Assessment by a 'heart team' deemed essential to guide treatment in valvular heart disease TAVI included the latest joint guidelines on valve disease from ESC and EACTS New guidelines on valvular heart disease unveiled today at ESC Congress 2012 are a joint collaboration between the ESC and the EACTS (European Association for Cardio-Thoracic Surgery). (1) The collaboration, say Task Force chairmen Alec Vahanian (Hôpital Bichat, Paris) and Ottavio Alfieri (San Raffaele University Hospital, Milan) is critical, particularly in high-risk patients, given the guidelines' emphasis on a team approach. The "heart team" should include cardiologists, cardiac surgeons, imaging specialists, anaesthetists and others if needed in the decision-making process.
The Task Force emphasises the importance of a comprehensive evaluation of the cardiac and extra-cardiac condition of the patient, constantly checking consistency between the results of diagnostic investigation and clinical findings at each step of the decision-making process. In aortic stenosis and mitral regurgitation which are the two most frequent native valve disease the following recommendations have been emphasised: In aortic stenosis, the most important new treatment reviewed is transcatheter aortic valve implantation (TAVI). TAVI is recommended only "in hospitals with cardiac surgery on-site" and with a heart team available to assess individual patient risks. The indications for TAVI are based on the results of large European registries and, importantly, on results of the randomised PARTNER trials. TAVI is given a Class I B recommendation for use in patients with severe symptomatic aortic stenosis who are judged by the heart team as unsuitable for valve replacement, and a Class IIa B recommendation for high risk patients with severe symptomatic aortic stenosis based on the individual risk profile. The guidelines emphasise that, at present, TAVI should not be performed in patients at intermediate risk for surgery, for which no supporting data are currently available.
In mitral regurgitation, the second most frequent valve disease requiring surgery, the Task Force states that mitral valve repair should be the preferred approach when the repair is considered durable. Thus, it is important to increase surgical expertise and the number of reference centres. Following results from the EVEREST trials and European registries, edge to edge percutaneous mitral valve repair is reported to be relatively safe and generally well tolerated, even by patients in poor clinical condition. But the procedure reduces mitral regurgitation less effectively than mitral valve surgery. Thus, the Task Force states that percutaneous mitral valve repair using the edge to edge technique (Mitraclip) may be considered in high risk or inoperable patients refractory to optimal medical management with the aim of improving symptoms. The authors stress that longer follow-up is needed as well randomised clinical trials. On the difficult question of antithrombotic therapy after valve surgery, the need for a three-month period of postoperative anticoagulant therapy has been challenged in patients with aortic bioprostheses, with the use of low dose aspirin now favoured as an alternative. Finally, because of the paucity of evidence-based data in the field of valvular disease, the Task Force urges an increase in the research efforts in this field.
The content of the press release has been approved by the investigator.
1. The Joint Task Force on the Management of Valvular Heart Disease, of the European Society of Cardiology (ESC) and European Society of Cardio-Thoracic Surgery (EACTS). Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012; doi:10.1093/eurheartj/ehs109
* The most frequent acquired valvular heart diseases are regurgitation and stenosis of the heart's four valves (aortic and mitral on the left and pulmonary and tricuspid on the right). About the European Society of Cardiology The European Society of Cardiology (ESC) represents more than 75,000 cardiology professionals across Europe and the Mediterranean. Its mission is to reduce the burden of cardiovascular disease in Europe.
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