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2021 ACC/AHA Valvular Heart Disease Clinical Practice Guidelines

The American College of Cardiology (ACC) and American Heart Association (AHA) released their updated recommendations on managing valvular heart disease in December 2020.^{[50, 51]}Key messages are outlined below.

Valvular heart disease (VHD) stages (stages A-D) in patients should be classified based on symptoms, valve anatomy, severity of valve dysfunction, and response of the ventricle and pulmonary circulation.

When evaluating patients with VHD, findings from the history and physical examination (PE) should be correlated with those from noninvasive testing (ie, electrocardiography [ECG], chest x-ray, transthoracic echocardiography [TTE]). If conflict exists between results on the PE and that of initial noninvasive studies, consider obtaining further noninvasive (computed tomography [CT], cardiac magnetic resonance imaging [CMRI], stress testing) or invasive (transesophageal echocardiography [TEE], cardiac catherization) studies to decide the optimal treatment strategy.

In the setting of VHD and atrial fibrillation (AF) (except for patients with rheumatic mitral stenosis [MS] or a mechanical prosthesis), the decision to use oral anticoagulation with either a vitamin K antagonist (VKA) or a non-VKA anticoagulant to prevent thromboembolic events should be a shared decision-making process based on the CHA2DS2-VASc score (congestive heart failure [CHF], hypertension, age ≥75 years, diabetes mellitus, previous stroke/transient ischemic attack/thromboembolic event, vascular disease, age 65-74 years, sex). Oral anticoagulation with a VKA should be given to those with rheumatic MS or a mechanical prosthesis and AF.

All those with severe VHD under consideration for valve intervention should be evaluated by a multidisciplinary team, either with a referral or in consultation with a primary or comprehensive valve center.

Treatment of severe aortic stenosis (AS) with either a transcatheter or surgical valve prosthesis should be based primarily on symptoms or reduced ventricular systolic function. Consider earlier intervention if indicated by the results of exercise testing, biomarkers, rapid progression, or the presence of very severe stenosis.

Expanded indications for transcatheter aortic valve implantation (TAVI) are a result of findings from multiple randomized trials of TAVI versus surgical aortic valve replacement (SAVR). The selection of intervention type for patients with severe AS should be a shared decision-making process that considers the lifetime risks and benefits associated with the valve type (mechanical vs bioprosthetic) and approach type (transcatheter vs surgical).

Bioprosthetic valve dysfunction may occur because of either degeneration of the valve leaflets or valve thrombosis. Catheter-based treatment for prosthetic valve dysfunction is reasonable in selected patients for bioprosthetic leaflet degeneration or paravalvular leak in the absence of active infection.

Go to 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: Developed by the Task Force on cardiac pacing and cardiac resynchronization therapy of the European Society of Cardiology (ESC) with the special contribution of the European Heart Rhythm Association (EHRA) for full details.

For more information, please go to Aortic Regurgitation, Mitral Stenosis, Mitral Regurgitation, and Tricuspid Regurgitation.

For more Clinical Practice Guidelines, please go to Guidelines.

2021 ESC/EACTS Management of Valvular Heart Disease (VHD) Clinical Practice Guidelines

Guidelines for the management of patients with valvular heart disease (VHD) were published in August 2021 by the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS),^[52]including the following recommendation on aortic valve disease.

Intervention is recommended for symptomatic patients with severe, high-gradient aortic stenosis or with severe low-flow, low-gradient aortic stenosis with LVEF < 50% and evidence of flow reserve, as well as for asymptomatic patients with severe stenosis who have systolic LV dysfunction (LVEF < 50%) without another cause or who have symptoms on exercise testing.

2017 Multisociety Appropriate Use Criteria

In 2017, the first document to address appropriate use criteria for the treatment of severe aortic stenosis was released as a collaborative effort by the American College of Cardiology (ACC) Appropriate Use Criteria Task Force, American Association for Thoracic Surgery (AATS), American Heart Association (AHA), American Society of Echocardiography (ASE), European Association for Cardio-Thoracic Surgery (EACTS), Heart Valve Society (HVS), Society of Cardiovascular Anesthesiologists (SCA), Society for Cardiovascular Angiography and Interventions (SCAI), Society of Cardiovascular Computed Tomography (SCCT), Society for Cardiovascular Magnetic Resonance (SCMR), and Society of Thoracic Surgeons (STS).^{[53, 54]}Eight key recommendations are outlined below.

