Prosthetic valve choice

  • Shared decision-making remains a Class I indication (LOE C-LD) in selecting a mechanical versus bioprosthetic valve.
  • Among patients undergoing aortic or mitral valve replacement, the age range was expanded from ages 60 to 70 to ages 50 to 70 for the Class IIa (LOE B-NR) indication for either a mechanical or bioprosthetic valve choice.

    Prosthetic valve antithrombotic therapy

    • There are unchanged recommendations for use of a vitamin K antagonist (international normalized ratio [INR] 2.5 for bileaflet or current-generation tilting disk valves in the absence of additional thromboembolic [TE] risks, INR 3.0 for mitral mechanical prostheses or for aortic valve prostheses plus additional TE risks) plus aspirin 75 to 100 mg among patients with a mechanical valve prosthesis.
    • There is a new consideration for a lower INR target of 1.5 to 2.0 for patients with an On-X bileaflet mechanical aortic valve and no additional TE risks (Class IIb, LOE B-R).
    • The prior recommendation for use of a vitamin K antagonist after bioprosthetic valve replacement was changed to include both aortic and mitral bioprosthesis, for 3 to 6 months after surgery, in patients with a low risk for bleeding (Class IIa, LOE B-NR).
    • A vitamin K antagonist (INR target 2.5) may be reasonable for at least 3 months after TAVR in patients at low risk for bleeding (Class IIa, LOE B-NR).

      Bioprosthetic valve thrombosis

      • Initial treatment with a vitamin K antagonist is reasonable among hemodynamically stable patients with suspected or confirmed bioprosthetic valve thrombosis and no contraindication to anticoagulation (Class IIa, LOE C-LD).
      • A TAVR valve-in-valve procedure is reasonable among severely symptomatic patients with bioprosthetic aortic valve stenosis who are assessed by the heart valve team to be at high or prohibitive surgical risk (Class IIa, LOE B-NR).

        Prosthetic valve regurgitation

        • Transcatheter valve-in-valve is reasonable for severely symptomatic patients with bioprosthetic aortic valve regurgitation judged by the heart valve team to be at high or prohibitive risk for surgery (Class IIa, LOE B-NR).

        Infective endocarditis

        • Operation without delay may be considered in patients with IE and an indication for surgery who have had a stroke but have no evidence of intracranial hemorrhage or extensive neurologic damage (Class IIb, LOE B-NR).
        • If a patient is hemodynamically stable, delaying valve surgery for ≥4 weeks may be considered among patients with IE and major ischemic stroke or intracranial hemorrhage (Class IIb, LOE B-NR).

          References

          1. Nishimura RA, Otto CM, Bonow RO, , et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease. J Am Coll Cardiol. 2017 Mar 10. pii: S0735-1097(17)36019-9. doi: 10.1016/j.jacc.2017.03.011 [Epub ahead of print]
          2. Nishimura RA, Otto CM, Bonow RO,  et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease. Circulation. 2017 Mar 15. doi: 10.1161/CIR.0000000000000503 [Epub ahead of print]
          3. Bach DS. 2017 AHA/ACC Focused Update of Valvular Heart Disease Guideline. Published March 15, 2017. Accessed March 29, 2017.