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Guideline for the Management of Patients With Valvular Heart Disease PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Guideline for the Management of Patients With Valvular Heart Disease" by American Heart Association.

This medical PowerPoint presentation provides guidelines for the management of patients with valvular heart disease. The American Heart Association and the American College of Cardiology have jointly released guidelines for the management of patients with valvular heart disease.

It is important to note that these guidelines are intended to serve as a general framework for the management of valvular heart disease and that individual patient management should be tailored based on a patients specific clinical circumstances.

Tags : Valvular Heart Disease, cardiology

Published on : Mar 17, 2023 | Views : 858 | Downloads : 2

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Clinical Update ADAPTED FROM: 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease
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Table 1. ACC/AHA Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)* COR and LOE are determined independently (any COR may be paired with any LOE). A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. *The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information). †For comparative-effectiveness recommendation (COR 1 and 2a; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated. ‡The method of assessing quality is evolving, including the application of standardized, widely-used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee. COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE, Level of Evidence; NR, nonrandomized; R, randomized; and RCT, randomized controlled trial. 2
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Evaluation of the Patient With Known or Suspected Native VHD Abbreviations: CW indicates continuous wave; LV, left ventricle; PASP, pulmonary artery systolic pressure; PW, pulsed wave; RV, right ventricle; TTE, transthoracic echocardiography; and VHD, valvular heart disease. Stenotic Lesions Maximum velocity Mean gradient Valve area Regurgitant Lesions Regurgitant orifice area Regurgitant volume Regurgitant fraction 3 Initial Diagnosis History & Physical VHD Presence & Severity Co-morbidities Heart Failure ECG & CXR Rhythm LV Function Hypertrophy TTE Concurrent Valvular Disorders Associated Abnormalities LV Function & Anatomy Assessment of Valvular Anatomy & Etiology of VHD Hemodynamics CW & PW Doppler Flow Reversal PA Systolic Pressure RV Size
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Table 3. Additional Diagnostic Evaluation in VHD Pre-procedural Testing Required Before Valve Intervention Abbreviations: CW indicates continuous wave; LV, left ventricle; PASP, pulmonary artery systolic pressure; PW, pulsed wave; RV, right ventricle; TTE, transthoracic echocardiography; and VHD, valvular heart disease. Chest X-Ray Important for symptomatic patient Establishes heart size Presence or absence of pulmonary vascular congestion, intrinsic lung disease, calcification of aorta & pericardium TEE Provides high-quality assessment of mitral and prosthetic valve, including definition of intracardiac masses & possible associated abnormalities CMR Provides assessment of LV volumes and function, valve severity, and aortic dilation Quantitation of aortic regurgitant severity in selected cases. PET-CT Aids in determination of active infection or inflammation Cardiac Catheterization Provides measurement of intracardiac and pulmonary pressures, valve severity, and hemodynamic response to exercise & drugs Exercise Testing Gives an objective measure of exercise capacity Identifies patients at high risk Dental examination Rules out potential infection sources CT coronary or invasive coronary angiogram Gives an assessment of coronary anatomy CT: Peripheral Assesses femoral access for TAVI and other transcatheter procedures CT: Cardiac Assesses suitability for TAVI and other transcatheter procedures 4 Additional Testing
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Table 4. Stages of VHD Abbreviations: C1 indicates stage C1; C2; stage C2; LV; left ventricle; RV, right ventricle; and VHD, valvular heart disease. 5
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Diagnostic Testing: Follow-up Table 5. Frequency of Echocardiograms in Asymptomatic Patients With VHD and Normal LV Function Patients with mixed valve disease may require serial evaluations at intervals earlier than recommended for single-valve lesions. These intervals apply to most patients with each valve lesion and do not take into consideration the etiology of the valve disease. *With normal stroke volume. Stages C2 and D disease are not included in this table because they would be considered candidates for intervention. Abbreviations: CMR indicates cardiac magentic resonance; LV, left ventricle; mo, month; m/s, milliseconds; MV, mitral valve; STS, Society of Thoracic Surgeons; TAVI, transcathether aortic valve implantation; TTE, trasnsthoracic echocardiography; VHD, valvular heart disease; y, year; Vmax, maximum transvalvular velocity. Deterioration of the ventricular response to volume or pressure overload Repeat TTE Other etiologies Yearly history & physical TTE frequency based on type and severity of lesion, known rate of progression and effect on associated ventricle Valve dysfunction New symptoms or Change in symptoms Established VHD Routine follow up 6