Asymptomatic Patients with High-Gradient Severe Aortic Stenosis

No intervention is appropriate or intervention may be considered for those with a left ventricular ejection fraction (LVEF) of at least 50%, V_max 4.0-4.9 m/s, negative exercise stress, and no predictors of rapid progression.

Intervention is appropriate or no intervention may be considered for those with a high-risk profession or lifestyle and low surgical risk, or for those with a predictor of rapid progression. Intervention is appropriate for those with very severe aortic stenosis (V_max ≥5.0 m/s or mean gradient ≥60 mmHg) and low surgical risk, and it is appropriate or may be considered for those at intermediate or high surgical risk.

Intervention is appropriate for patients with an abnormal exercise test, an LVEF below 50%, or when undergoing another cardiac surgical procedure.

Low-Flow (LF) Low-Gradient (LG) Severe Aortic Stenosis and Reduced LVEF (< 50%)

Intervention is appropriate for patients with LFLG severe aortic stenosis and an LVEF of 20-49% with flow reserve on low-dose dobutamine stress echocardiography (DSE); intervention is appropriate or balloon aortic valvotomy (BAV) or no intervention may be considered for patients with no flow reserve, but with a very calcified aortic valve suggestive of truly severe aortic stenosis.

For patients with an LVEF below 20%, intervention is appropriate or BAV may be considered for patients with severe high-gradient aortic stenosis, or for patients with LFLG aortic stenosis and flow reserve on DSE.

Intervention is inappropriate for patients with pseudo-severe aortic stenosis; or for patients with an LVEF below 20%, mean gradient less than 20 mmHg, and no flow reserve on DSE.

LG Severe Aortic Stenosis and Preserved LVEF (≥50%)

Intervention is appropriate for patients with severe aortic valve calcification, symptoms referable to aortic stenosis, and the following:

LFLG severe aortic stenosis
Normal flow (NF) LG aortic stenosis

Symptomatic Severe Aortic Stenosis and High or Extreme Surgical Risk

For symptomatic patients with an STS predicted risk of mortality (STS-PROM) of 8-15% due to multiple comorbidities, transcatheter aortic valve replacement (TAVR) is appropriate and surgical AVR (SAVR) may be reasonable if the anticipated life expectancy is greater than 1 year; neither TAVR nor SAVR is reasonable if the anticipated life expectancy is less than 1 year.

For patients with an STS-PROM above 15% due to multiple comorbidities, TAVR is appropriate if the health status appears influenced more by aortic stenosis than by comorbidities and the anticipated life expectancy is longer than 1 year.

For patients with an STS-PROM of 8-15% due to frailty with symptoms of fatigue but no chest pain, syncope, or shortness of breath, TAVR is appropriate if B-type natriuretic peptide (BNP) is elevated or if the aortic stenosis is very severe (V_max ≥5 m/s).

TAVR is appropriate for patients with severe symptomatic aortic stenosis and porcelain aorta or hostile chest.

Symptomatic Severe High-Gradient Aortic Stenosis with Associated Coronary Artery Disease (CAD)

For patients with 1- or 2-vessel CAD:

SAVR plus coronary artery bypass grafting (CABG) is appropriate for low, intermediate, or high surgical risk;
TAVR plus percutaneous coronary intervention (PCI) is appropriate for patients at intermediate or high surgical risk; and
SAVR plus PCI may be appropriate in the absence of proximal left anterior descending artery (LAD) involvement

For patients with 3-vessel CAD:

SAVR plus CABG is appropriate for low, intermediate, or high surgical risk and regardless of the SYNTAX (Synergy between percutaneous coronary intervention with Taxus and Cardiac Surgery) score; and
TAVR plus PCI is appropriate for patients at intermediate or high surgical risk and a SYNTAX score below 22

For patients with left main CAD:

SAVR plus CABG is appropriate for low, intermediate, or high surgical risk and regardless of the SYNTAX score;
TAVR plus PCI is appropriate for patients at intermediate or high surgical risk and a SYNTAX score below 33; and
TAVR plus PCI may be appropriate for patients at intermediate or high surgical risk and a SYNTAX score of at least 33

Symptomatic Severe Aortic Stenosis with Another Valve or Ascending Aorta Pathology

SAVR plus surgical mitral intervention is appropriate for patients at low, intermediate, or high surgical risk in the settings of severe primary mitral regurgitation (MR) or severe secondary MR. Either SAVR plus surgical mitral intervention or TAVR plus percutaneous balloon mitral valvotomy (PBMV) is appropriate in the setting of severe rheumatic MS with no contraindication to PMBV and high surgical risk.

