2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: What Changed From the 2017 Update?
The field of valvular and structural heart disease is rapidly evolving and witnessing unprecedented advances in diagnostic modalities as well as transcatheter and surgical therapies. As a reflection of this wave of change, the current 2020 American College of Cardiology (ACC)/American Heart Association (AHA) guideline for the Management of Patients with Valvular Heart Disease (VHD)1 included important updates that will influence how clinicians diagnose and treat valvular heart disease. Diagnostics and therapeutics in aortic and mitral valve diseases have witnessed the most expansion, so what major changes were made in the current guidelines that the clinician should be aware of?
Timing of Intervention: Emphasis on Disease Progression
With the increased therapeutic options, timing of intervention is key. Data has emerged supporting earlier intervention in severe valvular heart disease: identifying that deferring operative intervention until conventional left ventricular ejection fraction (LVEF) and chamber dimension thresholds is associated with worse outcomes and the potential for irreversible myocardial damage. Moreover, the advances in surgical and transcatheter techniques have shifted the risk/benefit balance, allowing earlier intervention with lower risk. The 2020 guidelines1 have incorporated recommendations to support earlier intervention if valvular dysfunction progresses highlighting the importance of sequential change rather than attaining absolute threshold targets:
- In patients with asymptomatic severe aortic stenosis (stage C1) at a low surgical risk, aortic valve replacement received a IIa recommendation when serum B-type natriuretic peptide (BNP) level is more than three times normal.2 Similarly, there is a 2b recommendation for progressive decrease in LVEF on three serial imaging studies to less than 60%.3
- In patients with asymptomatic aortic regurgitation, the current guideline recommends aortic valve replacement (AVR) if LVEF is below 55% instead of 50% in the previous iteration.4 Similar to aortic stenosis, a progressive decline in LVEF to the low-normal range (55-60%) on serial imaging studies or progressive increase in the left ventricular (LV) end diastolic dimension into the severe range (>65 mm) receives class 2a and 2b recommendations to proceed with AVR.5 The guideline also mentioned for the first time the growing role LV volumes on echocardiography and cardiac magnetic resonance imaging, as well as other markers for early LV dysfunction detection such as global longitudinal strain and biomarkers, but also recognizes the need for more clinical outcomes studies to be adopted into practice guidelines.6
- In chronic primary mitral regurgitation, the use of biomarkers and global longitudinal strain to help guide early intervention in asymptomatic patients received a class 2b recommendation.7 In asymptomatic patients with severe chronic primary mitral regurgitation and normal LV systolic function (EF>60% and left ventricular end systolic dimension [LVESD] <40 mm), any progressive dilatation in LV size or deterioration in ejection fraction receives a 2b indication to proceed with intervention.8
Transcatheter Valvular Interventions: A Paradigm Shift
Considering the lower procedural risks and improved outcomes in the treatment of valvular heart disease, the thresholds for intervention is now distinctly lower. The 2020 ACC/AHA guideline1 expands the indications for transcatheter therapies and provides more direction for the clinician:
- Detailed guidance on risk assessment for transcatheter and surgical valve procedures. This includes procedure-specific risks that were not incorporated into traditional risk scores such as prior mediastinal radiation, ascending aorta calcification, etc.9
- Guidance on the procedures needed to meet competence and outcome criteria to be designated as a comprehensive or primary valve center.10
- Guidance on timing of periodic imaging after transcatheter aortic and mitral therapies; mainly baseline followed by annual imaging was recommended.
- Detailed guidance regarding choice of surgical versus transcatheter aortic valve replacement as the indication for transcatheter aortic valve replacement (TAVR) was expanded to all risk groups. Particularly, age as well as life expectancy criteria were integrated into the decision making to guide approach in low and intermediate risk patients.
