Table 1. ESC/EACTS and AHA/ACC Guideline recommendations for intervention in asymptomatic patients with valvular heart disease
| 2014 and 2017 AHA/ACC Guidelines |
2017 ESC/EACTS Guidelines |
| ASYMPTOMATIC SEVERE AORTIC STENOSIS |
| LV systolic dysfunction with LVEF ≤50 % (IB) |
LV systolic dysfunction with LVEF <50% not due to another cause (IC) |
| Decreased exercise tolerance or exercise fall in blood pressure (IIaB) |
Abnormal exercise test showing
• symptoms clearly related to AS (IC)
• fall in blood pressure below baseline (IIaC)
|
Low surgical risk and
• very severe AS (V max ≥ 5.0 m/s) (IIaB)
or
• rapid disease progression (≥0.3 m/s/year) (IIbC) |
Low surgical risk and one of the following (IIaC)
• very severe AS (V max ≥ 5.5 m/s)
• severe calcification and rate of V max progression ≥ 0.3 m/s/year
• markedly elevated BNP (>three-fold age- and sex-corrected range)
• severe pulmonary hypertension (PA systolic pressure > 60 mmHg confirmed by invasive measurement) without other explanation
|
| ASYMPTOMATIC CHRONIC SEVERE AORTIC REGURITATION |
| LV systolic dysfunction (LVEF < 50%) (IB) |
LV systolic dysfunction (LVEF ≤ 50%) (IB) |
| Normal LV systolic function (LVEF ≥ 50%) but with severe LV dilation (LVESD > 50 mm) (IIaB) |
Normal LV systolic function (LVEF > 50%) with severe LV dilatation: LVEDD > 70 mm or LVESD > 50 mm (or LVESDi > 25 mm/m2 BSA in patients with small body size) (IIaC) |
| Normal LV systolic function (LVEF ≥ 50%) but with progressive severe LV dilation (LVEDD > 65 mm) if surgical risk is low (IIbC) |
|
| Bicuspid aortic valve: indications for surgery on the ascending aorta |
Aortic root or tubular ascending aorta aneurysm a (irrespective of the severity of AR) |
| Diameter of the aortic sinuses or ascending aorta >50 mm and risk factor for dissection is present (family history of aortic dissection or if the rate of increase in diameter is ≥5 mm per year) (IIaC) |
Patients with Marfan syndrome with maximal ascending aortic diameter ≥50 mm (IC) |
| Diameter of the aortic sinuses or ascending aorta >55 mm (IB) |
Patients with aortic root disease and maximal ascending aortic diameter: (IIaC)
• ≥45 mm in the presence of Marfan syndrome and additional risk factors,b or patients with TGFBR1 or TGFBR2 mutation (including Loeys–Dietz syndrome)c
• ≥50 mm in the presence of a bicuspid valve with additional risk factorsb or coarctation
• ≥55 mm for all other patients. |
| Patients with aortic valve surgery because of severe AS or AR if the diameter of the ascending aorta is >45 mm (IIaC) |
Patients with primary indication for the aortic valve with maximal ascending aortic diameter ≥45 mm, particularly in the presence of a bicuspid valve.d (IIaC) |
| ASYMPTOMATIC MITRAL STENOSIS |
| PMC for very severe mitral stenosis (mitral valve area ≤1.0 cm2) and favourable valve morphology in the absence of left atrial thrombus or moderate-to-severe mitral regurgitation (IIaC) PPMC for severe mitral stenosis (mitral valve area ≤1.5 cm2) and favourable valve morphology in the absence of left atrial thrombus or moderate-to-severe mitral regurgitation, with new onset of atrial fibrillation (IIbC) |
Valve area ≤1.5 cm2, without unfavourable clinical and anatomical characteristics for PMCe and
• high thromboembolic risk (history of systemic embolism, dense spontaneous contrast in the left atrium, new onset, or paroxysmal atrial fibrillation) (IIaC)
and/or
• high risk of haemodynamic decompensation (systolic pulmonary pressure > 50 mmHg at rest, need for major non-cardiac surgery, desire for pregnancy) (IIaC) |
| ASYMPTOMATIC CHRONIC SEVERE PRIMARY MITRAL REGURGITATION |
| LV systolic dysfunction (LVEF 30–60% and/or LVESD ≥ 40 mm) (IB) |
LV systolic dysfunction (LVESD ≥ 45 mm or LVEF ≤ 60%) (IB) |
| Preserved LV function (LVEF >60% and LVESD <40 mm) and a high likelihood of a successful and durable repair with new onset of atrial fibrillation or PA systolic pressure at rest >50 mm Hg (IIaB) |
Preserved LV function (LVEF >60% and LVESD <45 mm) and atrial fibrillation secondary to severe MR or PA systolic pressure at rest >50 mm Hg confirmed by invasive measurement (IIaB) |
Preserved LV function (LVEF >60% and LVESD < 40 mm) if (all must be present):
• likelihood of a successful durable repair is >95%,
• expected surgical mortality is <1%,
• valve repair if performed at a Heart Valve Center of Excellence (IIaB) |
Normal LV function (LVEF > 60% and LVESD 40–44 mm) and all of the following:
• a durable repair is likely,
• surgical risk is low,
• valve repair if performed at a Heart Valve Center, and
• a flail mitral leaflet or severe LA dilation (volume >60 mL/m2 in sinus rhythm) is present (IIaC) |
| Preserved LV function (LVEF > 60% and LVESD < 40 mm) with a progressive increase in LV size or decrease in EF on serial imaging studies (IIaC) |
|
Adapted from Refs.1–3
ACC, American College of Cardiology; AHA, American Heart Association; AR, aortic regurgitation; AS, aortic stenosis; AVR, aortic valve replacement; BSA, body surface area; EACTS, European Association for CardioThoracic Surgery; ECG, electrocardiogram; ESC, European Society of Cardiology; LA, left atrium; LV, left ventricle; LVEDD, left ventricular end-diastolic dimension; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic dimension; PA, pulmonary artery; PMC, percutaneous mitral commissurotomy; V max, peak transvalvular velocity.
aFor clinical decision-making, dimensions of the aorta should be confirmed by ECG-gated CT measurement.
bFamily history of aortic dissection (or personal history of spontaneous vascular dissection), severe aortic regurgitation or mitral regurgitation, desire of pregnancy, systemic hypertension, and/or aortic size increase >3 mm/year (on repeated measurements using the same ECG-gated imaging technique, measured at the same level of the aorta with side-by-side comparison and confirmed by another technique).
cIn females with low body surface area, presence of TGFBR2 mutation, or patients with severe extra-aortic features a lower threshold of 40 mm may be considered.
dConsidering age, BSA, aetiology of valvular disease, presence of a bicuspid aortic valve, and intraoperative shape and thickness of the ascending aorta.
eUnfavourable characteristics for percutaneous mitral commissurotomy can be defined by the presence of several of the following characteristics: (i) clinical characteristics: old age, history of commissurotomy, NYHA Class IV, permanent atrial fibrillation, and severe pulmonary hypertension. (ii) Anatomical characteristics: echo score >8, Cormier score 3 (calcification of mitral valve of any extent, as assessed by fluoroscopy), very small mitral valve area, and severe tricuspid regurgitation.
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