SAVR plus surgical tricuspid valve intervention is appropriate for patients at intermediate surgical risk with severe secondary tricuspid regurgitation and dilated right ventricular (RV) or tricuspid annulus, but minimal pulmonary hypertension (PH) regardless of RV systolic function. TAVR alone is appropriate for patients at high surgical risk with severe secondary tricuspid regurgitation and dilated RV or tricuspid annulus, with severe PH and moderate to severe RV dysfunction; in the same patients, SAVR plus tricuspid valve surgery may be appropriate.

SAVR plus ascending aorta repair is appropriate for patients with bicuspid valve and an ascending aorta of at least 4.5 cm at low, intermediate, or high surgical risk; SAVR alone is appropriate for patients with bicuspid valve and an ascending aorta of less than 4.5 cm at low, intermediate, or high surgical risk; TAVR alone may be appropriate in patients with bicuspid valve at high surgical risk regardless of the aorta size.

SAVR plus myectomy is appropriate and SAVR alone may be appropriate for patients with prominent basal septal hypertrophy with outflow tract narrowing and flow acceleration at low, intermediate, or high surgical risk; TAVR alone may be appropriate for patients at high or intermediate surgical risk.

Severe or Critical Aortic Stenosis and Major Noncardiac Surgery

For symptomatic patients with severe aortic stenosis undergoing elective or urgent major noncardiac surgery, aortic valve intervention is appropriate, and BAV may be considered.

For asymptomatic patients with severe aortic stenosis and no evidence of LV decompensation undergoing elective major noncardiac surgery, aortic valve intervention is appropriate, and no intervention may be considered.

For asymptomatic patients with severe aortic stenosis and no evidence of LV decompensation undergoing urgent major noncardiac surgery, aortic valve intervention, no intervention, or BAV may be considered.

Aortic bioprosthesis with structural valve degeneration and severe symptomatic aortic stenosis or aortic regurgitation

SAVR or TAVR is appropriate in patients at intermediate or high surgical risk and a bioprosthesis size of at least 23 mm.

SAVR is appropriate and TAVR may be appropriate in the following patients:

Those at intermediate or high surgical risk and a bioprosthesis size of 21 mm
Those at high surgical risk and a bioprosthesis size up to 19 mm

SAVR is appropriate (and TAVR is not appropriate) in patients at intermediate risk and a bioprosthesis size up to 19 mm.

2017 AHA/ACC Guidelines for the Management of Patients with Valvular Heart Disease

In 2017, the AHA/ACC also released a focused update to their 2014 guidelines for the management of patients with valvular heart disease (VHD).^[55]Their updated recommendations for the treatment of aortic stenosis are summarized below.

Surgical AVR is recommended for symptomatic patients with severe aortic stenosis (Stage D) and asymptomatic patients with severe aortic stenosis (Stage C) who meet an indication for AVR when the surgical risk is low or intermediate.

Surgical AVR or TAVR is recommended for symptomatic patients with severe aortic stenosis (Stage D) and high risk for surgical AVR, depending on patient-specific procedural risks, values, and preferences.

TAVR is recommended for symptomatic patients with severe aortic stenosis (Stage D) and a prohibitive risk for surgical AVR who have a predicted post-TAVR survival greater than 12 months.

TAVR is a reasonable alternative to surgical AVR for symptomatic patients with severe aortic stenosis (Stage D) and an intermediate surgical risk, depending on patient-specific procedural risks, values, and preferences.

