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2021 ESC/EACTS Guidelines for the management of valvular heart disease

Alec Vahanian et al. EuroIntervention. .
No abstract available

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Figures

Figure 1 (Central illustration)
Figure 1 (Central illustration). Patient-centred evaluation for intervention.
VHD: valvular heart disease; CCT: cardiac computed tomography; CMR: cardiac magnetic resonance; TOE: transoesophageal echocardiography; TTE: transthoracic echocardiography.
Figure 2
Figure 2. Management of patients with aortic regurgitation.
BSA: body surface area; LV: left ventricle/left ventricular; LVESD: left ventricle end-systolic diameter; LVEF: left ventricular ejection fraction. aSee recommendations on indications for surgery in severe aortic regurgitation and aortic root disease for definition. bSurgery should also be considered if significant changes in LV or aortic size occur during follow-up.
Figure 3
Figure 3. Integrated imaging assessment of aortic stenosis.
AS: aortic stenosis; AV: aortic valve; AVA: aortic valve area; CT: computed tomography; ΔPm: mean pressure gradient; DSE: dobutamine stress echocardiography; LV: left ventricle/left ventricular; LVEF: left ventricular ejection fraction; SVi: stroke volume index; Vmax: peak transvalvular velocity. aHigh flow may be reversible in patients with anaemia, hyperthyroidism or arterio-venous fistulae, and may also be present in patients with hypertrophic obstructive cardiomyopathy. Upper limit of normal flow using pulsed Doppler echocardiography: cardiac index 4.1 L/min/m2 in men and women, SVi 54 mL/m2 in men, 51 mL/m2 in women). bConsider also: typical symptoms (with no other explanation), LV hypertrophy (in the absence of coexistent hypertension) or reduced LV longitudinal function (with no other cause). cDSE flow reserve: >20% increase in stroke volume in response to low-dose dobutamine. dPseudo-severe aortic stenosis: AVA >1.0 cm2 with increased flow. eThresholds for severe aortic stenosis assessed by means of CT measurement of aortic valve calcification (Agatston units): men >3000, women >1600: highly likely; men >2000, women >1200: likely; men <1600, women <800: unlikely.
Figure 4
Figure 4. Management of patients with severe aortic stenosis.
BP: blood pressure; EuroSCORE: European System for Cardiac Operative Risk Evaluation; LVEF: left ventricular ejection fraction; SAVR: surgical aortic valve replacement; STS-PROM: Society of Thoracic Surgeons – predicted risk of mortality; TAVI: transcatheter aortic valve implantation; TF: transfemoral. aSee Figure 3: Integrated imaging assessment of aortic stenosis. bProhibitive risk is defined in Supplementary Table 5. cHeart Team assessment based upon careful evaluation of clinical, anatomical, and procedural factors (see Table 6 and table on Recommendations on indications for intervention in symptomatic and asymptomatic aortic stenosis and recommended mode of intervention). The Heart Team recommendation should be discussed with the patient who can then make an informed treatment choice. dAdverse features according to clinical, imaging (echocardiography/CT), and/or biomarker assessment. eSTS-PROM: http://riskcalc.sts.org/stswebriskcalc/#/calculate, EuroSCORE II: http://www.euroscore.org/calc.html. fIf suitable for procedure according to clinical, anatomical, and procedural factors (Table 6).
Figure 5
Figure 5. Management of patients with severe chronic primary mitral regurgitation.
AF: atrial fibrillation; HF: heart failure; LA: left atrium/ left atrial; LVEF: left ventricular ejection fraction; LVESD: left ventricular end-systolic diameter; SPAP: systolic pulmonary arterial pressure; TEER: transcatheter edge-to-edge repair. aLA dilatation: volume index ≥60 mL/m2 or diameter ≥55 mm at sinus rhythm. bExtended heart failure treatment includes the following: CRT; ventricular assist devices; heart transplantation.
Figure 6
