What is the recommended management approach for patients with valvular heart disease according to the American Heart Association (AHA)/American College of Cardiology (ACC) guidelines?

Management of Valvular Heart Disease: 2020 AHA/ACC Guideline Framework

All patients with severe valvular heart disease being considered for intervention must be evaluated by a Multidisciplinary Heart Valve Team, with referral to or consultation with a Primary or Comprehensive Valve Center. 1

Core Staging System

The 2020 guidelines mandate classification of valvular heart disease into four stages (A through D) based on:

• Symptom severity 1
• Valve anatomic abnormalities 1
• Degree of valve dysfunction 1
• Ventricular and pulmonary circulatory response 1

Diagnostic Algorithm

Initial Evaluation

Correlate physical examination findings with noninvasive testing results (ECG, chest x-ray, transthoracic echocardiogram) to establish diagnosis and severity. 1

When Discordance Exists

If physical examination conflicts with initial noninvasive testing, proceed with: 1

• Advanced noninvasive imaging: CT, cardiac MRI, or stress testing 1
• Invasive testing: Transesophageal echocardiography or cardiac catheterization 1

Anticoagulation Management in Atrial Fibrillation

For Most Valvular Heart Disease Patients with AF

Use shared decision-making based on CHA₂DS₂-VASc score to choose between: 1

• Vitamin K antagonist 1
• Non-vitamin K antagonist oral anticoagulant (NOAC) 1

Mandatory Vitamin K Antagonist Use

Patients with rheumatic mitral stenosis or mechanical prosthetic valves and atrial fibrillation must receive vitamin K antagonist therapy—NOACs are contraindicated. 1

Aortic Stenosis Management

Primary Intervention Triggers

Intervention with transcatheter or surgical valve replacement is indicated primarily for symptomatic severe aortic stenosis or reduced left ventricular systolic function. 1

Earlier Intervention Considerations

Consider intervention before symptom onset when: 1

• Exercise testing demonstrates objective exercise limitation or abnormal hemodynamic response 1
• Biomarkers (BNP/NT-proBNP) are significantly elevated 1
• Rapid hemodynamic progression is documented on serial imaging 1
• Very severe stenosis is present (aortic velocity >5 m/s or mean gradient >60 mmHg) 1

TAVR vs. SAVR Decision-Making

The choice between transcatheter aortic valve implantation and surgical aortic valve replacement requires shared decision-making that weighs lifetime risks and benefits of valve type (mechanical vs. bioprosthetic) and approach (transcatheter vs. surgical). 1

The indications for TAVR have expanded based on multiple randomized trials across all surgical risk categories. 1

Valvular Regurgitation Management

Intervention Thresholds

Thresholds for intervention in valvular regurgitation are now lower than previously recommended due to more durable treatment options and reduced procedural risks. 1

Primary indications remain: 1

• Relief of symptoms 1
• Prevention of irreversible left ventricular volume overload consequences 1

Mitral Regurgitation: Transcatheter Edge-to-Edge Repair

For primary mitral regurgitation: TEER benefits severely symptomatic patients at high or prohibitive surgical risk. 1

For secondary mitral regurgitation: TEER benefits a select subset who remain severely symptomatic despite optimal guideline-directed management and therapy for heart failure. 1

Tricuspid Regurgitation

Surgical intervention for severe symptomatic isolated tricuspid regurgitation should occur before the onset of severe right ventricular dysfunction or end-organ damage to liver and kidney. 1

This is particularly relevant for patients with device leads and atrial fibrillation, who commonly develop this condition. 1

Multidisciplinary Heart Valve Team Requirements

Team Composition (Class I Recommendation)

The team must include at minimum: 1

• Cardiologist with valvular heart disease expertise 1
• Cardiovascular surgeon 1
• Structural valve interventionalist (when catheter-based therapy considered) 1

When to Consult Valve Centers (Class IIa Recommendation)

Consultation with or referral to Primary or Comprehensive Heart Valve Centers is reasonable for: 1

• Asymptomatic patients with severe valvular heart disease 1
• Patients who may benefit from valve repair versus replacement 1
• Patients with multiple comorbidities for whom valve intervention is considered 1

Comprehensive (Level I) vs. Primary (Level II) Valve Centers

Comprehensive Centers must offer: 1

• All transcatheter approaches including alternative access TAVI (transaortic, transapical, subclavian, carotid) 1
• Complex surgical procedures including valve-sparing aortic root procedures, root enlargement, and reoperative valve surgery 1
• Multivalve operations 1
• Advanced imaging expertise including CT for procedural planning and interventional echocardiography 1

Primary Centers must offer: 1

• Transfemoral TAVI 1
• Standard SAVR 1
• Mitral repair for posterior leaflet primary MR 1
• Mitral valve replacement 1

Prosthetic Valve Dysfunction

Catheter-based treatment for bioprosthetic valve dysfunction is reasonable in selected patients with leaflet degeneration or paravalvular leak in the absence of active infection. 1

Bioprosthetic valve dysfunction occurs through two mechanisms: 1

• Structural valve degeneration 1
• Valve thrombosis 1

Surgical Risk Assessment

Operative Mortality Rates (STS Database 2019)

The following median mortality rates inform risk stratification: 1

• Isolated AVR: 2.2% 1
• AVR with CABG: 4% 1
• Mitral valve repair: 1% 1
• Mitral valve replacement: 5% 1
• AVR with mitral valve replacement: 9% 1
• Mitral valve replacement with CABG: 9% 1

High-Risk Features

Major organ system compromise includes: 1

• Severe LV systolic/diastolic dysfunction or RV dysfunction with fixed pulmonary hypertension 1
• Chronic kidney disease stage 3 or worse 1
• FEV₁ <50% or DLCO₂ <50% of predicted 1
• Central nervous system dysfunction (dementia, Parkinson's, CVA with persistent limitation) 1
• Active malignancy 1
• Cirrhosis history, variceal bleeding, or elevated INR without anticoagulation 1

Critical Pitfalls to Avoid

Do not operate on moderate mitral regurgitation outside of concomitant cardiac surgery, as this exposes patients to surgical risk without established benefit. 2

Do not bypass medical optimization in patients with heart failure and valvular disease, as guideline-directed medical therapy may reduce functional components of regurgitation and obviate or delay surgery. 2

Do not delay tricuspid valve intervention until severe right ventricular dysfunction or end-organ damage develops, as outcomes deteriorate significantly at this stage. 1

Do not use NOACs in patients with mechanical prosthetic valves or rheumatic mitral stenosis, as vitamin K antagonists are mandatory in these populations. 1