Valvular heart disease: 2017 updated guideline from the AHA/ACC

The updated guideline includes recent advances in diagnostic imaging and improvements in catheter-based and surgical interventions.
The updated guideline includes recent advances in diagnostic imaging and improvements in catheter-based and surgical interventions.

The American Heart Association (AHA) and American College of Cardiology (ACC) have released a 2017 focused update to their 2014 Guideline for the Management of Patients with Valvular Heart Disease. The updated guideline, published in the Journal of the American College of Cardiology and in Circulation, includes recent advances in diagnostic imaging and improvements in catheter-based and surgical interventions.

New and modified recommendations have been made regarding indications for antibiotic prophylaxis for infective endocarditis (IE), the use of direct oral anticoagulants (DOACs) in patients with atrial fibrillation and heart valve disease, indications for transcatheter aortic valve replacement (TAVR), surgical management of patients with primary and secondary mitral regurgitation (MR), and management of patients with a heart valve prosthesis.

The AHA/ACC Task Force on Clinical Practice Guidelines worked in collaboration with the American Association for Thoracic Surgery, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and the Society of Thoracic Surgeons.

A summary of the key recommendations, provided by the ACC, is as follows:

IE prophylaxis

  • Antibiotic prophylaxis before dental procedures now is also recommended for patients with transcatheter prosthetic valves and for patients with prosthetic material used in valve repair (including an annuloplasty ring or artificial chords) (Class IIa, Level of Evidence [LOE] C-LD).

Anticoagulation for atrial fibrillation

  • In patients with atrial fibrillation and rheumatic mitral stenosis, anticoagulation with a vitamin K antagonist still is indicated (Class I, LOE B-NR).
  • Anticoagulation should be used among patients with atrial fibrillation and a CHA2DS2-VASc score ≥2 in the setting of native aortic valve disease, tricuspid valve disease, or MR (Class I, LOE C-LD).
  • The use of a DOAC is reasonable among patients with native aortic valve disease, tricuspid valve disease, or MR; and atrial fibrillation with a CHA2DS2-VASc score ≥2 (Class IIa, LOE C-LD).

Aortic stenosis

  • The recommendation for either surgical AVR or TAVR among high-risk patients with severe, symptomatic AS (stage D), after consideration by a heart valve team, was changed from Class IIa (LOE B) to Class I (LOE A).
  • After consideration by a heart valve team, TAVR is a reasonable alternative to surgical AVR for patients with severe, symptomatic aortic stenosis (stage D) and intermediate surgical risk (Class IIa, LOE B-R).

Primary MR

  • In asymptomatic patients with severe primary MR with preserved left ventricular (LV) systolic function (LV ejection fraction [LVEF] >60%, LV end-systolic dimension <40 mm [stage C1]), mitral valve surgery is reasonable in the setting of serial imaging studies that reveal a progressive increase in LV size or decrease in LVEF (Class IIa, LOE C-LD).

Secondary MR

  • The definition of severe secondary MR is now the same as for severe primary MR (effective regurgitant orifice area ≥0.4 cm2, regurgitant volume ≥60 mL, regurgitant fraction ≥50%).
  • It is reasonable to choose chordal-sparing mitral valve replacement over reduction annuloplasty mitral valve repair in patients operated on for severe, symptomatic (New York Heart Association class III or IV) secondary MR (stage D) (Class IIa, LOE B-R).
  • After a randomized trial showed no clinical benefit of mitral valve repair among patients with chronic, moderate ischemic MR undergoing coronary artery bypass grafting, the LOE was changed from C (consensus) to B-R (moderate quality evidence from ≥1 randomized controlled trial [RCT] or meta-analyses of moderate-quality RCT) for the Class IIb recommendation for mitral valve repair in this population.

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