New ESC/EACTS Valvular Heart Disease Guidelines Change Several Repair Indications

Ted Bosworth

September 09, 2021

New European guidelines for the management of valvular heart disease offer more than 45 revised or completely new recommendations relative to the previous version published in 2017, according to members of the writing committee who presented the changes during the annual congress of the European Society of Cardiology.

With their emphasis on early diagnosis and expansion of indications, these 2021 ESC/European Association for Cardio-Thoracic Surgery guidelines are likely to further accelerate the already steep growth in this area of interventional cardiology, according to Alec Vahanian, MD, a professor of cardiology at the University of Paris.

"Valvular heart disease is too often undetected, and these guidelines stress the importance of clinical examination and the best strategies for diagnosis as well as treatment," he said.

Of the multiple sections and subsections, which follow the same format of the previous guidelines, the greatest number of revisions and new additions involve perioperative antithrombotic therapy, according to the document, which was published in conjunction with the ESC Congress.

Eleven New Guidelines for Anticoagulants

On the basis of evidence published since the previous guidelines, there are 11 completely new recommendations regarding the use of anticoagulants or antiplatelet therapies. The majority of these have received a grade I indication, which signifies "recommended" or "indicated." These include indications for stopping or starting anticoagulants and which anticoagulants or antiplatelet drugs to consider in specific patient populations.

The next most common focus of new or revised recommendations involves when to consider surgical aortic valve repair (SAVR) relative to transcatheter aortic valve implantation (TAVI) in severe aortic stenosis. Most of these represent revisions from the previous guidelines, but almost all are also grade I recommendations.

"SAVR and TAVI are both excellent options in appropriate patients, but they are not interchangeable," explained Bernard D. Prendergast, BMedSci, MD, director of the cardiac structural intervention program, Guy's and St Thomas' Hospital, London.

While the previous guidelines generally reserved TAVI for those not suitable for SAVR, the new guidelines are more nuanced.

As a rule, SAVR is generally preferred for younger patients. The reason, according to Prendergast, is concern that younger patients might outlive the expected lifespan of the prosthetic TAVI device.

No Single Criterion for Selecting SAVR Over TAVI

However, there are many exceptions and additional considerations beyond age. When both SAVR and TAVI are otherwise suitable options, but TAVI cannot be performed with a transfemoral access, Prendergast pointed out that SAVR might be a better choice.

Transfemoral access is the preferred strategy in TAVI, but Prendergast emphasized that a collaborative "heart team" should help patients select the most appropriate option. In fact, there is a grade IIb recommendation ("usefulness or efficacy is less well established") to consider other access sites in patients at high surgical risk with contraindications for transfemoral TAVI.

Of new recommendations in the area of severe aortic stenosis, valvular repair may now be considered in asymptomatic patients with a left ventricular ejection fraction of less than 55%, according to a grade IIb recommendation. The 2017 guidelines did not address this issue.

Grade I Recommendation for Bioprostheses

A substantial number of the revisions involve minor clarifications without a change in the grade, but a revision regarding bioprosthetics is substantial. In the 2017 guidelines, there was a grade IIa recommendation ("weight of evidence is in favor") to consider bioprosthetics in patients with a life expectancy less than the expected durability of the device. The 2021 guidelines have changed this to a grade I indication, adding an indication for bioprostheses in patients contraindicated for or unlikely to achieve good-quality anticoagulation.

On this same topic, there is a new grade IIb recommendation to consider bioprosthesis over alternative devices in patients already on a long-term non–vitamin K oral anticoagulant because of the high risk of thromboembolism.

There are two new recommendations in the realm of severe secondary mitral regurgitation, reported Fabien Praz, MD, an interventional cardiologist at the University of Bern (Switzerland). The first, which is perhaps the most significant, is a grade I recommendation for valve surgery in patients with severe secondary mitral regurgitation who remain symptomatic despite optimized medical therapy.

The second is a grade IIa recommendation for invasive procedures, such as a percutaneous coronary intervention, for patients with symptomatic secondary mitral regurgitation and coexisting coronary artery disease. In both cases, however, Praz emphasized language in the guidelines that calls for a collaborative heart team to agree on the suitability of these treatments.

Ultimately, none of these recommendations can be divorced from patient expectations and values, according to Friedhelm Beyersdorf, MD, chairman of the department of cardiovascular surgery at the Heart Center of the University of Freiburg (Germany).

Even if treatment is not expected to prolong life, "symptom relief on its own may justify intervention," said Beyersdorf. However, he emphasized that "thoroughly informed" patients are an essential part of the process in selecting a treatment strategy most likely to satisfy patient goals.

Vahanian and Prendergast reported no conflicts of interest relevant to these guidelines. Praz reported a financial relationship with Edwards Lifesciences. Beyersdorf reported a financial relationship with Resuscitec.

This article originally appeared on, part of the Medscape Professional Network.


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