- A class 2a recommendation is now provided for transcatheter mitral valve edge-to-edge repair (TEER) for patients with severe primary mitral valve regurgitation at high risk for surgery.11 In the prior guideline iteration, this was designated a class 2b recommendation. For the first time, TEER was recommended (class 2a) in severe secondary mitral regurgitation (MR) on optimal guideline directed medical therapy when the LVEF is between 20-50%, LVESD ≤70 mm, and pulmonary artery systolic pressure was ≤70 mmHg.12
Anticoagulation for Patients with VHD and Atrial Fibrillation
Large randomized controlled trials and real-world evidence for patients with atrial fibrillation and VHD has provided excellent evidence supporting the use of direct oral anticoagulants (NOACs). The 2020 AHA/ACC guideline1 indicates an enhanced preference for NOACs over vitamin K antagonists for multiple indications, except in patients with rheumatic mitral valve disease and mechanical heart valves.13
In summary, changes in the 2020 AHA/ACC guideline for management of VHD1 reflects the rapid evolution in the field. Given this trajectory, it is likely that future iterations will continue to advocate for earlier intervention and will incorporate advances in imaging to enable early recognition of valvular heart disease and potentially inform and guide transcatheter therapies such as tricuspid valve repair and replacement and transcatheter aortic valve replacement for aortic regurgitation.
- 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.
- Nakatsuma K, Taniguchi T, Morimoto T, et al. B-type natriuretic peptide in patients with asymptomatic severe aortic stenosis. Heart 2019;105:384-90.
- Bohbot Y, de Ravenstein CdM, Chadha G, et al. Relationship between left ventricular ejection fraction and mortality in asymptomatic and minimally symptomatic patients with severe aortic stenosis. JACC Cardiovasc Imaging 2019;12:38–48.
- Saisho H, Arinaga K, Kikusaki S, et al. Long term results and predictors of left ventricular function recovery after aortic valve replacement for chronic aortic regurgitation. Ann Thorac Cardiovasc Surg 2015;21:388–95.
- de Meester C, Gerber BL, Vancraeynest D, et al. Do guideline-based indications result in an outcome penalty for patients with severe aortic regurgitation? JACC Cardiovasc Imaging 2019;12:2126–38.
- Murashita T, Schaff HV, Suri RM, et al. Impact of left ventricular systolic function on outcome of correction of chronic severe aortic valve regurgitation: implications for timing of surgical intervention. Ann Thorac Surg 2017;103:1222–28.
- Alashi A, Mentias A, Patel K, et al. Synergistic utility of brain natriuretic peptide and left ventricular global longitudinal strain in asymptomatic patients with significant primary mitral regurgitation and preserved systolic function undergoing mitral valve surgery. Circ Cardiovasc Imaging 2016;9:e004451.
- Tribouilloy C, Rusinaru, Szymanski C, et al. Predicting left ventricular dysfunction after valve repair for mitral regurgitation due to leaflet pro lapse: additive value of left ventricular end-systolic dimension to ejection fraction. Eur J Echocardiogr 2011;12:702–10.
- Kapadia SR, Leon MB, Makkar RR, et al. 5-year outcomes of transcatheter aortic valve replacement compared with standard treatment for patients with inoperable aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet 2015;385:2485–91.
- Nishimura RA, O'Gara PT, Bavaria JE, et al. 2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: a proposal to optimize care for patients with valvular heart disease: a joint report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2019;73:2609–35.
- Feldman T, Kar S, Elmariah S, et al. Randomized comparison of percutaneous repair and surgery for mitral regurgitation: 5-year results of EVEREST II. J Am Coll Cardiol 2015;66:2844–54.
- Obadia JF, Messika-Zeitoun D, Leurent G, et al. Percutaneous repair or medical treatment for secondary mitral regurgitation. N Engl J Med 2018;379:2297–2306.
- Renda G, Ricci F, Giugliano RP, De Caterina R. Non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation and valvular heart disease. J Am Coll Cardiol 2017;69:1363–71.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Mitral Regurgitation
Keywords: Stroke Volume, Transcatheter Aortic Valve Replacement, Mitral Valve Insufficiency, Natriuretic Peptide, Brain, Mitral Valve, Aortic Valve, Aortic Valve Insufficiency, Atrial Fibrillation, American Heart Association, Reference Values, Dilatation, Life Expectancy, Administration, Oral, Blood Pressure, Pulmonary Artery, Tricuspid Valve, Ventricular Function, Left, Anticoagulants, Heart Valve Diseases, Aortic Valve Stenosis, Risk Assessment, Echocardiography, Aorta, Magnetic Resonance Imaging, Cardiology, Surgical Instruments, Treatment Outcome, Disease Progression, Biomarkers, Radiation, Risk Factors, Decision Making, Vitamin K
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