Timing of Intervention in Asymptomatic Patients With Valvular Heart Disease

Baumgartner H, Iung B, Otto CM.
Timing of Intervention in Asymptomatic Patients With Valvular Heart Disease. Eur Heart J 2020;Sep 9:[Epub ahead of print].

Current management recommendations for patients with valvular heart disease time intervention in an attempt to optimize long-term outcomes. The following are key points to remember from this review, which summarizes current recommendations for intervention in asymptomatic patients with heart valve disease and discusses more recently published data that might favor earlier intervention in some patients:

  1. Weighing the risks and benefits for intervention in asymptomatic patients:
    • Rationale for intervention in asymptomatic patients include the risk of life-threatening events in the absence of pre-existing symptoms, irreversible end-organ damage (particularly the left ventricle [LV] and pulmonary vasculature) despite the absence of symptoms, a lower risk associated with earlier intervention, insidious symptoms that might not be recognized, and avoiding problems with suboptimal follow-up or delayed intervention once an indication is recognized.
    • The risks of intervention include operative risks and long-term risks after intervention.
    • Variables to be weighed include the type of heart valve disease; the type of intervention; the strength of any predictors for adverse outcomes; and patient age, comorbidities, and general condition.
  2. Aortic stenosis (AS):
    • Variables that have been associated with outcomes are derived from echocardiography, exercise testing, and biomarkers including B-type natriuretic peptide (BNP).
    • Current American Heart Association/American College of Cardiology (AHA/ACC) and/or European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS) guidelines support intervention in asymptomatic patients with severe AS plus LV systolic dysfunction not due to another cause (variably LV ejection fraction [LVEF] ≤50% or <50%), abnormal exercise testing, or low surgical risk, and either very severe AS or rapid progression of AS.
    • Several randomized clinical trials are underway testing early intervention in patients with asymptomatic AS.
    • Published studies support the roles of myocardial fibrosis on cardiac magnetic resonance imaging, LVEF <55% or <60%, LV global longitudinal strain (GLS), and biomarkers in the assessment of AS outcomes.
  3. Aortic regurgitation (AR):
    • Variables that have been associated with outcomes include LV enlargement and systolic dysfunction, BNP, and concomitant ascending aorta enlargement.
    • Current AHA/ACC and/or ESC/EACTS guidelines support intervention in asymptomatic patients with severe AR plus LV systolic dysfunction (variably LVEF <50% or ≤50%), or severe LV dilation.
    • Published studies support the roles of a lower threshold for LV dilation (LV end-systolic diameter index 20-25 mm/m2 rather than >25 mm/m2), LVEF <55%, or abnormal LV GLS in the assessment of AR outcomes.
  4. Mitral stenosis (MS):
    • Because asymptomatic MS is associated with low mortality, intervention in asymptomatic MS is aimed at reducing the risk of complications (predominantly thromboembolic events) and delaying symptom onset.
    • Current guidelines recommend intervention for asymptomatic patients with MS only in the form of percutaneous mitral balloon commissurotomy.
    • Intervention in asymptomatic patients with severe MS will remain restricted to rheumatic MS with anatomy favorable for percutaneous balloon commissurotomy among patients who are at high risk of thromboembolic events or hemodynamic decompensation.
  5. Primary mitral regurgitation (MR):
    • Factors identified as predictors of outcome among asymptomatic patients with primary MR include LV size and function, atrial fibrillation, pulmonary hypertension, leaflet flail, and marked left atrial enlargement in the setting of sinus rhythm.
    • Current guidelines support intervention in asymptomatic patients with severe MR and LV enlargement or systolic dysfunction (LVEF ≤60%, LV end-systolic diameter ≥40 or 45 mm), atrial fibrillation, or pulmonary hypertension; or if there is a high likelihood of successful and durable repair, low operative mortality, and surgery is performed at a Heart Valve Center of Excellence.
    • Published studies support the roles of natriuretic peptides, exercise testing, and LV GLS in the assessment of primary MR outcomes.
    • The primary factors in determining whether asymptomatic patients with severe degenerative MR and normal LV systolic function should undergo intervention are the safety, efficacy, and durability of mitral repair; which in turn are dependent on the underlying mitral valve pathology, as well as surgeon skill and program experience. Numerous studies have demonstrated that successful valve repair is dependent on surgeon and center volume.

Clinical Topics: 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, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Heart Failure and Cardiac Biomarkers, Pulmonary Hypertension, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Mitral Regurgitation

Keywords: Aortic Valve Insufficiency, Aortic Valve Stenosis, Atrial Fibrillation, Cardiac Surgical Procedures, Cardiology Interventions, Diagnostic Imaging, Dilatation, Echocardiography, Exercise Test, Fibrosis, Gadolinium, Heart Valve Diseases, Hypertension, Pulmonary, Magnetic Resonance Imaging, Mitral Valve Insufficiency, Mitral Valve Stenosis, Natriuretic Peptide, Brain, Stroke Volume, Thromboembolism

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