2014 Multisociety Guidelines for the Management of Valvular Heart Disease

In 2014, the AHA/ACC released a revision to their 2008 guidelines for the management of patients with VHD^[6]and the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) issued a revision of its 2007 guidelines in 2012.^[5]The Society of Thoracic Surgeons (STS) published guidelines for the management of aortic valve disease in 2013.^[56]

The 2014 AHA/ACC guidelines classify progression of valvular aortic stenosis (AS) into four stages (A to D), as summarized below.^[6]:

Stage A: At risk of AS

Stage B: Progressive AS

Stage C: Asymptomatic severe AS, as follows:

C1: Asymptomatic severe AS
C2: Asymptomatic severe AS with LV dysfunction

Stage D: Symptomatic severe AS, as follows

D1: Symptomatic severe high-gradient AS
D2: Symptomatic severe low flow/low gradient AS with reduced left ventricular ejection fraction (LVEF)
D3: Symptomatic severe low gradient AS with normal LVEF or paradoxical low flow severe AS

According to the 2012 ESC/EACTS guidelines, the echocardiographic criteria for defining severe AS also include valve area less than 1.0 cm², mean gradient greater than 40 mmHg, and maximum jet velocity greater than 4 m per second.^[5]

Both the AHA/ACC and ESC/EACTS guidelines require intervention decisions for severe VHD be based on an individual risk-benefit analysis. Improved prognosis should outweigh the risk of intervention and potential late consequences, particularly complications related to prosthetic valves.^{[5, 6]}

Recognizing the known limitations of the EuroSCORE (European System for Cardiac Operative Risk Evaluation) and the STS score, the AHA/ACC guidelines suggest using the STS criteria plus three additional indicators: frailty (using accepted indices), major organ system compromise not improved postoperatively, and procedure-specific impediment when assessing risk.^[6]

The 2014 AHA/ACC updated guidelines recommendations for AS include the following^{[6, 57]}:

Patients with signs or symptoms of AS or a bicuspid aortic valve should be evaluated with transthoracic echocardiography (TTE); selected patients with stage D2 AS may be evaluated with low-dose dobutamine stress testing
Hypertension should be treated in patients at risk for, and with, asymptomatic AS
Surgical aortic valve replacement (AVR) is recommended for patients who meet an indication for AVR as summarized below, in Table 3.

According to the ESC/EACTS guidelines, aortic valve replacement should be performed in all symptomatic patients with severe AS, regardless of left ventricular (LV) function, as survival is better with surgical treatment than with medical treatment.^[5]

Table 3. Indications for Aortic Valve Replacement in Aortic Stenosis (Open Table in a new window)

Indication	Class
Symptomatic severe high-gradient AS (Stage D1)	I
Asymptomatic severe AS (Stage C2) with and LVEF < 50%	I
Severe AS (Stage C or D) undergoing other cardiac surgery	I
Asymptomatic, very severe AS (Stage C1, aortic velocity ≥5.0 m/s) and low surgical risk	IIa
Asymptomatic, severe AS (Stage C1) and decreased expercise tolerance or an exercise fall in blood pressure	IIa
Symptomatic severe low flow/low gradient AS with reduced LVEF (Stage D2) with a low-dose dobutamine stress study with aortic velocity ≥4.0 m/s with a value are ≤1.0 cm²at any dobutamine dose	IIa
Symptomatic severe low flow/low gradient AS (Stage D3) who are normotensive and have an LVEF ≥50% if clinical, hemodynamic and anatomic data support valve obstruction as the most likely cause of symptoms	IIa
Moderate AS (Stage B) who are undergoing other cardiac surgery	IIa
Asymptomatic severe AS (Stage C1) with rapid disease progression and low surgical risk	IIb

A comparison of recommendations for surgical and transcatheter intervention for AS is provided in Table 4, below.

Table 4. Guideline Recommendations for Aortic Stenosis Intervention (Open Table in a new window)

Intervention Selection	AHA/ACC (2014)^[6]	ESC/EACTS (2012)^[5]	STS(2013)^[56]
Surgical AVR in patients with low or intermediate surgical risk	Class I	Class I
Transcatheter aortic valve replacement (TAVR) for patients who have a prohibitive surgical risk and a predicted post-TAVR survival >12 mo	Class I	Class I	Class I
TAVR for patients who have high surgical risk	Class IIa-Reasonable	Class IIa-Reasonable
TAVR is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS	Class III	Class III
Balloon aortic valvuloplasty (BAV) as a bridge to surgical AVR or TAVR in severely symptomatic patients	Class IIb-Consider	Class IIb-Consider	Class IIa-Reasonable
BAV as bridge to AVR in hemodynamically unstable patients with severe AS where immediate AVR is not feasible		Class IIb-Consider	Class IIa-Reasonable
BAV in severely symptomatic patients where AVR is not an option for symptom relief			Class IIb-Consider
BAV as a palliative measure when surgery is contraindicated because of severe comorbidities		Class IIb-Consider	Class IIb-Consider

