ACC/AHA 2020 Guideline for Valvular Heart Disease Spotlights Transcatheter Treatments

December 17, 2020—The American College of Cardiology (ACC) announced the release, with the American Heart Association (AHA), of the “2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease.” The guideline is available online in the Journal of the American College of Cardiology and AHA’s Circulation.

The ACC announcement advised that the new clinical guideline aims to provide health care professionals with concise, evidence-based, updated recommendations to optimize care and management of patients with valvular heart disease. This document replaces the 2014 guideline and a focused update from 2017.

According to the ACC, approximately half of all people aged ≥ 65 years have some form of valvular heart disease. The most common causes of valvular heart disease among adults in the United States are age-related thickening and calcification or anatomic valve variants, which manifest either as stenosis or regurgitation.

In developing the recommendations, the writing committee used evidence-based methodologies based on an extensive review of available data through March 1, 2020. Like all ACC/AHA clinical practice guidelines, the review focused on trials, studies, registries, systematic reviews and expert opinion.

ACC noted that the use of transcatheter aortic valve replacement (TAVR) is expanding to more patients because research shows comparable outcomes to surgical replacement.

Aortic stenosis patients and their health care teams should consider factors surrounding the lifetime risks and benefits associated with both the type of valve used (mechanical or bioprosthetic) and the procedure itself (transcatheter or surgical).

Management of valve regurgitation has improved because of more durable treatment options and lower risks surrounding procedures to repair or replace the valve. This is promising because earlier intervention can offer symptom relief and potential prevention of the irreversible consequences of too much blood volume in the left ventricle, noted the ACC announcement.

The writing committee advised that the optimal timing of intervention for stenosis or regurgitation issues depends on the severity of the valve condition, as well as the safety and long-term effectiveness of treatment options. As ongoing clinical research data evolves, the recommended timing of interventions will shift to earlier in the disease course for some patients.

Additionally, the committee notes there are limitations in the research used for some areas of the guideline due to the small numbers of patients with specific types of valvular heart disease. More disease-specific studies and patient-centered trials that focus on each stage of the disease process are recommended.

As stated in the guideline, patients who have severe valvular heart disease and are being considered for valve repair or replacement should be evaluated by a specialized team working with a primary or comprehensive valve center. A comprehensive valve center (level I) has the resources and capabilities to perform a full range of interventional and surgical valve procedures. A primary valve center (level II) can perform TAVR and more limited surgical procedures.

Catherine Otto, MD, and Rick A. Nishimura, MD, served as co-chairs of the guideline writing committee. Dr. Otto is the J. Ward Kennedy-Hamilton Endowed Chair in Cardiology, Professor of Medicine, and Director of the Heart Valve Clinic at the University of Washington School of Medicine in Seattle, Washington. Dr. Nishimura is the Judd and Mary Morris Leighton Professor of Cardiovascular Diseases at the Mayo Clinic in Rochester, Minnesota.

Dr. Otto commented in the ACC announcement, “Current research and new technology continue to transform the treatment of heart valve disease, as updated lifestyle and medication guidance evolve, and less invasive procedures have replaced traditional surgery for many patients.”

She continued, “Clinical studies over the past decade have increased awareness of the prevalence and importance of valvular heart disease in contributing to excess mortality, morbidity and a reduced quality of life, particular in older people. Simultaneously, clinical studies have demonstrated the safety and effectiveness of new, less-invasive approaches for treatment of heart valve dysfunction. Integration of this expanded evidence base, in conjunction with expert clinical experience, will furnish both providers and patients with the guidance needed to ensure optimal outcomes for patients with heart valve conditions.”

Dr. Nishimura added, “There is a knowledge explosion in medicine today, which can overwhelm the clinician. This is particularly true in the area of valvular heart disease, in which multiple investigational trials are being rapidly performed and released, so that it becomes extremely difficult for an individual clinician to keep up with optimal treatments for each specific patient. The Valvular Heart Disease Guideline brings together experts in the field who review all the data and arrive at a consensus opinion for best treatment, outlined in the Class Recommendations.”

Finally, Dr. Otto advised, “While this guideline focuses on patients with end-stage heart valve disease, future research will also lead to treatments to prevent heart valve disease or earlier interventions to slow its progression.”

The “2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease” was prepared by a volunteer writing committee on behalf of the ACC and the AHA Joint Committee on Clinical Practice Guidelines. The writing group consisted of clinicians, including cardiologists, interventionalists, surgeons and anesthesiologists, and a patient representative.

This guideline was developed in collaboration with and endorsed by the American Association for Thoracic Surgery, the American Society of Echocardiography, the Society for Cardiovascular Angiography and Interventions, the Society of Cardiovascular Anesthesiologists, and the Society of Thoracic Surgeons.