2020 ACC/AHA Heart Valve Disease Guideline: Key Perspectives, Part 2

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 2020;Dec 17:[Epub ahead of print].

The 2020 guideline for the management of patients with valvular heart disease replaces the American Heart Association/American College of Cardiology (AHA/ACC) 2014 guideline and the 2017 focused update. The following is Part 2 of 3 key perspectives regarding mitral stenosis (MS), mitral regurgitation (MR), and tricuspid valve disease:

  1. Recurrent rheumatic fever is associated with worsening of rheumatic heart disease. Therefore, for secondary prevention of rheumatic fever, in patients with previous episodes of rheumatic fever or evidence of rheumatic heart disease, long-term antistreptococcal prophylaxis is indicated (Class 1 recommendation). Antibiotic options include penicillin, sulfadiazine, and macrolides. The recommended durations of prophylaxis are as follows:
    • Rheumatic fever with carditis and residual valvular disease: 10 years or until patient is ≥40 years of age (whichever is longer)
    • Rheumatic fever with carditis but no residual valvular disease: 10 years or until patient is ≥21 years of age (whichever is longer)
    • Rheumatic fever without carditis: 5 years or until patient is ≥21 years of age (whichever is longer)
  2. Rheumatic MS is much more common in women than in men (80% of cases in women). Worldwide, most MS is rheumatic, though calcific MS is becoming more common in the elderly population in high-income countries.
  3. In patients with Stage D rheumatic MS (symptomatic MS with mitral valve area ≤1.5 cm2 and/or diastolic pressure half-time ≥150 ms, typically with mean mitral valve gradient >5-10 mm Hg) and favorable valve morphology with less than moderate MR and no left atrial appendage thrombus, percutaneous mitral balloon commissurotomy (PMBC) is recommended if it can be performed at a Comprehensive Valve Center (Class 1). If PMBC is not an option due to anatomic considerations, severe MR, or failed prior PMBC, surgical intervention is recommended, unless risk is prohibitive.
  4. Patients with calcific MS often have multiple comorbidities and are of advanced age. Because stenosis results from mitral annular calcification encroaching on the leaflet bases, without involvement of the leaflet tips, PMBC is not beneficial. Severe mitral annular calcification can make secure implantation of a surgical prosthesis challenging and may result in residual MS following valve replacement. Therefore, in Stage D calcific MS, surgical intervention should be undertaken only after careful consideration of risks and potential benefits (Class 2b).
  5. Timing of intervention for chronic primary MR should be based on symptoms and left ventricular (LV) size and function. Recommendations for surgical intervention for MR remain similar to those in the 2014 guideline. For severe primary MR due to degenerative mitral valve disease, surgical repair is recommended in preference to valve replacement, provided that a successful and durable repair is technically feasible (Class 1). In asymptomatic patients, surgery is recommended if LV ejection fraction (LVEF) ≤60% and/or LV end-systolic diameter ≥40 mm (Stage C2, Class 1 recommendation). Surgery may be considered if these LV criteria are not met but the likelihood of a successful and durable repair is >95% with <1% expected mortality at a Primary or Comprehensive Valve Center. Transcatheter edge-to-edge repair (TEER) outcomes in severe primary MR are inferior to those of surgical mitral valve repair, but TEER is a reasonable option if surgical risk is high or prohibitive and anatomy is favorable.
  6. For secondary MR in the setting of LV dysfunction, guideline-directed medical therapy for heart failure is the mainstay of treatment, and secondary MR often improves with medical optimization.
  7. In patients with severe secondary MR with LVEF 20-50%, LV end-systolic diameter ≤70 mm, and pulmonary artery systolic pressure <70 mm Hg who remain symptomatic after medical optimization for heart failure, TEER is reasonable if anatomy is favorable (Class 2a). Surgical intervention for severe secondary MR is reasonable if performed concomitantly with coronary artery bypass grafting (Class 2a). For secondary MR in the setting of atrial annular dilation in the setting of atrial fibrillation with preserved LV systolic function, if symptoms persist despite heart failure optimization and arrhythmia management, mitral valve surgery may be considered (Class 2b).
  8. Tricuspid regurgitation (TR) is most often secondary, due to annular dilation in the setting of right ventricular (RV) dilation and/or dysfunction, as seen in pulmonary hypertension, or in right atrial dilation in the setting of atrial fibrillation. Medical treatment for TR consists of diuresis and treatment of underlying causes of heart failure and pulmonary hypertension.
  9. In severe primary TR with symptoms of right heart failure, isolated tricuspid valve surgery can improve symptoms and reduce hospitalizations (Class 2a). In asymptomatic patients with severe primary TR, tricuspid valve surgery may be considered if RV dilation or dysfunction develop (Class 2b). With respect to secondary TR, patients undergoing left-sided valve surgery should be considered for concomitant tricuspid valve surgery if the TR is severe (Class 1), or if the tricuspid annulus is dilated (>4.0 cm) and/or if right heart failure symptoms have occurred (Class 2a). In symptomatic patients with severe, functional TR (particularly if related to atrial fibrillation and atrial dilation), surgical intervention is reasonable in the absence of severe RV dysfunction, pulmonary hypertension, and liver/kidney damage (Class 2a).

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, Acute Heart Failure, Pulmonary Hypertension, Interventions and Structural Heart Disease, Mitral Regurgitation

Keywords: Antibiotic Prophylaxis, Anticoagulants, Atrial Fibrillation, Blood Pressure, Cardiac Surgical Procedures, Constriction, Pathologic, Dilatation, Heart Failure, Heart Defects, Congenital, Heart Valve Diseases, Hypertension, Pulmonary, Mitral Valve Insufficiency, Mitral Valve Stenosis, Myocarditis, Penicillins, Rheumatic Heart Disease, Secondary Prevention, Tricuspid Valve Insufficiency, Ventricular Dysfunction, Left

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