Recommendations L. Recommendations.
| Recommendations | Classa | Levelb |
|---|---|---|
| Recommendations for management of CAD in patients with VHD | ||
| Diagnosis of CAD | ||
| Coronary angiography is recommended before valve surgery in patients with severe VHD and any of the following: • History of cardiovascular disease. • Suspected myocardial ischaemia. • LV systolic dysfunction. • In men >40 years of age and postmenopausal women. • One or more cardiovascular risk factors. |
I | C |
| Coronary angiography is recommended in the evaluation of severe SMR. | I | C |
| Indications for myocardial revascularization | ||
| CABG is recommended in patients with a primary indication for aortic/mitral/tricuspid valve surgery and coronary artery diameter stenosis ≥70%. | I | C |
| Recommendations on management of atrial fibrillation in patients with native VHD | ||
| Anticoagulation | ||
| For stroke prevention in AF patients who are eligible for OAC, NOACs are recommended in preference to VKAs in patients with aortic stenosis, aortic and mitral regurgitation. | I | A |
| The use of NOACs is not recommended in patients with AF and moderate to severe mitral stenosis. | III | C |
| Recommendations on indications for surgery in (A) severe aortic regurgitation and (B) aortic root or tubular ascending aortic aneurysm (irrespective of the severity of aortic regurgitation) | ||
| A) Severe aortic regurgitation | ||
| Surgery is recommended in symptomatic patients regardless of LV function. | I | B |
| Surgery is recommended in asymptomatic patients with LVESD >50mm or LVESD >25 mm/m2 BSA (in patients with small body size) or resting LVEF ≤50%. | I | B |
| Surgery is recommended in symptomatic and asymptomatic patients with severe aortic regurgitation undergoing CABG or surgery of the ascending aorta or of another valve. | I | C |
| B) Aortic root or tubular ascending aortic aneurysm (irrespective of the severity of aortic regurgitation) | ||
| Valve-sparing aortic root replacement is recommended in young patients with aortic root dilation, if performed in experienced centres and durable results are expected. | I | B |
| Ascending aortic surgery is indicated in patients with Marfan syndrome who have aortic root disease with a maximal ascending aortic diameter ≥50 mm. | I | C |
| Recommendations on indications for intervention in symptomatic (A) and asymptomatic (B) aortic stenosis and recommended mode of intervention (C) | ||
| A) Symptomatic aortic stenosis | ||
| Intervention is recommended in symptomatic patients with severe, high-gradient aortic stenosis [mean gradient ≥40 mmHg, peak velocity ≥4.0 m/s and valve area ≤1.0 cm2 (or ≤0.6 cm2/m2)] . | I | B |
| Intervention is recommended in symptomatic patients with severe low-flow (SVi ≤35 mL/m2), low-gradient (<40 mmHg) aortic stenosis with reduced ejection fraction (<50%) and evidence of flow (contractile) reserve. | I | B |
| Intervention is not recommended in patients with severe comorbidities when the intervention is unlikely to improve quality of life or prolong survival >1 year. | III | C |
| B) Asymptomatic patients with severe aortic stenosis | ||
| Intervention is recommended in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF <50%) without another cause. | I | B |
| Intervention is recommended in asymptomatic patients with severe aortic stenosis and demonstrable symptoms on exercise testing. | I | C |
| C) Mode of intervention | ||
| Aortic valve interventions must be performed in Heart Valve Centres that declare their local expertise and outcomes data, have active interventional cardiology and cardiac surgical programmes on site, and a structured collaborative Heart Team approach. | I | C |
| The choice between surgical and transcatheter intervention must be based upon careful evaluation of clinical, anatomical, and procedural factors by the Heart Team, weighing the risks and benefits of each approach for an individual patient. The Heart Team recommendation should be discussed with the patient who can then make an informed treatment choice. | I | C |
| SAVR is recommended in younger patients who are low risk for surgery (<75 years and STS-PROM/ EuroSCORE II <4%), or in patients who are operable and unsuitable for transfemoral TAVI. | I | B |
| TAVI is recommended in older patients (≥75 years), or in those who are high risk (STS-PROM/EuroSCORE II >8%) or unsuitable for surgery. | I | A |