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Recommended Treatment Regimens & Duration of Secondary Prophylaxis Table 6. Secondary Prevention of Rheumatic Fever Table 7. Duration of Secondary Prophylaxis for Rheumatic Fever *In patients with documented valvular heart disease, the duration of rheumatic fever prophylaxis should be ≥10 y or until the patient is 40 y of age (whichever is longer). Lifelong prophylaxis may be recommended if the patient is at high risk of group A streptococcus exposure. Secondary rheumatic heart disease prophylaxis is required even after valve replacement. †Administration every 3 week is recommended in certain high-risk situations. ‡Macrolide antibiotics should not be used in persons taking other medications that inhibit cytochrome P450 3A, such as azole antifungal agents, HIV protease inhibitors, and some selective serotonin reuptake inhibitors. Abbreviations: IM indicates intramuscular; mg; milligrams; Q; every; RHD, rheumatic heart disease; U; units; and VHD, valvular heart disease. 7
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Classification of Recommendations for RHD & IE Abbreviations: IE indicates infective endocarditis; RHD, rheumatic heart disease; VHD valvular heart disease. 8
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Figure 1. Anticoagulation for AF in Patients With VHD * 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 3:Harm. Abbreviations: AF indicates atrial fibrillation; CHA2DS2-VASc score, congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, sex category; MS, mitral stenosis; NOAC, non–vitamin K oral anticoagulant; VHD, valvular heart disease; and VKA, vitamin K antagonist. Rheumatic MS Patient with VHD and AF Native valve disease (except rheumatic MS) Bioprosthetic Valve* New-onset AF within 3 months of valve implantation > 3 month after procedure Long-term VKA anticoagulation (1) VKA or NOAC based on CHA2DS2-VASc Score (1) Anticoagulation with VKA (2a) 9
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Management of Patients with VHD After Valve Intervention Abbreviations: 1̊ indicates primary; 2 ̊, secondary; AF, atrial fibrillation; CAD, coronary artery disease; INR, international normalized ratio; Op, operative; VHD, valvular heart disease; and VKA, vitamin K antagonist. Periodic Assessment is Needed Procedural Complications Post Op AF Stroke Bleeding Vascular Complications Pericarditis Heart Block Heart Failure Renal Dysfunction Infection Paravalvular Leak Patient Management Evaluate and treat patients with CAD risk factors according to guidelines Encourage heart healthy lifestyle behaviors Endocarditis prophylaxis Periodic imaging If Symptoms After Valve Intervention: Assess valve function Evaluate and treat concurrent cardiac and non-cardiac conditions For VKA anticoagulation, review INR 10
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Imaging After Valve Intervention Abbreviations: cm indicates centimeters; LV, left ventricle; and PA, pulmonary artery. 11
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Table 13. The Evaluation and Management of Aortic Stenosis Abbreviations: AR indicates aortic regurgitation; AS aortic stenosis; AVA, aortic valve area circulation; AVAi, aortic valve area indexed to body surface area; LVEF, left ventricular ejection fraction; ∆P, pressure gradient between the left ventricle and aorta; and Vmax, maximum velocity. 12
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Figure 2. Timing of Intervention for Aortic Stenosis *See section 3.2.4.2 Abbreviations: AS indicates aortic stenosis; AVA, aortic valve area; cm, centimeter; AVR, aortic valve replacement; BNP, B-type natriuretic peptide; DSE, dobutamine stress echocardiography; ETT, exercise treadmill test; LVEF, left ventricular ejection fraction; mmHg, millimeters of mercury; ∆Pmean, average change in pressure; SAVR, surgical aortic valve replacement; SVI, stroke volume index; TAVI, transcatheter aortic valve implantation; and Vmax, maximum transvalvular velocity. AS Stage C Vmax >4 m/s Abnormal Aortic Valve With Reduced Systolic Opening No AS Symptoms Other Cardiac Surgery Severe AS Stage D1 Vmax >4 m/s ∆Pmean > 40mmhg AVR (SAVR or TAVI) (1)* SAVR (2a) 13 SAVR (2b) Vmax <4 m/s and AVA < 1 cm2 LVEF<50% YES NO AS most likely cause of symptoms Severe AS Stage D2 DSE Vmax >4 m/s Severe AS Stage D3 AVA < 0.6cm2/m2 and SVI <35 ml/m2 Symptoms due to AS AS Stage B Vmax 3-3.9 m/s LVEF <50% Other Cardiac Surgery ETT with drop in BP or ex. capacity Vmax >5 m/s OR BNP>3x normal OR Rapid disease progression Drop in LVEF to <60% on 3 serial studies Low surgical risk
