All what you want to know about the recent AHA valvular guidelines 2020

1. AHA Valvular Guidelines 2020
What is new?
Ahmed ElBorae, MSc
Assistant lecturer of Cardiology, Cairo University
Associate specialist of Cardiology, Aswan Heart Centre

2. AHA Valvular Guidelines
2006
2008
1998
2017
2020
2014

3. Agenda
• Aortic regurgitation
• Mitral regurgitation
• Tricuspid regurgitation
• PVL

4. 2017
2020

5. Input determines output
Unless you believe in magic

6. Progressive increase in post-operative mortality with LVEF < 55%
[HR]: 1.65 [95% (CI): 1.01 to 2.69] per 1% decrease in LVEF, p ¼ 0.007)
Why setting EF 55% instead of 50%?
de Meester et al. Do guideline-based indications result in an outcome penalty for patients with severe aortic regurgitation? JACC cardiovascImaging. 2019;12:2126–38.

7. de Meester et al. Do guideline-based indications result in an outcome penalty for patients with severe aortic regurgitation? JACC cardiovascImaging. 2019;12:2126–38.
Towards early intervention

8. 2020

9. 9
Risk factors for dissection
• Family H/O dissection
• Growth≥0.5 cm/year
• Coarctation
2017
2020
Risk factors for dissection
• Family H/O dissection
• Growth≥0.3 cm/year
• Coarctation
• Severe MR or AR
• Desire of pregnancy
• Systemic hypertension

11. COR LOE Recommendations
1 B-NR
2. In patients with severe AR who have symptoms and/or LV
systolic dysfunction (Stages C2 and D) but a prohibitive
surgical risk, GDMT for reduced LVEF with ACE inhibitors,
ARBs, and/or sacubitril/valsartan is recommended.
Medical Therapy of Chronic AR
2020

12. Agenda
• Aortic regurgitation
• Mitral regurgitation
• Tricuspid regurgitation
• PVL

13. Primary MR

14. 2017
Invasive
2020
AF/+PASP
No longer

15. Towards early repair 2020
AF/+PASP
No longer
Enriquez-SM,et al. Is there an outcome penalty linked to guideline-based indications for valvular surgery? Early and long-term analysis of patients with organic mitral regurgitation. J Thorac Cardiovasc Surg. 2015;150:50–8

16. TVT registry
2952 patients
145 USA centers

17. 2b B-NR
2. In asymptomatic patients with severe primary MR (Stages B and C1), use of serum
biomarkers and novel measurements of LV function, such as global longitudinal
strain, may be considered as an adjunct to guide timing of intervention.
Alashi et al. Synergistic utility of BNP and LV GLS in patients with significant primary MR and preserved systolic function undergoing mitral valve surgery. Circ Cardiovasc Imaging. 2016;9:e004451
Towards early detection of LV dysfunction

18. 3: No
Benefit
B-NR
2. In asymptomatic patients with primary MR and normal LV systolic
function (Stages B and C1), vasodilator therapy is not indicated if
the patient is normotensive.

19. Concomitant MV repair is reasonable in patients with
chronic moderate primary MR (stage B) undergoing
other cardiac surgery IIa C
2020
2017
Not indicated anymore

20. Secondary MR

21. 2017
2020
For both (Primary and secondary)

22. 2017
2020
With CABG
And EF > 30%
With CABG
And EF < 30%
+Viability
Alone And EF > 30%
+On Max. HF TTT
including CRT
+Low surgical risk
Alone And EF > 30%
+On Max. HF TTT
including CRT
+High surgical risk
Alone And EF < 30%
+On Max. HF TTT
including CRT-Assist
device and
transplantation
Clip

23. It is reasonable to choose chordal-sparing MVR over downsized
annuloplasty repair if operation is considered for severely
symptomatic patients (NYHA class III to IV) with chronic severe
ischemic MR (stage D) and persistent symptoms despite GDMT for
HF
IIa B-R
2020
In patients with chronic, moderate, ischemic MR (stage B)
undergoing CABG, the usefulness of mitral valve repair is uncertain IIb B-R
2017
2017
Not indicated anymore
Downgraded
ISTIMIR Trial

24. EVEREST II trial 2015
258 patients
TEER vs. Surgery
Primary and secondary MR
COAPT trial 2018
614 patients
TEER vs. GDMT
Secondary MR
MITRA FR 2018
304 patients
TEER vs. GDMT
Secondary MR
Different sample size, Inclusion and exclusion, MR grade, endpoints, FU duration

26. Philippe P,et al. MITRA-FR vs. COAPT: lessons from two trials with diametrically opposed results, European Heart Journal - Cardiovascular Imaging, Volume 20, Issue 6, June 2019.

