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Important Changes Published in the new 2020 ACC/AHA Valvular Heart Disease Guidelines

Important changes have been published in the new 2020 ACC/AHA Valvular Heart Disease Guidelines

There are some important changes that diverge from older recommendations in the recently published 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease, available in full here.

TAVR vs. SAVR in Intermediate- and Low-Risk Aortic Stenosis Patients

The biggest changes came in response to findings from the PARTNERS randomized trials of TAVR versus SAVR in intermediate- and low-risk aortic stenosis patients, led by Cedars-Sinai and published last year in the New England Journal of Medicine. At five years, intermediate-risk TAVR patients experienced lower risk of hospital readmission. Findings related to death and stroke were similar.

TAVR is now recommended for symptomatic patients with severe aortic stenosis above 80 years of age, or younger patients with a life expectancy of less than 10 years. Will the two-year outcomes in low-risk patients translate into long-term benefits? The jury is still out on the role of TAVR in middle-aged patients and those with bicuspid aortic stenosis, with calls for a clinical trial in bicuspid patients.

Aortic Stenosis (Trileaflet)

2017 ACC/AHA Guidelines

2020 ACC/AHA Guidelines

Surgical aortic valve replacement (AVR) is recommended for symptomatic and asymptomatic patients with severe aortic stenosis who meet an indication for AVR when surgical risk is low or intermediate.

Class of Recommendation 1
Level of Evidence B

For symptomatic patients with severe aortic stenosis who are above 80 years of age or for younger patients with a life expectancy of less than 10 years and no anatomic contraindication to transfemoral TAVR, transfemoral TAVR is recommended in preference to surgical AVR.

Class of Recommendation 1
Level of Evidence B

Common conditions that favor surgical aortic valve replacement (AVR) include bicuspid aortic valve, extensive subaortic calcification, rheumatic valve disease, small or large aortic annulus, preference for mechanical prosthesis, concern for patient-prosthesis mismatch, aortic dilatation and concomitant conditions that can be treated surgically. These can include severe primary mitral regurgitation, severe coronary disease, septal hypertrophy and atrial fibrillation.

Mitral Valve Regurgitation

Mitral valve regurgitation secondary to heart failure also benefited from two major randomized trials that informed new guidelines for treatment of chronic, severe functional mitral regurgitation. COAPT showed better survival free from repeat heart-failure hospitalizations two years after edge-to-edge transcatheter mitral repair in patients who had failed optimal medical therapy.

Functional Mitral Regurgitation

2017 ACC/AHA Guidelines

2020 ACC/AHA Guidelines

No recommendation

In patients with chronic, severe secondary mitral regurgitation related to LV systolic dysfunction (LVEF<50%) who have persistent severe symptoms while on optimal goal-directed medical therapy for heart failure (Stage D), transcatheter edge-to-edge mitral repair is reasonable in patients with appropriate anatomy, LVEF 20-50%, LVESD ≤70 mm, and pulmonary artery systolic pressure  ≤70 mm Hg.

Class of Recommendation 1
Level of Evidence B

What does this mean for treatment of severe degenerative (primary) mitral regurgitation (MR)? Severely symptomatic high- and prohibitive-risk patients with severe degenerative MR may benefit from transcatheter repair. However, the standard of care for low- and intermediate-risk patients remains surgical repair. Cedars-Sinai is leading the pivotal multinational trial designed to address this question: TRANSFORM (TRANs catheter or Surgical repair FOR Mitral regurgitation) will randomize all-comers aged >65 years with degenerative mitral regurgitation to surgical repair or transcatheter repair.

Anticoagulation in Valvular Heart Disease

Finally, the other major changes in the 2020 ACC/AHA Guidelines focused on anticoagulation in valvular heart disease, with non-vitamin K oral anticoagulant recommended for patients with atrial fibrillation and native heart disease in a variety of settings, including postoperatively.

Anticoagulation in AF for Valvular Heart Disease Patients

2017 ACC/AHA Guidelines

2020 ACC/AHA Guidelines

It is reasonable to use a DOAC as an alternative to a VKA in patients with AF and native aortic valve disease, tricuspid valve disease or MR, and with a CHA2DS2-VASc score of 2 or greater.

Class of Recommendation 2a
Level of Evidence C

For patients with AF and native heart disease (except rheumatic mitral stenosis) or who received a bioprosthetic valve more than three months ago, a non-vitamin K oral anticoagulant is an effective alternative to VKA anticoagulation and should be administered on the basis of the patient’s CHA2DS2-VASc score.

Class of Recommendation 1
Level of Evidence A

No recommendation

For patients with new-onset AF <3 months after surgical or transcatheter bioprosthetic valve replacement, anticoagulation with a VKA is reasonable.

Class of Recommendation 2a
Level of Evidence B

No recommendation

In patients with mechanical heart valves with or without AF who require long-term anticoagulation with VKA to prevent valve thrombosis, NOACs are not recommended.

Class of Recommendation 3 Harm
Level of Evidence B

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