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Figure 3. Choice of SAVR versus TAVI for AVR in Valvular AS *See section 3.2.3 Abbreviations: AS indicates aortic stenosis; AVR, aortic valve replacement; LVEF, left ventricular ejection fraction; QOL, quality of life; SAVR, surgical aortic valve replacement; STS, Society of Thoracic Surgeons; TAVI, transcatheter aortic valve implantation; TF, transfemoral; and VKA, vitamin K antagonist. 14 Indication for AVR* Shared Decision-making with patient and Heart Valve Team with discussion of SAVR or TAVI (1) Surgical Risk Assessment YES NO Not high or Prohibitive Risk High or Prohibitive Risk STS>8% > 2 frailty measures or < 2 organ systems or Procedural impediment Life expectancy with acceptable QOL >1 year? Valve and vascular anatomy suitable for TF TAVI? YES NO Palliative Care (1) TAVI (1) YES Amenable for VKA Anticoagulation? SAVR (2a) TF TAVI (1) TF TAVI (1) SAVR (1) SAVR (1) SAVR Age >80 Age 65 to 80 Age < 65 Bioprosthetic (1) >65 50-65 <50 Age Symptomatic severe AS (D1,D2, D3) OR asymptomatic severe AS with LVEF < 50% and anatomy suitable for TF TAVI? (Individualize) Mechanical or Bioprosthetic (2a) Mechanical AVR (2a) Pulmonic autograft (2b) Bioprosthetic (2a) NO NO YES
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Acute Aortic Regurgitation Abbreviations: AR indicates aortic regurgitation; IE, infective endocarditis, and TAVR, transcatheter aortic valve replacement. 15 Abnormalities of the Valve Most often due to IE Abnormalities of the Aorta Aortic Dissection Iatrogenic complication of a transcatheter procedure Blunt chest trauma Acute volume overload in the LV Severe pulmonary congestion Low forward cardiac output Urgent diagnosis and rapid intervention are lifesaving
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Table 15. Stages of Chronic AR Abbreviations: AR indicates aortic regurgitation; cm. centimeter; ERO, effective regurgitant orifice; HF, heart failure; IE, infective endocarditis; LV, left ventricle; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic diameter; LVOT, left ventricular outflow track; mm, millimeter; and TAVR, transcatheter aortic valve replacement. 16
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Figure 4. Timing of intervention for AR Abbreviations: AR indicates aortic regurgitation; AVR, aortic valve replacement; EDD, end-diastolic dimension; ERO, effective regurgitant orifice; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic dimension; RF, regurgitant fraction; RVol, regurgitant volume; and VC, vena contracta. Aortic Regurgitation 17 Severe AR (VC>0.6 cm, holodiastolic aortic flow reversal, RVol > 60mL, RF> 50%, ERO > 0.3 cm2) Moderate AR Asymptomatic (Stage C) Symptomatic (Stage D) AVR (1) AVR (2a) Other cardiac surgery LVEF >55% and/or LVESD>50 (LVESD >25mm/m2) Other cardiac surgery Progressive decrease in LVEF to <55% -60% or increase in size to >65 mm on at least 3 studies Low surgical risk LVEF < 55% (Stage C2) AVR (2a) AVR (2b)
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Timing of Intervention in Chronic Aortic Regurgitation Abbreviations: AR indicates aortic regurgitation; COR classification of recommendation; LVEF, left ventricular ejection fraction, LVESD, left ventricular end-systolic diameter; mm; millimeter; SAVR, surgical aortic valve replacement; TAVI, transcatheter aortic valve implantation. 18
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Diagnosis & Treatment: Bicuspid Aortic Valve Figure 5. Diagnosis Figure 6. Treatment Aortopathy is present in 20-40% of patients with BAV *Family history of aortic dissection, aortic growth rate ≥0.5 cm/y, and/or presence of aortic coarctation. Abbreviations: BAV indicates bicuspid aortic valve; CMR, cardiac magnetic resonance imaging; CTA, computed tomography angiography; CVC, comprehensive valve center; and TTE, trasnsthoracic echocardiography. 19 Bicuspid Aortic Valve TTE screening of 1st degree relatives (2b) TEE including measurement of aortic sinuses and ascending aorta (1) CMR or CTA if TTE not adequate for aortic measurement (1) Aortic diameter (sinuses or ascending aorta) 24.0 cm BAV with prior aortic valve replacement Periodic imaging by TTE, CMR or CTA with interval determined by: Degree and rate of progression of aortic dilation Family history of aortic dissection (2a) Continued lifelong periodic imaging if aortic diameter is 24.0 cm (2a) Bicuspid Aortic Valve Aortic sinus or ascending aortic diameter >5.5 cm Aortic sinus or ascending aortic diameter 5.0-5.5 cm with risk factors for dissection* Indications for surgical AVR and aortic sinus or ascending aortic diameter >4.5cm Aortic sinus or ascending aortic diameter 5.0-5.5 cm without risk factors for dissection* Replace aortic sinuses and/or ascending aorta (1) Valve-sparing surgery may be considered at a CVC (2b) Replace aortic sinuses and/or ascending aorta at CVC (2a) Replace aortic sinuses and/or ascending aorta if performed in low risk patients at CVC (2b)
