CardioExchange Archive

The American Heart Association and the American College of Cardiology today released new practice guidelines for the management of patients with valvular heart disease (VHD). Among its most notable features, the new document provides a new system of classification for VHD and lowers the threshold for interventions, including, for the first time, transcatheter as well as surgical interventions.

The new guidelines includes a new system of classification, similar to the one used in the ACC/AHA heart failure guidelines. The four stages of progression are:

• Stage A, for people with risk factors that place them at risk for VHD.
• Stage B, for people with asymptomatic but progressive, mild-to-moderate VHD.
• Stage C, for people with asymptomatic but severe VHD. C1 is for people in whom the left or right ventricle remains compensated. C2 is for people with a decompensated ventricle.
• Stage D, for people with severe VHD who have developed symptoms.

The guideline endorses the movement in recent years towards the use of a multidisciplinary Heart Valve Team. “Patients with severe VHD should be evaluated by a multidisciplinary Heart Valve Team when intervention is considered,” the document states.

The Heart Valve Team also plays a central role in the decision to choose surgical aortic valve replacement (AVR) or the newer transcatheter AVR (TAVR). In general, surgery is recommended for patients who require AVR who are at low or intermediate surgical risk.  TAVR is recommended for patients with an appropriate indication for AVR but who have a prohibitive surgical risk. TAVR is “a reasonable alternative” to surgery in some patients with a high surgical risk.

The document also includes a new and more comprehensive method of risk assessment of patients for whom intervention is being considered.

“Due to more knowledge regarding the natural history of untreated patients with severe VHD and better outcomes from surgery, we’ve lowered the threshold for operation to include more patients with asymptomatic severe valve disease,” said the Mayo Clinic’s Rick Nishimura, co-chair of the writing committee, in a press release. “Now, select patients with severe asymptomatic aortic stenosis and severe asymptomatic mitral regurgitation can be considered for intervention, depending on certain other factors, such as operative mortality and in the case of mitral regurgitation, the ability to achieve a durable valve repair.”