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Highlights from the new ESC Guidelines on the management of valvular heart disease (version 2012)

Valvular Heart Disease

The most important and/or novel aspects of the guidelines were:

1. The importance of consensus decision-making and the establishment of the “heart team” as the cornerstone of diagnosis, prognostic evaluation, and decision-making on treatment

The ‘heart team’ should have a particular expertise in valvular heart disease (VHD), including cardiologists, cardiac surgeons, imaging specialists, anaesthetists and, if needed, general practitioners, geriatricians, or intensive care specialists. This ‘heart team’ approach is particularly advisable in the management of high-risk patients and is also important for other subsets, such as asymptomatic patients, where the evaluation of valve reparability is a key component in decision-making.

2. Clinical evaluation
The patient should be questioned on his/her lifestyle to detect progressive changes in daily activity in order to limit the subjectivity of symptom analysis, particularly in the elderly. Clinical examination plays a major role in the detection of VHD in asymptomatic patients. It is the first step in the definitive diagnosis of VHD and the assessment of its severity. An electrocardiogram (ECG) and a chest X-ray are usually carried out in conjunction with a clinical examination.

Intervention is indicated in patients with severe valve disease causing symptoms and /or ventricular dysfunction unless the ‘heart team’ states that the patient is not suitable for surgery.

Essential questions in the evaluation of a patient for valvular intervention:

  • Is valvular heart disease severe?
  • Does the patient have symptoms?
  • Are symptoms related to valvular disease?
  • What are patient life expectancy and expected quality of life?
  • Do the expected benefits of intervention (vs. spontaneous outcome) outweigh its risks?
  • What are the patient's wishes?
  • Are local resources optimal for planned intervention?

3. Confirmation of echocardiography as the key tool in diagnosing and quantifying the severity of valvular heart disease, and for prognostic evaluation

The wider use of echocardiography due to new technologies and its use in different situations are also noted. Echocardiography is recognized as the patient assessment technique par excellence. However, the guidelines emphasize that decisions should not be based on any one parameter or threshold, but rather on an integrated approach to assessing the severity of lesions.

4. Developments in aortic stenosis (AS), which included a recognition that low-gradient, low-flow aortic stenosis (AS) with preserved ejection fraction constituted a new problem for clinical diagnosis, and modifications to surgical indications for asymptomatic AS:

  • Aortic valve replacement should be considered in symptomatic patients with low-flow, low gradient (<40 mmHg) aortic stenosis with normal ejection fraction only if comprehensive evaluation suggests significant obstruction.
  • Surgery should be considered in asymptomatic patients at low operative risk, with normal exercise performance, with very severe aortic stenosis or progressive disease. There is a new IIa (B) indication for very intense stenosis using a maximum transvalvular speed of 5.5 m/s. Surgery may also be considered in patients with markedly elevated natriuretic peptide levels, significant increase of mean pressure gradient by exercise echocardiography or excessive left ventricular hypertrophy.

5. Changes in previous recommendations regarding aortic surgery, and assumption that in aortic regurgitation pathology of the aortic root is frequent

  • In patients with Marfan syndrome, surgery is indicated when the maximal ascending aortic diameter is ≥ 50 mm, while the threshold for intervention should be lower in patients with risk factors for progression.
  • For patients with bicuspid valve and risk factors, the indication for surgery remains a diameter of 50 mm. In other circumstances, surgery is indicated at diameters ≥ 55 mm.
  • The thresholds are lower if aortic valve replacement is combined with the treatment of aortic root disease or if valve repair is performed.

6. Developments in surgical indications for mitral regurgitation (MR)

  • Valve repair should be the preferred technique when it is expected to be durable. As a consequence it is important to increase surgical expertise and the number of reference centres for this frequently occurring disease.
  • In asymptomatic patients with primary mitral regurgitation (MR) surgery should be considered in those patients with preserved left ventricular function, high likelihood of durable repair, low surgical risk, flail leaflet and left ventricular end-systolic diameter >40 mm. Modifications have been introduced for asymptomatic patients and surgery is now considered an option in patients with normal ejection fraction, a high probability of effective repair, low surgical risk, and any of the following:
    • Leaflet prolapse and end-systolic diameter>40 mm (or >22 mm/m2 in small-stature patients) (class IIa).
    • Atrial size>60 mm/m2 in sinus rhythm (class IIb).
    • Pulmonary hypertension on exertion (systolic pulmonary artery>60 mmHg) (class IIb)
  • In patients with secondary MR, severe MR should be corrected at the time of bypass surgery. The indications for isolated mitral valve surgery in symptomatic patients with severe secondary MR and severely depressed systolic LV function, who cannot be revascularized or who present with cardiomyopathy, are questionable.
  • Percutaneous mitral valve repair using the edge to edge technique may be considered in high risk or inoperable patients refractory to optimal medical management with the aim of improving symptoms.