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Table 16. Stages of Mitral Stenosis Abbreviations: cm indicates centimeter; HTN, hypertension; LA, left atrium; mm Hg; millimeters of mercury; MS, mitral stenosis; and PASP, pulmonary artery systolic pressure. Note: DIAGNOSTICS* include Valve Hemodynamics measured by Echocardiography (doppler) or Cardiac Catheterization. 20
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Figure 7. Recommendations for Mitral Stenosis *Repair, commissurotomy, or valve replacement. Abbreviations: AF indicates atrial fibrillation; CVC, Comprehensive Valve Center; MR, mitral regurgitation; MS, mitral stenosis; MV, mitral valve; MVA, mitral valve area; MR, Mitral Regurgitation; NYHA, New York Heart Association; PASP, pulmonary artery systolic pressure; +, plus; and PMBC, percutaneous mitral balloon commissurotomy. 21 PBMC at CVC (1) Progressive MS MVA >1.5cm2 Symptomatic Stage D Asymptomatic Stage C MV surgery* (1) PBMC at CVC (2b) PBMC at CVC (2a) PBMC at CVC (2b) Exertional symptoms Stress test Hemodynamically Significant MS PASP >50mm HG New AF Rheumatic Mitral Stenosis Pliable valve No clot <2+MR Pliable valve No clot <2+MR Pliable valve No clot <2+MR Severe symptoms NYHA III-IV Surgical candidate YES NO Severe MS MVA <1.5cm2 YES NO
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Table 17. Stages of Chronic Primary MR *Valve Hemodynamics measured by echocardiography (doppler) or cardiac catheterization. Abbreviations: cm indicates centimeter; ERO, effective regurgitant orifice; IE, infective endocarditis; LA, left atrium/atrial; LV, left ventricular; LVEF, left ventricular ejection fraction; LVESD; left ventricular end-systolic dimension; mL, milliliter; mm, millimeter; and MR, mitral regurgitation. 22
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Diagnostic Testing of Primary Mitral Regurgitation Abbreviations: CMR indicates cardiac magnetic resonance; COR, classification of recommendation; GDMT, guideline directed medical therapy; LV, left ventricle, LVEDD, left ventricular end-diastolic dimension; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic dimension; MR, mitral regurgitation; PET, positron emission tomography; and TTE, transthoracic echocardiography. 23
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Figure 8. Management of Primary Mitral Regurgitation .*See Prosthetic Valve section (11.1.2) for choice of mitral valve replacement if mitral valve repair is not possible. Abbreviations: CVC indicates comprehensive valve center; ERO, effective regurgitant orifice; ESD, end-systolic dimension; LVEF, ejection fraction; MR, mitral regurgitation; MV, mitral valve; MVR, mitral valve replacement; RF, regurgitant fraction; RVol, regurgitant volume; and VC, vena contracta. 24 No symptoms due to MR (Stage C) Severe MR (VC>0.7 cm, RVol > 60mL, RF>50%,ERO>0.40 cm2) Symptoms due to MR (Stage D) (regardless of LV function) Degenerative MV disease LV systolic dysfunction (Stage C2) (LVEF<60% or ESD>40 mm) Normal LV systolic Function (Stage C1) (LVEF>60% or ESD<40 mm) Expected surgical mortality <1% with >95% likelihood of successful and durable repair without residual MR Progressive increase in LV size or decrease in LVEF on at least 3 studies Transcatheter edge-to-edge MV Repair (2a) MV surgery* at Primary or CVC (1) MV repair at CVC (2b) MV repair at primary or CVC (2a) MV repair or replacement (2b) High or prohibitive Surgical risk with anatomy favorable for transcatheter approach and life expectancy > 1 year MV surgery (1) Successful and durable repair possible Rheumatic MV disease Successful and durable repair possible NO YES
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Diagnostic Testing Chronic Secondary Mitral Regurgitation Abbreviations: CMR indicates cardiac magnetic resonance; COR, classification of recommendation; GDMT, guideline directed medical therapy; LV, left ventricle; LVEDD, left ventricular end-diastolic dimension; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic dimension; MR, mitral regurgitation; PET, positron emission tomography; TEE, transesophageal echocardiography; and TTE, transthoracic echocardiography. 25
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Table 18. Stages of Secondary MR *Several valve hemodynamic criteria are provided for assessment of MR severity, but not all criteria for each category will be present in each patient. Categorization of MR severity as mild, moderate, or severe depends on data quality and integration of these parameters in conjunction with other clinical evidence. †The measurement of the proximal isovelocity surface area by 2D TTE in patients with secondary MR underestimates the true ERO because of the crescentic shape of the proximal convergence. ‡May be lower in low-flow states. Abbreviations: 2D indicates 2-dimensional; CAD, coronary artery disease; ERO, effective regurgitant orifice; HF, heart failure; LA, left atrium; LV, left ventricular; MR, mitral regurgitation; and TTE, transthoracic echocardiogram. 26
