ESC Issues New Guidelines on Valve Disease


For the first time since 2007, the European Society of Cardiology (ESC) has released new guidance on the treatment of valve disease, this time teaming up with the European Association for Cardiothoracic Surgery (EACTS) [1].
The document, made available online to coincide with its release at the European Society of Cardiology 2012 Congress as well as in "pocket edition" and PDA formats, is published online August 24, 2012 in the European Heart Journal.

The guidelines are focused on acquired valve disease (endocarditis, congenital valve disease, and pulmonary valve disease are the subject of other ESC guidance). According to the writing group, led by Drs Alec Vahanian (Hôpital Bichat, Paris, France) and Ottavio Alfieri (S Raffaele University Hospital, Milan, Italy), an update was necessitated by advances in diagnostics, particularly echocardiography; developments in the field of surgical valve repair; and the arrival of percutaneous valve replacement and repair techniques.

Speaking with heartwire , Vahanian highlighted the heart-team approach, which dominates the entire document, requiring a cardiologist, surgeon, and others to be involved in the patient workup. "That's very important, because we felt that teamwork is crucial in the management of patients with valve disease, especially high-risk patients."

Another key point is that the new guidelines "are moving away" from reliance on EuroSCOREs and STS scores. "We've included a strong message about patient evaluation and risk assessment in high-risk patients. We want to convey that the scores are less than perfect, so we encourage people to evaluate patients with the heart team. Clinical judgment is more important than the scoring."

Key new recommendations in the new guidance also include:
Comprehensive review of echocardiographic criteria for defining severe valve regurgitation, as well as the role of other imaging modalities.

Indications for surgery in both severe aortic regurgitation and aortic root disease and conversely the role of medical therapy.

Transcatheter aortic-valve implementation (TAVI) is given a class I B recommendation in patients with symptomatic aortic stenosis who are not candidates for surgery, as assessed by a heart team (cardiologists, surgeons, imaging specialists, and anesthesiologists).

TAVI is given a class IIa B for high-risk patients with severe aortic stenosis in whom TAVI is deemed a better approach than surgery by the heart team.

TAVI contradictions, including limited life expectancy, low ejection fraction, and specific comorbidities, among others, are listed.

TAVI "should not be performed" in patients at intermediate risk for surgery "at the present stage."

The MitraClip device, which mimics edge-to-edge repair via a percutaneous procedure, also makes a debut in the new guidelines, with the writing group noting that what data exist suggest the device "is relatively safe and generally well-tolerated."

Also in the mitral-valve disease arena, the guidelines "are not much different from 2007," Vahanian said, although there has been a slight "widening" of the indications for surgery in asymptomatic patients with flail leaflet.

With regards to choice of prosthesis in surgical patients, the new guidance emphasize that this is a multifactorial decision, with an emphasis on patient input, but the writing group lowered the threshold for recommending a bioprosthetic valve in patients over 65 for aortic-valve disease and 65 to 70 for mitral-valve disease.

In terms of postoperative medical care, the new guidelines favor antiplatelet therapy alone in patients with bioprosthetic valves and no other risk factors--a departure from the three months of warfarin recommended in the 2007 guidance.

author: Shelley Wood

References:
Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012): The joint task force on the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2012; DOI:10.1093/eurheartj/ehs109. Available at: http://eurheartj.oxfordjournals.org.

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