ESC/EACTS Guidelines Address the Management of Valvular Heart Disease
September 5, 2017—European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) 2017 guidelines for the management of valvular heart disease were recently published online in European Heart Journal and on the ESC website.
In the ESC press release announcing the new guidelines, ESC Chairperson Prof. Helmut Baumgartner, MD, commented, “Since the 2012 guidelines, a large amount of new data have accumulated, particularly in the field of catheter interventional treatment of valvular heart disease. In aortic stenosis, there have been five randomized clinical trials comparing surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) as well as large-scale registry data.”
Prof. Baumgartner continued, “There is also new evidence regarding predictors of outcome in asymptomatic patients with valvular heart disease and on antithrombotic therapy in this patient population, among other innovations. This definitely required an update of management recommendations.”
EACTS Chairperson, Prof. Volkmar Falk, MD, added, “We have now expanded the indications for transcatheter valves because there is new evidence in the intermediate-risk population.”
Regarding SAVR and TAVR for symptomatic aortic stenosis, the guidelines emphasize that the decision should be made by a heart team of surgeons and cardiologists. A new recommendation is that both procedures should be performed in a heart valve center with departments for cardiac surgery and cardiology and one that provides structured collaboration on site, conducts structured training, records data on performance and patient outcomes, and participates in registries.
The guidelines state that broadly speaking, patients at high risk for surgery should receive TAVR and those at low risk (especially younger patients) should undergo SAVR.
Prof. Baumgartner stated, “The choice of SAVR or TAVR is not simply based on a risk score or age. The heart team must weigh the risks and benefits of both procedures, particularly in the intermediate-risk situation. Discussion should include age, comorbidities, anatomy, and outcomes of the center for surgery and transcatheter intervention.”
He continued, “Evidence is based on trials in patients with a mean age of 80 years and the recommendations cannot be applied to those below 70 to 75 years. Younger patients have more bicuspid valves, which may have worse TAVR results than tricuspid valves, and there are no long-term data on the durability of TAVR valves. Complications such as paravalvular leakage or need for a pacemaker are still more frequent with TAVR compared to surgery, which is important in younger patients with a longer life expectancy. In younger patients, there must still be a critical risk of surgery before considering TAVR.”
The guidelines advise that studies suggested that early surgery may improve outcomes in asymptomatic patients with valve disease, but deciding when to intervene remains controversial. For example, pulmonary hypertension has been introduced into the criteria for selecting asymptomatic aortic stenosis patients for surgery after studies showed it was a predictor of poor outcomes. Conflicting studies on the prognostic value of exercise echocardiographic parameters resulted in their removal from the selection criteria for asymptomatic patients with aortic stenosis and mitral regurgitation.
In the area of antithrombotic therapy, the guidelines note that there is now sufficient data to recommend non–vitamin K antagonist oral anticoagulants (NOACs) as an alternative to vitamin K antagonists in patients with atrial fibrillation and aortic valve disease or mitral regurgitation. However, NOACs remain contraindicated in patients with mechanical valves and in mitral stenosis.
Prof. Falk noted, “This is a joint guideline between cardiologists and surgeons. It is absolutely essential that both specialties follow the same recommendations because we are treating the same patients. Decisions in structural valve disease must be taken by a heart team of cardiologists and surgeons.”
Those who want more information can consult the updated chapter on valvular heart disease in the ESC Textbook of Cardiology, which was written by the same team, noted the ESC. These two documents will be linked, and the ESC will evaluate user acceptance.