2017 Focused Update on Management of Valvular Heart Disease

Guideline Watch |
April 24, 2017

2017 Focused Update on Management of Valvular Heart Disease

  1. Howard C. Herrmann, MD

These guidelines touch upon infective endocarditis, treatment of aortic stenosis and of primary and secondary mitral regurgitation, and direct-acting oral anticoagulants, among other topics.

  1. Howard C. Herrmann, MD

Sponsoring Organizations: American Heart Association and American College of Cardiology

Target Audience: Primary care providers and cardiologists (both general and subspecialists) who treat patients with valvular heart disease (VHD)

Target Population: Adults with VHD

Background and Objective

Since the 2014 publication of the last comprehensive guideline on VHD (NEJM JW Cardiol Jun 2014 and J Am Coll Cardiol 2014; 63:2438, knowledge has rapidly progressed regarding the natural history of VHD; new medications have been approved, such as the direct-acting oral anticoagulants (DOACs); and transcatheter therapies have advanced. This progress has prompted this focused update.

Key Points

  • The Class IIa (moderate recommendation) guideline that antibiotic prophylaxis before dental procedures is reasonable for patients at increased risk for infective endocarditis has now been extended to patients with transcatheter prosthetic valves.

  • DOACs are now considered reasonable alternatives (Class IIa) to vitamin K antagonists (VKAs) for patients with VHD and atrial fibrillation (CHA2DS2-VASc score, ≥2), although VKAs are specifically preferred for patients with mitral stenosis, who were excluded from DOAC trials.

  • Transcatheter aortic valve replacement (TAVR) has received a Class I (strong) recommendation along with surgery for patients with severe and symptomatic aortic stenosis (AS) at high risk for surgery and a Class IIa recommendation for those at intermediate risk. Treatment decisions depend on individual patients' risks, values, and preferences.

  • For primary or degenerative severe mitral regurgitation (MR), surgery is now considered reasonable (Class IIa) in asymptomatic patients even with ejection fraction >60% and left ventricular end-systolic diameter <40 mm if adverse progression on serial imaging studies is evident.

  • In chronic secondary (functional) MR, chordal-sparing mitral valve replacement is a reasonable alternative to downsized annuloplasty repair (Class IIa).

  • The age limit for considering a mechanical prosthesis is lowered from 60 to 50 (Class IIa), unless anticoagulation is not desired, cannot be monitored, or is contraindicated.

  • New data on leaflet thrombus with surgical and TAVR prostheses have prompted new anticoagulation guidelines. VKA is reasonable for ≤6 months after surgical mitral and aortic valve replacement in patients at low bleeding risk (Class IIa) and ≥3 months after TAVR (Class IIb; weak recommendation). Initial therapy with VKA is reasonable (a new Class IIa guideline) in patients with suspected or confirmed bioprosthetic valve thrombosis who are hemodynamically stable.

  • TAVR valve-in-valve is reasonable therapy for bioprosthetic aortic valve stenosis or regurgitation in patients at high or prohibitive redo surgical risk (Class IIa).

Comment

This focused update provides new recommendations in several important areas. The recommendation to consider mitral valve replacement in chronic MR may be controversial as it is based on a single trial (mostly in patients undergoing coronary artery bypass grafting), powered for a surrogate endpoint, and due to the high recurrence rate with annuloplasty alone. The Class IIa recommendation for TAVR for intermediate risk may already be outdated (NEJM JW Cardiol May 2017 and N Engl J Med 2017; 376:1321) and may need to be “upgraded” to Class I. Finally, these updated guidelines emphasize the importance of shared decision making between providers and patients about types of valve prosthesis, in ways that balance the risks of age, procedures, bleeding risk, and patient preferences.

Editor Disclosures at Time of Publication

  • Disclosures for Howard C. Herrmann, MD at time of publication Consultant / Advisory board Leerink Swann; Wells Fargo; Edwards Lifesciences; BMO Capital Markets Equity Micro Interventional Devices, Inc. Grant / Research support Abbott Vascular; Bayer; Boston Scientific; Corvia; Edwards Lifesciences; St. Jude Medical; Medtronic; Cardiokinetix; University of Laval Editorial boards Catheterization and Cardiovascular Interventions; Circulation: Cardiovascular Interventions; Journal of Interventional Cardiology; Journal of Invasive Cardiology; Journal of the American College of Cardiology

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