What are the management approaches for patients with valvular heart disease according to the 2020 American College of Cardiology (ACC) and American Heart Association (AHA) guidelines?

Management of Valvular Heart Disease According to 2020 ACC/AHA Guidelines

The management of valvular heart disease (VHD) should be guided by a systematic approach based on disease staging, with all patients with severe VHD being evaluated by a Multidisciplinary Heart Valve Team when intervention is considered. 1

Disease Staging Framework

The 2020 ACC/AHA guidelines classify VHD into four progressive stages:

• Stage A: At risk for VHD
• Stage B: Progressive VHD
• Stage C: Asymptomatic severe VHD
• Stage D: Symptomatic severe VHD

This staging system incorporates valve anatomy, valve hemodynamics, ventricular response, and patient symptoms to guide management decisions.

Diagnostic Evaluation

Initial Assessment

• Comprehensive transthoracic echocardiography (TTE) is the cornerstone for diagnosis and evaluation of VHD 1
• Correlation of physical examination findings with imaging results is essential 1

Advanced Imaging

When TTE results are discordant with clinical findings:

• Transesophageal echocardiography (TEE)
• Cardiac CT
• Cardiac MRI
• Stress testing
• Cardiac catheterization

Management Principles by Valve Lesion

Aortic Stenosis (AS)

1. Symptomatic severe AS (Stage D):

   • AVR is recommended for all patients with symptomatic severe high-gradient AS 1
   • For symptomatic patients with low-flow, low-gradient AS with reduced LVEF, dobutamine stress echocardiography is useful to determine treatment strategy

2. Asymptomatic severe AS (Stage C):

   • AVR is recommended for asymptomatic patients with LVEF <50% 1
   • AVR is reasonable for very severe AS (Vmax ≥5 m/s) or rapidly progressing disease
   • Exercise testing may help identify seemingly asymptomatic patients who develop symptoms with exertion

Aortic Regurgitation (AR)

1. Symptomatic severe AR:

   • AVR is indicated regardless of LV systolic function 1

2. Asymptomatic severe AR:

   • AVR is indicated when LVEF ≤55% 1
   • AVR is reasonable with normal LVEF but severe LV dilation (LVESD >50 mm)

Mitral Stenosis (MS)

1. Symptomatic severe MS:

   • Percutaneous mitral balloon commissurotomy (PMBC) is recommended for patients with favorable valve morphology
   • Mitral valve surgery for patients with unfavorable valve morphology

2. Asymptomatic severe MS:

   • Intervention may be considered for very severe MS or new-onset atrial fibrillation

Mitral Regurgitation (MR)

1. Primary MR:

   • Mitral valve surgery is recommended for symptomatic patients with severe primary MR and LVEF >30% 1
   • Mitral valve repair is preferred over replacement when possible
   • For asymptomatic patients, surgery is recommended with LVEF 30-60% or LVESD ≥40 mm
   • Transcatheter edge-to-edge repair (TEER) is beneficial for severely symptomatic patients at high surgical risk 1

2. Secondary MR:

   • Optimize guideline-directed medical therapy (GDMT) for heart failure
   • TEER may benefit select patients with severe secondary MR who remain symptomatic despite GDMT 1

Tricuspid Regurgitation (TR)

1. Primary TR:

   • Surgery is recommended for severe TR in symptomatic patients
   • Surgery is reasonable for asymptomatic patients with progressive RV dilation

2. Secondary TR:

   • Diuretics are useful for symptom management 1
   • Treatment of the primary cause of heart failure is essential 1
   • Tricuspid valve surgery at the time of left-sided valve surgery is recommended for severe TR

Prosthetic Valve Management

1. Valve Selection:

   • Choice between mechanical and bioprosthetic valves should be based on shared decision-making 1
   • For patients <50 years without contraindication to anticoagulation, mechanical AVR is reasonable 1
   • Bioprosthetic valves are recommended when anticoagulation is contraindicated or undesired 1

2. Follow-up:

   • Baseline post-procedural TTE is recommended for all patients 1
   • For bioprosthetic surgical valves: TTE at 5 and 10 years, then annually 1
   • For transcatheter valves: Annual TTE is reasonable 1

Heart Valve Centers and Multidisciplinary Teams

The guidelines emphasize a heart valve center model with two tiers:

1. Comprehensive (Level I) Valve Centers:

   • Full range of transcatheter and surgical interventions
   • Advanced imaging capabilities
   • Recommended for complex cases

2. Primary (Level II) Valve Centers:

   • More limited range of interventions
   • Appropriate for less complex cases

Consultation with or referral to a valve center is reasonable for:

• Asymptomatic patients with severe VHD
• Patients who may benefit from valve repair versus replacement
• Patients with multiple comorbidities 1

Special Considerations

VHD and Noncardiac Surgery

• For symptomatic patients meeting standard indications for valve intervention, valve surgery should be performed before elective noncardiac surgery if possible 1
• Asymptomatic patients with moderate or greater VHD can generally undergo elective noncardiac surgery with appropriate perioperative monitoring 1

Mixed Valve Disease

• TTE is recommended to assess etiology, severity, and pathophysiological impact 1
• For mixed AS and AR with a peak velocity ≥4.0 m/s or mean gradient ≥40 mm Hg, AVR is recommended for symptomatic patients 1

Monitoring After Valve Intervention

• Baseline post-procedural TTE is recommended for all patients 1
• Periodic monitoring with TTE depends on type of intervention, time since intervention, ventricular function, and concurrent cardiac conditions 1
• For prosthetic valves with suspected dysfunction, additional imaging with TEE, CT, or fluoroscopy is recommended even if TTE appears normal 1

The management of VHD requires a systematic approach based on accurate diagnosis, appropriate timing of intervention, and long-term monitoring to optimize outcomes related to mortality, morbidity, and quality of life.