Valvular Heart Disease Clinical Practice Guidelines (ACC/AHA, 2021)
The American College of Cardiology (ACC) and American Heart Association (AHA) released their updated recommendations on managing valvular heart disease in December 2020. [23, 24] 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.
Indications for intervention for valvular regurgitation are symptomatic relief and prevention of the irreversible long-term consequences of left ventricular volume overload. Lowered thresholds for intervention than they were previously are owing to more durable treatment options and lower procedural risks.
A mitral transcatheter edge-to-edge repair benefits patients with severely symptomatic primary mitral regurgitation (MR) who are at high or prohibitive surgical risk, as well as benefits a select subset of patients with secondary MR who remain severely symptomatic despite guideline-directed management and heart failure therapy.
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.
For more information, please go to Aortic Stenosis, Aortic Regurgitation, Mitral Stenosis, Mitral Regurgitation, and Tricuspid Regurgitation.
For more Clinical Practice Guidelines, please go to Guidelines.
Management of Valvular Heart Disease (VHD) Clinical Practice Guidelines (ESC/EACTS, 2021)
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), [25] including the following recommendations on mitral valve disease:
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Surgery (mitral valve repair) is recommended for symptomatic patients with severe primary mitral regurgitation who are operable and not high-risk and for asymptomatic patients with LV dysfunction.
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In cases of severe secondary mitral regurgitation, valve surgery/intervention is recommended only for patients who remain symptomatic despite guideline-directed medical treatment (GDMT; including cardiac resynchronization therapy [CRT] if indicated).
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Acute stage of mitral regurgitation (MR) (mitral valve insufficiency).
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Chronic compensated stage of mitral regurgitation (MR) (mitral valve insufficiency).
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Chronic decompensated stage of mitral regurgitation (MR) (mitral valve insufficiency).
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Dilated cardiomyopathy with significant mitral regurgitation (MR) (mitral valve insufficiency) by transthoracic echocardiogram (A) and cardiac magnetic resonance imaging (B).
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Cleft mitral valve seen in parasternal short axis view (A) with mild mitral regurgitation (MR) (mitral valve insufficiency) in 4-chamber apical view (B).
