New Valvular Heart Disease Guidelines Integrate Catheter-based Interventions

New guidelines for the management of patients with valvular heart disease (VHD) provide updated definitions of disease severity and incorporate recommendations on the use of catheter-based interventions. The guidelines, issued jointly by the American College of Cardiology (ACC) and the American Heart Association (AHA) on March 3, 2014, have not been updated since 2008. The full guidelines will be published in future issues of Circulation and the Journal of the American College of Cardiology.

A novel aspect of the guidelines is a 4-stage classification of the progression of VHD. Created to help clinicians determine the optimal timing of intervention, the stages consider the degree of valve narrowing or leakage, presence of symptoms, response of the left and/or right ventricle to the valve lesion, and any change in heart rhythm (table 1).

Table 1. Stages of Progression of VHD

In a video interview released by the AHA, writing committee member Robert O. Bonow, MD, of Northwestern University Feinberg School of Medicine (Chicago, IL), said the new classification system for valvular disease is meant to be similar to the approach for treating heart failure.

“Once we categorize patients that way, then it’s much easier to talk about how we’re managing those patients differently according to the guidelines-based approach, based upon those various stages,” he explained.

TAVR, MitraClip Addressed

Transcatheter aortic valve replacement (TAVR), which has evolved significantly in the years since the previous guidelines were issued, is included for the first time. TAVR is recommended for patients with prohibitive risk for surgical AVR and a predicted post-TAVR survival greater than 12 months. According to the guidelines, it is a reasonable alternative to surgical AVR in patients who meet an indication for AVR and who have high surgical risk.

In addition to recommendations for symptomatic patients, the guidelines lower the threshold for valve replacement, stating for example:

• AVR is reasonable in asymptomatic patients (stage C1) with severe aortic stenosis and decreased exercise tolerance or an exercise fall in blood pressure
• AVR may be considered for asymptomatic patients with severe aortic stenosis (stage C1), rapid disease progression, and low surgical risk

For asymptomatic patients with mitral valve disease, the guidelines state that surgical repair is reasonable in those with chronic severe nonrheumatic primary MR (stage C1) and preserved LV function in whom there is a high likelihood of a successful and durable repair with new onset of A-fib or resting pulmonary hypertension (pulmonary artery systolic arterial pressure >50 mm Hg).

“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,” noted writing committee co-chair Rick A. Nishimura, MD, of Mayo Clinic (Rochester, MN), 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.”

The guidelines also address recommendations for use of the MitraClip device, recently approved by the US Food and Drug Administration. According to the guidelines, transcatheter mitral valve repair may be considered for severely symptomatic patients (NYHA class III to IV) with chronic severe primary mitral regurgitation (stage D) who have favorable anatomy for the repair procedure and a reasonable life expectancy but who have a prohibitive surgical risk because of severe comorbidities and remain severely symptomatic despite optimal medical therapy for heart failure.

Other recommendations of note include:

• Percutaneous repair of paravalvular regurgitation is reasonable in patients with prosthetic heart valves and intractable hemolysis or NYHA class III/IV heart failure who are at high risk for surgery and have anatomic features suitable for catheter-based therapy when performed in centers with expertise in the procedure
• CT coronary angiography is a reasonable method to exclude the presence of significant obstructive CAD in select patients with a low/intermediate pretest probability of CAD. A positive coronary CT angiogram can be confirmed with invasive coronary angiography
• Surgery or PCI is reasonable in patients undergoing valve repair or replacement with significant CAD
• Catheter ablation for A-fib should not be performed in patients with severe mitral regurgitation when mitral repair or replacement is anticipated, with preference for the combined maze procedure plus mitral valve repair
• Percutaneous mitral balloon commissurotomy may be considered for asymptomatic patients with severe mitral stenosis (mitral valve area ≤ 1.5 cm², stage C) and favorable valve morphology in the absence of left atrial thrombus or moderate-to-severe mitral regurgitation who have new-onset A-fib

Format Facilitates Future Updating

According to co-chair Catherine M. Otto, MD, of the University of Washington Medical School (Seattle, WA), the new guideline was developed in a modular format that will allow the update or addition of individual recommendations based on the publication of new evidence.

“This novel approach to evidence-based guideline development will revolutionize the clinical impact of guideline recommendations, ensuring they are always current and allowing seamless integration with electronic medical record systems,” she said in a press release.

 “We’re looking forward to seeing how these guidelines play out in the community,” Dr. Bonow stated, adding that he hopes clinicians find that “there is much more substance here than previously.” 

Due to an editing error, an earlier version of this article mistakenly listed the surgical indications for mitral valve repair as indications for a transcatheter procedure. TCTMD apologizes for the error.