The American College of Cardiology (ACC) and American Heart Association (AHA) closed out 2020 by publishing an updated guidance on the management of valvular heart disease.
The document, published in both the Journal of the American College of Cardiology and Circulation, covered significant ground.
Two specialists—Anthony A. Bavry, MD, of UT Southwestern Medical Center in Dallas, and George J. Arnaoutakis, MD, of the University of Florida in Gainesville—have written a helpful summary, sharing it in Circulation.
“Although transcatheter mitral valve procedures are increasingly being performed, transcatheter aortic valve procedures are now approved for use in low-risk patients,” Bavry and Arnaoutakis wrote. “This updated 2020 guideline presents a thoughtful framework for how to manage these special groups of patients who providers will increasingly encounter in clinical practice.”
The duo’s analysis focused on four key subjects from the updated guidance:
1. Comprehensive heart valve centers can boost patient care
The ACC/AHA guidance introduced the level 1 comprehensive heart valve center, identified as such by the fact that it sees a high number of patients and can tackle numerous complex procedures. High-volume centers, Bavry and Arnaoutakis noted, have been associated with “excellent results and low mortality.”
Level 2 primary valve centers can provide patients with “many of the same valve procedures,” the authors explained, but the number of offerings is going to be less than a level 1 center.
“For example, the 2020 guideline recommends that specialized procedures such as alternative access TAVR, valve-in-valve TAVR, transcatheter edge-to-edge mitral valve repair, paravalvular leak closure, and percutaneous mitral balloon commissurotomy be performed at a level 1 center,” the authors explained. “The 2020 guideline also provides important guidance regarding adjunctive imaging services and hospital infrastructure requirements.”
2. The choice between TAVR and surgery remains critical
When patients are going to receive a bioprosthetic valve, a choice has to be made between surgical aortic valve replacement (SAVR) and TAVR. The ACC/AHA guidance recommends that patients between the ages of 65 and 80 years old make that determination through shared decision making. Bavry and Arnaoutakis noted that both SAVR and TAVR have their own advantages and disadvantages.
“Some characteristics that favor SAVR include bicuspid aortic valve (especially with adverse valve characteristics and aortopathy), left ventricular outflow tract calcification, severe or multivessel coronary artery disease, high-risk of coronary occlusion, or concomitant disease of a second valve,” they wrote. “Some of these coexisting cardiac conditions may render open surgery the preferred approach even in carefully selected nonfrail patients >80 years. Some characteristics that favor TAVR include shorter estimated life expectancy; severely calcified or porcelain ascending aorta; severe hepatic, renal, or pulmonary disease; limited ability for rehabilitation after SAVR; and previous mediastinal radiation.”
3. Another key decision: surgical mitral valve repair/replacement or transcatheter edge-to-edge mitral valve repair?
In this latest guidance, Bavry and Arnaoutakis noted, transcatheter edge-to-edge mitral repair is only recommended for high-risk patients. When patients have secondary mitral regurgitation, the recommendation is “guideline-directed medical therapy supervised by a heart failure specialist.”
Also, mitral valve surgery is considered the go-to choice for patients with normal left ventricular ejection fraction. If left ventricular ejection fraction is 20-50% and other persistent symptoms are present, on the other hand, transcatheter edge-to-edge mitral valve repair “can be considered.”
4. Physicians need to know the latest on antiplatelet and antithrombotic therapies
The ACC/AHA guidance didn’t include much new information related to antiplatelet/antithrombotic therapy, but Bavry and Arnaoutakis said many key points “deserve emphasis.”
Vitamin K antagonists are now recommended for patients with a mechanical valve, for instance, and aspirin “is no longer routinely recommended in combination with warfarin for a mechanical valve and can be individualized according to other medical conditions that might necessitate its use.”
The two specialists also noted that aspirin alone “may be preferential” to dual antiplatelet therapy for patients after they undergo a TAVR procedure.
“Despite reports of clinical and subclinical leaflet thrombosis after TAVR, a modified dose, direct oral anticoagulant regimen in combination with aspirin has been shown to be harmful in patients without an indication for antithrombotic therapy,” they added.
Also: To learn more about these latest updates, tune into the upcoming webinar and live Q&A from Cardiovascular Business. Registry for this one-hour event is completely free. More information is available here.