In the 2014 joint guidelines on the management of atrial fibrillation (AF), the American College of Cardiology Foundation, American Heart Association, and Heart Rhythm Society (ACCF/AHA/HRS) recommended against the use of dabigatran in patients with AF and a mechanical heart valve. (Class III)^[58]

Medication

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Media Gallery

Stenotic aortic valve (macroscopic appearance).

of 1

Table 1. Common Causes of Aortic Stenosis Among Patients Requiring Surgery

Age < 70 years (n=324)

Age >70 years (n=322)

Bicuspid AV (50%)

Postinflammatory (25%)

Degenerative (18%)

Unicommissural (3%)

Hypoplastic (2%)

Indeterminate (2%)

Degenerative (48%)

Bicuspid (27%)

Postinflammatory (23%)

Hypoplastic (2%)

Table 2. Criteria for Determining Severity of Aortic Stenosis

Severity	Mean gradient (mmHg)	Aortic valve area (cm²)
Mild	< 25	>1.5
Moderate	25-40	1-1.5
Severe	>40	< 1 (or < 0.5 cm²/m² body surface area)
Critical	>80	< 0.5

Table 3. Indications for Aortic Valve Replacement in Aortic Stenosis

Indication	Class
Symptomatic severe high-gradient AS (Stage D1)	I
Asymptomatic severe AS (Stage C2) with and LVEF < 50%	I
Severe AS (Stage C or D) undergoing other cardiac surgery	I
Asymptomatic, very severe AS (Stage C1, aortic velocity ≥5.0 m/s) and low surgical risk	IIa
Asymptomatic, severe AS (Stage C1) and decreased expercise tolerance or an exercise fall in blood pressure	IIa
Symptomatic severe low flow/low gradient AS with reduced LVEF (Stage D2) with a low-dose dobutamine stress study with aortic velocity ≥4.0 m/s with a value are ≤1.0 cm²at any dobutamine dose	IIa
Symptomatic severe low flow/low gradient AS (Stage D3) who are normotensive and have an LVEF ≥50% if clinical, hemodynamic and anatomic data support valve obstruction as the most likely cause of symptoms	IIa
Moderate AS (Stage B) who are undergoing other cardiac surgery	IIa
Asymptomatic severe AS (Stage C1) with rapid disease progression and low surgical risk	IIb

Table 4. Guideline Recommendations for Aortic Stenosis Intervention

Intervention Selection	AHA/ACC (2014)^[6]	ESC/EACTS (2012)^[5]	STS(2013)^[56]
Surgical AVR in patients with low or intermediate surgical risk	Class I	Class I
Transcatheter aortic valve replacement (TAVR) for patients who have a prohibitive surgical risk and a predicted post-TAVR survival >12 mo	Class I	Class I	Class I
TAVR for patients who have high surgical risk	Class IIa-Reasonable	Class IIa-Reasonable
TAVR is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS	Class III	Class III
Balloon aortic valvuloplasty (BAV) as a bridge to surgical AVR or TAVR in severely symptomatic patients	Class IIb-Consider	Class IIb-Consider	Class IIa-Reasonable
BAV as bridge to AVR in hemodynamically unstable patients with severe AS where immediate AVR is not feasible		Class IIb-Consider	Class IIa-Reasonable
BAV in severely symptomatic patients where AVR is not an option for symptom relief			Class IIb-Consider
BAV as a palliative measure when surgery is contraindicated because of severe comorbidities		Class IIb-Consider	Class IIb-Consider

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Author

Xiushui (Mike) Ren, MD Cardiologist, The Permanente Medical Group; Associate Director of Research, Cardiovascular Diseases Fellowship, California Pacific Medical Center

Xiushui (Mike) Ren, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Society of Echocardiography

Disclosure: Nothing to disclose.

Chief Editor

Terrence X O'Brien, MD, MS, FACC Professor of Medicine/Cardiology, Director, Clinical Cardiovascular Research, Medical University of South Carolina College of Medicine; Director, Echocardiography Laboratory, Veterans Affairs Medical Center of Charleston

Terrence X O'Brien, MD, MS, FACC is a member of the following medical societies: American College of Cardiology, American Heart Association, American Society of Echocardiography, Heart Failure Society of America, South Carolina Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Jerry Balentine, DO Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St Barnabas Hospital

Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine