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2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Originally publishedhttps://doi.org/10.1161/CIR.0000000000000932Circulation. 2021;143:e35–e71

Abstract

Aim:

This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.

Methods:

A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline.

Structure:

Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

Top 10 Take-Home Messages

  1. Disease stages in patients with valvular heart disease should be classified (Stages A, B, C, and D) on the basis of symptoms, valve anatomy, the severity of valve dysfunction, and the response of the ventricle and pulmonary circulation.

  2. In the evaluation of a patient with valvular heart disease, history and physical examination findings should be correlated with the results of noninvasive testing (ie, ECG, chest x-ray, transthoracic echocardiogram). If there is discordance between the physical examination and initial noninvasive testing, consider further noninvasive (computed tomography, cardiac magnetic resonance imaging, stress testing) or invasive (transesophageal echocardiography, cardiac catheterization) testing to determine optimal treatment strategy.

  3. For patients with valvular heart disease and atrial fibrillation (except for patients with rheumatic mitral stenosis or a mechanical prosthesis), the decision to use oral anticoagulation to prevent thromboembolic events, with either a vitamin K antagonist or a non–vitamin K antagonist anticoagulant, should be made in a shared decision-making process based on the CHA2DS2-VASc score. Patients with rheumatic mitral stenosis or a mechanical prosthesis and atrial fibrillation should receive oral anticoagulation with a vitamin K antagonist.

  4. All patients with severe valvular heart disease being considered for valve intervention should be evaluated by a multidisciplinary team, with either referral to or consultation with a Primary or Comprehensive Valve Center.

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

  6. Indications for transcatheter aortic valve implantation are expanding as a result of multiple randomized trials of transcatheter aortic valve implantation atrioversus surgical aortic valve replacement. The choice of type of intervention for a patient with severe aortic stenosis should be a shared decision-making process that considers the lifetime risks and benefits associated with type of valve (mechanical versus bioprosthetic) and type of approach (transcatheter versus surgical).

  7. Indications for intervention for valvular regurgitation are relief of symptoms and prevention of the irreversible long-term consequences of left ventricular volume overload. Thresholds for intervention now are lower than they were previously because of more durable treatment options and lower procedural risks.

  8. A mitral transcatheter edge-to-edge repair is of benefit to patients with severely symptomatic primary mitral regurgitation who are at high or prohibitive risk for surgery, as well as to a select subset of patients with secondary mitral regurgitation who remain severely symptomatic despite guideline-directed management and therapy for heart failure.

  9. Patients presenting with severe symptomatic isolated tricuspid regurgitation, commonly associated with device leads and atrial fibrillation, may benefit from surgical intervention to reduce symptoms and recurrent hospitalizations if done before the onset of severe right ventricular dysfunction or end-organ damage to the liver and kidney.

  10. 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.

Purpose of the Executive Summary

This executive summary of the valvular heart disease (VHD) guideline provides a synopsis with algorithms to guide clinicians in the screening, diagnosis, and management of patients with VHD. Tables and figures that are mentioned in this executive summary, but are not included here, appear in the full guideline.1

The full guideline1 has been updated with new evidence and provides newer options for diagnosis and treatment of VHD. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline document1 for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

This full guideline1 will replace the 2014 guideline2 and the 2017 focused update.3 Some recommendations from the earlier VHD guidelines have been updated by new evidence or a better understanding of earlier evidence, whereas others that were outdated, irrelevant, or overlapping were deleted or modified. The overall goal was to provide the clinician with concise, evidence-based, contemporary recommendations with supporting data to encourage their use. Sections were divided into the following: 1) general principles, 2) aortic stenosis, 3) aortic regurgitation, 4) bicuspid aortic valve, 5) mitral stenosis, 6) mitral regurgitation, 7) tricuspid valve disease, 8) mixed valve disease, 9) prosthetic valves, 10) infective endocarditis, 11) pregnancy, 12) surgical considerations, and 13) noncardiac surgery.

Document Review and Approval

This document was reviewed by 2 official reviewers each nominated by both the ACC and the AHA, as well as content reviewers nominated by the ACC and AHA. Authors’ RWI information is published in Appendix 1 of the full guideline.1 Reviewers’ RWI information is published in Appendix 2 of the full guideline.1

Class of Recommendation and Level of Evidence

The Class of Recommendation (COR) indicates the strength of recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The Level of Evidence (LOE) rates the quality of scientific evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 2).4

Table 2. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*

Table 2.