27. COR LOE Recommendation
2a C-LD
1. Antibiotic prophylaxis is reasonable before dental procedures that involve
manipulation of gingival tissue, manipulation of the periapical region of teeth, or
perforation of the oral mucosa in patients with VHD who have any of the
following:
a. Prosthetic cardiac valves, including transcatheter-implanted prostheses and
homografts.
b. Prosthetic material used for cardiac valve repair, such as annuloplasty rings,
chords, or clips
c. Previous IE.
d. Unrepaired cyanotic congenital heart disease or repaired congenital heart
disease, with residual shunts or valvular regurgitation at the site of or
adjacent to the site of a prosthetic patch or prosthetic device.
e. Cardiac transplant with valve regurgitation attributable to a structurally
abnormal valve.
IE Prophylaxis

28. Medical Therapy of Chronic MR
2020
COR LOE Recommendations
1 A
1. Patients with chronic severe secondary MR (Stages C and D)
and HF with reduced LVEF should receive standard GDMT for
HF, including ACE inhibitors, ARBs, beta blockers, aldosterone
antagonists, and/or sacubitril/valsartan, and biventricular
pacing as indicated.

29. Agenda
• Aortic regurgitation
• Mitral regurgitation
• Tricuspid regurgitation
• PVL

30. 2020
2017

31. Medical therapies to reduce elevated pulmonary
artery pressures and/or pulmonary vascular
resistance might be considered in patients with
severe functional TR (stages C and D)
IIb C
2a C-EO
2. In patients with signs and symptoms of right-sided HF attributable
to severe secondary TR (Stages C and D), therapies to treat the
primary cause of HF (e.g., pulmonary vasodilators to reduce
elevated pulmonary artery pressures, GDMT for HF with reduced
LVEF, or rhythm control of AF) can be useful.
2020
2017
AF atrial (annular) dilatation is suspected:
Isolated TR with EF> 60% and PASP < 50 mmHg and
normal valve leaflets

32. Agenda
• Aortic regurgitation
• Mitral regurgitation
• Tricuspid regurgitation
• PVL

33. 2017 2020

34. Meta-analysis of 5 studies 2018
ViV TAVI was comparable to Re-SAVR
Gozdek M, et al. Comparative performance of TAVI VIV vs. RE-SAVR t in patients with degenerated aortic valve bioprostheses: systematicreview and meta-analysis. Eur J Cardiothorac Surg. 2018;53:495–504
2020

35. 2020
> 6560-65< 60 > 70< 65 65-70
2017
2017
< 50 Mechanical
>70  Bioprosthesis
50-70  individualized
Decision making: (Patient preference)
• Age and Life expectancy
• Anticoagulation issues (Pregnancy, indication)
• Risk of future redo surgery
• Accelerated degeneration (young, CKD, DM,
Hyperparathyroidism)

36. 50%
30%
22%
10%
0%
10%
20%
30%
40%
50%
60%
20 Years 40 years 50 Years 70 Years
15-Year risk of AV Bioprosthesis degeneration
15-Year risk of degeneration Linear (15-Year risk of degeneration)

37. Take home message
• Multi-disciplinary team and informed patient discussion is important in determining the
appropriate intervention plan
• Lower threshold towards earlier intervention for valvular regurgitation could prevent
irreversible ventricular overload consequences
• Mitral TEER is of benefits in selected cases of 1ry and 2ry MR who remain severely
symptomatic with high or prohibitive surgical risk
• Early intervention for severely symptomatic isolated TR might be beneficial before RV
failure or end organ damage
• Catheter based treatment (ViV/PVL) of prosthetic valve dysfunction is reasonable in
properly selected patients

38. Thank You