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Figure 9. Secondary MR *Chordal-sparing MV replacement may be reasonable to choose over downsized annuloplasty repair. Abbreviations: GDMT indicates guideline directed medical therapy; HF, heart failure; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic dimension; MR, mitral regurgitation; MV, mitral valve; PASP, pulmonary artery systolic pressure; RF, regurgitant fraction; RVol, regurgitant volume; and Rx, medication. LVEF > 50% LVEF < 50% 27 Management of Secondary Mitral Regurgitation GDMT supervised by an HF specialist (1) Severe MR Stage D (RVol >60mL, RF>50%, ERO>0.40 cm2) Persistent Symptoms on 0ptimal GDMT and AF Rx Persistent Symptoms on optimal GDMT MV surgery (2b) MV surgery (2b) MV surgery* (2a) Transcatheter edge-to-edge repair (2a) Mitral anatomy favorable LVEF 20%-50% LVESD < 70mm PASP < 70mm Hg Severe Symptoms Undergoing CABG NO
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Table 19. Classification of TR Primary Rheumatic Infective endocarditis Iatrogenic (device leads, endomyocardial biopsy) Congenital (eg, Ebstein’s, levo-transposition of the great arteries) Other (eg, trauma, carcinoid, drugs, irradiation) Secondary Pulmonary hypertension with RV remodeling (primary or secondary to left-sided heart disease) Dilated cardiomyopathy Annular dilation (associated with AF)* RV volume overload (shunts/high output) *Isolated TR is associated with AF and has LVEF >60%, pulmonary artery systolic pressure <50 mm Hg, and no left-sided valve disease, with normal appearing tricuspid valve leaflets. Abbreviations: AF indicates atrial fibrillation; LVEF, left ventricular ejection fraction; RV, right ventricular; and TR, tricuspid regurgitation. 28
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Figure 10. Management of Tricuspid Regurgitation Abbreviations: GDMT indicates guideline-directed management and therapy; HF, heart failure; PAP, pulmonary artery pressure; PH, pulmonary hypertension; RV, right ventricular; TR, tricuspid regurgitation; and TV, tricuspid valve. 29 Tricuspid Regurgitation Severe TR (Stage C and D) Progressive TR (Stage B) At time of left-sided valve surgery Annular dilation >4.0 cm or prior right HF TV surgery (2a) Asymptomatic (Stage C) Primary TR with progressive RV dilation or systolic dysfunction TV surgery (2b) Right heart failure (Stage D) At time of left-sided valve surgery Primary TR Secondary TR Prior left-sided valve surgery Poorly responsive to GDMT Annular dilation  without PAP or left-sided disease TV surgery (2b) TV surgery (2a) TV surgery (1) Absences of severe PH or RV systolic dysfunction
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Mixed Valve Disease: Diagnosis and Follow up Abbreviations: AR indicates aortic regurgitation; AS, aortic stenosis; AVR, aortic valve replacement; CO, cardiac output; LA, left atrium; MR, mitral regurgitation; MS, mitral stenosis; PAWP, pulmonary artery wedge pressure; PMBC, percutaneous mitral balloon commissurotomy; SAVR, surgical aortic vale replacement; SV, stroke volume; and TTE transthoracic echocardiogram. 30 Mitral Stenosis Mostly associated with rheumatic valve disease MS protects LV from overload due to severe MR MR LA enlargement, high transmitral gradient, elevated LA or PAWP suggestive of patient’s symptom Diuretic or in severe limiting symptoms, mitral valve replacement MS limits LV filling  reduction in SV  Underestimation of AR AR Contrast aortography directly visualizes AR flow Diuretic or intervention with surgery: PMBC for MS and AVR/ SAVR and open mitral commissurotomy If either lesion is severe, CO is reduced, leading to underestimation of severity of coexisting valve lesions AS Invasive hemodynamic measurements Appropriate individual intervention with AVR/ mitral valve surgery PATHOPHYSIOLOGY DIAGNOSIS TREATMENT
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Mixed Valve Disease: Decision-Making Abbreviations: AVR indicates aortic valve replacement; LVEF, left ventricle ejection fraction; MR, mitral regurgitation; SAVR, surgical aortic valve replacement; TAVI, transcatheter aortic valve implantation; and TEER, transcatheter edge-to-edge repair. Primary MR 31 Aortic stenosis Aortic Regurgitation Mitral Regurgitation Symptomatic patients with a peak transvalvular velocity of at least 4.0m/s or a mean transvalvular gradient of at least 40mmHg AVR (1) Asymptomatic patients with peak transvalvular velocity of at least 4.0m/s with an LVEF <50% SAVR (1) Secondary MR Repairable Valve Not repairable valve SAVR Candidate TAVI Candidate SAVR and Surgical Mitral Valve Repair SAVR and Surgical Mitral Valve replacement TAVI/ Mitral TEER Low- Intermediate Risk High- Prohibitive Risk SAVR & surgical mitral valve repair/ replacement Or TAVR/ Mitral TEER TAVI/ Mitral TEER Requires multidisciplinary team with shared decision making with patients recommended. Limited data to support COR