| SAVR or TAVI are recommended for remaining patients according to individual clinical, anatomical, and procedural characteristics. | I | B |
| D) Concomitant aortic valve surgery at the time of other cardiac/ascending aorta surgery | ||
| SAVR is recommended in patients with severe aortic stenosis undergoing CABG or surgical intervention on the ascending aorta or another valve. | I | C |
| Recommendations on indications for intervention in severe primary mitral regurgitation | ||
| Mitral valve repair is the recommended surgical technique when the results are expected to be durable. | I | B |
| Surgery is recommended in symptomatic patients who are operable and not high risk. | I | B |
| Surgery is recommended in asymptomatic patients with LV dysfunction (LVESD ≥40 mm and/or LVEF ≤60%). | I | B |
| Recommendations on indications for mitral valve intervention in chronic severe secondary mitral regurgitation | ||
| Valve surgery/intervention is recommended only in patients with severe SMR who remain symptomatic despite GDMT (including CRT if indicated) and has to be decided by a structured collaborative Heart Team. | I | B |
| Patients with concomitant coronary artery or other cardiac disease requiring treatment | ||
| Valve surgery is recommended in patients undergoing CABG or other cardiac surgery. | I | B |
| Recommendations on indications for percutaneous mitral commissurotomy and mitral valve surgery in clinically significant (moderate or severe) mitral stenosis (valve area ≤1.5 cm2) | ||
| PMC is recommended in symptomatic patients without unfavourable characteristics for PMC. | I | B |
| PMC is recommended in any symptomatic patients with a contraindication or a high risk for surgery. | I | C |
| Mitral valve surgery is recommended in symptomatic patients who are not suitable for PMC in the absence of futility. | I | C |
| Recommendations on indications for intervention in tricuspid valve disease | ||
| Recommendations on tricuspid stenosis | ||
| Surgery is recommended in symptomatic patients with severe tricuspid stenosis. | I | C |
| Surgery is recommended in patients with severe tricuspid stenosis undergoing left-sided valve intervention. | I | C |
| Recommendations on primary tricuspid regurgitation | ||
| Surgery is recommended in patients with severe primary tricuspid regurgitation undergoing left-sided valve surgery. | I | C |
| Surgery is recommended in symptomatic patients with isolated severe primary tricuspid regurgitation without severe RV dysfunction. | I | C |
| Recommendations on secondary tricuspid regurgitation | ||
| Surgery is recommended in patients with severe secondary tricuspid regurgitation undergoing left-sided valve surgery. | I | B |
| Recommendations for prosthetic valve selection | ||
| Mechanical prostheses | ||
| A mechanical prosthesis is recommended according to the desire of the informed patient and if there are no contraindications to long-term anticoagulation. | I | C |
| A mechanical prosthesis is recommended in patients at risk of accelerated SVD. | I | C |
| Biological prostheses | ||
| A bioprosthesis is recommended according to the desire of the informed patient. | I | C |
| A bioprosthesis is recommended when good-quality anticoagulation is unlikely (adherence problems, not readily available), contraindicated because of high bleeding risk (previous major bleed, comorbidities, unwillingness, adherence problems, lifestyle, occupation), and in those patients whose life expectancy is lower than the presumed durability of the bioprosthesis. | I | C |
| A bioprosthesis is recommended in case of reoperation for mechanical valve thrombosis despite good long-term anticoagulant control. | I | C |
| Recommendations for perioperative and postoperative antithrombotic management of valve replacement or repair | ||
| Management of antithrombotic therapy in the perioperative period | ||
| It is recommended that VKAs are timely discontinued prior to elective surgery to aim for an INR <1.5. | I | C |
| Bridging of OAC, when interruption is needed, is recommended in patients with any of the following indications: • Mechanical prosthetic heart valve. • AF with significant mitral stenosis. • AF with a CHA2DS2-VASc score ≥3 for women or 2 for men. • Acute thrombotic event within the previous 4 weeks. • High acute thromboembolic risk. |