2. GENERAL PRINCIPLES

2.4. Basic Principles of Medical Therapy

2.4.1. Secondary Prevention of Rheumatic Fever

Tables in this section are located in the full guideline.1

2.4.2. IE Prophylaxis
2.4.3. Anticoagulation for AF in Patients With VHD

2.5. Evaluation of Surgical and Interventional Risk

2.6. The Multidisciplinary Heart Valve Team and Heart Valve Centers

2.7. Management of Patients With VHD After Valve Intervention
2.7.4. Periodic Imaging After Valve Intervention

3. AORTIC STENOSIS

3.2. Aortic Stenosis

3.2.1. Diagnosis and Follow-Up
3.2.1.1. Diagnostic Testing: Initial Diagnosis
3.2.1.5. Diagnostic Testing: Exercise Testing
3.2.2. Medical Therapy
3.2.3. Timing of Intervention
3.2.4. Choice of Intervention
3.2.4.1. Choice of Mechanical Versus Bioprosthetic AVR
3.2.4.2. Choice of SAVR Versus TAVI for Patients for Whom a Bioprosthetic AVR Is Appropriate

4. Aortic Regurgitation

4.3. Chronic AR

4.3.1. Diagnosis of Chronic AR
4.3.2. Medical Therapy
4.3.3. Timing of Intervention

5. Bicuspid Aortic Valve

5.1. BAV and Associated Aortopathy

5.1.1. Diagnosis and Follow-up of BAV
5.1.1.1. Diagnostic Testing: Initial Diagnosis
5.1.1.2. Diagnostic Testing: Routine Follow-Up
5.1.2. Interventions for Patients With BAV
5.1.2.1. Intervention: Replacement of the Aorta
5.1.2.2. Intervention: Repair or Replacement of the Aortic Valve

6. MITRAL STENOSIS

6.2. Rheumatic MS

6.2.1. Diagnosis and Follow-Up of Rheumatic MS
6.2.1.1. Diagnostic Testing: Initial Diagnosis
6.2.1.5. Diagnostic Testing: Exercise Testing
6.2.2. Medical Therapy
6.2.3. Intervention

6.3. Nonrheumatic Calcific MS

7. Mitral Regurgitation

7.2. Chronic Primary MR

7.2.2. Diagnosis and Follow-Up of Chronic Primary MR
7.2.2.1. Diagnostic Testing: Initial Diagnosis
7.2.2.2. Diagnostic Testing: Changing Signs or Symptoms
7.2.2.3. Diagnostic Testing: Routine Follow-Up
7.2.2.5. Diagnostic Testing: Exercise Testing
7.2.3. Medical Therapy
7.2.4. Intervention

7.3. Chronic Secondary MR

7.3.2. Diagnosis of Chronic Secondary MR
7.3.3. Medical Therapy
7.3.4. Intervention

8. Tricuspid Valve Disease

8.2. Tricuspid Regurgitation

8.2.1. Diagnosis of TR
8.2.2. Medical Therapy
8.2.3. Timing of Intervention

10. Mixed Valve Disease

10.1. Diagnosis of Mixed VHD

10.2. Timing of Intervention for Mixed VHD

10.2.1. Intervention for Mixed AS and AR

11. Prosthetic Valves

11.1. Evaluation and Selection of Prosthetic Valves

11.1.1. Diagnosis and Follow-Up of Prosthetic Valves
11.1.2. Selection of Prosthetic Valve Type: Bioprosthetic Versus Mechanical Valve

11.2. Antithrombotic Therapy

11.3. Bridging Therapy

11.4. Excessive Anticoagulation and Serious Bleeding With Prosthetic Valves

11.5. Thromboembolic Events With Prosthetic Valves

11.6. Acute Mechanical Valve Thrombosis

11.6.1. Diagnosis of Acute Mechanical Valve Thrombosis
11.6.2. Intervention

11.7. Bioprosthetic Valve Thrombosis

11.7.1. Diagnosis of Bioprosthetic Valve Thrombosis
11.7.2. Medical Therapy

11.8. Prosthetic Valve Stenosis

11.8.1. Diagnosis of Prosthetic Valve Stenosis
11.8.2. Intervention for Prosthetic Valve Stenosis

11.9. Prosthetic Valve Regurgitation

11.9.1. Diagnosis of Prosthetic Valve Regurgitation
11.9.3. Intervention

12. Infective Endocarditis

12.2. Diagnosis of IE

Tables in this section are located in the full guideline.1

12.3. Medical Therapy

12.4. Intervention

13. Pregnancy and VHD

13.1. Initial Management of Women With VHD Before and During Pregnancy

13.1.1. Medical Therapy for Women With VHD Before and During Pregnancy
13.1.2. Intervention for Women With Native VHD Before and During Pregnancy
13.1.2.1. Pre-Pregnancy Intervention
13.1.2.2. During-Pregnancy Intervention