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Figure 12. Antithrombotic Therapy for Prosthetic Valves *Thromboembolic risk factors include an older-generation valve, AF, previous thromboembolism, hypercoagulable state, and LV systolic dysfunction. †For a mechanical On-X AVR and no thromboembolic risk factors, a goal INR of 1.5–2.0 plus aspirin 75–100 mg daily may be reasonable starting ≥3 months after surgery. Abbreviations: ASA indicates aspirin; AVR, aortic valve replacement; INR, international normalized ratio; MVR, mitral valve replacement; Rx, medication; TAVI, transcatheter aortic valve implantation; and VKA, vitamin K antagonist. 32 Mechanical Valve VKA anticoagulation (1) Mechanical AVR with other risk factors Mechanical AVR with no other risk factors Mechanical mitral valve INR goal 2.5† (1) INR goal 3.0 (1) If antiplatelet Rx Indicated, add ASA 75-100mg (2b) No bridging needed † (1) Bridging anticoagulation during time when INR is subtherapeutic (2a) If VKA therapy interrupted for noncardiac procedures, minimize time subtherapeutic INR Bioprosthetic Valve Surgical bioprosthetic AVR or MVR TAVI Initial 3-6 month Lifelong Initial 3-6 month VKA anticoagulation INR goal 2.5 (2a) ASA 75-100mg Daily (2a) ASA 75-100mg daily PLUS clopidogrel 75 mg (2b) VKA anticoagulation INR goal 2.5 (2b) Low risk of bleeding OR
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Management of Prosthetic Valve Complications Serious Bleeds: For mechanical valves, use of four-factor prothrombin complex is reasonable (2a). If bleeding is not controlled despite four-factor prothrombin complex, intravenous Vitamin K is reasonable to consider if use of a VKA is not anticipated for 7 days (2a). For patients with bioprosthetic valves or annuloplasty rings who are receiving a DOAC and who require immediate reversal of anticoagulation because of uncontrollable bleeding, treatment with idarucizumab (for dabigatran) or andexanet alfa (for anti-Xa agents) is reasonable (2a). For patients with a mechanical prosthetic valve and supratherapeutic INR (>5.0) who are not actively bleeding, the benefit of individualized treatment with oral vitamin K, in addition to temporary withdrawal of the VKA, is uncertain (2b). Thromboembolic Events: For a mechanical AVR, increase the INR from 2.5 to 3 or add Aspirin 75-100 mg (2a). For a mechanical MVR, increase the INR from 3 to 4 or add Aspirin 75-100 mg (2a). For a bioprosthetic valve, VKA anticoagulation can be considered in place of an antiplatelet regimen (2b). Acute Valve Thrombosis: For mechanical valves, urgent TTE, TEE, fluro, and/or CT imaging is recommended for suspected valve thrombosis (1). For a thrombosed left sided mechanical valve, slow infusion, low dose fibrinolytic therapy or emergency surgery is recommended (1). In a suspected bioprosthetic valve thrombosis, 3D or 4D CT imaging is reasonable (2a). In a suspected bioprosthetic valve thrombosis, initial treatment with a VKA is reasonable (2a). Abbreviations: AVR indicates aortic valve replacement; DOAC, direct oral anticoagulant; INR, international normalized ratio; MVR, mitral valve replacement; and VKA, vitamin K antagonist. 33
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Figure 14. Management of Prosthetic Valve Stenosis Abbreviations: 3D indicates 3-dimensional; 4D, 4-dimensional; CT, computed tomography; CVC, Comprehensive Valve Center; HF, heart failure; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography/echocardiogram; and ViV, valve-in-valve. 34 Patient with Prosthetic Valve TTE and TEE for all valve types (1) Fluoroscopy or cine-CT for mechanical valves (1) 3D TEE or 4D CT imaging (2a) Suspected valve stenosis Mechanical valve Bioprosthetic valve Surgical Intervention (1) Transcatheter ViV at CVC (2a) High prohibitive surgical risk Symptomatic severe stenosis NO YES
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Figure 14. Management of Prosthetic Valve Regurgitation Abbreviations: 3D indicates 3-dimensional; 4D, 4-dimensional; CT, computed tomography; CVC, Comprehensive Valve Center; HF, heart failure; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography/echocardiogram; and ViV, valve-in-valve. 35 Suspected prosthetic valve regurgitation Intractable Hemolysis or HF Asymptomatic with severe regurgitation and low surgical risk 2D or 3D TTE and TEE (1) High prohibitive surgical risk Bioprosthetic valve regurgitation Surgical Intervention (1) Surgical Intervention (2a) YES NO Transcatheter ViV at CVC (2a) Paravalvular regurgitation Percutaneous repair at CVC (2a)
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Infective Endocarditis: Diagnostic Evaluation Patients At risk OR with suspected NVE or PVE At Risk: Congenital or acquired VHD Previous IE Prosthetic heart valves Certain congenital or heritable cardiac malformations Immunodeficiency state Injection drug use Blood Cultures (1) Purpose of TTE (1) Identify vegetations Hemodynamic severity of valvular lesions Assess ventricular function and pulmonary pressures Detect complications Utilize TEE (1) If TTE non-diagnostic Complication suspected or present Intra-cardiac leads present Heart Valve Team (1) Cardiology Cardiac Surgery Infectious Disease If surgery - cardiac anesthesia If neurological event - neurology Abbreviations: IE indicates infective endocarditis; NVE, native valve endocarditis; PVE, prosthetic valve endocarditis; TTE, trans-thoracic echocardiography; and TEE, trans-esophageal echocardiography. 36
