2021 European Valvular Heart Disease Guidelines Are Published by ESC/EACTS Task Force

August 28, 2021—The European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS) announced the publication of the 2021 ESC/EACTS guidelines for the management of valvular heart disease (VHD). The document by Professor Alec Vahanian, MD, et al is available online in European Heart Journal.

Prof. Vahanian, who is with the University of Paris in Paris, France, serves as the ESC task force chairperson for developing the guidelines. The EACTS task force chairperson is Professor Friedhelm Beyersdorf, MD, of the University of Freiburg in Freiburg, Germany.

According to the societies’ announcement, the guidelines advise that the choice and timing of treatment (including medication and percutaneous or surgical valve replacement/repair) should be made by a heart team of clinical and interventional cardiologists, cardiac surgeons, imaging specialists, cardiovascular anesthesiologists, and nurses who should consider clinical and anatomical factors, coexisting conditions which are frequent in the elderly, and patient preferences.

As summarized by the societies, key points of the guidelines include:

• Interventions (percutaneous or surgery) are indicated in symptomatic patients if there is an expected benefit.
• Decision-making in asymptomatic patients must weigh the risk of intervention against the expected natural history of VHD. If rapid symptom progression is predicted, intervention may be justified if the procedural risk is low.
• In elderly patients, decisions should consider the estimated impact of treatment on life expectancy and quality of life.
• Regarding surgery, increased experience and procedural safety have led to expanded indications toward earlier surgery in asymptomatic patients with aortic stenosis, aortic regurgitation, or mitral regurgitation. The guidelines emphasize the need for more comprehensive evaluation and earlier surgery in tricuspid regurgitation to avoid irreversible heart damage.
• Regarding percutaneous techniques, good results in high risk or inoperable patients with aortic stenosis and mitral regurgitation have led to increased indications, provided futility is avoided. The guidelines state that the encouraging preliminary experience with transcatheter tricuspid valve interventions suggests a potential role for inoperable patients, but this needs to be confirmed by further evaluation.

“VHD is too often undetected, and the guidelines stress the importance of clinical examination as the first step in diagnosis,” commented Prof. Vahanian in the societies’ announcement. “Noninvasive evaluation using echocardiography first, and other cardiac imaging techniques when needed, is essential to assess severity and catheterization should only be used when imaging is inconclusive.”

Prof. Vahanian added, “The use of surgery and transcatheter techniques as complementary treatment options has substantially increased the number of patients with aortic stenosis and mitral regurgitation undergoing interventions in the past decade.”

Addressing the guidelines on patient preference, Prof. Beyersdorf stated, “Patients’ expectations and values are an important part of the decision-making process. Patients and their families should be thoroughly informed and assisted in their choices. Symptom relief on its own may justify intervention if it is a priority for the patient. However, treatment is considered futile when it is not expected to prolong life or relieve symptoms.”

Finally, the guidelines note that sufficient volumes of procedures are required to deliver high quality care, but precise numbers per physician or hospital remain controversial due to inequalities between high- and middle-income countries. Prof. Beyersdorf advised, “Performance is not exclusively related to procedural volumes and heart valve centers should conduct internal quality assessment by systematically recording procedural data and patient outcomes.”