New 2021 Valvular Heart Disease Guidelines

The world of valvular heart disease has seen the publication in 2020-2021 of the updated version of guidelines for the management of heart valve diseases from both European and American committees, which provide important and novel insights, although with some substantial differences.^1,2

The most noticeable evolutions are these:

• •More evidence to support earlier intervention in low-risk asymptomatic patients with aortic stenosis and aortic, mitral, or tricuspid regurgitation.
• •New information from randomized controlled trials comparing transcatheter aortic valve implantation (TAVI) with surgery contributed to clarifying the role of each procedure in low-risk patients. Selection of the most appropriate mode of intervention should be performed according to heart team evaluation, considering the patient’s age, surgical risk, and clinical and anatomical characteristics (such as feasibility of transfemoral access). The guidelines stipulate an age cutoff for surgical replacement of <75 years with an STS score of <4% or unsuitable transfemoral access (Class I). The transcatheter option is reserved for those >75 years, STS score >8%, or unsuitable for surgery (Class I). Nontransfemoral transcatheter aortic valve replacement (TAVR) can be considered for those who are inoperable (Class IIb). In contradistinction to the European guidelines, the age cutoff in the American College of Cardiology/American Heart Association 2020 guidelines is 65 years. Local experience and outcome data, and, importantly, informed patient preference, play a fundamental role as well.
• •Single antiplatelet therapy is recommended after TAVI in patients without other indications for oral anticoagulants. For stroke prevention in patients with atrial fibrillation, the recommendation for non–vitamin K antagonist oral anticoagulants has been reinforced in patients with aortic stenosis and aortic and mitral regurgitation (MR) and those with surgical bioprostheses 3 months after implantation.
• •New definitions of the severity of secondary MR are proposed based on the outcomes of randomized trials on transcatheter edge-to-edge intervention (TEER). TEER has been evaluated against optimal medical therapy in secondary MR, resulting in an upgrade of the recommendation for patients fulfilling the criteria.
• •Transcatheter valve-in-valve implantation after the failure of surgical bioprostheses received an upgrading in its indications, based on many observational studies.
• •Preliminary experience suggests a potential role for transcatheter tricuspid valve intervention in inoperable symptomatic patients with severe tricuspid regurgitation.

These guidelines have to be understood also as a tool to address a vexing problem in patients with valvular heart disease (VHD), ie, undertreatment by the “mechanical” interventions that correct the “mechanical” dysfunctions represented by VHD. TAVR has been demonstrated in the massive number of patients with aortic stenosis who used to be considered inoperable.³ The massive and pervasive undertreatment of mitral and tricuspid regurgitation recently emphasized reinforce this call to action.^4,5 Because new therapeutic modalities offer new options and may be beneficial to treat patients6, 7, 8 who have been too often neglected, it is essential that improved algorithms for the evaluation and treatment of valve diseases be implemented (Figure 1). This approach is crucial for each cardiologist to translate the guidelines into the treatment of the individual patients who come under their care.

Figure 1.

Case Management of Valvular Heart Diseases

The management of valvular disease is often indicated after screening echocardiography requires comprehensive imaging, evaluation, and heart-team members who specialize in the various therapeutic modalities. The rescue intervention palliates the VHD and improves the complication, but generally with less than optimal outcome. Early intervention does not relieve an asymptomatic patient but aims at restoring life expectancy. Although the technical assessment is essential, the patients’ desires for their care are central to all decisions. AF = atrial fibrillation; BNP = B-type natriuretic peptide; Ex = exercise; HF = heart failure; Rx = therapy; VHD = valvular heart disease.

Although one would have wished for this goal of addressing the undertreatment of VHD that an increased emphasis on defining aortic stenosis severity based on the severity of aortic valve calcifications, on the consideration that patients with moderate MR may be at risk and warrant attention, on a specific scale of severity of functional MR among the most glaring issues, our whole process of evaluating valve disease warrants reconsideration to address VHD undertreatment.

In that regard it is essential that the comprehensive imaging required for optimal decisions be differentiated from screening echocardiography, which too often leaves gaps in the description of the causes, mechanism, and severity of VHDs.

Furthermore, to achieve this goal of optimized therapy, the most remarkable aspect in our opinion is the crucial emphasis on patient-centered evaluation for the intervention, taking into account their expectations and values. The concept of multidisciplinary heart valve centers and clinics and that of centers of excellence is described as a requirement for the first time in the Guidelines, as a further evolution of the heart team. The importance of the heart team is mentioned more than 30 times in the United States guidelines and more than 70 in the European guidelines. The concept of specialized disease-oriented clinics and teams is becoming a must in all centers performing valve interventions. This point emphasizes the central role of the VHD specialist, warranting specific education and training of the next future generation of physicians involved in the valve clinics. As a matter of fact, independently from the core specialization, heart valve disease now requires specific competences that are not included in the classic educational pathways of interventional cardiologists, cardiovascular surgeons, echocardiographers, or heart failure specialists. A common and standardized training pathway is advocated. The introduction of the concept of valve clinics represents in our opinion a strong call for a rethinking of the educational and training of new generations, which will naturally translate into the modern heart team concept operating in the valve clinic, hopefully allowing the heart team members to function together, respect one another, and avoid unproductive conflicts partially defined by the “old” educational tracks. We believe that many more therapeutic developments will soon become available to optimally restore the life expectancy of patients affected by VHD worldwide and that the best is yet to come.

Funding Support and Author Disclosures

Dr Taramasso has been a consultant or the recipient of consultancy fees from Abbott, Edwards Lifesciences, Boston Scientific, Shenqi Medical, CoreMedic, 4tech, Simulands, MTEx, Cardiovalve, and MEDIRA. Dr Enriquez-Sarano has been a consultant for Cryolife, Edwards, ChemImage, and HighLife.