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Figure 15. Diagnosis of Infective Endocarditis Abbreviations: CT indicates computed tomography; IE, infective endocarditis; 18FDG, 18F-fluorodeoxyglucose; NVE, native valve endocarditis; PET, positron emission tomography; PVE, prosthetic valve endocarditis; S, staph; TEE, transesophageal echocardiography; and TTE, transthoracic echocardiography. 37 Patient at Risk or with Suspected NVE or PVE Blood cultures Modified Duke Criteria Heart Valve Team (1) TTE (1) TTE nondiagnostic IE complications suspected Intracardiac leads present IE with change in signs or symptoms High risk complications Staph, enterococci, or fungal infection OR Undergoing valve surgery for IE S. aureus without known source Prosthetic valve with persistent fever without bacteremia or new murmur Echo images not adequate with suspected paravalvular abscess Possible IE by Modified Duke Criteria Nosocomial S. aureus bacteremia with known portal OR Stable IE being considered for change to oral antibiotics OR TTE (1) Intraoperative TTE (1) TEE(2a) Cardiac CT (2a) 18FDG PET/CT (2a) TEE(2b)
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Infective Endocarditis: Medical Therapy Antibiotics Antibiotics should be initiated after blood cultures are obtained, with guidance from infectious disease plus antibiotic sensitivity data (1) *In stable left-sided IE - consider changing to oral antibiotics if: No paravalvular infection on TEE Follow-up can be assured Follow-up TEE can be performed 1-3 days prior to antibiotics completion (2b) Patients with known VHD and unexplained fever should NOT receive antibiotics before blood cultures are obtained (3:Harm) Anticoagulation If there is evidence of cerebral embolism or stroke, irrespective of other indications for anticoagulation, it is reasonable to temporarily hold anticoagulation (2a) In patients on VKA anticoagulation at the time of IE diagnosis, temporary discontinuation of VKA may be considered (2b) Addiction Rx If IE is a consequence of injection drug use, the patient should be referred to addiction treatment for opioid substitution therapy (1) *IE caused by streptococcus, E. faecalis, S. aureus, or coagulase-negative staphylococci deemed stable by the Heart Valve Team. Abbreviations: IE indicates infective endocarditis; Rx, treatment; TEE, trans-esophageal echocardiography; VHD, valvular heart disease; and VKA, vitamin K antagonists. 38
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Figure 17. Preconception Management of Women with NVD Abbreviations: AS indicates aortic stenosis; MR, mitral regurgitation; MS, mitral stenosis; TTE, transthoracic echocardiography; and VHD, valvular heart disease. Severe valve disease? 39 Monitor with dedicated Multidisciplinary Heart Valve Team with expertise in management of high-risk cardiac conditions during pregnancy (1) All women with suspected valve disease who are considering pregnancy should undergo a clinical evaluation & TTE before pregnancy (1) Pre-pregnancy counseling by cardiologist with expertise in managing VHD during pregnancy (1) Exercise testing is reasonable before pregnancy (2a) Intervention before pregnancy (1) Balloon commissurotomy before pregnancy (2a) Severe AS? Provoked symptoms Clinical symptoms? Severe rheumatic MS amenable to balloon commissurotomy? Severe MR and valve suitable for repair? Valve intervention before pregnancy is reasonable (2a) Valve repair may be considered after detailed discussion with patient (2b) Prosthetic valve required? Shared decision-making regarding bioprosthetic versus mechanical valve (1) Bioprosthetic valve preferred over mechanical heart valve (2a) See Section 13.2 Normal YES NO YES NO YES NO YES NO YES NO YES
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Figure 18. Anticoagulation for Prosthetic Mechanical Heart Valves in Pregnancy *Dose-adjusted LMWH should be given at least 2 times per day, with close monitoring of anti-Xa levels. Target to Xa level of 0.8 to 1.2 U/mL, 4 to 6 hours after dose. Trough levels may aid in maintaining patient in therapeutic range. Continuous UFH should be adjusted to aPTT 2 times control. Abbreviations: aPTT indicates activated partial thromboplastin time; IV, intravenous; LMWH, low-molecular-weight heparin; UFH, unfractionated heparin; and VKA, vitamin K antagonist. At least 1 week before delivery At least 36 hours before delivery 4-6 hours before planned delivery Stop IV heparin (1) Discontinue warfarin, switch to continuous IV UFH or dose-adjusted LMWH* (1) Switch to continuous IV UFH* (1) If labor begins or urgent delivery is requested in a woman