I | C |
| Therapeutic doses of either UFH or subcutaneous LMWH are recommended for bridging. | I | B |
| In patients with MHVs, it is recommended to (re)-initiate the VKA on the first postoperative day. | I | C |
| In patients who have undergone valve surgery with an indication for postoperative therapeutic bridging, it is recommended to start either UFH or LMWH 12-24 h after surgery. | I | C |
| In patients undergoing surgery, it is recommended that aspirin therapy, if indicated, is maintained during the periprocedural period. | I | C |
| In patients treated with DAPT after recent PCI (within 1 month) who need to undergo heart valve surgery in the absence of an indication for OAC, it is recommended to resume the P2Y12 inhibitor postoperatively as soon as there is no concern over bleeding. | I | C |
| Patients with an indication to concomitant antiplatelet therapy | ||
| After uncomplicated PCI or ACS in patients requiring long-term OAC, early cessation (≤1 week) of aspirin and continuation of dual therapy with OAC and a P2Y12 inhibitor (preferably clopidogrel) for up to 6 months (or up to 12 months in ACS) is recommended if the risk of stent thrombosis is low or if concerns about bleeding risk prevail over concerns about risk of stent thrombosis, irrespective of the type of stent used. | I | B |
| Discontinuation of antiplatelet treatment in patients treated with an OAC is recommended after 12 months. | I | B |
| Surgical valve replacement | ||
| OAC using a VKA is recommended lifelong for all patients with a MHV prosthesis. | I | B |
| For patients with a VKA, INR self-management is recommended provided appropriate training and quality control are performed. | I | B |
| OAC is recommended for patients undergoing implantation of a surgical BHV who have other indications for anticoagulation. | I | C |
| NOACs are not recommended in patients with an MHV. | III | B |
| Transcatheter aortic valve implantation | ||
| OAC is recommended lifelong for TAVI patients who have other indications for anticoagulation. | I | B |
| Lifelong SAPT is recommended after TAVI in patients with no baseline indication for OAC. | I | A |
| Routine use of OAC is not recommended after TAVI in patients who have no baseline indication for OAC. | III | B |
| Recommendations on management of prosthetic valve dysfunction | ||
| Mechanical prosthetic thrombosis | ||
| Urgent or emergency valve replacement is recommended for obstructive thrombosis in critically ill patients without serious comorbidity. | I | B |
| Bioprosthetic thrombosis | ||
| Anticoagulation using a VKA and/or UFH is recommended in bioprosthetic valve thrombosis before considering reintervention. | I | C |
| Haemolysis and paravalvular leak | ||
| Reoperation is recommended if a paravalvular leak is related to endocarditis or causes haemolysis requiring repeated blood transfusions or leading to severe heart failure symptoms. | I | C |
| Bioprosthetic failure | ||
| Reoperation is recommended in symptomatic patients with a significant increase in transprosthetic gradient (after exclusion of valve thrombosis) or severe regurgitation. | I | C |
| ACS: acute coronary syndrome; AF: atrial fibrillation; BHV: biological heart valve; BSA: body surface area; CABG: coronary artery bypass grafting; CAD: coronary artery disease; CRT: cardiac resynchronization therapy; DAPT: dual antiplatelet therapy; EuroSCORE: European System for Cardiac Operative Risk Evaluation; GDMT: guidelinedirected medical therapy; h: hours; INR: international normalized ratio; LMWH: low-molecular-weight heparin; LV: left ventricle/left ventricular; LVEF: left ventricular ejection fraction; LVESD: left ventricular end-systolic diameter; MHV: mechanical heart valve; MR: mitral regurgitation; NOAC: non-vitamin K antagonist oral anticoagulant; OAC: oral anticoagulation; PCI: percutaneous coronary intervention; PMC: percutaneous mitral commissurotomy; RV: right ventricle/right ventricular; SAPT: single antiplatelet therapy; SAVR: surgical aortic valve replacement; SMR: secondary mitral regurgitation; STS-PROM: Society of Thoracic Surgeons – predicted risk of mortality; SVD: structural valve deterioration; SVi: stroke volume index; TAVI: transcatheter aortic valve implantation; UFH: unfractionated heparin; VHD: valvular heart disease; VKA: vitamin K antagonist. | ||