Comment on 2021 ESC/EACTS Guidelines for the management of valvular heart disease

The 2021 ESC/EACTS Guidelines has been recently published reporting new evidence and making a revision of the previous recommendations necessary. Besides the epidemiology-related remarks, the current practices, referring to the interventions and medical management, have been revised and updated.

1. From the etiological standpoint, the document has clearly indicated the rise of the degenerative disease and secondary involvement of the heart valves.
2. Secondly, the importance and quality of diagnosis provided by advanced imaging, like non-invasive evaluation using three-dimensional (3D) echocardiography , cardiac computed tomography (CCT) , cardiac magnetic resonance (CMR) , has been highlighted and is considered crucial before any type of interventions. In fact, a growing emphasis is put on the need for a comprehensive evaluation which should lead to an earlier and tailored surgery.
3. The raised experience and intervention safety allowed to focus much more efforts in expanding the indications for asymptomatic patients, particularly for patients with aortic stenosis and regurgitation, as well as tricuspid and mitral regurgitation. Under this light, the implementation of several anatomical criteria, derived from the more and more precise non-invasive tools, is particularly stressed along the revised recommendations. For instance, surgery in severe aortic regurgitation is now recommended in class I in asymptomatic patients not only with resting LVEF <_50%, but also with isolated LVESD >50 mm or LVESD >25 mm/m2 BSA (in patients with small body size) . Again, asymptomatic patients with severe aortic stenosis should be already considered for surgery (class IIa) when systolic LV is less than 55% without another cause . Also, the indications for intervention in primary and secondary mitral regurgitation have been clearly expanded and the very early approach became pivotal. The LVESD cut off for surgery in primary MR has been significantly reduced from 45 mm to 40 mm, indicating a confident commitment to act as early as possible (class I) . Moreover, mitral valve intervention (either surgical or endovascular) was proposed in advanced heart failure and characterized by secondary MR, despite of optimal medical treatment including cardiac resynchronization therapy (class Ia).
4. The procedures for tricuspid regurgitation have received a particular attention. Asymptomatic or mildly symptomatic patients affected by severe primary tricuspid regurgitation should be referred to surgery (Class IIa) when the RV and/or the tricuspid annulus is/are dilated before the progression to RV dysfunction. Likewise, patients with severe secondary tricuspid regurgitation who are symptomatic or have RV dilatation should be addressed to surgery, also in the absence of severe RV or LV dysfunction, severe pulmonary vascular hypertension, or previous left sided surgery (Class IIa) . Yet, prompted diagnosis and treatment. These recommendations are strongly in line with the AHA/ACC Valvular Heart Disease Management. Despite of slight differences in the indication class, the raising attention for an early diagnosis and interventions based on multi-modality non-invasive and invasive tools, as well as the straight anatomical cutoffs were similarly stressed.
5. With reference to transcatheter techniques, the new information from randomized studies have allowed to better state the role of this innovative endovascular approach. TAVI recommendation was implemented, being the first choice (class I) in older patients (>=75 years) or in those who are high-risk (STS-PROM/ EuroSCORE II >8%) . On the contrary, the previous guidelines suggested TAVI only in patients who were not suitable for surgery. However, the Heart Team must carefully evaluate the clinical, anatomical, and procedural factors in each patient1. The TAVI indication significantly differed from AHA/ACC guidelines. In fact, between 65 to 80 years of age, the American recommendation indicated the transfemoral TAVI as a valid option, comparable to surgery, based on a dedicated Heart Team discussion evaluating anatomical features and long-term durability. As for the aortic stenosis as to the mitral regurgitation, the indication for transcatheter edge-to-edge repair (TEER) has been implemented. TEER was indicated in severe secondary MR, mainly in the context of advanced heart failure, not suitable for surgery, under optimal medical treatment (including cardiac resynchronization therapy if indicated), after an appropriate discussion in a structured Heart Team (class Ia)8. The COAPT criteria has been cited (class IIa) . Also, the AHA/ACC recommendation clearly stated the criteria for TEER in secondary MR, derived from COAPT study13. Both guidelines left an opportunity for TEER also in primary severe MR, if the patient is not a surgery candidate (Class IIb).
6. The endovascular approach has been encouraged also in patients who needed tricuspid valve intervention and not suitable for surgery . However, the fresh limited experience in this field required to be further confirmed during the next years. Similarly, the positive outcomes derived from several studies on transcatheter valve-in-valve implantation after failure of surgical bioprostheses led to consider this option in selected patients at high-risk for surgical re- intervention (Class IIb).
7. Regarding the pharmacological treatment, the antithrombotic and anticoagulation therapies were carefully regulated and implemented, acquiring a wide and specific treatise in this guideline. Specific focus has been posed on the bridge perioperative period and over the long term for either surgical or transcatheter prostheses. Additionally, recommendation for non- vitamin K antagonist oral anticoagulants (NOACs) has been reinforced, as well as the combination with antiplatelet therapy has been completely upgraded.
8. Another important aspect, already highlighted by the AHA/ACC guidelines, is related to the importance of creating Heart Valve Centre and Heart Valve Team, in order to create a patient-tailored assessment and patient-related indication and treatment by experts in the field.
9. The importance of surgical approach, besides other fields, has been particularly stressed for the treatment of aortic insufficiency, primary mitral regurgitation and secondary tricuspid valve insufficiency.
10. There are, moreover, several “first-time mention” about the percutaneous treatment of tricuspid valve disease at high risk for surgery, the recommendation of bioprosthesis in patients with atrial fibrillation and with anticoagulation treatment, and the use of NOACS, as alternative for aspirin and other anticoagulants, for the first 3 months after the procedure.
11. Finally, this recommendation leaves several gaps in evidence, which require to be further investigated. Noteworthy, the urgent need of a better patient risk stratification, the prognostic role of biomarkers and non-invasive tool indices, as well as the long-term durability and outcomes of all transcatheter procedures.