Population: Adults requiring anticoagulation for mechanical valve or mitral stenosis.
Organizations
AHA/ACC/HRS 2020, ESC 2018, ACCP 2018
Recommendations
–If mechanical valve present, anticoagulate with warfarin titrated to following INR goals:
• Mitral valve: INR 2.5–3.5.
• Aortic valve without increased risk factors for VTE: INR 2.0–3.0.
• Aortic valve with increased risk factors for VTE (AF, prior VTE, LV dysfunction, hypercoagulable state): INR 2.5–3.5. Bridge with heparin or low-molecular-weight heparin for procedures that require warfarin to be held. Do not use direct thrombin inhibitors (dabigatran/edoxaban) or DOAC (rivaroxaban/apixaban).
– DOAC may be used in mild-to-moderate valvular disease. They are also likely acceptable in aortic stenosis (including severe) and >3 mo after mitral valve repair or bioprosthetic valve placement.
Sources
–Eur Heart J. 2018;39(16):1330-1393.
–Chest. 2018;154(4):1121-1201.
–2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS. Guideline for the Management of Patients with Atrial Fibrillation.
–Circulation. 2021;143:e72-e227.
Population: Adults with valvular heart disease.
See following sections for specific guidance on aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation, mitral regurgitation as related to infective endocarditis, bicuspid aortic valve.
Organization
ACC/AHA 2020
General Recommendations
–Obtain transthoracic echocardiogram (TTE) with 2D or 3D evaluation of chamber volume. Doppler echo gives noninvasive determination of valve dynamics. Each subtype of VHD has different recommendations of follow-up imaging if TTE is discordant with clinical picture.
–In valvular stenosis, important measurements are maximum velocity across the valve, mean pressure gradient, and valve area.
–In valvular regurgitation, important measurements are regurgitant surface area, volume fraction, and severity grade.
–Patients should be seen at least annually for clinical evaluation. Repeat TTE if there are new symptoms or a change in physical exam.
–Valve replacement replaces a native value disease with a palliated valve disease. If choosing between mechanical and bioprosthetic valves, then patient is choosing between risk of long-term anticoagulation with warfarin versus a risk of reintervention. Therefore, generally older patients receive bioprosthetic valves and younger patients receive mechanical valves.
–If AF develops in first 3 mo after a bioprosthetic valve replacement, use warfarin. After 3 mo with new bioprosthetic valve, if AF develops, can use an DOAC.
–With a mechanical heart valve, the corresponding INR goals for warfarin depend on the location of the valve. Determine the INR at least weekly during initiation and at least monthly when anticoagulation is stable following these goals:
• Mitral valve: INR 2.5–3.5.
• Aortic valve without increased risk factors for VTE: INR 2.0–3.0.
• Aortic valve with increased risk factors for VTE (AF, prior VTE, LV dysfunction, hypercoagulable state): INR 2.5–3.5.
–Symptoms ongoing after valve replacement may be due to irreversible causes of valve disease such as LV dysfunction, pulmonary HTN, or RV dysfunction. Also may be due to concurrent noncardiac etiologies or other cardiac etiology.
–After repair, repeat TTE at 1–3 mo. Then patients should be seen at least annually for clinical evaluation.
–Risk calculator for valve replacement surgery: https://riskcalc.sts.org/stswebriskcalc/calculate
Population: Adults with aortic stenosis (AS).
Organization
ACC/AHA 2020
Recommendations
–No medical therapy is available to specifically address AS symptoms or disease progression.
–On TTE, note that velocity and pressure gradients across the valve measured by Doppler may be underestimated if the patient is hypertensive.
–Note that pressure gradients are underestimated if there is LV dysfunction.
–In severe AS with velocity >4.0 m/s, rate of progression is high.
–Exercise treadmill testing is rarely indicated but helpful to evaluate patients who have discordant echo/clinical findings (ie, moderate or severe stenosis in the absence of expected symptoms). Previously undetected symptoms of chest pain, shortness of breath, exertional dizziness, or syncope may be identified to prevent sudden death.
–Guideline-directed medical therapy for HF should be continued in AS.
–Statins prevent atherosclerosis in calcific AS but do not prevent progression of AS hyperdynamics.
–Treat hypertension in the presence of significant AS. HTN doubles the risk for mortality in AS and increases the risk for cardiovascular event in AS. However, abruptly lowering the systolic blood pressure should be avoided so start medication at low dose and increase slowly over months. Resolving the HTN will not stop AS progression.
–Strong indications for aortic valve replacement (AVR):
• Symptomatic patient (exertional dyspnea or presyncope, HF, angina, syncope).
• Asymptomatic patients with severe AS and decreased LV function (EF 50%).
• Asymptomatic patient with severe AS already undergoing another cardiac surgery.