therapeutically anticoagulated with a VKA, cesarean section should be performed after reversal of anticoagulation (1) 1st, 2nd, 3rd trimesters Warfarin dose >5mg/dl? Dose-adjusted LMWH with monitoring of Xa levels available? YES Dose-adjusted LMWH* for 1st trimester then warfarin for 2nd & 3rd (2b) Continuous warfarin in all trimesters (2a) OR Dose-adjusted LMWH* for all trimesters (2b) Dose-adjusted LMWH* for 1st trimester then warfarin for 2nd & 3rd (2a) OR Continuous dose-adjusted UFH* for 1st trimester then warfarin for 2nd & 3rd (2a) NO 40 Pregnant women with a mechanical prosthesis should receive therapeutic anticoagulation with frequent monitoring (1) Women with Mechanical Heart Valve Can woman maintain therapeutic anticoagulation with frequent monitoring? Counsel against pregnancy (1) Patient counseled that there is no anticoagulation strategy that is safe for mother and fetus. Shared decision-making (1) NO YES NO YES
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Figure 19. Valve Intervention in CAD *Including men age >40 years and postmenopausal women. Abbreviations: AVR indicates aortic valve replacement; CAD, coronary artery disease; CABG, coronary artery bypass graft; CT, computed tomography; LV, left ventricular; MR, mitral regurgitation; PCI, percutaneous coronary intervention; SYNTAX, Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery; and TAVI, transcatheter aortic valve implantation. 41 PCI prior to TAVI (2a) Surgical AVR and CABG (2a) CABG (2a) Coronary CT angiography (2a) Patients undergoing valve interventions TAVI Valve Surgery Low risk of CAD Chronic severe secondary MR Angina, decreased LV systolic function, history of CAD, or CAD risk factors* Low to intermediate risk of CAD Coronary angiography (1) Left main or proximal CAD Complex bifurcation left main and/or multivessel CAD with a SYNTAX score>33 Significant proximal CAD or left main disease NO YES Coronary CT angiography (1) Coronary angiography (1) YES ABNORMAL
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Figure 20. Intervention for AF in patients with VHD Abbreviations: AF indicates atrial fibrillation; CAD, coronary artery disease; CHA2DS2-VASc score, congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, sex category; LAA, left atrial appendage; VHD, valvular heart disease; VKA, vitamin K antagonists. 42 Patients Undergoing Surgical Valve Intervention Atrial Fibrillation LAA ligation or excision may be harmful (3 Harm) Discuss benefits/ risks of adjunctive AF Procedure (1) Surgical pulmonary vein isolation or maze procedure (2a) LAA ligation or excision (2a) Anticoagulation therapy for at least 3 months after the procedure regardless of CHA2DS2-VASc risk score (2a) Discontinuation of anticoagulant despite these procedures associated with late stroke. VKA preferred over others for first 3 months in patients receiving bioprosthetic device YES NO
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Recommendations for Noncardiac Surgery in Patients with VHD Abbreviations: AR indicates aortic regurgitation; AS, aortic stenosis; COR, classification of recommendation; LV, left ventricular, mm hg, millimeters of mercury; MR, mitral regurgitation; MS, mitral stenosis; and VHD valvular heart disease. 43
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Evidence Gaps and Future Directions in VHD STAGE A Prevention of VHD: Disease mechanism and risk factors: Ca++ in BAV, Lp(a) Primary & secondary prevention of risk factors STAGE B Medical therapy to prevent VHD progression: Disease mechanism and targets Understanding the interplay between severity of VHD and LV modulation and vascular dysfunction STAGE C Timing of intervention: Improvement in measures of disease severity and impact on LV Patient-centered research and diverse patient groups STAGE D Better management options: Prosthetic valve durability and long-term management Optimal anti-thrombotic regimen Prevention of complications Promoting equity in care of pts with VHD Abbreviations: Ca++ in BAV indicates calcium in bicuspid aortic valve; Lp(a), lipoprotein (a); LV indicates left ventricle; pts, patients; and VHD, valvular heart disease. 44
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Acknowledgments Many thanks to our Guideline Ambassadors who were guided by Dr. Elliott Antman in developing this translational learning product in support of the 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease. Yuvraj Chowdhury, MD Marat Fudim, MD, MHS Charles German, MD Agnes Kozco, MD Arnav Kumar, MD Sonali Kumar, MD Dae Hyun Lee, MD Jainy Savla, MD Mrinali Shetty, MD Lina Ya'qoub, MD The American Heart Association requests this electronic slide deck be cited as follows: Chowdhury, Y., Fudim, M., German, C., Kozco, A., Kumar, A., Kumar, S., Lee, D., H., Savla, J., Shetty, M., Ya’qoub, L, Bezanson, J. L., & Antman, E. (2020). Clinical Update; Adapted from: 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease [PowerPoint slides]. Retrieved from https://professional.heart.org/en/science-news 45