7. Few changes in mitral stenosis

  • Most patients with severe mitral stenosis and favourable valve anatomy currently undergo percutaneous mitral commissurotomy.
  • Decision-making as to the type of intervention in patients with unfavourable anatomy is still a matter of debate and must take into account the multifactorial nature of predicting the results of percutaneous commissurotomy.

8. Changes in surgical indications for tricuspid regurgitation

  • Isolated tricuspid valve surgery in severe primary tricuspid regurgitation (TR) is recommended in patients with symptoms as well as in asymptomatic patients with progressive right ventricular (RV) enlargement and/or initial signs of RV dysfunction. Severe, isolated tricuspid regurgitation in patients with mild symptoms and progressive deterioration of right ventricular function is now a IIa C indication.
  • During left sided valve surgery, tricuspid valve surgery is indicated in patients with severe tricuspid regurgitation (TR) and should be considered in the presence of moderate primary TR or mild to moderate secondary TR if there is significant annular dilatation. In patients undergoing left valve heart surgery, tricuspid repair is considered a type IIa C indication in those with mild tricuspid regurgitation when the annulus is dilated (>40 mm or >21 mm/m2)

9. Indications and choice on prosthesis types

The choice of the type of valve prosthesis should be individualized and discussed in detail with the patient and surgeon, taking into account multiple factors, but age is the crucial factor.

  • The age at which a bioprosthesis is recommended over a mechanical prosthesis has been lowered. The IIa recommendation is now to use an aortic bioprosthesis in patients older than 65 years and a mitral bioprosthesis in those over 70 years. Both bioprostheses and mechanical prostheses are considered acceptable in patients aged 60 years to 65 years (aortic prosthesis) or 65 years to 70 years (mitral position), depending on individual patient factors.
  • The new guidelines also emphasize a preference for bioprosthesis over mechanical prosthesis in the tricuspid position. Also new is the recommendation to perform, as required, an enlargement of the aortic annulus to increase the size of the implanted prosthesis and prevent significant disparity of the prosthesis (defined as effective valve area <0.65 cm2/m2).

10. Indications on antithrombotic therapy for patients with prosthetic valves

  • A recommendation for concomitant treatment with acetylsalicylic acid and low-dose oral anticoagulant for patients with mechanical prostheses and arteriosclerosis.
  • In the first 3 months after implantation of a mitral or tricuspid bioprosthetic, oral anticoagulant is recommended; In patients with aortic bioprostheses the use of low-dose aspirin is now favoured for a 3-month postoperative period.
  • Oral anticoagulation is also recommended for the first 3 months after mitral valve repair.
  • The guidelines explicitly recognize that the new anticoagulants (factor IIa or Xa inhibitors) are not indicated for patients with mechanical prostheses and that low molecular weight heparins may be useful for anticoagulation of mechanical prostheses. The guidelines also support the use of dual antiplatelet therapy in patients who have undergone transcatheter aortic valve implantation  or percutaneous mitroplasty, although there is no evidence to indicate its exact duration.

11. The incorporation of percutaneous techniques for selected cases of severe AS and MR

  • TAVI should be performed only ‘in hospitals with cardiac surgery on-site’ and with a ‘heart team’ available to assess individual patient risks.
  • TAVI is indicated in patients with severe symptomatic aortic stenosis who are judged, by the ‘heart team’, to be unsuitable for surgery but have sufficient life expectancy is a IB indication. TAVI should be considered as a class IIa B  indication for high-risk patients with severe symptomatic aortic stenosis based on the individual risk profile as assessed by the ‘heart team’, rather than on thresholds of risk scores. TAVI should not be performed in patients at low or intermediate risk for surgery.
  • Most patients with severe mitral stenosis and favourable valve anatomy currently undergo percutaneous mitral commissurotomy.
  • There is some support for percutaneous treatment using the MitraClip in selected MR patients; it is considered a class IIb indication in high risk or inoperable patients with secondary MR.