: Valvular guidelines do not mention this.3

Official Pre-TAVR Imaging Guidelines

2020	Prior Recommendations
In patients undergoing TAVR, a contrast-enhanced coronary CT angiography (in patients with a low pretest probability for coronary artery disease) or an invasive coronary angiogram is recommended to assess coronary anatomy and guide revascularization (Class I, LOE C).1	2017: TAVR guidelines mention this.6
	2014: Valvular guidelines do not mention this.3

Preference for CT vs. MRI for Evaluation of Aortic Pathology in Patients With Bicuspid Aortic Valves

2020	Prior Recommendations
In patients with bicuspid aortic valves where TEE is not able to fully evaluate for aortic pathology, CT angiography or cardiac MRI is indicated. The decision depends on patient preference, insurance coverage, institutional expertise, and consideration of radiation exposure (Class I, LOE C).1	2014: MRI angiography was preferred over CT angiography imaging, when possible, because of the absence of ionizing radiation exposure in patients who likely will have multiple imaging studies over their lifetimes (Class I, LOE C).3

TEE to Determine Feasibility for TEER in High Surgical-Risk Patients With Primary Severe MR

2020

Prior Recommendations

Patients with primary severe MR at high surgical risk should have a TEE to determine feasibility for TEER.1 This is supportive of the recommendation that in severely symptomatic patients (New York Heart Association Class III or IV) with primary severe MR and high or prohibitive surgical risk, TEER is reasonable if mitral valve anatomy is favorable for the repair procedure and patient life expectancy is at least 1 year (Class IIa, LOE B).1

2014: Transcatheter mitral valve repair may be considered for patients with New York Heart Association Class III to IV and stage D primary MR who have favorable anatomy, prohibitive surgical risk, and reasonable life expectancy and remain symptomatic despite optimal goal-directed medical therapy (Class IIb, LOE B). However, there is no mention of the use of TEE to determine feasibility.3

Structure of Primary and Comprehensive Valve Centers Defined

2020

Prior Recommendations

The 2020 guidelines define the structure of a primary valve center and comprehensive valve center for the first time to include valve echocardiographer and CT expert in both and interventional echocardiographer in a comprehensive center. This is due to the increasing diagnostic and therapeutic options for patients with valvular heart disease and for the ability to optimize patient outcomes by appropriately matching patients to providers and facilities with appropriate expertise, experience, and resources.1

These definitions are not provided in previous guidelines.

References

1. Otto CM, Nishimura RA, Bonow RO, et al. 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 Am Coll Cardiol 2021;77: e25-e197.
2. Stewart WJ. Echocardiography After Bioprosthetic Valve Replacement: Need for Early Surveillance (www.acc.org). April 3, 2017. Accessed April 13, 2021. Available at https://www.acc.org/latest-in-cardiology/articles/2017/03/30/10/45/echocardiography-after-bioprosthetic-valve-replacement.
3. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:e57-e185.
4. Onishi T, Sengoku K, Ichibori Y, et al. The role of echocardiography in transcatheter aortic valve implantation. Cardiovasc Diagn Ther 2018;8:3-17.
5. Iversen K, Ihlemann N, Gill SU, et al. Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis. N Engl J Med 2019;380:415-24.
6. Otto CM, Kumbhani DJ, Alexander KP, et al. 2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis: A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol 2017;69:1313-46.

Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and VHD, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Structural Heart Disease, Angiography, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Nuclear Imaging

Keywords: Coronary Angiography, Mitral Valve, Coronary Artery Disease, Transcatheter Aortic Valve Replacement, Magnetic Resonance Angiography, Aortic Valve, Life Expectancy, Patient Preference, Anti-Bacterial Agents, Feasibility Studies, Heart Valve Diseases, Echocardiography, Endocarditis, Registries, Radiation, Ionizing, Insurance Coverage

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