The 2020 guideline for the management of patients with valvular heart disease replaces the American Heart Association/American College of Cardiology (AHA/ACC) 2014 guideline and the 2017 focused update. The following is Part 1 of 3 key perspectives regarding some general considerations; and regarding patients with aortic stenosis (AS), aortic regurgitation (AR), or bicuspid aortic valve (BAV):

1. The guideline continues to recommend the use of disease stages among patients with valvular heart disease, consisting of Stage A (at risk), Stage B (progressive), Stage C (asymptomatic severe; with ventricular compensation [Stage C1] or with ventricular decompensation [Stage C2]), and Stage D (symptomatic severe). Disease stages should be assigned based on valve anatomy, the severity of valve dysfunction, the ventricular and pulmonary circulation response to valve dysfunction, and symptoms.
2. Among patients with atrial fibrillation and native heart valve disease other than rheumatic mitral stenosis, or among patients with atrial fibrillation and a bioprosthesis >3 months after valve replacement, a non–vitamin K oral anticoagulant (NOAC) is an effective alternative to anticoagulation with a vitamin K antagonist (VKA); among these patients, either a NOAC or VKA should be used based on the CHA₂DS₂-VASc score. Anticoagulation with a VKA should be used among patients with atrial fibrillation and rheumatic mitral stenosis. A NOAC should not be used in patients with a mechanical prosthesis without or with atrial fibrillation.
3. All patients with severe valvular heart disease being considered for intervention should be evaluated by a Multidisciplinary Heart Valve Team. Consultation with or referral to a Primary Valve Center or a Comprehensive Valve Center is reasonable for the discussion of treatment options in the setting of asymptomatic patients with severe valve disease, patients who might benefit from valve repair rather than valve replacement, and among patients with multiple comorbidities.
4. Among patients with severe symptomatic (Stage D) AS, the disease is subcategorized based on the gradient, flow, and left ventricular ejection fraction (LVEF). Stage D1 reflects patients with high-gradient symptomatic AS (V_max ≥4.0 m/s, mean gradient ≥40 mm Hg, aortic valve area [AVA] ≤1.0 cm²); Stage D2 reflects low-flow, low-gradient severe AS with reduced LVEF (AVA ≤1.0 cm², V_max <4.0 m/s or mean gradient <40 mm Hg, LVEF <50%); and Stage D3 reflects low-flow, low-gradient severe AS with normal LVEF ("paradoxical low-flow severe AS"; LVEF ≥50%, stroke volume index <35 ml/m²).
5. Intervention for severe AS predominantly is based on the presence of symptoms or LV systolic dysfunction (Class 1); or in asymptomatic patients at low surgical risk with decreasing exercise tolerance or exercise-associated decrease ≥10 mm Hg in systolic blood pressure, very severe AS (V_max ≥5.0 m/s), serum B-type natriuretic peptide (BNP) >3 times normal, or progression of V_max ≥0.3 m/s per year (Class 2a). In addition, intervention can be considered among asymptomatic patients with severe high-gradient AS and a progressive decrease in LVEF to <60% on ≥3 serial imaging studies (Class 2b).
6. Among patients in whom a bioprosthesis is appropriate, decisions between surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) should include the presence of symptoms, patient age and anticipated life expectancy, the indication for intervention, predicted surgical risk, and anatomy or other factors referable to transfemoral (TF) TAVI feasibility (all Class 1):
   • SAVR is preferred among patients <65 years of age or with life expectancy >20 years.
   • SAVR is preferred if vascular anatomy or other factors preclude TF TAVI.
   • SAVR is preferred among asymptomatic patients with a Class 2a indication for intervention, such as an abnormal exercise test, very severe AS, rapid progression, or elevated BNP.
   • If feasible, TF TAVI is preferred among patients >80 years of age or with life expectancy <10 years.
   • SAVR or TF TAVI is recommended after shared decision making among symptomatic patients ages 65-80 years with no contraindication to TF TAVI.
   • TAVI is preferred among symptomatic patients of any age with high or prohibitive surgical risk, if predicted survival after intervention is >12 months with an acceptable quality of life.
   • After shared decision making, palliative care is recommended among symptomatic patients with predicted post-TAVI survival <12 months or for whom minimal improvement in quality of life is expected.
7. Among patients with asymptomatic severe (Stage C) AR, the disease is subcategorized based on LVEF and LV end-systolic diameter (LVESD). Stage C1 reflects normal LVEF (≥55%; previously ≥50% in the 2014 AHA/ACC guidelines) and mild to moderate LV dilation (LVESD <50 mm). Stage C2 reflects abnormal LV systolic function (LVEF <55%; previously <50%) or severe LV dilation (LVESD 50 mm or indexed LVESD >25 mm/m²; unchanged from previous).
8. Intervention for severe AR is based on the presence of symptoms or LV systolic dysfunction (LVEF ≤55%; both Class 1); or the presence of severe LV dilation (LVESD >50 mm or indexed LVESD >25 mm/m²; Class 2a).
9. Among patients with BAV, transthoracic echocardiography is recommended to assess valve morphology, assess AS and AR, assess the aortic root and ascending aorta, and evaluate for the presence of aortic coarctation. If the aortic sinuses, sinotubular junction, and ascending aorta cannot be accurately or fully assessed on echocardiography, then cardiac magnetic resonance angiography or computed tomography angiography is indicated. Lifelong serial imaging is indicated if the aorta diameter is ≥4.0 cm.
10. Among patients with BAV, indications for replacement of the aorta remain similar to previous: aortic diameter >5.5 cm (Class 1), aortic diameter 5.0-5.5 cm plus an additional risk factor for dissection (family history of dissection, aortic growth >0.5 cm per year, aortic coarctation; Class 2a), or aortic diameter ≥4.5 cm with an indication for SAVR (Class 2a).

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Interventions, Interventions and Imaging, Interventions and Structural Heart Disease, Angiography, Computed Tomography, Magnetic Resonance Imaging, Nuclear Imaging

Keywords: Anticoagulants, Aortic Coarctation, Aortic Valve Insufficiency, Aortic Valve Stenosis, Atrial Fibrillation, Bioprosthesis, Cardiac Surgical Procedures, Coronary Angiography, Diagnostic Imaging, Exercise Tolerance, Geriatrics, Heart Defects, Congenital, Heart Valve Diseases, Heart Valve Prosthesis, Magnetic Resonance Angiography, Mitral Valve Stenosis, Natriuretic Peptide, Brain, Pulmonary Circulation, Stroke Volume, Tomography, X-Ray Computed, Transcatheter Aortic Valve Replacement

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