Figure 6. Management of patients with chronic severe secondary mitral regurgitation.
CAD: coronary artery disease; CABG: coronary artery bypass grafting; CRT: cardiac resynchronization therapy; ESC: European Society of Cardiology; GDMT: guideline-directed medical therapy; HF: heart failure; HTx: heart transplantation; LVAD: left ventricular assist devices; LV: left ventricle/left ventricular; LVEF: left ventricular ejection fraction; MV: mitral valve; PCI: percutaneous coronary intervention; RV: right ventricle/right ventricular; SMR: secondary mitral regurgitation; TAVI: transcatheter aortic valve implantation; TEER: transcatheter edge-to-edge repair. aLVEF, predicted surgical risk, amount of myocardial viability, coronary anatomy/target vessels, type of concomitant procedure needed, TEER eligibility, likelihood of durable surgical repair, need of surgical mitral replacement, local expertise. bParticularly when concomitant tricuspid valve surgery is needed. cCOAPT criteria (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation): see Supplementary Table 7.
Figure 7
Figure 7. Management of clinically significant rheumatic mitral stenosis (MVA ≤1.5 cm2).
AF: atrial fibrillation; LA: left atrium/left atrial; MVA: mitral valve area; NCS: non-cardiac surgery; PMC: percutaneous mitral commissurotomy. aHigh thromboembolic risk: history of systemic embolism, dense spontaneous contrast in the LA, new-onset AF. High-risk of haemodynamic decompensation: systolic pulmonary pressure >50 mmHg at rest, need for major NCS, desire for pregnancy. bSurgical commissurotomy may be considered by experienced surgical teams in patients with contraindications to PMC. cSee recommendations on indications for PMC and mitral valve surgery in clinically significant mitral stenosis in section 7.2. dSurgery if symptoms occur for a low level of exercise and operative risk is low.
Figure 8
Figure 8. Management of tricuspid regurgitation.
LV: left ventricle/left ventricular; RV: right ventricle/right ventricular; TA: tricuspid annulus; TR: tricuspid regurgitation; TV: tricuspid valve. aThe Heart Team with expertise in the treatment of tricuspid valve disease evaluates anatomical eligibility for transcatheter therapy including jet location, coaptation gap, leaflet tethering, potential interference with pacing lead. bReplacement when repair is not feasible.
Figure 9
Figure 9. Antithrombotic therapy for valve prostheses.
AF: atrial fibrillation; ASA: acetylsalicylic acid; CAD: coronary artery disease; DAPT: dual antiplatelet therapy; INR: international normalized ratio; LMWH: low-molecular-weight heparin; LV: left ventricle/left ventricular; MHV: mechanical heart valve; MVR: mitral valve replacement or repair; OAC: oral anticoagulation; SAPT: single antiplatelet therapy; SAVR: surgical aortic valve replacement; TAVI: transcatheter aortic valve implantation; TVR: tricuspid valve replacement or repair; UFH: unfractionated heparin; VKA: vitamin K antagonist. Colour coding corresponds to class of recommendation.
Figure 10
Figure 10. Management of left-sided obstructive and non-obstructive mechanical prosthetic thrombosis.
ASA: acetylsalicylic acid; CCT: cardiac computed tomography; i.v.: intravenous; TOE: transoesophageal echocardiography; TE: thromboembolism; TTE: transthoracic echocardiography; UFH: unfractionated heparin. Risk and benefits of both treatments should be individualized. The presence of a first-generation prosthesis is an incentive to surgery. aRefer to recommendations for the imaging assessment of prosthetic heart valves. Evaluation generally includes TTE plus TOE or CCT and occasionally fluoroscopy.
Figure 11
Figure 11. Management of non-cardiac surgery (NCS) in patients with severe aortic stenosis.
AV: aortic valve; BAV: balloon aortic valvuloplasty; NCS: non cardiac surgery; SAVR: surgical aortic valve replacement; TAVI: transcatheter aortic valve implantation.
See this image and copyright information in PMC

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