Valvular heart disease guidelines add TAVR, updates

Recently released practice guidelines for treating patients with valvular heart disease forged new ground on several fronts. For the first time, they included recommendations for transcatheter aortic valve replacement (TAVR) as well as a new classification system.

The 2014 American College of Cardiology and the American Heart Association Guideline for the Management of Patients with Valvular Heart Disease was published online March 3 in Circulation and March 4 in the Journal of the American College of Cardiology.

According to the guidelines, TAVR should be performed in patients considered too high-risk for AVR and are expected to survive more than 12 months after the procedure. The guidelines call for a multidisciplinary Heart Valve Team to collaborate. The team should consist of a cardiologist and surgeon, and if a catheter-based therapy is recommended, there should also be a structural valve interventionist. There may also be imaging specialists, anesthesiologists and nurses with experience in managing VHD.

Clinicians may consider percutaneous aortic balloon dilation as a bridge to surgical or transcatheter AVR in patients with severe aortic stenosis with severe symptoms. The panel does not recommend TAVR in patients with comorbidities that would override the benefits from correcting aortic stenosis.

After TAVR, the panel recommends clopidogrel (Plavix, Bristol-Myers Squibb) for six months as a reasonable therapy followed by a lifelong aspirin regimen.

The guidelines also introduced a new system of classification for valvular heart disease similar to the system proposed for the classification of heart failure. There are now four stages, A through D, defined as “at risk,” “progressive,” “asymptomatic severe” and “symptomatic severe.”

In addition, the panel proposed a new scoring system to assess risk that combines the tool used by the Society of Thoracic Surgeons (STS) Predicted Risk of Mortality score, frailty, major organ system dysfunction and procedure-specific impediments.

They also recommended lowering the threshold for surgical intervention to include more patients with severe asymptomatic aortic stenosis and severe asymptomatic mitral regurgitation. Other factors must be considered, however, such as operative mortality and the likelihood of a durable valve repair in cases of mitral regurgitation.

The STS, American Association for Thoracic Surgery, American Society for Echocardiography, Society for Cardiovascular Angiography and Interventions and Society of Cardiovascular Anesthesiologists also collaborated on the guidelines.