13.2. Prosthetic Valves in Pregnant Women

13.2.1. Initial Management
13.2.2. Anticoagulation for Pregnant Women With Mechanical Prosthetic Heart Valves

14. Surgical Considerations

14.1. Evaluation and Management of CAD in Patients With VHD

14.1.1. Management of CAD in Patients Undergoing TAVI
14.1.2. Management of CAD in Patients Undergoing Valve Surgery

14.2. Intervention for AF in Patients With VHD

15. Noncardiac Surgery in Patients With VHD

15.1. Diagnosis of Patients With VHD Undergoing Noncardiac Surgery

15.2. Management of the Symptomatic Patient

15.3. Management of the Asymptomatic Patient

ACC/AHA Joint Committee Members

Patrick T. O’Gara, MD, MACC, FAHA, Chair; Joshua A. Beckman, MD, MS, FAHA, Chair-Elect; Glenn N. Levine, MD, FACC, FAHA, Immediate Past Chair*; Sana M. Al-Khatib, MD, MHS, FACC, FAHA*; Anastasia Armbruster, PharmD, AACC; Kim K. Birtcher, PharmD, MS, AACC; Joaquin Ciggaroa, MD, FACC*; Anita Deswal, MD, MPH, FACC, FAHA; Dave L. Dixon, PharmD, FACC; Lee A. Fleisher, MD, FACC, FAHA*; Lisa de las Fuentes, MD, MS, FAHA, FASE; Federico Gentile, MD, FACC*; Zachary D. Goldberger, MD, MSc, FACC, FAHA; Bulent Gorenek, MD, FACC, FESC; Norrisa Haynes, MD, MPH; Adrian F. Hernandez, MD, MHS; Mark A. Hlatky, MD, FACC, FAHA*; José A. Joglar, MD, FACC, FAHA; W. Schuyler Jones, MD, FACC; Joseph E. Marine, MD, FACC*; Daniel Mark, MD, MPH, FACC, FAHA; Latha Palaniappan, MD, MS, FAHA, FACC; Mariann R. Piano, RN, PhD, FAHA; Erica S. Spatz, MD, MHS, FACC; Jacqueline Tamis-Holland, MD, FACC; Duminda N. Wijeysundera, MD, PhD*; Y. Joseph Woo, MD, FAHA, FACC

* Former Joint Committee member; current member during the writing effort.

Footnotes

*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 in the full guideline for detailed information.

†ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison.

The American Heart Association requests that this document be cited as follows: Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O’Gara PT, Rigolin VH, Sundt TM 3rd, Thompson A, Toly C. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143:e35-e71. doi: 10.1161/CIR.0000000000000932

Developed in collaboration with and endorsed by the American Association for Thoracic Surgery, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons

ACC/AHA Joint Committee on Clinical Practice Guidelines Members, see page e54

https://www.ahajournals.org/journal/circ

This document was approved by the American College of Cardiology Clinical Policy Approval Committee in August 2020, the American Heart Association Science Advisory and Coordinating Committee in August 2020, and the American Heart Association Executive Committee in September 2020.

The Comprehensive RWI Data Supplement table is available in the full guideline at https://www.ahajournals.org/doi/suppl/10.1161/CIR.0000000000000932

Supplemental materials are available with this article at https://www.ahajournals.org/doi/suppl/10.1161/CIR.0000000000000932

This article has been copublished in the Journal of the American College of Cardiology.

Copies: This document is available on the websites of the American College of Cardiology (www.acc.org) and the American Heart Association (professional.heart.org). A copy of the document is also available at https://professional.heart.org/statements by selecting the “Guidelines & Statements” button. To purchase additional reprints, call 215-356-2721 or email .

The expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit https://professional.heart.org/statements. Select the “Guidelines & Statements” drop-down menu near the top of the webpage, then click “Publication Development.”

Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at https://www.heart.org/permissions. A link to the “Copyright Permissions Request Form” appears in the second paragraph (https://www.heart.org/en/about-us/statements-and-policies/copyright-request-form).

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