Valvular heart disease guideline addresses less-invasive options, shared decision-making
Embrace of less-invasive interventions, shared decision-making and earlier management of regurgitation are among the hallmarks of a new multisociety guideline on management of valvular heart disease.
The 2020 American College of Cardiology/American Heart Association Guideline for the Management of Patients with Valvular Heart Disease was developed by those societies in conjunction with the American Association for Thoracic Surgery, the American Society of Echocardiography, the Society for Cardiovascular Angiography and Interventions, the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons.
“There is a knowledge explosion in medicine today, which can overwhelm the clinician,” Rick A. Nishimura, MD, MACC, FAHA, Judd and Mary Morris Leighton Professor of Cardiovascular Diseases at the Mayo Clinic in Rochester, Minnesota, and co-chair of the guideline writing committee, said in a press release. “This is particularly true in the area of valvular heart disease, in which multiple investigational trials are being rapidly performed and released, so that it becomes extremely difficult for an individual clinician to keep up with optimal treatments for each specific patient. The Valvular Heart Disease Guideline brings together experts in the field who review all the data and arrive at a consensus opinion for best treatment, outlined in the class recommendations.”
Takeaways from the updated guideline
Among patients with valvular heart disease, stages of disease (A, B, C or D) should be classified based on symptoms, valve anatomy, severity of valve dysfunction and response of the ventricle and pulmonary circulation, according to the guideline.
“Criteria for ‘severe’ valvular heart disease are based on predictors of clinical outcome from observational studies, registry data and randomized clinical trials of patients with valvular heart disease,” the committee wrote. “Of course, severity is a continuous variable; categorizing disease into stages, from A to D, simply provides a framework, or starting point, for diagnosis and management, and it is recognized that not all patients will fit perfectly into a specific stage. Some patients will have symptoms or end-organ damage with valve hemodynamics that do not quite meet specific disease severity criteria, and numerical measures may not match exactly across all categories. Conversely, other patients may remain asymptomatic without obvious evidence of end-organ damage despite apparently severe valvular heart disease.”
Additionally, medical history and physical examination findings should be correlated with the results of noninvasive testing including ECG, chest X-ray and transthoracic echocardiogram. According to the guideline, discordance between the physical examination and initial noninvasive testing may prompt further testing, noninvasive or invasive, to verify the optimal treatment strategy.
“After initial evaluation of an asymptomatic patient with valvular heart disease, the clinician should continue regular follow-up with periodic examinations and transthoracic echocardiogram,” the committee wrote. “The purpose of follow-up is to prevent the irreversible consequences of severe valvular heart disease, primarily affecting the status of the ventricles and pulmonary circulation, which may occur in the absence of symptoms. At a minimum, a yearly history and physical examination are necessary.”
For patients with valvular heart disease and atrial fibrillation, the decision to use oral anticoagulants for the prevention of thromboembolic events should be made with a shared decision-making process based on the CHA2DS2-VASc score.
Moreover, patients with rheumatic mitral stenosis or a mechanical prosthesis and AF should receive oral anticoagulation with a vitamin K antagonist, according to the updated guidance.
Recommendations for intervention
According to the guideline, all patients considered for valve intervention should be evaluated by a multidisciplinary team, including referral to or consultation with a primary or comprehensive valve center.
“The value of the multidisciplinary team has become increasingly apparent as options in the treatment of valvular heart disease have broadened,” the committee wrote. “Heart Valve Centers, in the context of an integrated multi-institutional model of care for patients with valvular heart disease, allow optimization of patient outcomes through improved decision-making and matching of patients to providers with appropriate expertise, experience and resources.”
The authors wrote that the decision to treat severe aortic stenosis with a transcatheter or surgical valve prosthesis should be based on symptoms or reduced ventricular function, and earlier intervention can be considered based on results of exercise testing, biomarkers, rapid disease progression or the presence of very severe stenosis.
Indications for transcatheter aortic valve replacement have expanded, but choice regarding type of intervention should be a shared decision-making process and take into consideration lifetime risks and benefits associated with valve type and approach to implantation.
“Decision-making is particularly challenging for the asymptomatic valvular heart disease patient, for whom the risks of operative mortality and perioperative morbidity must be very low and the chances of a successful and durable surgical outcome very high,” the committee wrote. “There is a substantial body of literature to support a relationship between institutional volume and mortality rate for many cardiovascular procedures, including surgical AVR, TAVR and surgical mitral valve repair.”
According to the guidance, mitral transcatheter edge-to-edge repair may benefit patients with severely symptomatic primary mitral regurgitation who are high risk for surgery, as well as a subset of patients with secondary mitral regurgitation who remain severely symptomatic despite optimal guideline-based management and therapy for HF.
Moreover, patients with severe symptomatic isolated tricuspid regurgitation may benefit from surgical intervention to improve symptoms and reduce recurrent hospitalizations. These benefits may only be observed if intervention is done before the onset of severe right ventricular dysfunction or end-organ damage to the liver and kidney.
The committee added that bioprosthetic valve dysfunction may occur due to degeneration of the valve leaflets or valve thrombosis and a catheter-based treatment for prosthetic valve dysfunction in the absence of active infection may be reasonable.
Expanded evidence base
“Clinical studies over the past decade have increased awareness of the prevalence and importance of valvular heart disease in contributing to excess mortality, morbidity and a reduced quality of life, particular in older people,” Catherine Otto, MD, FACC, FAHA, J. Ward Kennedy-Hamilton Endowed Chair in Cardiology, professor of medicine, and director of the Heart Valve Clinic at the University of Washington School of Medicine in Seattle, and co-chair of the guideline writing committee, said in the release. “Simultaneously, clinical studies have demonstrated the safety and effectiveness of new, less-invasive approaches for treatment of heart valve dysfunction. Integration of this expanded evidence base, in conjunction with expert clinical experience, will furnish both providers and patients with the guidance needed to ensure optimal outcomes for patients with heart valve conditions.”
Otto also said in the press release that “future research will also lead to treatments to prevent heart valve disease or earlier interventions to slow its progression.”