2017 AHA/ACC Focused Update of Valvular Heart Disease Guideline

Nishimura RA, Otto CM, Bonow RO, et al.
2017 AHA/ACC Focused Update of the 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 Clinical Practice Guidelines. J Am Coll Cardiol 2017;Mar 15:[Epub ahead of print].

The management of patients with heart disease is rapidly evolving, with advances in diagnostic imaging, and improvements in catheter-based and surgical interventions. This update of the 2014 guideline on the management of patients with heart valve disease includes changes in indications for antibiotic prophylaxis for infective endocarditis (IE), the use of direct oral anticoagulants (DOACs) among patients with atrial fibrillation and heart valve disease, indications for transcatheter aortic valve replacement (TAVR), surgical management of patients with primary and secondary mitral regurgitation (MR), and management of patients with a heart valve prosthesis. The following are points to remember:

  1. IE prophylaxis:
    • Antibiotic prophylaxis before dental procedures now is also recommended for patients with transcatheter prosthetic valves, and for patients with prosthetic material used in valve repair (including an annuloplasty ring or artificial chords) (Class IIa, Level of Evidence [LOE] C-LD).
  2. Anticoagulation for atrial fibrillation:
    • Among patients with atrial fibrillation and rheumatic mitral stenosis, anticoagulation with a vitamin K antagonist still is indicated (Class I, LOE B-NR).
    • Anticoagulation should be used among patients with atrial fibrillation and a CHA2DS2-VASc score ≥2 in the setting of native aortic valve disease, tricuspid valve disease, or MR (Class I, LOE C-LD).
    • The use of a DOAC is reasonable among patients with native aortic valve disease, tricuspid valve disease, or MR; and atrial fibrillation with a CHA2DS2-VASc score ≥2 (Class IIa, LOE C-LD).
  3. Aortic stenosis:
    • The recommendation for either surgical AVR or TAVR among high-risk patients with severe, symptomatic AS (stage D), after consideration by a heart valve team, was changed from Class IIa (LOE B) to Class I (LOE A).
    • After consideration by a heart valve team, TAVR is a reasonable alternative to surgical AVR for patients with severe, symptomatic aortic stenosis (stage D) and intermediate surgical risk (Class IIa, LOE B-R).
  4. Primary MR:
    • Among asymptomatic patients with severe primary MR with preserved left ventricular (LV) systolic function (LV ejection fraction [LVEF] >60%, LV end-systolic dimension <40 mm [stage C1]), mitral valve surgery is reasonable in the setting of serial imaging studies that reveal a progressive increase in LV size or decrease in LVEF (Class IIa, LOE C-LD).
  5. Secondary MR:
    • The definition of severe secondary MR is now the same as for severe primary MR (effective regurgitant orifice area ≥0.4 cm2, regurgitant volume ≥60 ml, regurgitant fraction ≥50%).
    • It is reasonable to choose chordal-sparing mitral valve replacement over reduction annuloplasty mitral valve repair among patients operated for severe, symptomatic (New York Heart Association class III or IV) secondary MR (stage D) (Class IIa, LOE B-R).
    • After a randomized trial showed no clinical benefit of mitral valve repair among patients with chronic, moderate ischemic MR undergoing coronary artery bypass grafting, the LOE was changed from C (consensus) to B-R (moderate quality evidence from ≥1 randomized controlled trial [RCT] or meta-analyses of moderate-quality RCT) for the Class IIb recommendation for mitral valve repair in this population.
  6. Prosthetic valve choice:
    • Shared decision-making remains a Class I indication (LOE C-LD) in selecting a mechanical versus bioprosthetic valve.
    • Among patients undergoing aortic or mitral valve replacement, the age range was expanded from age 60-70 to age 50-70 for the Class IIa (LOE B-NR) indication for either a mechanical or bioprosthetic valve choice.
  7. Prosthetic valve antithrombotic therapy:
    • There are unchanged recommendations for use of a vitamin K antagonist (international normalized ratio [INR] 2.5 for bileaflet or current-generation tilting disk valves in the absence of additional thromboembolic [TE] risks, INR 3.0 for mitral mechanical prostheses or for aortic valve prostheses plus additional TE risks) plus aspirin 75-100 mg among patients with a mechanical valve prosthesis.
    • There is a new consideration for a lower INR target of 1.5-2.0 for patients with an On-X bileaflet mechanical aortic valve and no additional TE risks (Class IIb, LOE B-R).
    • The prior recommendation for use of a vitamin K antagonist after bioprosthetic valve replacement was changed to include both aortic and mitral bioprosthesis, for 3-6 months after surgery, in patients at low risk for bleeding (Class IIa, LOE B-NR).
    • A vitamin K antagonist (INR target 2.5) may be reasonable for at least 3 months after TAVR in patients at low risk for bleeding (Class IIa, LOE B-NR).
  8. Bioprosthetic valve thrombosis:
    • Initial treatment with a vitamin K antagonist is reasonable among hemodynamically stable patients with suspected or confirmed bioprosthetic valve thrombosis and no contraindication to anticoagulation (Class IIa, LOE C-LD).
    • A TAVR valve-in-valve procedure is reasonable among severely symptomatic patients with bioprosthetic aortic valve stenosis who are assessed by the heart valve team to be at high or prohibitive surgical risk (Class IIa, LOE B-NR).
  9. Prosthetic valve regurgitation:
    • Transcatheter valve-in-valve is reasonable for severely symptomatic patients with bioprosthetic aortic valve regurgitation judged by the heart valve team to be at high or prohibitive risk for surgery (Class IIa, LOE B-NR).
  10. Infective endocarditis:
    • Operation without delay may be considered in patients with IE and an indication for surgery who have suffered a stroke, but have no evidence of intracranial hemorrhage or extensive neurological damage (Class IIb, LOE B-NR).
    • If hemodynamically stable, delaying valve surgery for ≥4 weeks may be considered among patients with IE and major ischemic stroke or intracranial hemorrhage (Class IIb, LOE B-NR).

Keywords: Antibiotic Prophylaxis, Anticoagulants, Aortic Valve, Aortic Valve Insufficiency, Aortic Valve Stenosis, Aspirin, Atrial Fibrillation, Bioprosthesis, Cardiovascular Surgical Procedures, Catheters, Diagnostic Imaging, Endocarditis, Fibrinolytic Agents, Heart Defects, Congenital, Heart Valve Diseases, Heart Valve Prosthesis, Intracranial Hemorrhages, Mitral Valve, Mitral Valve Insufficiency, Mitral Valve Stenosis, Perioperative Period, Platelet Aggregation Inhibitors, Stroke, Thrombosis, Transcatheter Aortic Valve Replacement, Tricuspid Valve, Vitamin K

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