–Percutaneous aortic balloon dilation procedure should be considered a “bridging therapy” to surgical AVR or TAVR/TAVI therapy. However, this procedure is used less frequently in adults given increased availability and success of transcatheter intervention. It is now mostly used in children, adolescents, and young adults.
Population: Adults with aortic regurgitation (AR).
Organization
ACC/AHA 2020
Recommendations
–Endocarditis is the most common cause of AR. Other causes include aortic dissection, transcatheter procedure, or blunt chest trauma.
–Acute AR may acutely lead to higher LV volumes contributing to low cardiac output and pulmonary congestion.
• Using beta-blockers for associated ascending aortic dissection or aneurysm may increase the transaortic stroke volume, causing a paradoxical increase in systolic blood pressure. Go slowly.
• Do not use beta-blockers in other causes of AR. Cardiac output may suffer without the compensatory tachycardia.
–Cardiac magnetic resonance (CMR) is an alternative form of evaluation if the TTE is nondiagnostic or suboptimal.
–Treat hypertension to keep SBP <140 mmHg with nondihydropyridine calcium channel blocker, ACE inhibitor, or ARB agent.
–Strong indications for AVR:
• Symptomatic (decrease in exercise capacity) with severe AR.
• Asymptomatic with chronic AR and LVEF <55%.
• Going for another cardiac surgery and have severe AR.
Population: Adults with mitral regurgitation (MR).
Organization
ACC/AHA 2020, 2017
Recommendations
–Determine etiology of MR: primary (papillary muscle rupture, mitral valve prolapse, etc.) or secondary (dilated LV).
–Treatment options for primary MR:
• Observe with periodic monitoring (TEE q6-12 mo) if nonsevere or severe/asymptomatic but repair/replacement contraindicated.
• Refer for repair if stage C11 and likelihood of successful repair is >95% with <1% mortality.
• Refer for replacement if symptomatic, or asymptomatic but LVEF 30%–60% or LVEF >60% but falling.
–Treatment options for secondary MR:
• Refer for replacement if severe MR with persistent class III–IV symptoms.
• Otherwise, optimize therapies for CAD and CHF, consider cardiac resynchronization therapy if indicated, and monitor with TEE q6-12 mo.
Population: Adults with mitral regurgitation related to infective endocarditis.
Organization
ACC/AHA 2017
Recommendations
–Valve surgery during initial hospitalization before completion of full course of antibiotics is indicated for infective endocarditis (IE) associated with:
• Valve dysfunction resulting in symptoms of HF.
• Left-sided IE caused by S. aureus, fungal, or other highly resistant organisms.
• Complicated by heart block, annular or aortic abscess, or destructive penetrating lesions.
–Evidence of persistent infection as manifested by persistent bacteremia or fevers lasting longer than 5 to 7 d after onset of appropriate antimicrobial therapy.
–Surgery is recommended for patients with prosthetic valve endocarditis and relapsing infection (defined as recurrence of bacteremia after a complete course of appropriate antibiotics and subsequently negative blood cultures) without other identifiable source for portal of infection.
–Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is indicated as part of the early management plan in patients with IE with documented infection of the device or leads.
Population: Adults with mitral stenosis.
Organization
ACC/AHA 2020
Recommendations
–The majority of mitral stenosis is due to rheumatic heart disease. The time between initial rheumatic illness and MS can be decades. In older people the cause of MS is more often calcific MS. Between age and comorbidities, the prognosis of calcific MS is <50% in 5 y, meaning the indications for intervention are palliative in highly asymptomatic patients.
–Consider transesophageal echocardiogram (TEE) prior to sending the patient for percutaneous mitral balloon commissurotomy (PMBC) to exclude the presence of left atrial thrombus.
–Give warfarin to patients with mitral stenosis and AF, prior embolic event, or intracardiac thrombus. Rheumatic MS patients were excluded from DOAC studies, hence indication for warfarin in Afib.
–Use rate control in Afib and MS to allow optimal diastolic filling time across the stenotic valve. The fibrosis in rheumatic MS may also make it more challenging to rhythm control.
–To increase exercise duration and improve symptoms in younger people, beta-blockers or ivabradine may be beneficial.
–Balloon commissurotomy is indicated in symptomatic patients with severe mitral stenosis (MVA < 1.5 cm2) with no atrial thrombus and no or minimal mitral insufficiency. In rheumatic disease, delay until NYHA III or IV due to slow course of disease.
–Mitral valve replacement is indicated if balloon commissurotomy is contraindicated in a patient with severe symptoms and severe mitral stenosis.
Population: Adults with bicuspid aortic valve (BAV).
Organization
ACC/AHA 2020
Recommendations
–Aortic aneurysms will affect 20%–40% of adults with BAV. They therefore require lifelong surveillance even in the absence of symptoms.
–Replace the valve if the diameter of the ascending aorta or aortic sinuses is >5.5 cm.
Sources
–Circulation. 2021;143:e72-e227.
–Circulation. 2017;135:e1159-e1195.